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The facial nerve
- 1. FACIAL NERVE AND APPLIED ANATOMY Dr Alok kumar Singh
- 2. CONTENTS 1. INTRODUCTION 2. FACIAL NERVE ANATOMY 3. VARIATIONS OF BRANCHING PATTERN OF FACIAL N. 4. SURGICAL ANATOMY relation of main trunk to stylomastoid foramen Variations of marginal mandibular nerve Identification of facial nerve 5. UPPER MOTOR v/s LOWER MOTOR NEURON LESIONS 6. FACIAL NERVE REPAIR 7. FACIAL NERVE GRAFT 8. CROSS FACE NERVE GRAFTING 9. NERVE CROSS OVERS
- 3. INTRODUCTION • Seventh cranial nerve. • Nerve innervates the facial muscles • It also provides lacrimation, salivation, impedence regulation of the middle ear, and senses of touch, temperature, and taste. • It has got two roots I. Sensory root II. Motor root
- 4. NUCLEI OF FACIAL NERVE 1. Motor nucleus( motor component) 2. Sensory nucleus or nucleus of tractus solitarius( special sensory ) 3. Parasympathetic nucleus or superior salivatory nucleus( visceral motor ) 4. Upper part of nucleus of the spinal tract of 5th nerve( general sensory )
- 9. RELATIONS OF MAIN TRUNK AFTER IT EXITS STYLOMASTOID FORAMEN
- 10. TEMPORAL BRANCH
- 12. STUDIES ON THE VARIATION OF THE MARGINAL MANDIBULAR NERVE • DINGMAN N GRABB-100 FACIAL HALVES 21%cases single branch 67%cases two branches 9%cases three branches 3%cases four branches • ZIARAH AND ATKINSON-53%OF 76FACIAL HALVES • AL HAYANI-50 HUMAN SUBJECTS 32%cases single branch 40%cases two branches 28%cases three branches
- 13. Identification of main trunk of facial nerve
- 14. INJURY TO FACIAL NERVE AT DIFFERENT LEVELS IN ITS COURSE • Facial nerve lesion caudal to geniculate ganglion or cephalad to stapedial branch • Lesion b/w stapedial nerve & chorda tympani • Lesion caudal to chorda tympani • Facial nerve lesion at the stylomastoid foramen • Lesions within the confines of parotid gland
- 16. UMN LMN Affects lower half of face on contralateral side Affects ipsilateral side of face Weakness of voluntary movements Weakness of both voluntary and involuntary movements Bell’s phenomenon not present Bell’s phenomenon present Functionof both frontalis & orbicularis occuli muscles preserved absence of frontalis function
- 17. BELL’S PALSY
- 19. House-Brackmann Grading System Grade Characteristics I. Normal facial function in all areas II. Mild dysfunction •Slight weakness noticeable on close inspection •Forehead - Moderate-to-good function •Eye - Complete closure with minimal effort •Mouth - Slight asymmetry III. Moderate dysfunction -First time you can notice a difference at rest •Obvious but not disfiguring difference between the two sides • Forehead - Slight-to-moderate movement •Eye - Complete closure with maximum effort •Mouth - Slightly weak with maximum effort IV. Moderately severe dysfunction -First time you have incomplete eye closure -No forehead movement •Obvious weakness and/or disfiguring asymmetry • Forehead – No motion •Eye - Incomplete closure •Mouth - Asymmetric with maximum effort V. Severe dysfunction •Only barely perceptible motion •At rest, asymmetry •Forehead – No movement •Eye - Incomplete closure •Mouth - Slight movement VI. Total paralysis No movement
- 20. DIAGNOSTIC TESTS • ETIOLOGIC TESTS-1>Serological tests 2>Radiographic evaluation 3>CT/MRI • PROGNOSTIC TESTS-1>Nerve excitability test 2>Maximal stimulation test 3>Electroneuronography-a current sufficient to evoke a maximal response in facial muscles is delivered percutaneously to the s.m foramen region.CMAP(compound muscle action potential) measured
- 21. • TOPOGRAPHIC-1>Schirmer test 2>Stapedial reflex-When presented with a high-intensity sound stimulus, the stapedius and tensor tympani muscles of the ossicles contract.. The reflex decreases the transmission of vibrational energy to the cochlea
- 22. Medical Management • Physical Therapy – Application of heat, facial massage & exercises • Pharmacological Therapy – Use of steroids – Vitamins – Treat underlying conditions eg. herpes • Psychophysical Therapy – Biofeedback – Depression – counseling • Botulinum toxin
- 24. FACIAL NERVE REPAIR • IMMEDIATE (0 TO 3 WEEKS) • DELAYED (3WEEKS TO 2 YEARS) • LATE (OVER 2 YEARS)
- 25. DIRECT NERVE REPAIR • 2 main types-1.Epineureal 2.Fascicular • Goal of nerve repair 1>Epineureal repair- a.Most common method b.Level of repair c.Intraneural sheath not invaded d.Disadvantageous in extratemporal facial nerve repairs
- 26. FASCICULAR(PERINEUREAL REPAIR) • Langley and Hashimoto(1917)
- 27. NERVE GRAFTING • If the nerve ends cannot be approximated without tension • Commonly used grafts are Greater Auricular, Sural, Cervical Plexus & Lateral femoral cutaneous nerves • Greater length of nerve graft should always be taken
- 30. CROSS FACE NERVE GRAFTING • Principle – cross innervation from non paralysed side by sural grafts that connects the reservoir of healthy peripheral facial nerve fascicles to corresponding branches of specific muscle groups on paralysed side • Length of graft -6 – 8cms
- 33. oNERVECROSSOVERS(REINNERVATION) • Hypoglossal, Spinal accessory or Phrenic nerve used
- 34. Indications for nerve crossovers • Radical resection of temporal bone • Resection of intracranial tumors • Ear or mastoid surgery • Primary ablative surgery for regional cancer, when nerve grafting is not feasible.
- 36. INCISION THROUGH SKIN AND SUBCUTANEOUS TISSUE
- 37. ELEVATION OF ANTERIOR FLAP
- 38. Elevn of tail of parotid gland from sternomastoid muscle and post. Belly of digastric with preservatn of post. Branches of gr. Auricular nerve
- 40. REFERENCES 1. GRAY'S ANATOMY FOR STUDENTS-RICHARD L. DRAKE,WAYNE VOGL,HENRY GRAY 2. SICHER AND DUBRUL'S ORAL ANATOMY-E LLOYD DUBRUL 3. FACIAL NERVE DISORDERS AND SURGERY- Robert G Anderson 4. PLATIC SURGERY-VOLUME 3 PART 2-JOSEPH G. Mc CARTHY 5. PLASTIC AND RECONSTRUCTIVE SURGERY:FIRST EDITION- MACK L. CHENEY 6. APPROACHES TO THE FACIAL SKELETON-Edward Ellis 7. THE FACIAL NERVE-MARK MAY 8. PLASTIC MAXILLOFACIAL AND RECONSTRUCTIVE SURGERY:THIRD EDITION-GREGORY S. GEORGIADE 9. ATLAS OF HEAD & NECK SURGERY--OTOLARYNGOLOGY - Byron J. Bailey 10. ATLAS OF NEUROSURGICAL TECHNIQUES: BRAIN - Laligam N. Sekhar, Richard G. Fessler
Editor's Notes
- 1.Facialn. Emerges from the brain at the pontocerebellar angle in front n medial to vestibuloc. Nerve.it enters into internal acoustic meatus along with vestib. Nerve. 2. Within the internal acoustic meatus the facial nerve enters the facial canal 3.The small sensory geniculate ganglion lies where the facial canal bends sharply 4. The first branch of the facial nerve, the greater superficial petrosal nerve (GSPN) branches from the geniculate ganglion within the genu(sharp bend) of the facial canal and enters the middle cranial fossa (MCF) by way of the hiatus(opening) of the canal for the GSPN. The GSPN leaves the mcf through foramen lacerum.Now it joins with the deep petroszal nerve(comes from sympathetic plexus around the internal carotid a.) and forms the pterygoid or vividian nerve which passes through pterygoid canal into pterygopalatine ganglion. From the ganglion, the postganglionic fibres carry impulses via maxillary br. Of trigeminal nerve to lacrimal gland and other glands of nasal cavity n palate. 5. The second branch of the facial nerve, the stapedial nerve, branches from the descending portion of the facial nerve and enters the middle ear.It supplies the stapedius muscle which is attached to the stapes.(find out action of stapedius muscle) 6. The third branch of the facial nerve, the chorda tympani nerve, branches from the descending portion of the facial nerve and enters the middle ear. Within the middle ear the chorda tympani nerve crosses the medial surface of the tympanic membrane. It then passes through the petrotympanic fissure to enter the infratemporal fossa.Here it passes medial to inferior alveolar nerve n then joins lingual n.The fibres of chorda tympani continue in the sheath of lingual nerve.The secretory fibres leave the lingual n. close to upper pole of submandibular gland n enter submandibular ganglion.From the ganglion postganglionic fibres sent to submandibular n sublingual glands.the taste fibres of chorda tympani follow the lingual n. into the substance of the tongue n r distributed to taste buds. 7. The descending portion of the facial nerve exits the facial canal at the stylomastoid foramen and continues into the parotid region
- 2. CN VII exits the skull base via the stylomastoid foramen ,then passes( mastoid process-medial). It immediately gives off three motor branches upon exiting the foramen: 1) To Stylohyoid muscle 2) To Postauricular muscle 3) To posterior belly of Digastric After exiting the foramen, CN VII turns laterally to enter the Parotid gland at its posterior margin. The nerve then branches at the Pes Anserinus (goose’s foot) approximately 1.3 cm from the stylomastoid foramen. The nerve then gives rise to 2 divisions: 1) Temperofacial (upper) -divides into temporal,zygom. And upper buccal branches 2) Cervicofacial (lower) -into marginal mand,cervical and lower buccal
- Length of facial nerve trunk visible to surgeon is 1.3cm Avg distance b/w bony external auditory meatus to bifurcation of facial nerve-2.3 cm Post toparotid glandNerve trunk 2 cm deep to the skin
- -At the superior temporal line,the SCALP changes.the 1st 2 layers r same.3rd layer is temporoparietal facia in pl;ace of galea.the sup. Temporal artery lies in temporoparietal facia.below it is the facia that covers the temporalis muscle i.e the deep temporal facia.it splits into superficial n deep layers at the level of supraorbital margin.in between these 2 is the fat pad.the temporal br. Of facial artery lies in between temporoparietal facia and sup. Layer of deep temporal facia.in bicoronal approach disection is done in subgaleal layer i.e below temporop. Facia so superficial temp. artery is saved anyway.to save the temporal br. Of facial nerve,just when v r 3-4 cm above the zyg. Arch,an incisn is made in to the sup. Layer of deep temporal facia so that v can proceed under the nerve(dissectn now is in temporal fat pad) n this is how v reach the zyg. Arch. 1. The temporal branch or branches of the facial nerve leave the parotid gland immediatel inferior to the zygomatic arch (Fig. 6-3). The general course is from a point 0,5 cm below the tragus to a point 1,5 cm above the lateral eyebrow (2). It crosses superficial to the zygomatic arch an average of 2 cm anterior to the anterior concavity of the external auditory canal, but in some cases, it is as near as 0,8 cm and as far as 3.5 cm anterior to the external auditory canal (Fig. 6-4) (3). As it crosses the lateral surface of the arch, the temporal branch courses along the undersurface of the temporoparietal fascia, and subgaleal fascia (see Fig. 6-1). As the nerve courses anterosuperiorly toward the frontalis muscle, it lies on the undersurface of the temporoparietal fascia (Fig. 6-5), and enters the frontalis muscle 2 cm above the level of the superior orbital rim.It commonly branches into three or four rami along its course.
- In Dingman and Grabb's classic dissection of 100 fascial halves, the marginal mandibular branch was as much as 1cm below the inferior border in 19% of cases (1). Anterior to the point where the nerve crossed the facial artery, all dissections displayed the nerve above the inferior border of the mandible. Another important finding in the study by Dingman and Grabb (1) was that only 21% of cases had a single marginal mandibular branch between the angle of the mandible and the facial vessels (Fig. 9-2); 67% had two branches (see Fig. 9-1), 9% had three branches, and 3% had four. Ziarah and Atkinson (2) found an even higher number of cases in which the marginal mandibular branch passed below the inferior border. In 53% of 76 facial halves, they found the marginal mandibular branch below the inferior border reaching the facial vessels, and in 6%, the nerve continued for a farther distance of as much as 1.5 cm before turning upward and crossing the mandible. The farthest distance between a marginal mandibular branch and the inferior border of the mandible was 1.2 cm. In view of these findings, most surgeons recommend that the incision and deeper dissection be at least 1.5 cm below the inferior border of the mandible. A. Al-Hayani studied post mortem in 50 human subjects.The nerve was found to be presented by one branch (32%), two branches (40%) and three branches (28%). The relationship of the nerve to the lower border ofthe mandible was variable: it was either totally above the lower border of the mandible (28%), below the mandible (44%) or in 28% of cases lying above and below it.(Folia Morphologica is an official journal of the Polish Anatomical Society)
- Tragal pointer-1cm medial and anteroinferior to tip of pointer Tympanomastoid suture-6-8mm medial to suture Digastric muscle attachment to digastric groove-sup & same plane as muscle attachment Mastoid bone- within mastoid bone
- 1.Complete peripheral facial paralysis 2. complete peripheral facial paralysis WITH normal tear production, normal stapedial muscle function 3 peripheral extracranial paralysis 4. Complete peripheral nerve paralysis – no disturbance of tear, stapedius muscle function saliva production, taste, 5. Selective paralysis of voluntary motor functions Paralysis of temporal branch – asymmetric motion of forehead, some dysfunction of upper & lower eyelids Zygomatic branch – paralysis of zygomatic minor, major, levator anguli oris, levator superioris – impairment of smile Buccal branch – buccinator, RISORIUS,orbicularis oris muscle distortion Mandibular branch – triangularis, rizorius, mentalis, orbicularis oris muscle dysfunction – asymmetry of smile, Cervical branch – innervation of platysma, little functional loss
- It is defined as an idiopathic paresis or paralysis of facial nerve of sudden onset (unilateral lower motor neuron) Age- middle age Side involvement- equally Etiology- 1)rheumatic hypothesis 2)cold hypothesis 3)ischaemic hypothesis 4)immunological hypothesis 5)viral hypothesis We are not completely certain what the cause of Bell's palsy is. However, experts believe it is most likely caused by a virus, usually the herpes virus, which inflames the nerve. The herpes virus is the one that also causes cold sores and genital herpes. Other viruses have also been linked to Bell's palsy, including the chickenpox and shingles viruses, which are both related to the herpes virus. The virus that causes mononucleosis (Epstein-Barr) as well as the cytomegalovirus have also been linked to Bell's palsy. Lyme disease in areas where it is endemic may be a principal cause of Bell's palsy type symptoms caused by bacteria. If the nerve is inflamed it will press against the cheekbone or may pinch in the tight corridor (narrow gap of bone) - this can result in damage to the protective covering of the nerve. If the protective covering of the nerve becomes damaged, the signals which are being sent from the brain to the muscles in the face may not be transmitted properly, leading to weakened or paralyzed facial muscles - Bell's palsy
- CLINICAL FEATURES -sudden onset ,after awakening early in the morning -unilateral involvement of one side of face ,there abrupt loss of muscular control -inability to smile ,or whistle(lips cant be purched) , close the eye ,wink or raise the eyebrow -corner of the mouth droops causing drooling of saliva -obliteration of nasolabial fold -Face appears distorted and mask like appearance -speech is slurred -Bell’s sign-when attempting to close the eye on the side of the face affected,the eyeballs roll outward and upward.also known as bordier frankels sign. This neurological disorder also only affects the facial areas, unlike a stroke, which can affect all of one side of the body (limbs and trunk included.)
- 1)Serological tests to b done for syphilis n diabetes mellitus.All patients should be evaluated for neurosyphilis, a treatable infectious disease that is increasing in frequency.In addition, diabetic patients afflicted with Bell’s palsy tend to recover nerve function if they receive steroids. 2) Routine mastoid films may show destructive lesions, opacification of the mastoid air cells, and, occasionally, widening of the internal auditory canal. 3)High-resolution, thin-section CT scans may reveal intracranial, intratemporal, or extratemporal tumors 4) The nerve excitability test (NET) is performed with the Hilger nerve stimulator. The test is simple and requires minimal equipment, but is subjective and does not reflect denervation at the moment it is occurring. An abnormal test result is a 3.0–3.5- ma difference between the two sides of the face. 5)The maximal stimulation test (MST) uses the same equipment, but the stimulus is increased until the patient experiences discomfort, at which point the main trunk of the nerve and each of the distal branches is sequentially tested. Any difference in facial movement between the two sides denotes an abnormal test result. The MST becomes positive before the NET in lesions of the facial nerve. 6)ENOG- A current sufficient to evoke a maximal response in the facial muscles is delivered percutaneously to the stylomastoid foramen region. compound muscle action potentials (CMAP) is measured over the skin of the nasolabial fold. 1.To determine integrity of lacrimal function annd localize the lesion proximal or distal to geniculate ganglion.strip is placed at junctn of middle and lateral 1/3rd of lower eyelid.pt. told to look forward n blink normally.strip removed after 5 mins n wetting recorded in mm.eyes may be open r closed.litmus paper or blotting paper can b used.less than 6mm indicates tear deficiency.(study pg 641 of cheney) 2.INTRODUCED BY Blatt. PT. has to wait for 3 weeks before any test can b done.
- The stapedius muscle is innervated by the facial nerve, and measurement of the reflex can be used to locate the injury on the nerve. If the injury is distal to the stapedius muscle, the reflex is still functional.
- Nnnastta-neuropeptides-cream nsaids-k and d nmethyldaspartateblocking agents-k anticonvulsants-c sympathomimetics-c topical anesthetics-l tricyclic antidepressants-a antispasmodics-baclofen Richard P, Clark, Craig E, Berris used Botulinum toxin as a treatment for facial asymmetry caused by facial nerve paralysis They injected 12.5 units of this toxin to correct the wrinkling forehead every 3 months for a period of 2 yrs & the results were satisfactory DOSE OF PREDNISOLONE:Tab Prednisolone 1mg/kg/day for 10 – 14 days
- IMMEDIATE (0 TO 3 WEEKS)-(LEFR)a>lacerations and iatrogenic injuriesb>elasticity permits closure without graftc>absence of scarring and fibrosis d>complete recovery DELAYED (3WEEKS TO 2 YEARS)(penm)a>cell body and proximal segment capable of regenerating upto 2 years so Endoneural tubules are preserved and guide regenerating axons to facial musclesc>Muscles undergo degeneration but capable of regenerating once nerves reach themd>nerve grafting or nerve cross over peferred LATE (OVER 2 YEARS)(mebm)a>muscle atrophy and fibrosisb>Electromyography-absence of nerve potentialc>Biopsy –absence of muscle fibersd>regional muscle transfer or micro-vascular muscle transfer
- 1.Within temporal bone epineureal repair is most adequate n if extratemporal it shud b fascicular 2.To use fewest no. of sutures to align cut nerve ends with minimal amount of tension 1.a>of repairing severed peripheral nervesB>at the distal mastoid segment n stylom. Foramenc>advantage-so foreign suture material is placed only in outer investing sheathD>as the nerve becomes polyfascicular beyond stylom. F.
- A>most appropriate with nerves with less than 5 fasciclesb>contraindicated in cleanly severed nerves or large no. of fascicles(why??)c>
- 1.An interposition graft is used2.best optn is gr. Auricular nerve if the distance to be grafted is less than 10cms,sural used if length reqd is greater.3.than the straight line distance to be grafted since when the graft is placed in the gap it shud form an s or c n shud never form a straight line(why) Relative indications for nerve resection High grade malignant tumors Malignant tumors of parotid gland Malignant tumors presenting with facial palsy Relative indications for preserving facial nerve Benign tumors & cysts Early low grade malignant tumors Commonly used grafts are Greater Auricular, Sural, Cervical Plexus & Lateral femoral cutaneous nerves Graft should lie in healthy, well vascularised area Care to be taken to leave epineurium intact Approximation done with 10-0 nylon sutures Soft silicone cylinder is placed around it
- (only say the lines that r numbered)1.Sural n. diam. Is good n matches that of facial n. n upto 40 cm can b harvested.FORMATION(DON’T SAY)-union of medial sural cutaneus nerve(comes from tibial nerve from poplitial fossa) n lateral sural cutaneous br. Of peronial nerve. Why can v take such a big part from the sural nerve?-the nerve runs deep to muscular fascia for variable distance down the posterior calf n then pierces the facia to lie in close assoc. with cefanus vein at the lateral malleolus.it is here that the nerve divides into branches to supply skin of foot. The nerve is devoid of branches till it reaches here.
- A longitudinal incisn made 2/3rd of the way ant. From achilles tendon to the lateral malleolus.the nerve is found ant. And deep to lesser sephanous vein.once it is found,atraumatic dissectn is done with skin incisn gradually lengthened so that v follow the proximal course of the nerve.the nerve is cut as shrply as possible to avoid injury to the ends of the graft.wound closed in 2 layers.
- 1)Transected buccal divisn of normal side n routing the sural n. graft subcutaneously under the lip into the stump of the facial nerve on paralysed side. 2)Used dual grafts –in which br. Of zygomaticus on normal side is transected n attached to zygomaticus on paralysed side while simultaneously the buccal div. on normal side is grafted to mar. mand. Div. on paralysed side 3)Used 4 separate grafts from div. of temporal,zyg.,buccal n marg. Mand. Divisions of the normal side to the corresponding individual br. On paralysed side 4)BAKER N CONLEY-The entire lower div. of the nerve including the marg. Mand. N cervical br. On the normal side is grafted to the main trunk on the paralysed side.
- 3 types-1>facial-facial2>hypoglossal-facial3>spinal accessory-facial.When there is irreversible damage to facial nerve ;direct nerve suturing or grafting is not possible ; but muscles are still functioning well Indications for nerve crossovers-1>Radical resection of temporal bone2>Resection of intracranial tumors3>Ear or mastoid surgery4>Primary ablative surgery for regional cancer, when nerve grafting is not feasable Criteria-1>Intact muscle system (DON’T SAY)Advantages-1>Direct, uncomplicated technique2>Better balance of face and Little functional disability3>Closer anatomic relation with facial nerve in motor zone of cerebral cortex ACCESORY FACIAL REINNERVN not done usually due to associated trapezius muscle paralysis
- A modified Blair incision is planned in a preauricular crease coursing around the ear lobule and then into an upper neck crease
- The skin incision is made with a scalpel and carried down through the subcutaneous tissues and platysma muscle (Fig. 14.3). Care is taken to avoid division of the greater auricular nerve. and.
- An anterior flap is elevated superficial to the greater auricular nerve and the parotid fascia (Fig. 14.4).. As the flap is elevated toward the anterior aspect of the gland, the peripheral branches of the facial nerve are carefully avoided. A posterior, inferior flap is also elevated to expose the tail of the parotid
- 1.The tail of the parotid gland is dissected off of the sternocleidomastoid muscle by dissecting deep to the posterior branch of the greater auricular nerve, if preservation of this nerve is feasible based on tumor location. 2. Next,the posterior belly of the digastric muscle is exposed with further elevation of the tail of the parotid gland(Fig. 14.5). The posterior belly of the digastric muscle serves as a landmark for the facial nerve. 3. During elevation of the tail of the parotid, the integrity of the posterior facial vein also is preserved if possible. The facial nerve usually courses superficial to this vessel and division of this structure can contribute to increased venous bleeding during dissection of the gland. Occasionally some or all of the branches of the facial nerve will be found deep TO THE VEIN . 4.The preauricular space(CONTENTS?) is opened by division of the attachments of the parotid gland to the cartilaginous external auditory canal with blunt and sharp dissection. This plane of dissection exposes the tragal cartilage pointer which serves as another landmark for the facial nerve. A wide plane of dissection from the zygoma to the digastric muscle is created to facilitate exposure of the facial nerve .The gland is carefully retracted anteriorly. This exposes the operative field for identification of the facial nerve.. 5.The nerve is dissected into parotid to the level of cervicofacial n temporofacial bifurcn.the nerve is dissected proximally to stylomastoid foramen and transected.
- 1.Hypoglossal n. located in the angle bw post. Belly and sternomastoid.it passes lateral to internal and external carotid arteries.the nerve is followed anteriorly beneath the digastric into the submandibular triangle and transected as far distally as possible.the hypoglossal nerve is now dissected free of surrounding tissue n reflected superiorly over post. Belly.over a rubber dam,an end to end anastomosis of proximal hypoglossal to distal facial nerve is performed.an epineureal or perineureal repair can be done.the anastomosis is secured with 8-0 or 10-0 mono filament(ethilon) sutures.
- Facia lata-deep facia of thigh Tarsorrhaphy is a surgical procedure in which the eyelids are partially sewn together to narrow the opening (i.e. palpebral fissure).Palpebral fissure is the anatomic name for the separation between the upper and lower eyelids. In the adult this measures about 10mm vertically and 30 mm horizontally. Ramsay Hunt syndrome (also termed Hunt's Syndrome and herpes zoster oticus) is a herpes zoster virus infection of the geniculate ganglion of the facial nerve. Ramsay Hunt syndrome results in paralysis of the facial muscles on the same side of the face as the infection. So, the virus infects the facial nerve that normally innervates controls the muscles of the face. Ramsay Hunt syndrome is typically associated with a red rash and blisters (inflamed vesicles or tiny water-filled sacks in the skin) in or around the ear and eardrum and sometimes on the roof of the mouth or tongue. Raynaud's phenomenon (pronounced /reɪˈnoʊz/, us dict: rā·nōz′) is a vasospastic disorder causing discoloration of the fingers, toes, and occasionally other areas. This condition can also cause nails to become brittle with longitudinal ridges. Named for French physician Maurice Raynaud(1834–1881), the phenomenon is believed to be the result of vasospasms that decrease blood supply to the respective regions. Emotional stress and cold are classic triggers of the phenomenon. NUCLEII-Arise from 4 nuclei situated in lower pons1)Motor nucleus2)Sup. Salivatory3) Lacrimatory4)Nucleus of tractus solitarius(MSLN) LID LOADING-IN FACIAL PALSY PT UNABLE TO CLOSE EYELID.SO WEIGHT PLACED ON THE UPPER LID TO AID IN CLOSURE-MATERIALS USED-STAINLESS STEEL,GOLD & PLATINUM TECHNIQUE:Incision in the supratarsal crease Subcutaneous pocket Insert weight Close skin HYPERACUSIS:DAMAGE TO THE STAPEDIAL BRANCH OF FACIAL NERVE OR EFFERNT PART OF AUDITORY NERVE.EVEN NORMAL SOUNDS APPEAR LOUD TO PATIENT