Facial Paralysis: Objectives: • Discuss the Anatomy of the Facial Nerve

Facial Paralysis: Objectives: • Discuss the anatomy of the facial nerve

• Look at common patterns of facial nerve palsy

• Discuss imaging appearance of lesions that lead to facial paralysis.

Lindell R. Gentry, M.D.

Facial Nerve Anatomy: Facial Nerve Anatomy:

Facial Nerve Anatomy: Facial Nerve Anatomy: Facial Nerve Anatomy: Facial Nerve Anatomy:

Motor Root Branchial Motor (Main Facial Nerve)

- Muscles of facial expression Sensory Root Greater Superficial Petrosal Nerve Greater Petrosal Nerve Facial Nerve - Autonomic (parasympathetic)

Chorda Tympani Nerve Nerve to Stapedius - Taste to anterior 2/3 tongue

Posterior Auricular Nerve Chorda Tympani - Periauricular region

Muscles of Facial Expression

Facial Nerve: Symptoms Facial Nerve: Symptoms

• Loss of Function • Facial Weakness (Muscles of Facial Expression) – Central Facial Palsy – Peripheral Facial Palsy • Loss of Taste – Anterior 2/3 of the tongue • Hyperactive Function • Hyperacusis – Hemifacial Spasm • Loss of Lacrimation

Facial Nerve Palsy: Location Facial Nerve Palsy: Location Central Palsy Central Facial Palsy Peripheral Facial Palsy 1. Suprabulbar - Supranuclear – Sparing of the upper face Optimal imaging workup: 2. Brainstem - depends on location of offending lesion – Other CN Palsies (CN 5-6) - depends on pathology – May or may not spare upper face - depends on acuity Peripheral Palsy 1. Intratemporal – Loss of lacrimation – Hyperacusis – Loss of taste to anterior 2/3 of tongue 2. Intraparotid – Pure motor Facial Nerve Palsy: Location Facial Nerve Palsy: Location Central Palsy Central Palsy 1. Suprabulbar - Supranuclear 1. Suprabulbar - Supranuclear – Sparing of the upper face – Sparing of the upper face 2. Brainstem 2. Brainstem – Other CN Palsies (CN 5-6) – Other CN Palsies (CN 5-6) – May or may not spare upper face – May or may not spare upper face

Peripheral Palsy Peripheral Palsy Lymphoma 1. Intratemporal 1. Intratemporal – Loss of lacrimation – Loss of lacrimation – Hyperacusis – Hyperacusis – Loss of taste to anterior 2/3 of tongue – Loss of taste to anterior 2/3 of tongue 2. Intraparotid 2. Intraparotid – Pure motor – Pure motor

Left Facial Palsy with Sparing of the Upper Face 6th and 7th CN Palsy

Facial Nerve Palsy: Location Facial Nerve Palsy: Location Central Palsy Central Palsy 1. Suprabulbar - Supranuclear 1. Suprabulbar - Supranuclear – Sparing of the upper face – Sparing of the upper face 2. Brainstem 2. Brainstem – Other CN Palsies (CN 5-6) – Other CN Palsies (CN 5-6) – May or may not spare upper face – May or may not spare upper face

Peripheral Palsy 57 Y/O diabetic with HA, hearing loss, facial pain and lower facial palsy Peripheral Palsy 1. Intratemporal 1. Intratemporal – Loss of lacrimation – Loss of lacrimation – Hyperacusis – Hyperacusis – Loss of taste to anterior 2/3 of tongue – Loss of taste to anterior 2/3 of tongue 2. Intraparotid 2. Intraparotid – Pure motor – Pure motor

Meningoencephalitis Parotid Adeno Ca

Facial Nerve Palsy: Location Peripheral Facial Nerve Palsy: Central Palsy • Neoplasm 1. Suprabulbar - Supranuclear - Primary – Sparing of the upper face - Metastasis - Meningeal - Perineural Spread (H&N) 2. Brainstem - Vascular – Other CN Palsies (CN 5-6) – May or may not spare upper face • Infection-Inflammatory Peripheral Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus 1. Intratemporal - Mastoiditis - Cholesteatoma – Loss of lacrimation – Hyperacusis - Other – Loss of taste to anterior 2/3 of tongue • Trauma 2. Intraparotid – Pure motor • Other - Normal Variants CN 7 Schwannoma CN 7 Schwannoma Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants CN 7 Schwannoma CN 7 Schwannoma

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants CN 7 Schwannoma CN 7 Schwannoma Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal V2 V1 V2 - Perineural Spread (H&N) - Perineural Spread (H&N) V2 - Vascular - Vascular V3 • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma V3 V3 CN 7 • Other Courtesy of Michelle Michel CN 7 Schwannoma • Other CN 7

- Normal Variants - Normal Variants Auriculotemporal Nerve Plexiform Neurofibroma

• Other • Other Nasopharyngeal SCCA - Normal Variants CPA Meningioma - Normal Variants

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants Smoker Smoker Renal Cell Met Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants “Dropped” Metastasis SCCA of Cheek

• Neoplasm Progressive facial paralysis secondary to a rare temporal bone tumor: Glomus faciale. • Neoplasm - Primary Parker, NP & Huang, TC. Archives of Oto- HNS, 137:712-715. DOI: 10.1001/archoto.2011.96- - Primary a - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants Glomus Faciale - Normal Variants Intraosseous Venous Malformation

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary Idiopathic - Primary Demographics - Metastasis - Meningeal - Metastasis - Meningeal - Very common cause of facial paralysis - Bell’s Palsy - Perineural Spread (H&N) - Perineural Spread (H&N) - Afflicting 1 in 65 individuals - Vascular - Other Viral - Vascular - More common (elderly, DM, pregnancy, immunosuppressed) • Infection-Inflammatory Specific • Infection-Inflammatory Etiology - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Viral prodrome (60%) - Herpes Zoster Oticus - Bacterial (strep, H Flu, staph, pseudomonas) - Herpes Zoster Oticus - Unknown, probably viral (HSV 1) - Mastoiditis - Cholesteatoma - Spirochete (syphilis, Lyme) - Mastoiditis - Cholesteatoma - Other - Other - Fungal (blastomycosis, mucormycosis, aspergillosis) Features - Abrupt, isolated, unilateral, paralysis entire face - Viral (herpes zoster) • Trauma • Trauma - Hyperacusis, decreased tearing, dysgeusia - TB • Other • Other - Symptoms peak within days - No imaging required with these typical features - Normal Variants - Normal Variants

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm Imaging - Primary - Primary – Herpetic (Bell’s) Palsy is a clinical diagnosis - Metastasis - Meningeal - Metastasis - Meningeal – Imaging only required in atypical presentations - Perineural Spread (H&N) - Perineural Spread (H&N) – MRI to exclude other causes (CVA, neoplasm, TB infection) - Vascular - Vascular Treatment – Observation • Infection-Inflammatory • Infection-Inflammatory – Nerve regenerates at 1-2 millimeters per day - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy – Steroids, antivirals may slightly improve outcome - Herpes Zoster Oticus - Herpes Zoster Oticus – Surgical decompression controversial - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma Prognosis - Other - Other – Recovery = 85% Full recovery = 10% Partial deficit • Trauma • Trauma = 5% Complete deficit – Duration = 50% few months • Other • Other = 35% within a year - Normal Variants - Normal Variants Herpetic (Bell’s) Palsy – Recurrence = 10 - 20% Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants Herpetic (Bell’s) Palsy Herpetic (Bell’s) Palsy

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary Background - Primary Role of Imaging - Metastasis - Meningeal – J. Ramsay Hunt (1907) - Metastasis - Meningeal – Limited - Perineural Spread (H&N) - Perineural Spread (H&N) – Exclude other lesions - Vascular Clinical Triad - Vascular – Otalgia (+/- before paralysis) CN 7 Enhancement • Infection-Inflammatory – Facial paralysis • Infection-Inflammatory – Geniculate ganglion – Herpetic eruptions - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy – Labyrinthine segment facial nerve - Herpes Zoster Oticus - Herpes Zoster Oticus – IAC meninges - Mastoiditis - Cholesteatoma Etiology - Mastoiditis - Cholesteatoma – Degree enhancement not prognostic - Other – Varicella zoster (HV-3) - Other – Peri-auricular soft tissue edema > Bell’s • Trauma Features • Trauma – CN 8 dysfunction (> Bell’s) Treatment • Other – Vertigo, hearing loss, tinnitus • Other – IV acyclovir and steroids – Peri-auricular edema - Normal Variants - Normal Variants – No role for nerve decompression – < 50% complete recovery

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants Acute Pre-eruption Phase Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants Cholesteatoma Cholesteatoma

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants Blastomycosis Wegener’s Granulomatosis Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm Incidence • Neoplasm - Primary – Intralabyrinthine Fxs 30- 50% - Primary - Metastasis - Meningeal – Extralabyrinthine Fxs 10- 20% - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular Location of Injury - Vascular • Infection-Inflammatory – Perigeniculate 80% • Infection-Inflammatory - Herpetic (Bell’s) Palsy – Proximal mastoid 12% - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus – Multiple sites 20% - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other Etiology - Other • Trauma – Bony spicules 46% • Trauma • Other – Contusion / edema 36% • Other – Transection 9% - Normal Variants - Normal Variants – Intraneural hematoma 9%

Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • Neoplasm • Neoplasm - Primary - Primary - Metastasis - Meningeal - Metastasis - Meningeal - Perineural Spread (H&N) - Perineural Spread (H&N) - Vascular - Vascular • Infection-Inflammatory • Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Mastoiditis - Cholesteatoma - Other - Other • Trauma • Trauma • Other • Other - Normal Variants - Normal Variants Peripheral Facial Nerve Palsy: Objectives: • Neoplasm - Primary - Metastasis - Meningeal • Reviewed the anatomy of the facial nerve - Perineural Spread (H&N) - Vascular • Infection-Inflammatory - Herpetic (Bell’s) Palsy • Looked at common patterns of facial nerve palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other • Trauma • Discuss imaging appearance of common and • Other - Normal Variants uncommon lesions that lead to facial paralysis. Facial Nerve Prolapse

Facial Paralysis:

Central Facial Palsy Peripheral Facial Palsy

Lindell R. Gentry, M.D.