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Facial Nerve Palsy GARRETT GRIFFIN, AARON FAY, and BABAK AZIZZADEH 1

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Facial Nerve Palsy GARRETT GRIFFIN, AARON FAY, and BABAK AZIZZADEH 1 To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s), editor(s), reviewer(s), Elsevier and typesetter Toppan Best-set. It is not allowed to publish this proof online or in print. This proof copy is the copyright property of the publisher and is confidential until formal publication. AUTHOR QUERY FORM Book: Fay & Dolman Please e-mail your responses and any corrections to: Chapter: Chapter 31 E-mail: [email protected] Dear Author, Any queries or remarks that have arisen during the processing of your manuscript are listed below and are highlighted by flags in the proof. (AU indicates author queries; ED indicates editor queries; and TS/TY indicates typesetter queries.) Please check your proof carefully and answer all AU queries. 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SECTION 7: NEUROLOGIC DISORDERS c00031 31 Facial Nerve Palsy GARRETT GRIFFIN, AARON FAY, and BABAK AZIZZADEH 1 u0010 CHAPTER OUTLINE Introduction Ramsay Hunt Syndrome (Herpes Zoster u0080 u0015 Historical Background Oticus) u0020 Fundamental Science Lyme Disease u0085 u0025 Embryology Melkersson-Rosenthal Syndrome u0090 u0030 Epidemiology Bilateral Paralysis u0095 u0035 Classification of Peripheral Nerve Injury Traumatic Facial Paralysis u0100 u0040 Clinical Features Iatrogenic Injury u0105 u0045 History Sarcoidosis u0110 u0050 Physical Examination Otitis Media u0115 u0055 Facial Nerve Function Grading Scales Barotrauma u0120 u0060 Investigations Idiopathic Intracranial Hypertension u0125 u0065 Electrophysiologic Testing Facial Paralysis in Children u0130 u0070 Pathogenesis Synkinesis u0135 u0075 Bell Palsy Future Directions u0140 s0010 Introduction Fundamental Science s0020 p0145 Few ailments are as physically and psychologically debilitat- The facial nerve is a mixed nerve containing motor, p0165 ing as facial paralysis.1,2 Preventing corneal exposure and sensory and parasympathetic fibers comprising two affer- keratitis frequently becomes the first priority, requiring oph- ent (general sensory and special sensory taste) and two thalmic support early in the disease process. Thus, it is efferent (motor and parasympathetic) pathways. The path essential to understand the myriad causes of facial paraly- of the facial nerve is classically divided into six segments sis, diagnostic workup and potential medical and surgical (Table 31.1; Fig. 31.1 and Table 31.2 further illustrate the interventions. different components of this complex cranial nerve (CN).) p0150 Bell palsy is the most common cause of facial neuropathy It is important to remember that the upper motor neuron and most patients will recover with little to no sequelae. tracts destined for the upper face project to the bilateral Roughly 30% of patients with facial weakness, however, do facial motor nuclei, preserving bilateral upper facial move- not have Bell palsy.3 These patients have systemic or neo- ment (including eyelid blinking) in unilateral cerebrovascu- plastic disorders that, left untreated, could be life- lar accidents.4 threatening. The focused history and physical examination The facial nerve motor nucleus is located in the caudal p0170 can be life-saving. aspect of the ventrolateral pons. Efferent motor fibers take a circuitous path anteromedially to loop around the abdu- cens nucleus and then enter the internal auditory canal s0015 Historical Background with the cochlear and superior and inferior vestibular nerves. The mnemonic ‘7 UP over COKE’ reminds one that p0155 Greek and Roman scientists such as Hippocrates and Galen in the distal internal auditory canal, the CN VII is superior described facial spasm in their written works, but the earli- to the cochlear nerve. Motor fibers then take a sharp turn est thorough descriptions of peripheral facial palsy are posterolaterally as they pass through the geniculate gan- attributed to the Persian physicians Tabari and later glion (ganglion for taste and sensory fibers) and enter the Muhammad ibn Zakariya al-Razi. It was Razi who first middle ear space. In the middle ear, the motor nerve passes divided facial distortion into spastic and paralytic disorders, just superior to the oval window and stapes footplate. The described central and peripheral palsy and gave the first motor nerve then makes its ‘second genu’ as it leaves the description of loss of forehead wrinkling in peripheral facial middle ear to enter the mastoid bone. As the motor branch palsy. exits the stylomastoid foramen to enter the body of the p0160 Although facial palsy is relatively rare, it is common parotid gland, fibers innervate the auricular, stylohyoid, enough to have affected several well-known individuals, posterior digastric and occipitalis muscles. In the face, the including the poet Allen Ginsburg, composer Andrew Lloyd nerve arborizes extensively. Classic descriptions depict the Weber and actor George Clooney. nerve dividing into an upper and lower division at the pes Q 581 ISBN: 978-0-323-37723-2; PII: B978-0-323-37723-2.00031-1; Author: Fay & Dolman; 00031 Fay_7232_Chapter 31_main.indd 581 6/22/2016 5:42:35 PM To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s), editor(s), reviewer(s), Elsevier and typesetter Toppan Best-set. It is not allowed to publish this proof online or in print. This proof copy is the copyright property of the publisher and is confidential until formal publication. 582 SECTION 7 • Neurologic Disorders t0010 Table 31.1 Facial Nerve Segments Name Length Extent Key Components Intracranial 23 mm Brainstem to internal Contains fibers from the two afferent and two efferent nerve auditory canal (IAC) pathways. Meatal 8–10 mm Fundus of IAC to meatal In the IAC, the facial nerve runs superior to the cochlear nerve and foramen anterior to the superior vestibular nerve. Meatal foramen is the narrowest portion of the Fallopian canal and is felt to be the site at which nerve edema may cause Bell palsy. Labyrinthine 3–5 mm Meatal foramen to Gives off the greater superficial petrosal nerve (preganglionic geniculate ganglion parasympathetic fibers causing lacrimation and salivation). The geniculate ganglion contains the cell bodies of afferent general and special sensory fibers. Tympanic 8–11 mm Geniculate ganglion to The nerve passes through the middle ear space superior to the oval second genu window. Site of most injuries to the facial nerve related to temporal bone fractures. Mastoid (vertical) 10–14 mm Second genu to Gives off branches to the stapedius muscle and chorda tympani nerve stylomastoid foramen (afferent taste fibers from anterior two-thirds of tongue). Extratemporal NA Stylomastoid foramen Facial nerve innervates the stylohyoid, posterior digastric and intrinsic segment to facial muscles auricular muscles in addition to the muscles of facial expression. t0015 Table 31.2 Components of the Facial Nerve Type Component Function Efferent Branchial motor To supply the stapedius, stylohyoid, posterior digastric and muscles of facial expression, including the buccinators, platysma and occipitalis muscles. Visceral motor (general Preganglionic parasympathetic fibers passing through the greater superficial visceral efferent) petrosal nerve. Stimulates the lacrimal, submandibular and sublingual glands. Also glands within the mucous membrane of the nose and hard and soft palates. Afferent General sensory (general Sensory fibers from the skin of portions of the auricle and external auditory canal.
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