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 - 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 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 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 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 Adenoid Cystic Ca - 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 Adenoid Cystic Ca - Normal Variants Smoker Glomus Jugulare Peripheral Facial Nerve Palsy: Peripheral Facial Nerve Palsy: • 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