facial nerve, palsy and pain & trigeminal neuralgia
TRANSCRIPT
![Page 1: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/1.jpg)
![Page 2: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/2.jpg)
![Page 3: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/3.jpg)
Origin - Nucleus in the pons
Exit → Stylomastoid foramen
Upper part of VIIth nucleus supply upper face (principally frontalis) bilaterally
![Page 4: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/4.jpg)
Largely motor
Supplies muscles of facial expression
Chorda tympani◦ Motor fibres to the stapedius muscle◦ Sensory taste fibres from the anterior two-thirds
of the tongue
![Page 5: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/5.jpg)
![Page 6: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/6.jpg)
![Page 7: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/7.jpg)
Upper motor neuron (UMN lesions)◦ Facial Nucleus and above
Lower motor neuron (LMN) lesions◦ Below facial nucleus
![Page 8: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/8.jpg)
Upper motor neurone (UMN lesions)
Lower motor neurone (LMN) lesions
Contralateral IpsilateralLower part Entire faceFrontalis (frowning) spared Frontalis (frowning) affectedEye closure/blinking present Eye closure/blinking absentNo corneal exposure and ulceration
Corneal exposure and ulceration
Angle of the mouth falls; unilateral dribbling
Relative preservation of spontaneous emotional movement
Taste sensation is frequently also impaired
![Page 9: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/9.jpg)
UMN-◦ Cerebrovascular accident (stroke)
LMN
![Page 10: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/10.jpg)
LMN-◦ Pons
Tumours (e.g. glioma) Multiple Sclerosis Infarction
◦ Cerebellopontine angle (CPA) – V+VI+VII+VIIIA Acoustic neuroma Meningioma Metastasis Cholesteatoma
◦ Petrous temporal bone Bell’s palsy Trauma Middle ear infection Herpes zoster
![Page 11: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/11.jpg)
LMN-◦ Beyond the skull
Skull base tumours Paget’s disease of bone Parotid gland tumours Sarcoidosis Trauma.
![Page 12: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/12.jpg)
Acute isolated facial palsy Why?
?Viral infection (often herpes simplex) Lyme disease HIV seroconversion
Nerve swollen - petrous bone facial canal Unilateral LMN
![Page 13: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/13.jpg)
Evolves over 24–48 hours Taste on the tongue may be lost/altered Hyperacusis Pain behind the ear is common at onset Suspect a stroke Vague altered facial sensation Examination of facial sensation - normal.
![Page 14: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/14.jpg)
Prognosis good Recurrence unlikely Recovery-
◦ 3–8 weeks◦ At least 85%◦ Complete/near complete
![Page 15: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/15.jpg)
Eye care◦ Lubricants◦ Taping, lateral tarsorrhaphy, gold weight
Drugs◦ Steroids early◦ Prednisolone 1mg/kg/day X 7 days
![Page 16: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/16.jpg)
Rare Often less obviously apparent - no facial asymmetry Causes:
◦ Infections: Lyme (bilateral in 25% – Bannwarth’s syndrome) Viral: HIV seroconversion, EBV Mastoiditis (bilateral) Diphtheria and botulism (rare)
◦ Sarcoidosis◦ Skull base trauma and tumours◦ Pontine lesions, e.g. gliomas◦ Neuromuscular disorders:
Guillain–Barré syndrome Myasthenia Myotonic dystrophy and facioscapulohumeral dystrophy
◦ Congenital and genetic causes
![Page 17: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/17.jpg)
![Page 18: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/18.jpg)
Teeth Gums Paranasal sinuses Temporomandibular joints Jaw Eyes Neurological conditions
![Page 19: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/19.jpg)
Trigeminal◦ Autonomic cephalgias◦ Neuralgia
Migraine Carotid dissection Giant cell arteritis (temporal arteritis) Atypical facial pain (somatisation?)
![Page 20: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/20.jpg)
![Page 21: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/21.jpg)
6th and 7th decades Hypertension - main risk factor
![Page 22: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/22.jpg)
Compression At or near the pons Ectatic vascular loop High res MRI
![Page 23: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/23.jpg)
Younger patients Multiple sclerosis CP angle tumours
◦ Acoustic schwannomas◦ Meningiomas◦ Epidermoids
![Page 24: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/24.jpg)
Paroxysms pain Knife-like/electric shock-like Lasting seconds Vth nerve distribution Starts in mandibular division (V3) →
maxillary (V2) → occasionally ophthalmic divisions (V1).
![Page 25: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/25.jpg)
Bilateral ◦ Rare (3%)◦ Intrinsic brainstem pathology (demyelination)
Many times a day Trigger
◦ Trigger zones in the face◦ Washing, shaving, cold wind, chewing
![Page 26: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/26.jpg)
Drugs:-◦ Carbamazepine (600–1200 mg daily)◦ Oxcarbazepine, lamotrigine, gabapentin
Surgical:-◦ Percutaneous radiofrequency selective ablation of
the trigeminal ganglion◦ Microvascular decompression
![Page 27: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/27.jpg)
Spontaneous remissions◦ Months or years
BUT almost invariably recur
![Page 28: FACIAL NERVE, PALSY AND PAIN & TRIGEMINAL NEURALGIA](https://reader034.vdocument.in/reader034/viewer/2022050811/587ab1861a28abed218b6583/html5/thumbnails/28.jpg)