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ENT Specialties MAIN > Facial Nerve > Flashcards

Facial Nerve Flashcards

1
Q

How long does it take for tOO% Wallerian degeneration to occur after a compressive conduction block

A

14 - 21 days.

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2
Q

Defects greater than ___ cannot be rerouted and require cable grafting

A

15 - 17 mm.

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3
Q

What is Sutherland’s classification for nerve injury

A

1st degree: reversible conduction block. 2”d degree: Wallerian degeneration occurs but endoneurium stays intact and recovery is usually complete. Yd degree: endoneurium is destroyed but perineurium stays intact and recovery is incomplete. 4th degree: all is destroyed except for the epineurium; recovery is poor. 5th degree: complete nerve transection; untreated recovery is not expected.

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4
Q

Where on the lid is the implant placed

A

2 mm above the lash line.

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5
Q

What % of patients with Ramsay Hunt syndrome have Vlllth nerve involvement

A

20%.

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6
Q

What % of patients with Lyme disease have facial nerve paralysis as the sole manifestation

A

20%.

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7
Q

How long does it take for 100°/o Wallerian degeneration to occur after complete nerve transection

A

3 - 5 days.

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8
Q

What is the incidence of diabetes mellitus in patients with recurrent Bell’s palsy

A

31%.

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9
Q

What is the incidence of facial palsy as the presenting symptom of tuberculous mastoiditis

A

39%.

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10
Q

What is the minimal time for functional return of the facial nerve after anastomosis or grafting

A

4 - 6 months.

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11
Q

What is the outcome of these patients who are treated with steroids alone

A

42% have a good outcome.

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12
Q

After microneurovascular muscle transfer, what is the maximum muscle power attainable compared to normal

A

55%.

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13
Q

What is the incidence of recurrent facial palsy

A

5-7%.

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14
Q

Between which days after injury is the degree of axonotmesis and neurotmesis unclear

A

6 - 14.

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15
Q

What is the mean interval to the 1st recurrence

A

9.8 years.

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16
Q

What is the outcome of patients with Bell’s palsy who have 90% or more degeneration on ENoG within the 1st 14 days of onset and undergo decompression

A

91 % have a good outcome (House I or II) 7 months after paralysis.

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17
Q

What is the cog

A

A ridge of bone that extends inferiorly from the tegmen epitympanum and partially separates the anterior epitympanic compartment from the mesoepitympanum.

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18
Q

What causes hemifacial spasm

A

A vascular loop, most commonly of the anterior or posterior inferior cerebellar artery, impinging on the root of VI I.

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19
Q

What is the most commonly proposed theory of the etiology of Bell’s palsy

A

Activation of a latent virus present within the geniculate ganglion leading to entrapment, ischemia, and degeneration of the labyrinthine segment of VII.

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20
Q

What is the recommended treatment for Ramsay Hunt syndrome

A

Acyclovir 800 mg five times a day x I 0 days and prednisone taper x 14 days.

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21
Q

What is Tangier’s disease

A

Autosomal recessive disorder of lipid metabolism characterized by low apolipoprotein A-1 and H DL levels. Clinical features include facial diplegia, neuropathy, and coronary artery disease.

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22
Q

Which of these result in Wallerian degeneration

A

Axonotmesis and neurotmesis.

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23
Q

What is the initial treatment for hemifacial spasm

A

Baclofen.

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24
Q

When is ENoG evaluation meaningful

A

Between days 3 and 21 after complete loss of voluntary function.

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25
Q

What happens if the implant is placed too deep

A

Can damage the levator muscle, causing ptosis.

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26
Q

What are the surgical landmarks for the tympanic segment of VII

A

Cochleariform process, oval window, pyramidal process, semicanal for the tensor tympani, vertical groove on promontory for the tympanic nerve.

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27
Q

What is the outcome of Bell’s palsy left untreated

A

Complete recovery in 71 %; permanent diminished function in I 6%; poorer prognosis if>60 years of age and if onset of recovery >3 months after initial onset of paralysis.

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28
Q

How can dynamic rehabilitation be achieved in a patient with a 1 0-year history of facial paralysis following radical parotidectomy

A

Crossfacial nerve graft plus microneurovascular muscle transfer.

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29
Q

What factors increase the risk of recurrent Bell’s palsy

A

Diabetes mellitus and family history.

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30
Q

Which methods of facial nerve reconstruction have the potential for spontaneous emotional response

A

Direct anastomosis and cable grafting.

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31
Q

What electrophysiologic test is more useful 3 weeks after the onset of complete facial paralysis

A

EMG.

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32
Q

What is the narrowest intratemporal portion of the fallopian canal

A

Entrance to the fallopian canal at the lateral aspect of the lAC (fundus).

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33
Q

Which anastomotic technique is preferred by most surgeons

A

Epineural anastomosis using 3 - 8 sutures of 8-0 or I 0-0 synthetic monofilament suture.

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34
Q

What is Heerfordt’s syndrome

A

Facial nerve palsy with anterior uveitis, parotid gland enlargement, and fever.

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35
Q

T/F: Addition of acyclovir to prednisone for treatment of Bell’s palsy has not been shown to result in significant improvement of facial nerve function

A

False.

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36
Q

T/F: Evidence of viral etiology for Bell’s palsy is well documented

A

False.

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37
Q

T /F: There is a consistent topographic representation of fibers from a specific section of a nerve innervating certain parts of the face.

A

False.

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38
Q

What sort of EMG pattern is associated with nerve degeneration

A

Fibrillation potentials.

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39
Q

What is the most common cause of unilateral facial palsy in a newborn infant

A

Forceps delivery.

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40
Q

When the facial nerve is sacrificed, what must be done prior to reconstruction

A

Frozen section confirmation of negative nerve margins.

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41
Q

What are the limits of the tympanic segment of VII

A

Geniculate ganglion to the 2nd genu (adjacent to the pyramidal process).

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42
Q

What organisms are most often associated with facial palsy due to chronic otitis media

A

Gram-negative organisms and Staphylococcus aureus.

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43
Q

Which of these is used most often

A

Greater auricular nerve.

44
Q

How is the facial nerve identified using the tympanic nerve

A

Groove for the tympanic nerve is followed superiorly to the cochleariform process.

45
Q

What is the advantage of the microneurovascular muscle transfer over the temporalis muscle sling in the treatment of facial paralysis

A

Has the potential to restore spontaneous muscle expressions.

46
Q

What viruses are most commonly implicated in the etiology of Bell’s palsy

A

Herpes simplex and herpes zoster viruses.

47
Q

What is the best functional outcome of cable grafting

A

House grade III or IV.

48
Q

After primary anastomosis, what is the typical return of facial nerve function

A

House grade ll or II I.

49
Q

What test should be performed on Afro-Caribbean migrants with idiopathic facial nerve palsy

A

HTLV-1 antibody screen.

50
Q

What if the nerve is only partially transected

A

If greater than 1 /2 remains, reapproximate the remaining nerve and perform regional decompression. If less than 1/2 remains, remove the injured segment and repair as with complete transection.

51
Q

If a tumor-free proximal nerve stump is unavailable for nerve grafting, what method should be used for optimal functional outcome

A

If reconstruction is undertaken within 2 years of division, grafting of the proximal portion of another cranial nerve to the distal stump of the facial nerve is the next best choice.

52
Q

What is the significance of the Bell’s phenomenon prior to gold weight implantation

A

If the patient has a good Bell’s reflex, then the surgeon can be more conservative, choosing a lighter implant to avoid ptosis.

53
Q

What is the management of intraoperative facial nerve transection

A

Immediate repair with primary anastomosis if possible.

54
Q

What are negative prognostic factors for Ramsay Hunt syndrome

A

Increased age and a simultaneous onset of paralysis with vesicular eruption.

55
Q

What are the complications of gold weight implantation

A

Induced astigmatism, ptosis, migration, extrusion, persistent inflammation.

56
Q

What is the relationship of the 2”ct genu of the facial nerve to the lateral semicircular canal and short process of the incus

A

Inferior to the lateral semicircular canal and medial to the short process of the • lOCUS.

57
Q

Which cranial nerve is most often grafted to the distal facial nerve

A

Ipsilateral hypoglossal.

58
Q

What is the primary drawback of hypoglossal-facial nerve grafting

A

Ipsilateral tongue paralysis.

59
Q

What is the advantage of the dorsal radial cutaneous nerve

A

It branches as it approaches the wrist, making distal separation into bundles for facial nerve branch anastomosis easier.

60
Q

What are the landmarks of the tympanic segment of VII from the mastoid approach

A

Lateral SCC and the cog.

61
Q

What are the surgical landmarks for VII in its mastoid segment

A

Lateral SCC, fossa incudis, and the digastric ridge.

62
Q

What is the next most accurate test when ENoG is unavailable

A

Maximal stimulation test.

63
Q

What is the relationship of VII to the lateral SCC and the fossa incudis

A

Medial to the fossa incudis and inferior to the lateral canal.

64
Q

The triad of recurrent facial palsy, oro facial edema, and lingua plicata is classic for what disease

A

Melkersson-Rosenthal syndrome (orofacial granulomatosis).

65
Q

What is the procedure of choice for patients with hemifacial spasm

A

Microvascular decompression.

66
Q

What are other indications for free muscle transposition surgery for facial reanimation

A

Mobius syndrome or destruction of muscles secondary to trauma.

67
Q

Where is the facial nerve most commonly injured during mastoid surgery

A

Near the 2”d genu as it enters the mastoid cavity.

68
Q

What are the indications for surgical exploration of the facial nerve following temporal bone trauma

A

NET >3.5 rnA side-to-side threshold differences or ENoG >90% degeneration.

69
Q

What are the 3 types of nerve injury

A

Neuropraxia, axonotmesis, and neurotmesis.

70
Q

Which of these has a more rapid rate of Wallerian degeneration

A

Neurotmesis.

71
Q

What should be done if motor unit potentials are detected on EMG

A

No further therapy is indicated.

72
Q

What is a major contraindication to this procedure

A

Paralysis of 1 X or X.

73
Q

What prognostic information does ENoG provide

A

Patients with 95% degeneration or greater have a 50% chance of unfavorable recovery; if at least I 0% function is retained in the I st 21 days of paralysis, 80 - I OO% functional recovery is highly likely.

74
Q

What is the most common area of facial nerve injury following trauma

A

Perigenicular area.

75
Q

What sort of EMG pattern is associated with nerve regeneration

A

Polyphasic action potentials.

76
Q

Where are intracranial lesions that cause bilateral facial paralysis located

A

Pons.

77
Q

Where does the facial nerve lie in relation to the cochleariform process

A

Posterosuperior.

78
Q

What are the limits of the mastoid segment of VII

A

Pyramidal process to the stylomastoid foramen.

79
Q

What differentiates herpes zoster oticus from Ramsay Hunt syndrome

A

Ramsay Hunt syndrome is herpes zoster oticus + facial nerve paralysis.

80
Q

Which etiology of facial nerve palsy has a worse prognosis: Bell’s palsy or Ramsay Hunt syndrome

A

Ramsay Hunt syndrome.

81
Q

What is the most likely cause of bilateral facial palsy in a young adult

A

Sarcoidosis.

82
Q

What is lingua plicata

A

Scrotal tongue.

83
Q

What is the relation of the lateral SCC to the fossa incudis

A

Short crus of the incus is inferolateral to the lateral SCC; the fossa incudis is at the tip of the short crus.

84
Q

What is the outcome of these patients who undergo surgical decompression >14 days after injury

A

Similar outcome as patients treated with steroids.

85
Q

What are some other options for improvement of function after facial paralysis

A

Static fascial slings, dynamic muscle slings, free muscle transfers, gold weight upper lid implants, lid-tightening procedures, brow lift.

86
Q

Which reconstructive options restore facial nerve function most quickly

A

Static slings, gold weights, tarsorrhaphies.

87
Q

Into which plane is a gold weight placed

A

Suborbicularis.

88
Q

Which approach is best in patients with normal hearing

A

Supralabyrinthine approach.

89
Q

Which of these can provide the most length

A

Sural nerve (35 em).

90
Q

What are some possible nerves used for cable grafting

A

Sural, greater auricular, dorsal radial cutaneous, supraclavicular nerves.

91
Q

What is a jump graft

A

The greater auricular nerve is sutured end-to-side to XII and end-to-side to the distal facial nerve.

92
Q

Why must the dose of acyclovir be larger for patients with varicella zoster virus (VZV)

A

The thymidine kinase of VZV is much less sensitive to acyclovir than the herpes simplex virus.

93
Q

What is the most accurate predictor of poor recovery of facial nerve function following injury

A

Total paralysis of immediate onset.

94
Q

T/F: Enhancement of the facial nerve is commonly seen on MRI of patients with Bell’s palsy and is likely to resolve in 2 - 4 months

A

True.

95
Q

T/F: Evidence of viral etiology for Ramsay Hunt syndrome is well documented

A

True.

96
Q

T/F: Primary anastomosis after rerouting generally leads to a better functional outcome than cable grafting

A

True.

97
Q

T/F: No improvement in functional outcome has been demonstrated with the use of tubes or conduits in facial nerve anastomosis or grafting

A

True.

98
Q

T /F: Postoperative radiation does not significantly affect the outcome after facial nerve grafting.

A

True.

99
Q

What if primary anastomosis is not possible

A

Use a cable graft with great auricular nerve as the donor.

100
Q

What can be done to ameliorate this problem

A

Use of a mid-tongue Z-plasty~ use of only part of the hypoglossal nerve (jump graft); reinnervation of the hypoglossal nerve with the ansa cervicalis.

101
Q

Branches of the facial nerve anterior to ____ do not require reconstruction for return of function.

A

Vertical line from lateral canthus.

102
Q

What is the relationship of the tympanic portion of VII to the cog

A

VII lies anterior to the cog in the floor of the anterior epitympanum.

103
Q

What test should be performed when 100°/o neural degeneration is recorded with ENoG

A

Voluntary EMG recording; regenerating nerve fibers conducting at different rates can result in an overestimation of neural degeneration on ENoG.

104
Q

How is the facial nerve identified using the semicanal for the tensor tympani

A

When followed posteriorly, its inferior border is continuous with the upper margin of the oval window and the inferior border of VII.

105
Q

What is the treatment for otogenic facial palsy in association with acute suppurative otitis media

A

Wide myringotomy, cultures, and IV antibiotics.

106
Q

Can a patient with a gold weight have an M Rl

A

Yes.

ENT Specialties MAIN (17 decks)

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