Facial Palsy Flashcards by laura Capelle

Muscles of facial expression and Stapedius are innervated by what special CN7 subgroup? a. General Somatic Afferent b. General Visceral Efferent c. Special Visceral Afferent d. Special Visceral Efferent

d. Special Visceral Efferent (Facial n./ motor nucleus

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Sensory cutaneous, External auditory meatus and the back of the ear are innervated by what special CN7 subgroup? a. General Somatic Afferent b. General Visceral Efferent c. Special Visceral Afferent d. Special Visceral Efferent

a. General Somatic afferent (interm n.)

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Taste of anterior 2/3 of the tongue (chorda tympani) is innervated by what special CN7 subgroup? a. General Somatic Afferent b. General Visceral Efferent c. Special Visceral Afferent d. Special Visceral Efferent

c. Special Visceral Afferent (interm n./solitary nucleus)

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What innervates the Parasympathetic system of CN7 subtype? a. General Somatic Afferent b. General Visceral Efferent c. Special Visceral Afferent d. Special Visceral Efferent

b. General Visceral Efferent (interm n./salvatory nucleus)

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What are the 5 branches of he visceral efferent or terminal motor branches of the facial nerve?

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What type of pathway has the following characteristics:

incased in bone (either the fallopian or facial canal)
Have salivatory sensory
Exit cranial cavity via internal auditory meatus
Combined version of CN7 through tortuous facial canal
Geniculate Ganglion is involved
Exit occurs via stylomastoid foramen?

Intracranial Pathway

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The extracranial pathway is located, distal or proximal, to the stylomastoid foramen?

Distal

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True or False. Since the extracranial pathway, motor root, passes through the parotid gland, does it also innervate it too?

False.

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What are two major structures that the CN7 intermediate nerve will emerge from?

Facial motor root and CN8

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What are the two major functions of Visceral efferent of CN7 intermediate nerve?

Parasympathetic regulation of lacrimal and salivary system

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What are the two major functions of Visceral afferent of CN7 intermediate nerve?

Anterior toungue taste and Somatsensory distribution

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What can be affected by lesions along the CN7 pathway?

Facial muscles of expression + stapedius
Blink reflex
Salivation
Lacrimation
Tear drainage
Taste
Auditory
Cutaneous sensory

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What is the clinical work up protocol for Facial Paralysis?

History (viral prodome)

Ear (mass or vesicles –> may have ear pain due to external canal

Additional CN assessment (CN5,6,8 –> in the area of CN7)

Taste: Bitter or sweet anterior 2/3 tongue affected side

Facial motor weakness

Parotid mass

and

Schirmer’s Test

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What anatomical areas or structures are you observing when examing superior group?

Eyebrows, Forehead, Scalp, and Ears

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What anatomical areas or structures are you observing when examing inferior group?

Smiling, lips, note flattening of nasolabial fold

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What anatomical areas or structures are you observing when examing intermediate group?

tightly squeezing eyelids and ectropion

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Where the numbers are listed, name the type lesion that can occur?

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Supranuclear
Cerebellopontine angle
Ramsay-Hunt
Isolated ipsilateral tear deficiency
and 6. Bell’s palsy (total facial palsy)
Partial facial palsy per affected distal branches

Contralateral “voluntary” paralysis of lower 2/3 of face means that there is a supranuclear lesion. What pathway has been affected?

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Corticobulbar pathway

Signs/Symptoms:
a) Preserved frontalis volitional function because of “dual supply” to each CN VII motor nucleus from R and L corticobulbar tract.

b) Ipsilateral mostly innervates upper facial m.
c) Lesser preservation of o.o. function
d) Preserved taste, lacrimation, salivation
e) Rarely occur in isolation
f) May have ipsilateral hemiparesis

What type of pathway will cause dissociation of voluntary and mimetic (emotional) response?

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Supranuclear

What are the 4 possible etiologies of a Supranuclear lesion?

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a. Vascular (stroke)
b. Trauma
c. Neoplasm
- Look for VI n palsy (uni- or bi-lateral) resulting from elevated ICP
d. Infection

With the following signs, what type of lesion is this?

a. Upper and lower facial paralysis
b. Preserved taste & secretory
c. Ipsilateral VI n involved & other CN likely
d. May have contralateral hemiparesis of extremities

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Nuclear lesion

What is the most common etiology for Nuclear lesion ?

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Vascular

most common – basilar and vertebral a. branches

What are the signs of Ramsey-Hunt?

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Facial paralysis
Loss of taste, secretory
Hearing loss, tinnitus
Vertigo

Where does the lesion occur with Cerebellopontine Angle?

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Pre geniculate - before it exits the ear

What are the signs of cerebellopontine angle?

-Total ipsilateral facial weakness -Facial pain and twitching w/absent tearing, hyperacusis, loss of taste -Can associate w/ CN V, VI, VIII, Horner’s, gaze palsy, nystagmus, papilledema, cerebellar dysfunction

The following signs display what type of lesion? - Complete ipsilateral facial paralysis, hyperacusis, impaired secretory functions - Definite loss of taste anterior 2/3 - Impaired ipsilateral lacrimation (measure w/ Schirmer’s) - Knocks out all visceral afferent and parasympathetic - Complete lesion here produces permanent loss of taste and sensory - Preganglionic fibers can regenerate aberrantly -Crocodile tears

Lesion proximal to geniculate ganglion

With the following signs, where has this lesion occurred? - Complete ipsilateral facial paralysis PLUS - Possible hyperacusis - Possible impaired salivary function - Preganglionic parasympathetics - Often ipsilateral loss of taste anterior 2/3 - Special visceral afferents

Lesion distal to geniculate g. & pre stylomastoid foramen

The most common cause of facial paralysis is?

Bell's Palsy

What type of lesion is this?

Bell's Palsy

What are the peipheral lesions of Bell's Palsy?

Complete ipsilateral VII weakness No other associated CNS deficits Epiphora vs dry? Droopy lid vs widened fissure? Rarely: pain in ear canal Progresses over 2-10 days Absent corneal reflex but intact sensation May have widened palpebral fissures

What are the signs/symptoms and associated issues of cerebellopontine angle?

-Total ipsilateral facial weakness w/absent tearing, hyperacusis, loss of taste -Can associate w/ CN V, VI, VIII, Horner’s, gaze palsy, nystagmus, papilledema, cerebellar dysfunction

lesion at bend of facial canal & proximal to geniculate ganglion (parasymp via greater petrosal n) will show an absence in?

Reflex tearing

A lesion distal to bend of facial canal & geniculate g will POSSIBLY cause what issue?

Hyperacusis (absent stapedius reflex)

Absent of taste leads to what type of lesion?

Chorda tympani - mid facial lesion

What are the signs of Idiopathic CN7 palsy?

- Can have all the signs of infranuclear lesion - 40,000 Americans yearly - Gender female=male - Age 15-60 yo - More common in diabetics & recent URI

What is the course and prognosis of facial palsy?

1) Spontaneous resolution (90%) over 1-3 months }No tx for incomplete non-progressive dz }MRI if not resolving by 3 months 2)For complete paralysis: Steroids may speed resolution Prednisone 60mg po qd 4d, taper over 10d to 5mg Surgical decompression controversial. 3) Incomplete resolution possible (no test to predict) Synkinesis – simultaneous contracture of facial muscles Asynchronous contracture of facial muscles 4) Aberrant regeneration Crocodile tears Blinking with mouth movement

Lesion at the Vidian n. will show what deficiency?

Ipsilateral tear deficiency Note: Associated with CN6, if with Cavernous Sinus

What are the signs and symptoms of Guillian Barre?

1) Autoimmune polyneuropathy Progress over days to weeks Following infection (GI campylobacter most common) Lower motor weakness early Facial involvement 50% (uni or bilateral) 2) Ophthalmoplegia (CN III, IV, VI) w/ ptosis 3) Optic neuritis maybe

What are two issues are associated with CN7 spasm?

1)Facial myokymia Eyelid involvement frequent Hemifacial spasm –often start with eye Pontine disorder; vascular compression of VII Tx if benign: clonazepam, botox, surgical isolation of VII 2)Blepharospasm Bilateral contraction of o.o. Age 60-70 Female:male 3:1 Disorder of basal ganglion?

What is the treatment for CN7 spasm?

Tx clonazepam, botox, surgical CN VII resection

If there is a lesion at the extrapyramidal lesion (basal ganglia), what are the consequences?

Mimetic paralysis with preserved voluntary movement. Slide 20

Facial Palsy Flashcards

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