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Amy Stinson ENT PGY-2 Affinity Medical Center
Bell’s Palsy Amy Stinson ENT PGY-2 Affinity Medical Center
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Outline Anatomy Definition Differential Exam Electrophysiology
Treatment Outcome
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Anatomy: The Facial Nerve
Motor and Sensory SVA fibers: taste ant 2/3 tongue Lingual & Chorda geniculate nervous intermedius solitary nucleus SVE fibers: muscles of facial expression Facial motor nucleus stylomastoid foramen GVA fibers: parasympathetics lacrimal, palatine, parotid, submandibular, sublingual glands Sup salivatory nucleus GSPN/Sphenopalatine, lesser petrosal/otic, chorda/submandibular Sensory – concha and post auricular
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Anatomy: The Facial Nerve
Intracranial lateral for 12-14mm with CN8 to IAC Meatal 8-10mm ant/sup of IAC to meatal foramen Diameter changes from 1.2 mm to 0.68 mm Labyrinthine 2-4 mm to geniculate ganglion (GSPN exits) Tympanic First genu 11mm post/inf to 2nd genu Mastoid 12-14 mm inf (vertical seg) to SMF (chorda exits) Peripheral Pes anserus 20 mm then 5 terminal branches (upper and lower seg)
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Anatomy: The Facial Nerve
Favorite mnemonics Some Say Marry Money, But My Brother Says Big Breasts Matter More To Zanzibar By Motor Car Ten Zebras Bit My Crotch Ten Zebras Beat My Cock Today Zoe Broke My Car
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Anatomy
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Anatomy
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Bell’s Palsy Sir Charles Bell (1774-1842)
Studied facial anatomy extensively during Battle of Waterloo Concluded that facial nerve controlled facial expression “Respiratory nerve of the Face”
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Bell’s Palsy Idiopathic Facial Paralysis DIAGNOSIS OF EXCLUSION
MC Diagnosis given >60% Unilateral Rapid Onset <48hrs Not progressive!
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Bell’s Palsy 30/100,000 M = F 3.3x greater incidence in pregnancy
4-5x increased risk with DM Fam Hx 10% Recurrence rate 10%
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Bell’s Palsy - etiology
Exact etiology unknown Viral infection Herpes Simplex Vascular ischemia Autoimmune disorder Hereditary
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Bell’s Palsy Reduced Stapedial reflex 71%
Complete presentation 69% Tear flow % Post-auricular pain 52% Dysgeusia % Hyperacusis %
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Bell’s Palsy Complete Remission & Age
Peitersen E. Acta Otolaryngol 2002;549:4–30.
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Bell’s Palsy Peitersen E. Am. J. Otology. 1982
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DIAGNOSIS OF EXCLUSION
Bell’s Palsy DIAGNOSIS OF EXCLUSION
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Differential Diagnosis
Metabolic Diabetes Hypothyroidism Sarcoid Gullian Barre Autoimmune disorders Vascular Benign intracranial hypertension Neoplasm Facial neuroma Acoustic neuroma Cholesteatoma Menigioma Leukemia Metestatic Toxic Thalidomide Iatrogenic Infection Herpes Zoster Oticus (Ramsey Hunt Syndrome) Lyme disease Acute Otitis media +/- mastoiditis Malignant otitis externa TB AIDS Mono Congenital Treacher Collins syndrome Mobius syndrome Compression injury Trauma Temporal Bone fracture Barotrauma Penetration wounds, laceration, and contusions
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Differential Diagnosis
If nerve function had not returned or has gotten worse at the 6 month mark – You MUST revisit the previous list!
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History Onset Degree of paralysis Associated symptoms
Sudden, delayed, gradual Degree of paralysis Complete, incomplete Associated symptoms Numbness, otalgia, hyperacusis, diminished tearing, altered taste Intense ear pain and vesicles Sensorineural hearing loss, vertigo
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Exam Quick and dirty facial nerve exam Raise eyebrows
Tightly close eyes Wrinkle the nose Smile Pucker Grimace
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Exam Complete Head and Neck exam Special attention to otoscopy and CNs
Progressive segmental paralysis w/lesion Laceration, battle sign, hemotympanum Multiple CN deficits Compare motor function w/opposite side Bell phenomenon: visible vertical rotation of globe on closing affected eye Audiometry CT/MRI
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Pathophysiology HSV viral reactivation leading to damage of facial nerve Neuropraxia– no axonal discontinuity Axonotmesis Wallerian degeneration (distal to lesion) Axoplasmic disruption, endoneural sheaths intact Neurotmesis Axon disrupted, loss of tubules, support cells destroyed
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Electrophysiology Sunderland’s Classification Neurapraxia Axonotmesis
Neurotmesis
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Electrophysiology
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Electrophysiology Nerve Excitation test (NET)
Maximal Stimulation test (MST) Electroneurography (ENoG) Electromyography (EMG) Measure amounts of neural degeneration occurred distal to injury by measuring muscle response to electrical stimulus Able to differentiate nerve fibers undergoing Wallerian degeneration
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Treatment Observation Medical Treatment Surgery Facial Rehabilitation
Steroid Anti-viral agents Surgery Decompression Dynamic vs. static reanimation Facial Rehabilitation
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Treatment Steroid vs. Steroid + Acyclovir Double-blind RCT
99 Bell’s palsy patients 53 treated with acyclovir- prednisone 46 with placebo – prednisone Prednisone dose 400 mg five times daily x 10 days Combined therapy is better in terms of: Return of muscle motion Prevention of partial nerve degeneration
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Treatment Eye care Glasses/ Sunglasses/ avoid contact lens
Artificial tears, lacrilube Taping Gold weight to upper eyelid Opthalmologic consultation
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Treatment Surgical Decompression Middle Fossa Transmastoid
Translabyrinthine Retrolabyrinthine Retrosigmoid
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Outcome Complete Remission & Age
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Outcome Return of Muscular function 85 %
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