Facial Nerve Palsy
Dr. Abdel Hamid Deghidi
Copyright 2005 Lippincott Williams & Wilkins
Introduction:
 Facial nerve is the seventh cranial nerve which is referred to as the nerve
of facial expression. Facial nerve is a mixed nerve, having a motor root
,sensory root and automatic root
 The motor part supply the muscles of expressin of the face as well as the
other four muscles: platysma, Stapeddius, Stylohoid and posterior belly of
digastrics muscles
 The sensory part carries taste fibers from the anterior 2/3 of the tongue and
general sensation from the concha and retroauricular skin
 The autonomic part supplies the lacrimal , sublingual salivary and
submaxillary glands.
Anatomy of the motor part:
 The motor nucleus is located n the pons medial to the trigeminal nenclus
and anterior to the 6th nerve nucleus , Its upper part is bilaterally supplied
from the pyramidal tracts of both sides while the lower part is unilaterally
supplied from the pyramidal tract on the opposite side only.
 The motor fibers goes around the 6th nerve nucleus then pass laterally to
emerge the lower part of the pons
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 the nerve run laterally between the 6th and the 8th cranial nerves in the
subarachnoid space of the cerebello- pontine angle to entre the internal
autidatory meatus into the facial canal.
 The motor part of facial nerve leaves the canal through the stylomastoid
foramen, passes through the parotid gland to divide into terminal branches.
Anatomy of the sensory and autonomic parts:
In the facial canal lies the geniculate ganglion which contains unipolar cells
which divides into peripheral and central parts:
The peripheral part runs laterally and divides into greater superfical petrosal
nerve and the chorda tympani
The greater superfical petrosal form a new set of fibers gives autonomic supply
to lacrimal gland.
The chorda tympani supply sublingual salivary and submaxillary glands. and
convey sensation from the anterior 2/3 of the tongue.
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 Lesion of the Facial Nerve
 The Lesion may be:
 1- U.M.N.L affecting pyramidal tract above facial nucleus
 2- L.M.N.L affecting facial motor nucleus or the nerve itself
U.M.N.L
1. Paralysis of the muscles of lower half
of the face on the opposite side of the
lesion.
2. Paralysis involves the voluntary
movement but spare emotional and
associative movements
3. Presence of hypertonia and
hyperreflexia
4. Associated with hemiplegia on the
same side of paralysis
5. Dropping of angle of the mouth on the
affected side
6. Obliteration of naso-labial fold on
affected side
7. Inability to show the teeth on the
affected side
L.M.N.L
1. Paralysis of the muscles of
lower and upper halves of the
face of the same side of the
lesion
2. Paralysis involves the voluntary
movement, emotional and
associative movements
3. Presence of hypotonia and
hyporeflexia
4. Associated with hemiplegia on
the opposite side of paralysis
5. Inability to raise eye brow with
absence of wrinkles on the
affected side
6. Inability to close eye widened
palpebral fissure
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 Localization of the site of the lesion in L.M.N.L facial paralysis:
a. Lesion in the nucleus:
 1. paralysis of the facial muscles
 2. No impairment of salivation, Lacrimation and taste sensation
 3. paralysis of the other cranial nerve on the same side or hemiplegia on the opposite
side
b. Lesion in the cerebello- pontine angle:
1. paralysis of the facial muscles
 2. Diminished salivary, Lacrimal secretion
 3.Diminished taste sensation on the anterior 2/3 of the tongue
 4. Associated with 5th , 6th and 8th cranial nerve palsy on the same side
c. Lesion in geniculate ganglion:
1. paralysis of the facial muscles
 2. Diminished salivary, Lacrimal secretion
 3.Diminished taste sensation on the anterior 2/3 of the tongue
d. Lesion between greater superfical petrosal nerve and the chorda tympan
1. paralysis of the facial muscles
 2. Diminished salivary,
 3.Diminished taste sensation on the anterior 2/3 of the tongue
 4. No impairment of Lacrimal secretion
Copyright 2005 Lippincott Williams & Wilkins
Terminal branches of the facial nerve:
• 1- Temporal: supplies occiptio frontalies, orbicularis oclui and corrugators
• 2- Zygomatic: supplies orbicularis oclui
• 3-Buccal: procerus, Zygomaticus major. Levator labii superiors, Levator
anguli aris, Zygomaticus minor, Bucccinator and orbicularis oris and nasilas
• 4-Mandibular: risorius. Depressor albii, Depressor anguli oris and mentalis
• 5- Cervical supplies platysma
Nerve Injury and Regeneration:
Sunderland classification of the nerve injury:
Neuropraxia : reversible conduction block (1st damage)
Axonotemesis: Loss of structure continuity of the axon with intact endoneural
sheath 2nd damage
Neurotemesis:
3rd damage Loss of continuity of the axon and endoneural sheath
4th damage Loss of continuity of the axon ,sheath and funiculus
5th damage complete Loss of nerve continuity
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Degeneration: Interruption of the continuity of the axon, seperates the axon
from its metabolic source, or cell body
Presence of wallerian degeneration at distal end of the axon starts with first
24hours, Macrophages degraded the mylien sheaths
• Regeneration:
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Neuronal metabolism leads to increases in mRNA, enzymes and proteins
Axonal stump swell with axonplasm and proliferation of neurofilaments
Simple misdirection: the entry of axon into a tubule destined for a muscle
other than the one previously innervated this is called synkinesis or
associated movement
Complex misdirection: Single axon through branching innervates tubules
to different muscles this is called mass movements
• Chrocodil tear Syndrome:
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Tearing from the eyes when the patient attempts to yawn or do active facial
movement.
It occurs in some cases of facial palsy where the site of lesion before the
geniculate ganglion there is abnormal regeneration where there is cross
reinnervation between the automomic fibres of lacrimation and the motor
branch of the facial nerve
Copyright 2005 Lippincott Williams & Wilkins
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Evaluation of facial paralysis: Diagnosis can be made by histroy and some
clinical tests and examination.
Patient typically presents with sudden onset of either a parital or total
paralysis of the muscles on one side of the face, weakness, decrease
tearing abnormality of taste
Charastristcs of peripheral paralysis:
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1- At rest : less prominent wrinkles on the forehead of the affected side,
eyebrow drop, flatened nasolabial fold and drop on corner of the mouth
2-Unable to wrinkles the forehead of the affected side, raise eyebrow,
wrinkles nasolabial fold, show teeth, completely close eye
3-Bell's phenomena: is a medical sign that allows observers to notice an
upward and outward movement of the eye, when an attempt is made to
close the eyes due to contraction of superior rectus and relaxation of the
inferior rectus muscle.
Charastristcs of central paralysis:
1- Movements of frontal and upper orbicularis oculi muscles tend to be
spared
2- facial movements on the affected may be present during emotional
expression, presence of lacrimation and salivations
Copyright 2005 Lippincott Williams & Wilkins
Bell's Palsy
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Definition:
It is an acute, non supportive inflammation of facial nrrve at the stylomastoid
foremaen. It is the most common lower motor neuron lesion affecting the
seven cranial nerve with resultant paralysis of the facial musculature.
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Incidence: Bell's palsy affects 40000 American and 10000 Egyptian / year
It is common in people who have diabetes , influenza , pregnant women
Causes:
Unknown , although viral inflammatory immune reaction is commonly accepted as a
cause , Also it may be rheumatic cause which is precipitated by exposure to air
draught.
Clinical Picture:
The onset is ussually acute with pain noticed behind and in the front of the ear
One or two days later, there is flacid paralysis of facial muscles of lower motor neuron
lof the affected side.
Loss of mimetic movement of the half of the face on the same side of lesion
Face become asymmetrical at rest and movement
Patient cannot raise eye brow, unable to blow the mouth unable to close eye,
widening of palpebral fissure. Bells phenomena
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Reduced or absence of blinking or corneal reflexes leading to drying of the
cornea followed by its ulceration
Loss of habitual wrinkles, Obliteration of nasolabial fold Drooling.
Eye problems, such as excessive tearing or a dry eye.
Loss of ability to taste.
Numbness in the affected side of your face.
Increased sensitivity to sound
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Dropping of the corner of the mouth with deviation of the mouth to the affected side
Unable to smile , show teeth, Accumulation of the food on the affected side
• Prognosis:
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Complete recovery usually occur when return of the facial functions begin between
10 and 21 days after onset of paralysis
If return appears after 3 weeks but before 2 months recovery will be possible
Stages of Bell's Palsy:
1- Acute stage: From onset of paralysis till two weeks(after subsidence of pain)
2-Recovery stage: start after acute stage and continue till 17 to 18 months and may
extend to two years
3- Chronic stage : after two years where is little hope of recovery
Copyright 2005 Lippincott Williams & Wilkins
• Physical therapy assessment of Bell's Palsy:
1- History should be taken, Therapist should observe facial asymmetry and
notice all movements of the face
2-The patient – therapist position:
• A- comfortable sitting position in the front of a large mirror in front of mirror
therapist stand behind the patient
• B- supine lying position therapist beside the patient
3- Tenderness behind or n the front of the ear is carried out on the sound side
then on the affected side
4-Ms testing for facial muscles as functional(2),sub functional(1), zero (0)
5- Electro diagnosis should follow Ms testing
• Physiotherapy application in Bell's Palsy:
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Physical therapy program should start after the first three days after
the paralysis until subsidence of the inflammation
1- Acute stage:
A- Short wave diathermy: short wave electromagnetic radiations range in
frequency from 10-100 MHz continuous or pulsed mode better frequency
27.12MHz
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• Recovery Stage:
2- Thermo packs
• There are packs containing silica gel which have ability to absorb many
times of its own volume when heated , gives off moist heat for 30-40 min
• It penetrate only to epidermis level not more than 2mm and strongly
absorbed in the upper layer of skin
• Therapeutic effect of heat: causes vasodilation , increase flow of nutrients,
antibodies, leukocytes and oxygen to the tissue, release histamine like
substance and bradykinin which causes vasodilation that increase blood
flow will remain constant for 15 min-------------------cleaning of metabolites ,
relive pain, break the spasm cycle.
• It have analgesic effect on C fibres
• Treatment duration 10 min repeated daily or 5 times per week followed by 2
days rest
3- Massage:
Used in acute stage if not painful
Used in chronic stage for:
Relaxation, improve circulation, decrease resistance of skin before electrical
stimulation
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Types of massage: 1- Effleurage: whole or segmental
2- Kneading on the sound side 3- Friction longitudinal or transverse
4- Vibration
4- Faradic stimulation:
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Short duration interrupted direct currents with a pulse duration range from
0.1ms to 1ms and frequency of 50 to 100 Hz
• Modes: 1- Continuous -------constant contraction of the innervated muscle
• 2- Surged---------------- stimulate slow fibres
• 3- Pulsed--------------- Most preferable stimulate fast fibres
Therapeutic effects:
1- Stimulation of the motor fibres
2- prevent formation of adhesion
3- stimulation of sensory fibres but not very marked because it is short duration current
4- Vasomotor effect ----------vasodilation with slight eryththema
5-It increase semipermiability of cells , enhance the action potential of the
muscles
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5- High Voltage pulsed Galvanic stimulation (HVPS):
• It is a form of neuromuscular electrical stimulation : voltage between 100 to
500V, twin peaked monophasic wave, pulse duration up to 200 msec
• Therapeutic effects:
• 1- Increasing muscle power
2- facilitation, reduction of tone
• 3- Promotion of wound healing
4- Decrease pain , oedema
• 5- Increase blood flow
6- PNF Head and neck movements used as a type of reinforcement to
facilitate the weaker facial muscles
7- Exercises:
We cannot do normal muscle testing for facial muscle testing because of:
1- they are superficial , not passing over joint and not attached to the bone
2-There is no action potential ,no muscle spindle and no gravity effect
So we use functional muscle test:
Normal (functional): movement easily and smoothly
Subnormal(sub functional): incomplete movement
Zero no movements at all
Copyright 2005 Lippincott Williams & Wilkins
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Start strengthening exercises once flicker contraction appears
Ask patient to repeat the action of the muscles in front of the mirror
Resistance to movement on the sound side to stimulate movement on the
affect side
Gendrisic maneuver:
• Giving max resistance to body parts will radiate impulses from strong to
weak muscles.
Splinting:
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Used to elevate the angle of the mouth on the affected side
For infants, we use adhesive plaster
For old child: simple hook splint from corner of the mouth to the ear on the
affected side
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Copyright 2005 Lippincott Williams & Wilkins
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Copyright 2005 Lippincott Williams & Wilkins