1. Facial Nerve Palsy
• Anatomy
• function
• cause
• management
• medication

2. Facial nerve
• The facial nerve is 7/12 paired cranial nerves.
• emerges from the brainstem between the pons and the
medulla, and controls the muscles of facial expression,
and functions in the conveyance of taste sensations from
the anterior two-thirds of the tongue and oral cavity.
• also supplies preganglionic parasympathetic fibers to
several head and neck ganglia.
• The motor part of the facial nerve arises from the facial
nerve nucleus in the pons while the sensory part of the
facial nerve arises from the nervus intermedius.

3. Anatomy of Facial Nerve Branches
• The facial nerve exits the posterior cranial fossa (PCF) at
the internal acoustic meatus.
• Within the internal acoustic meatus the facial nerve enters
the facial canal.
• 1 branch of the facial nerve, the greater superficial petrosal
nerve (GSPN) branches from the geniculate ganglion within
the genu of the facial canal and enters the middle cranial
fossa by way of the hiatus of the canal for the GSPN.
• 2 branch of the facial nerve, the stapedial nerve, branches
from the descending portion of the facial nerve and enters
the middle ear.
• 3 branch of the facial nerve, the chorda tympani nerve,
branches from the descending portion of the facial nerve
and enters the middle ear. Within the middle ear the chorda
tympani nerve crosses the medial surface of the tympanic
membrane. It then passes through the petrotympanic
fissure to enter the infratemporal fossa.
• The descending portion of the facial nerve continues into the
parotid region by way of the stylomastoid foramen.

5. • The motor & sensory part of
the facial nerve enters
the petrous temporal
bone via the internal
auditory meatus (intimately
close to the inner ear)
• emerges from the
stylomastoid foramen and
passes through the parotid
gland, where it divides into
five major branches. Though
it passes through the parotid
gland
• The facial nerve forms
the geniculate ganglion prior
to entering the facial canal.

7. Inside skull
Greater petrosal nerve - provides parasympathetic innervation to lacrimal
gland, sphenoid sinus, frontal sinus, maxillary sinus, ethmoid sinus, nasal cavity, as
well as special sensory taste fibers to the palate via the Vidian nerve.
Nerve to stapedius - provides motor innervation for stapedius muscle in middle ear
Chorda tympani
Submandibular gland
Sublingual gland
Special sensory taste fibers for the anterior 2/3 of the tongue.

8. Outside skull
Distal to stylomastoid foramen, the following nerves branch off
the facial nerve:
• Posterior auricular nerve - controls movements of some of
the scalp muscles around the ear
• Branch to Posterior belly of Digastric and Stylohyoid muscle
• Five major facial branches (in parotid gland) - from top to
bottom:
• Temporal auricular and fronto-occipitalis muscles
• Zygomatic muscles of the zygomatic arch and orbit
• Buccal muscles in the cheek and above the mouth
• Marginal mandibular muscles in the region of the
mandible
• Cervical the platysma muscle

10. function
Efferent
• Its main function is motor control of most of the muscles of
facial expression. It also innervates the posterior belly of
the digastric muscle, the stylohyoid muscle, and
the stapedius muscle of the middle ear.
• The facial also supplies parasympathetic fibers to
the submandibular gland and sublingual glands via chorda
tympani. Parasympathetic innervation serves to increase
the flow of saliva from these glands. It also supplies
parasympathetic innervation to the nasal mucosa and
the lacrimal gland via the pterygopalatine ganglion.
• The facial nerve also functions as the efferent limb of
the corneal reflex.

11. • Afferent
• In addition, it receives taste sensations from the anterior two-thirds of
the tongue via the chorda tympani, taste sensation is sent to the gustatory
portion of the solitary nucleus. General sensation from the anterior two-thirds
of tongue are supplied by afferent fibers of the third division of the fifth cranial
nerve (V-3). These sensory (V-3) and taste (VII) fibers travel together as the
lingual nerve briefly before the chorda tympani leaves the lingual Nerve to
enter the tympanic cavity (middle ear) via the petrotympanic fissure. It thus
joins the rest of the facial nerve via canaliculus for chorda tympani. Facial nerve
then meets the geniculate ganglion (sensory ganglion of taste fibers of chorda
tympani and other taste pathways). From geniculate ganglion the taste fibers
continue as the intermediate nerve which goes to the upper anterior quadrant
of fundus of internal acoustic meatus along with the motor root of facial nerve.
intermediate nerve reaches the posterior cranial fossa via the internal acoustic
meatus before synapsing in the solitary nucleus. The cell bodies of the Chorda
tympani reside in the geniculate ganglion, and these parasympathetic fibers
synapse at the submandibular ganglion, attached to the lingual nerve.
• The facial nerve also supplies a small amount of afferent innervation to
the oropharynx below the palatine tonsil. There is also a small amount of
cutaneous sensation carried by the nervus intermedius from the skin in and
around the auricle (earlobe).

12. Aetiology
• In a LMN lesion the pt can't wrinkle their forehead
(unless a lesion in the parotid spares the temporal
branch) - the final common pathway to the muscles is
destroyed. Lesion in pons, or outside brainstem (post.
fossa, bony canal, middle ear or outside skull).
• In an UMN lesion, the upper facial muscles are partially
spared because of alternative pathways in the brainstem
(unless bilateral lesion). Different pathways for voluntary
and emotional movement. CVA's usually weaken
voluntary movement often sparing involuntary
movements (e.g. spontaneous smiling). The much rarer
selective loss of emotional movement is called mimic
paralysis and is usually due to a frontal or thalamic
lesion.

13. Investigation
• Serology - Lyme, herpes and zoster (paired samples 4-6
weeks apart).
• Check BP in children with Bell's palsy (2 case reports of
aortic coarctation).
• Schirmer tear test (reveals reduced flow of tears from an
affected greater palatine nerve).
• Stapedial reflex (an audiological test absent if stapedius
muscle is affected).
• Electrodiagnostic studies (generally a research tool)
reveal no changes in involved facial muscles for the first
three days, but a steady decline of electrical activity
often occurs over the next week, and will identify the
15% with axonal degeneration.

14. Branch of CN VII Location of Lesion Actions
Posterior auricular Posterior auricular Pulls ear backward
Occipitofrontalis, Moves scalp backward
occipital belly
Temporal Anterior auricular Pulls ear forward
Superior auricular Raises ear
Occipitofrontalis, Moves scalp forward
occipital belly
Corrugator supercilii Pulls eyebrow medially
and downward
Procerus Pulls medial eyebrow
downward
Temporal and Orbicularis oculi Closes eyelids and
zygomatic contracts skin around
eye
Zygomatic and buccal Zygomaticus major Elevates corners of
mouth

15. Buccal Zygomaticus minor Elevates upper lip
Levator labii Elevates upper lip and midportion
superioris nasolabial fold
Levator labii Elevates medial nasolabial fold and nasal
superioris alaeque ala
nasi
Risorius Aids smile with lateral pull
Buccinator Pulls corner of mouth backward and
compresses cheek
Levator anguli oris Pulls angles of mouth upward and
toward midline
Orbicularis Closes and compresses lips
Nasalis, dilator Flares nostrils
naris
Nasalis, Compresses nostrils
compressor naris

16. Buccal and Depressor anguli Pulls corner of
marginal oris mouth downward
mandibular Depressor labii Pulls lower lip
inferioris downward
Marginal Mentalis Pulls skin of chin
mandibular upward
Cervical Platysma Pulls down corners
of mouth

17. Case Report
• 59/malay/female
• c/o: unable to tolerate orally well
due to ulcer at rt lateral tongue
• k/c: facial nerve palsy grade IV,
on permanent tracheostomy (last
tube changed 4/10/12 on double
lumen 8.0)
• PMH: petroclival meningioma (rt)
• PSH: post craniotomy and
debulking of tumor at HUSM on
4/6/2009
• PDH: NKMI
• Allegies: -

18. Findings
• G/C: alert, wheelchair, can’t talk
• E/O:
– Assymetrical face (rt face
paralysed)
– On tracheostomy
– Rt eyelid can’t closed + blind
• I/O
– Mouth opening good
– OH bad
– Retain root
16,15,14,13,25,44,43,
– Traumatic ulcer 2x2cm at rt lt
tongue

19. • Dx: traumatic ulcer + multiple retain root
• Tx:
– xla retain root 16,15,14,13,44,43
– Oral toilet
– Gingigel applied
– Cont ent mx
• TP:
– To xla 25

20. BELL’S PALSY
• One of the common disorder affecting facial
nerve causing one sided paralysed face
• Caused: unknown, vascular, infection, genetic,
immunologic origin, brain lesion
• Sign: common c/o weakness on one side face
with drooling eyelid or coner of the mouth,
othr c/o dry eyes,altered sound, increased
sensitivity to sound

21. House-Brackman Scale (facial nerve palsy)
• Grade I
Normal symmetrical function
• Grade II
Slight weakness noticeable only on close inspection
Complete eye closure with minimal effort
Slight asymmetry of smile with maximal effort
Synkinesis barely noticeable, contracture, or spasm
absent
• Grade III
Obvious weakness, but not disfiguring
May not be able to lift eyebrow
Complete eye closure and strong but asymmetrical
mouth movement
Obvious, but not disfiguring synkinesis, mass movement
or spasm

22. House-Brackman Scale (facial nerve palsy)
• Grade IV
Obvious disfiguring weakness
Inability to lift brow
Incomplete eye closure and asymmetry of mouth with
maximal effort
Severe synkinesis, mass movement, spasm
• Grade V
Motion barely perceptible
Incomplete eye closure, slight movement corner mouth
Synkinesis, contracture, and spasm usually absent
• Grade VI
No movement, loss of tone, no synkinesis, contracture,
or spasm
House JW, Brackmann DE. Facial nerve grading system. Otolaryngol. Head Neck Surg 1985; 93:
146–147.

23. Management
• Pharmagological :
– Corticosteroid: prednisolone (1mg/kg/day - adult 60-
80 mg/day – can divide dose bd) PO 7-10d within 72h
is of proven benefit
– Antiviral agents: valacyclovir (1g PO q8h)
• Surgical: Surgical transmastoid decompression of the
facial nerve in severe cases is being investigated.
Cosmetic surgery or anastomosis of hypoglossal nerve
to the facial nerve may help if nerve fails to regenerate
• Artificial tears/lubricants & eyeglasses to proted eye
• Physical therapy (fasial exercise), acupunture with or
without electrical stimulation

24. Gently raise
Sit relaxed in Draw your Wrinkle up your
eyebrows, you can
front of a eyebrows nose.
help the movement
mirror. together, frown.
with your fingers.
Hold pencil or Turn down bottom Blow out cheeks.
Curl up top lip.
lollipop stick
between lips.

25. Reference
• Lo,Bruce (2010). Bell’sPalsy: http://emedicine.medscape.com/article/791311-overview
• Jean Hatchell, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge,
CB2 0QQ www.cuh.org.uk, Exercises_for_facial_weakness
• House JW, Brackmann DE. Facial nerve grading system. Otolaryngol. Head Neck Surg 1985;
93: 146–147.