7 TH
CRANIAL NERVE
LECTURE TAKEN BY :
DR. HEMANGI PARMAR
FACIAL NERVE ANATOMY :
▪ The facial nerve originates from the junction of the
pons and the medulla .
▪ It is a mixed nerve
▪ 3 nuclei
– Motor nucleus
– Parasympathetic nucleus
– Sensory nucleus
MOTOR NUCLEUS
▪ Motor nucleus is situated in the pons
▪ Has 2 parts
– Upper part which innervates the forehead muscles receive
fibers from both the cerebral hemisphere
– Lower part which supplies the lower face receives fibers
from one the contralateral hemisphere
▪ Also receives fibers from thalamus by alternate
routes and thus and provide involuntary control of
facial muscles
PARASYMPATHETIC NUCLEUS
▪ Parasympathetic nuclei lies postero lateral to the
motor nucleus
▪ The 2 nuclei are
▪ Superior salivary nucleus receives afferent from
the hypothalamus for information concerning
taste
▪ Lacrimal nucleus receives afferent fibers from
hypothalamus for emotional responses
SENSORY NUCLEUS
▪ Sensory nucleus forms the upper part of the
nucleus of the tractus solitary
▪ Lies close to the motor nucleus
▪ Sensation of taste travels the peripheral axons of
cells situated in the geniculate ganglion
PATHWAY :
▪ From pons, facial nerve travels anterolateral with
the VIII nerve, enters facial canal, traverses
temporal bone & comes out of stylomastoid
foramen
▪ As it runs to the stylomastoid foramen, facial nerve
is divided into 3 parts by the changes of direction:
– horizontal part (a few mm) at the bottom of internal
acoustic meatus
– transverse part (1 cm) located between the two bends
– vertical part (1 cm+) where it descends to reach
stylomastoid foramen.
▪ Course of the nerve can thus be divided into
– Intracranial part: from pons to internal acoustic meatus
(15-17mm)
– Intra temporal part: internal acoustic meatus to the
stylomastoid foramen
– Extra cranial part: from stylomastoid to pes anserinus (15-
20 mm). On emerging from the foramen, facial nerve
innervates the digastric & stylohyoid muscles and divides
into:
▪ Temporalfacial branch:
– Temporal
– Zygomatic
▪ Cervicofacial
– Cervical
– Mandibular
▪ Buccal branch formed by joining temperofacial and
cervicofacial branch
▪ Within the facial canal, it gives rise to intrapetrous
branches
– Greater petrosal nerve: innervates the lacrimal glands
– Nerve to stapedius: motor to stapedius
– Chorda tympani nerve: carries taste, supplies sub lingual
and sub mandibular glands
– Posterior auricular nerve: supplies occipitalis
FUNCTIONS :
▪ Facial expression
▪ Innervates muscles of face & scalp.
▪ Voluntary motor signals derive from the motor cortex.
▪ Large part of facial expression is involuntary and
controlled by the hypothalamus
▪ Anger, pain and disgust, attention, contempt, fear, joy, sadness,
surprise or astonishment.
▪ Even people who are blind from birth produce the
same expressions. These emotional manifestations
are not simply acquired, but are innate.
▪ Stapedius muscle
▪ Innervats the stapedius muscle
▪ This muscle diminishes the oscillation of the
ossicles of the middle ear, thereby diminishing the
vibrations caused by loud noises.
– Consequently, a lesion of the nerve branch to the
stapedius muscle results in hyperacusis
▪ Reflexes – E.g.
▪ The corneal reflex depends on the facial nerve by
its motor arc.
▪ The nasopalpebral reflex consists of bilateral
contraction of the orbicularis oculi muscles when
the bridge of the nose is percussed.
▪ However, a preferable way to evaluate this reflex is
to hold the patient’s eyes closed.
▪ Sensitivity function
▪ The facial nerve conveys general sensation from a
small area around the external acoustic meatus,
from the eardrum and the concha
▪ Sensory function
▪ The sensory root (nervus intermedius) conveys the
taste fibers for the anterior two thirds of the
tongue.
▪ Visceromotor function
▪ Controls lacrimal, submandibular & sublingual
salivary glands, as well as the pharyngeal, nasal
and palatine glands.
▪ Innervates all major glands of face, except skin glands & the
parotid.
▪ This nucleus is connected to the hypothalamus and
are able to evoke reflex activities like salivation or
tears in response to certain smells or emotional
states.
FACIAL NERVE PARALYSIS
▪ It is a common problem that causes paralysis of the
structures innervated by facial nerve
▪ The most common is Bell's palsy, an idiopathic
disease that may only be diagnosed by exclusion.
CLASSIFICATION :
▪ Facial nerve paralysis may be divided into
– Supranuclear lesions (UMN)
– Infranuclear lesions (LMN)
▪ Supranuclear:
– Central facial palsy caused by lacunar infarct affecting
fibers in internal capsule going to the nucleus.
– The facial nucleus itself can be affected by infarcts of
pontine arteries.
▪ Infranuclear:
– Injury to facial nerve
– Refer to the majority of causes of facial palsy
Causes
▪ Bells palsy
▪ Ramsay hunt syndrome: occurrence of facial
paralysis, herpetiform vesicular eruptions, &
vestibulocochlear dysfunction (H. Zoster)
▪ Lyme disease: Infection with Borrelia burgdorferi
via tick bites presenting along with all other
symptoms of disease
– 10% develop facial paralysis, with 25% of these patients
presenting with bilateral palsy
▪ Bacterial infection: acute otitis media or externa,
mastoiditis
▪ Trauma: fractures of the temporal bone, forceps
delivery
▪ Tumors: compressing the nerve e.g. facial
neuromas, hemangiomas, acoustic neuromas,
parotid gland neoplasms, or metastases of other
tumours
▪ Stroke: Central facial palsy caused by lacunar
infarct affecting internal capsule or facial nucleus
Other causes
▪ Diabetes mellitus
▪ Sarcoidosis of the nervous system, neurosarcoidosis
▪ GBS: Bilateral facial nerve paralysis
▪ Botulism: acute paralysis of muscles
▪ Pregnancy
▪ Arsenic intoxication
▪ Iatrogenic: mandibular block anaesthesia, post immunization,
dental extraction
▪ Myesthenia gravis
▪ Parkinsonism
▪ Moebius syndrome: bilateral facial paralysis
resulting from underdevelopment of VII nerve
which is present at birth.
– The VI cranial nerve, which controls lateral eye movement,
is also affected, so people with Moebius syndrome cannot
form facial expression or move their eyes from side to
side.
– Moebius syndrome is extremely rare, and its cause or
causes are not known.
Bells palsy
▪ Bell's palsy is an idiopathic form of facial palsy
resulting from a dysfunction of the cranial nerve VII
▪ It is diagnosed by exclusion , if no specific cause
can be identified, the condition is known as Bell's
palsy
▪ It is named after Scottish anatomist Charles Bell
(1774–1842), who first described it.
incidence
▪ Annual incidence is about 20 per 100,000 population
▪ It affects approximately 1 person in 65 during a
lifetime
▪ Familial inheritance is found in 4–14% of cases
▪ Three times more likely to affect pregnant women
than non-pregnant women
▪ It is more common in adults than children.
▪ The incidence is higher in people with diabetes than
in those without diabetes.
Cause
▪ Idiopathic
▪ Some viruses establish a latent infection without
symptoms e.g. varicella-zoster, Epstein-Barr virus
– Reactivation of an existing (dormant) viral infection has
been suggested as a cause of acute Bell's palsy
▪ New activation could be preceded by trauma,
environmental factors, metabolic or emotional
disorders
Pathology
▪ Inflammation of the nerve compresses the nerve
where it passes in the bony canal and where it exits
from the skull
▪ Latent infection without symptoms e.g. varicella-
zoster, Epstein-Barr virus can be activated due to
trauma, environmental factors, metabolic or
emotional disorders
– Reactivation of an existing (dormant) viral infection may
cause acute Bell's palsy
Signs and symptoms
▪ Sudden onset of paralysis of facials muscles
▪ Post auricular pain
▪ Loss of taste in anterior 2/3 on affected side
▪ Hyperaccusis
▪ Watering of eyes
▪ Loss of wrinkles on the forehead
▪ Bell’s phenomenon
▪ Flattening of nasolabial fold
▪ Angle of mouth deviated on the healthy side
▪ Whistling may not be possible
Other accompanying
features
▪ Facial tingling
▪ Moderate or severe headache
▪ Neck pain
▪ Memory problems
▪ Balance problems
▪ Ipsilateral limb paresthesias & weakness
▪ Sense of clumsiness
▪ Unexplained by facial nerve dysfunction
Differential diagnosis
▪ Stroke
▪ Ramsay Hunt syndrome
▪ Lyme disease
Diagnosis
▪ Electrical testing (SD Curve):
– distinguish degree I from II - V lesions but
cannot distinguish II from V
▪ Serology - Lyme, herpes and zoster (paired
samples 4-6 weeks apart). It may not
influence management but may reveal
etiology
▪ Electrodiagnostic studies – NCV/EMG
(generally a research tool) reveal no
changes in involved muscles for the first 3
days but a steady decline of electrical
activity occurs over the next week
▪ Imaging
– CT scanning and MRI are useful in the
diagnosis of injury to intratemporal or
intracranial affections
– May reveal temporal fracture patterns and
edema formation
▪ For suspected intracranial or infratemporal
injury, a Schirmer test of tearing to assess
lacrimal gland function
Complications
▪ Facial asymmetry
▪ Exposure keratitis
▪ Synkinesis
▪ Crocodile tears
▪ Frey’s syndrome
▪ Psychological and social issues
Prognosis
▪ 60-80% of the cases resolve completely within a
few weeks to months
▪ 15%, recovers in 3–6 months
▪ In few cases it leads to permanent deficits
▪ Approximately 7% of patients have a recurrence.
▪ Recurrent bell’s palsy may not fully recover
Treatment
▪ Pharmacological
▪ Physiotherapy
▪ Surgical
▪ Pharmacological
– Corticosteroid such as prednisone
– Antivirals (such as aciclovir)
– Lubricating eye drops
Surgical
▪ Decompression of facial nerve in the stylomastoid
foramen
▪ In cases which fails to recover
– Anastomosis of facial nerve with accessory (CN-XI) or
hypoglossal (CN-XII) nerve may be considered
▪ In the presence of crocodiles tear, cutting of
tympanic nerve which normally conveys the
glossopharyngeal salivary fibers
▪ In residual weakness and asymmetry, plastic
surgery, tendon transfer
PT assessment
▪ History:
– May not be relevant
– May have h/o viral infection, exposure to cold etc
– Associated with BP or HT
– Family history may not be relevant, some may have
positive family history
– H/o recurrent facial paralysis may be present
▪ Pain:
– Common complains of post auricular pain and earache.
– pulling type of pain in the face may be present
▪ Observation
– Turned out lower eyelid
– Sagging mouth
– Drooping appearance
– Absence of forehead wrinkles and nasolabial fold
– Bell’s phenomenon
▪ Cranial nerve examination
– Trigeminal nerve
– Auditory nerve etc.
– Facial nerve
▪ Refer cranial nerve examination PPT for details
– Motor
– Sensory
– Lacrimal
– Salivary
– Hyperaccusis
▪ Motor examination
– Weakness or paralysis of facial muscle on the affected side
– Hypotonic muscles
– Normal jaw jerk
▪ Sensory function
– Taste sensation in the anterior 2/3 may be lost on the
affected side
– Facial sensations are normal
▪ Reflex integrity
– Corneal reflex: loss of blinking on the affected side
– Nasopalpebral reflex: abnormal
▪ Disease specific scales
– Housebrakeman scale
– Sunny brook scale
– Yanagihara scale
▪ Special test/ investigation
– SD curve
– NCV
Yanagihara facial nerve grading system:
Pt management
▪ Control pain
– IRR to the face in the presence of post auricular and facial
pain
– SWD over face or parotid region
– US with phonophoresis in the post auricular region may
be helpful to control inflammation
▪ Maintain muscle property
– IG current to the facial muscles
▪ 60-90 contractions in each individual muscles
▪ Duration 30, 100 or 300ms
▪ Passive electrode can be placed in the nap of the neck or the
arm
– Massage to improve circulation
▪ For facial lift and reduce sagging
– Taping or S-hook splint from the corner of the mouth to
the ear to avoid facial sagging
▪ Re-education and strengthening of muscle
– Electrical stimulation
– Facial muscle PNF
– Facial exercises with mirror biofeedback
– Quick iceing techniques
– EMG biofeedback
▪ Other treatment modes
– Mime therapy
– Accupuncture
– Dry needling
– Nerve mobilization
– Facial yoga etc.
▪ Home advise
– Cotton plugging of ears while travelling
– Protective glasses for the eyes
– Cleaning of eyes with clean cold water splash frequently
– Facial exercise
▪ Wrinkle forehead
▪ Flare nostrils
▪ Pucker lips
▪ Whistling
▪ Smiling
▪ Blowing and sucking etc
THANK YOU
