1.

06 Facial Nerve and Traumatic Facial Paralysis

Dr. Jean Roschelle Meneses Alonso | THIS WAS NOT LECTURED!

I. ANATOMY OF THE FACIAL NERVE • Injury to the different segments of the facial nerve can illicit different
A. Anatomical Segments of the Facial Nerve symptoms
1. Intracranial
2. Intratemporal
3. Extratemporal
B. Functional Components of the Facial Nerve
1. Branchial Motor/Special Visceral Efferent (SVE)
2. Parasympathetic/General Visceral Efferent (GVE)
3. Sensory/General Sensory Afferent (GSA)
4. Taste/Visceral Sensory Afferent (VSA)
II. SUNDERLAND NERVE INJURY CLASSIFICATION
A. Class I Injury
B. Class II Injury
C. Class III Injury
D. Class IV Injury
E. Class V Injury
III. EVALUATION OF FACIAL NERVE PARALYSIS
A. History
B. Physical Exam
C. Ancillary Tests Figure 1. Branching of the Facial Nerve. The facial nerve leaves the
IV. IDIOPATHIC FACIAL PARALYSIS/BELL’S PALSY intrameatal area together with the Vestibulocochlear nerve. The first
A. Pathogenesis branch, the Greater Superficial Petrosal nerve, supplies the lacrimal gland
B. Symptoms and nasal mucosal glands. The Facial nerve also supplies the anterior 2/3
C. Diagnosis
of the tongue and part of the submandibular gland via the Chorda
D. Course and Prognosis
E. Guidelines for Management Tympani. It also supplies the stapes and stapedius muscle of the middle
V. TRAUMATIC FACIAL PARALYSIS ear. Once it passes through the stylomastoid foramen, this is the
A. Pathogenesis extracranial segment of the Facial nerve already, which subsequently
B. Diagnosis supplies the parotid gland and further branches.
C. Guidelines for Management
VI. INFECTION
A. Viral
B. Bacterial
C. Lyme Disease
D. Guidelines for Management
VII. SYSTEMIC DISEASES
VIII. NEOPLASM
IX. LATEROBASAL FRACTURES
A. Complications
B. Classifications of Temporal Bone Fracture
1. Transverse Temporal Bone Fracture
2. Isolated Meatal Fracture
3. Squam-mastoid Fracture
4. Longitudinal Temporal Bone Fracture
X. REFERENCES
XI. QUIZ

No objectives were given for this lecture. Figure 2. Course and relationship of the facial nerve to the
vestibulocochlear nerve. From the pontomedullary segment, the facial
Legend: nerve is seen together with the vestibulocochlear nerve.
Supplementary Emphasized
Audio Recording
Book Information Notes A. Anatomical Segments of the Facial Nerve
   REFER TO APPENDIX FOR THE COURSE OF CN7
1. Intracranial
• From  brainstem to internal auditory canal (IAC)
I. ANATOMY OF THE FACIAL NERVE
•  23 to 24 mm in length
• Supplies motor innervation to the muscles of the face
•  1.8 mm in diameter
• Travels an anatomically complex course through the temporal bone,
middle ear, and parotid gland o Smaller than the vestibulocochlear nerve
• Divided into 6 segments • Supplies the muscles of facial expression (temporal and
o Intracranial zygomaticus muscles)
o Intratemporal • Paralysis may be due to congenital anomalies or tumors of the brain
▪ Intrameatal • Before leaving the brainstem, its motor fibers wind around the
▪ Labyrinthine abducens nucleus, forming the internal genu of the nerve
▪ Tympanic • After leaving the brainstem, it enters the internal porus acusticus
▪ Mastoid with vestibulocochlear nerve (CN8)
o Extracranial

TRANSCRIBERS Constantino, Coralde, Cortez, C., Crisostomo EDITOR Jeo | 09992261137 1 of 11

2. Intratemporal • TYMPANIC
• INTRAMEATAL o  Horizontal segment
o Facial nerve travels with CN 8 through the IAC to the fundus o  8 to 11 mm
o  8 to 10 mm long o Makes a 40 to 80 turn to proceed posteriorly across the
o  Porus acusticus to meatal foramen of the IAC  tympanic cavity to pyramidal eminence
o Relative position of the nerves inside the IAC (Figure 3) ▪ Runs horizontally through the middle ear, passing above
▪ The Crista Falciformis divides the IAC into superior and the stapes into the aditus ad antrum near the
inferior halves semicircular canal
▪ Bills bar divides the superior component into an anterior o Site of majority of intratemporal injuries
and posterior part o Usually covered by a thin bony sheath
▪ The Facial nerve (7-up) is in the  supero-anterior part
together with the Nervus Intermedius
▪ The Superior Vestibular nerve (SV) is in the supero-
posterior part
▪ The Vestibulocochlear nerve (Coca-cola) is in the
inferoanterior part
▪ The Inferior Vestibular nerve (IV) is in the
inferoposterior part
o CN 7 passes anterosuperiorly through the meatal foramen,
leaving the meatus. This is the narrowest point in the bony
fallopian canal (facial canal), and is the site where the nerve
is most likely to be entrapped due to inflammatory swelling

Figure 5. Tympanic segment of the Facial Nerve.

• MASTOID
o  Vertical segment
o Longest intratemporal segment
o  10 to 14 mm long
o Extends from the  pyramidal process to stylomastoid
foramen; forms the 2 nd genu by the aditus ad antrum
▪ From the aditus ad antrum, it turns vertically downward
(90) through the mastoid and leaves the bony canal at
Figure 3. Mnemonic for the relative position of nerves inside the IAC.
the stylomastoid foramen
The relative position of these nerves in the IAC are facial nerve (7-up),
▪ Before leaving the foramen, it gives a branch, the
vestibulocochlear nerve (coca-cola) and the superior and inferior
Chorda Tympani, which contains sensory gustatory
vestibular nerves.
fibers thus innervating the  anterior 2/3 of the tongue
• LABYRINTHINE
3. Extratemporal
o  Shortest and narrowest segment
o  3 to 5 mm long from meatal foramen to geniculate • Postauricular nerve
ganglion o Most facial nerve problems present with earache because of
o Gives off the following: this nerve
▪ Greater Petrosal nerve, which has secretory fibers to • Nerve to stylohyoid
the lacrimal glands and nasal mucosal glands • Nerve to posterior digastric
o CN 7 turns sharply downward and posteriorly at the geniculate • Pes anserinus ( Goose’s foot)
ganglion, forming the first genu o Branching point of the extratemporal segments in the parotid
gland
o From the stylomastoid foramen, the facial nerve enters the
parotid gland wherein it branches at the pes anserinus
o Divides into:
▪ Upper: Temporozygomatic branch, which innervates
the forehead and orbicularis oculi
▪ Middle: Buccal branch
▪ Lower: Cervicofacial branch, which innervates the
orbicularis oris, the cheek, and platysma of the neck
Figure 4. Labyrinthine Segment of the Facial Nerve. It travels in an
anterior, superior and lateral direction. Antero-inferiorly to the facial nerve,
the basal turn of the cochlea can be found. Anterior to it is the geniculate
ganglion and more anteriorly is the greater petrosal nerve.

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 B. Functional Components of the Facial Nerve
1. Branchial Motor/Special Visceral Efferent (SVE)
• Supplies innervation for structures derived from the 2nd
pharyngeal/brachial arch
• Innervation for  muscles of facial expression
o Fibers that innervate the forehead receive  bilateral
innervations from UMN
o Fibers that innervate the lower face receive  contralateral
fibers only
• Also supplies stapedius, stylohyoid, posterior belly of the
digastric acid buccinators

Figure 6. Branches of the Extratemporal Segment of the Facial Nerve.

Figure 8. Upper and Lower Motor Lesion (SVE). Stroke and Bell’s Palsy
both have facial weakness and are 2 common causes of acute facial
paralysis in the clinics. In upper motor lesion, you still have innervation
coming from the lower motor neuron like in stroke; the affectation will only
be in the lower part of the face. While in Bell’s Palsy, which is a lower
motor neuron lesion, the whole side of the face will be affected.

2. Parasympathetic/General Visceral Efferent (GVE)

• Via greater personal nerve together with the zygomaticotemporal
nerve (V2), innervates the lacrimal gland
o Also innervates seromucinous glands of nasal and oral cavity
Figure 7. Pes Anserinus • Via chorda tympani provides secretomotor innervation to the
submandibular and sublingual salivary glands
Table 1. Terminal Branches of the Facial Nerve  •  Schirmer’s test – test of the lacrimal gland and determines
Branch Innervation whether the eye produces enough tears to keep it moist
Temporal Occipitofrontalis, corrugator, procerus, and
upper orbicularis oculi muscle 3. Sensory/General Sensory Afferent (GSA)
Zygomatic Lower orbicularis oculi muscle • Sensory to the auricular concha, postauricular skin, wall of EAC and
Buccal Zygomaticus major and minor, levator part of the tympanic membrane
anguli oris, buccinators, and upper • Sensation for soft palate and parts of the nasal cavity
orbicularis oris muscle
Marginal Lower orbicularis oris muscle, depressor
Mandibular anguli oris, depressor labii, mentalis 4. Taste/Visceral Sensory Afferent (VSA)
Cervical Platysma muscle • Innervates the anterior 2/3 of the tongue, hard and soft palate
• Supplies innervation for structures derived from the 1st
MNEMONIC: pharyngeal/brachial arch
• To Zigzag By Motor Car

1.06 FACIAL NERVE AND TRAUMATIC FACIAL PARALYSIS 3 of 11

 Figure 12. Nerve Injuries.

Figure 9. Course of the Facial Nerve and its Branches.
A. Class I Injury
• 1st degree; mildest form of injury
• Also known as  NEUROPRAXIA
•  Loss of the axon results in transient conduction block
o There is axonal compression or inflammation resulting in
conduction block
• Endoneurium, perineurium, and epineurium are intact
•  Loss of motor function is the most common finding
• Complete recovery is anticipated
• (-) Wallerian degeneration

Figure 10. Functional Components of Facial Nerve

II. SUNDERLAND NERVE INJURY CLASSIFICATION
• A classification of nerve injuries used by physicians to identify
prognosis and as a guide to treatment
Figure 13. 1st Degree Injury.
B. Class II Injury
• 2nd degree
• Also known as  AXONOTMESIS
•  Axons and myelin sheaths are disrupted
• Endoneurium, perineurium, and epineurium are preserved
• Injury to the nerves of  extremities
• Wallerian Degeneration occurs distal to the site of injury
• Complete recovery anticipated (1 mm/day)

Figure 14. 2nd Degree Injury.

Figure 11. Sunderland’s Nerve Injury Classification.

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C. Class III Injury III. EVALUATION OF FACIAL NERVE PARALYSIS
• 3rd degree A. History
• Also known as  NEUROTMESIS • The history, together with the modern gadgets, is 40-50% of the
• Nerve fiber interruption:  neural tube (endoneurium) diagnosis
• Character of the Paralysis
• Epineurium and perineurium are intact
▪ Onset: usually unknown
• Wallerian degeneration distal to the site of the injury ▪ Slow = tumor
• Unpredictable outcome, with risk of  synkinesis if regrowth occurs ▪ Abrupt = Bell’s Palsy, trauma, etc.
o Synkinesis o Duration: usually  unilateral weakness over 2-3 weeks
▪ Abnormal mass movement of muscles, which usually o Progression: beyond a 3-week period or if there is lack of
do not contract with each other improvement after 6 months, consider a neoplasm unless
proven otherwise
▪ Miswiring of nerves after trauma
• Contributing Factors
▪  “short-circuiting” o Recent infection or illness, trauma, surgery, recent tick bites
▪ The patient only intends to blink but the lips and mouth or outdoor activity
also move ▪ Syphilis, HIV, TB or herpes
• Surgical indication ▪ Toxin exposure
o History of otologic, neurologic, diabetic, or vascular disorders
o Previous history of facial nerve paralysis
• Associated Symptoms
o Fever
o Facial pain
o Hearing loss, Aural fullness, Otalgia, Vertigo
o Neurologic deficits
Figure 15. 3rd Degree Injury. o Changes in taste sensation, vision, drooling, cheek biting,
epiphora (excessive watering of eyes), dysacusis, or pain
D. Class IV Injury (preauricular/postauricular)
• 4th degree
• Violates  perineurium B. Physical Examination
• Observe facial asymmetry at rest and with movement
• Only  epineurium remains intact
o Eye closure
• Poor functional outcome with higher risk for synkinesis o Tear production/lacrimal gland function (can perform the
• Surgical repair is required Schirmer’s tear test)
o Corneal reflex
o Visual acuity
• Lesions of peripheral nerve involve the upper and lower face
• Complete Head and Neck Assessment
o Mass or fluid in the middle ear
o Vesicles in external auditory canal and concha
o Hitzelberger Sign
▪ Pain in  postauricular area
Figure 16. 4th Degree Injury. ▪ 99% accurate
o Other cranial nerve involvement
E. Class V Injury o Other lateralizing signs
• 5th degree o Parotid mass
• Complete transection
• Little chance of regeneration Table 2.  House-Brackmann Facial Nerve Grading System.
Grade Appearance Forehead Eye Mouth
• Risk of neuroma formation
I. Normal Normal Normal Normal Normal
• Recovery is impossible without proper surgical treatment II. Mild Slight Moderate Complete Slight
• Most of the time, it’s unsalvageable Dysfunction weakness, to good closure, asymmetry
Normal movement minimal
resting tone effort
III. Non- Slight to Complete Slight
Moderate disfiguring moderate closure, weakness,
Dysfunction weakness, movement maximal maximal
normal effort effort
resting tone
IV. Disfiguring None Incomplete Asymmetric
Figure 17. 5th Degree Injury
Moderately weakness, closure with
Severe normal maximal
REMEMBER THE DAMAGES: Dysfunction resting tone effort
• Class 1 injury – axon V. Severe Minimal None Incomplete Slight
Dysfunction movement, closure movement
• Class 2 injury – axon and myelin sheath
asymmetric
• Class 3 injury – endoneurium resting tone
• Class 4 injury – perineudium VI. Total Asymmetric None None None
• Class 5 injury – epineurium Paralysis

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 Table 3. Diagnosis Of Lesions From Level Of Impairment.
Level of Signs Diagnosis
Impairment
Supranuclear Good tone, intact upper Cerebrovascular
face, presence of accident, trauma
spontaneous smile,
associated neurologic
deficits
Nuclear Involvement of the 6th Vascular or
and 7th cranial nerves, neoplastic,
corticospinal tracts poliomyelitis,
multiple sclerosis,
encephalitis
Cerebellopontine Involvement of Schwannoma,
angle vestibular and cochlear meningioma,
portions of the 8th epidermoid tumor,
cranial nerve, 5th and glomus jugularis
later 9th, 10th and 11th
cranial nerves
Geniculate Facial paralysis, Herpes zoster
ganglion hyperacusis, decreased oticus, temporal
lacrimation and bone fracture, Bell
Figure 18. House-Brackmann Grade I. No asymmetry. salivation, altered taste palsy,
cholesteatoma,
schwannoma, AV
malformation,
meningioma
Tympanomastoid Facial paralysis, Bell palsy,
decreased salivation cholesteatoma,
and taste, lacrimation temporal bone
intact fracture, infection
Extracranial Facial paralysis (usually Trauma, tumor,
a branch is spared), parotid carcinoma,
salivation and taste pharyngeal
intact carcinoma

• Electroneurography (ENoG)
o  Most accurate test
o Records muscle response via electrodes after stimulation of
the facial nerve with transcutaneous impulse
o Not useful in acute setting as Wallerian degeneration occurs
Figure 19. House-Brackmann Grade IV. Moderately severe dysfunction: 24-72 hours after injury
normal symmetry but presence of mass on the left (most likely the parotid o Used for prognostication, if the patient has facial nerve
gland), movement of the forehead, incomplete closure of the eye on the paralysis after trauma
affected side, and mouth is asymmetric with maximal effort o Can distinguish neuropraxia versus more severe injuries
o involves supramaximal stimulation of the nerve trunk and
C. Ancillary Tests measuring the muscular response with surface electrodes.
• Electromyography (EMG) o The degree of degeneration is expressed as a percentage
relative to the healthy side (=100%).
o Electrodes inserted into muscles to rule out or rule in if
▪ >90% degeneration of the nerve fibers is a poor
there’s problem in the muscle or just the nerve
prognostic sign in terms of complete recovery
o Demonstrates the existence of functional motor units
o If no motion at all on one side of the face, ENoG will be used.
o Fibrillations from denervation appear after 1-2 weeks.
Electrodes will be placed at the nose and at the forehead.
o Presence of voluntary action potentials indicate at least partial
Stimulus will be given preauricular.
continuity of nerve.
o The electrical potentials of the mimetic muscles are measured
with needle electrodes.
o Recordings are made during spontaneous and voluntary
muscular activity for the objective detection of paralysis and
reinnervation.
o It is also used for the intraoperative monitoring of facial nerve
function during intracranial operations, and parotid and
otologic surgery.

Figure 20. Electromyography (R), Electroneurography (L).

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• Audiogram
o Detects middle ear problems such as otitis media
• Topognostic tests
o Localization of problem
o Schirmer’s tear test, Stapedial reflex, Salivary flow,
Gustometry
• CT/MRI of Temporal Bones
o Still questionable
o If asked in the exam, we do not do this test
• Treponemal Tests, CBC
o Test is also not usually performed
Table 4. Topognostic Tests.
Test Description
Schirmer's • Measures output of the lacrimal glands
Test • Lacrimation is measured with a 5-cm long strip
of litmus paper placed into the conjunctival sac
• Done bilaterally
• ABNORMAL if lacrimation reduced by 30%
relative to the opposite side
Stapedial • If the reflex is absent, the lesion must be
Reflex proximal to the mastoid segment
• Reflex is lost even with mild degrees of nerve
damage, as it is mediated by delicate fibers
Salivary flow / • Wharton duct or Stensen’s duct is
Sialometry catheterized on each side to measure salivary
production by the submandibular glands
• A discrepancy between the sides means that
the lesion is proximal to the origin of the
chorda tympani
• Rarely practiced
Gustometry • Taste sensation is evaluated and compared
between sides
• Tests the fibers of the chorda tympani
• A right-left discrepancy means that the lesion
is proximal to the mastoid segment
IV. IDIOPATHIC FACIAL PARALYSIS / BELL’S PALSY
• Synonyms: cryptogenic, rheumatic, or ischemic facial paralysis
• Bell’s palsy is a unilateral, peripheral facial paralysis of acute
onset that has no discernable cause and does not involve any other
cranial nerves
•  Most common form of facial paralysis
• Annual incidence of 15 to 40 per 100,000
• Any age group, most common in 3rd decade
• No sexual predilection
• Both sides of the face may be affected in equal proportions
• Recurrent in 10-12% of those affected
• Family history is found in 14% of those affected
 If there is bilateral facial paralysis, suspect that it might not be
Bell’s palsy; it might be something that is systemic, especially if the
patient is diabetic.
A. Pathogenesis
• Unknown
• Idiopathic by definition
• Theories include:
o Infection and inflammation (viral, autoimmune)
o Ischemic neuronitis
o Entrapment neuropathy
o Polyneuropathy
o Borreliosis
o Inflammation, which leads to entrapment and ischemia
o Traumatic: head injuries, surgical trauma (mastoid, parotid,
or middle ear surgery)
• Idiopathic facial paralysis is more common in  diabetic patients
and in  pregnancy (third trimester)
1.06 FACIAL NERVE AND TRAUMATIC FACIAL PARALYSIS
B. Symptoms
• The initial symptom is retroauricular pain, followed by unilateral
peripheral facial paralysis in which frontal branch is equally affected
• It develops within a few days (2-5 days) and has no systemic
manifestations
• Clinical features may include hyperacusis (stapedius muscle
paralysis), dysgeusia, and decreased lacrimation
• The most serious complication is corneal damage due to
lagophthalmos, ectropion, and/or deceased lacrimation
o  Lagophthalmos – inability to close the eyelids completely
o  Ectropion – lower eyelid turns outwards
C. Diagnosis
•  Minimum diagnostic criteria
o Paralysis or paresis of all muscle groups of one side
o Sudden onset
o Need to exclude all CNS disease, ear, or cerebellopontine
(CP) angle disease
• History and physical examination is the cornerstone of diagnosis
o Hearing loss
o Aural fullness
o Otalgia
o Vertigo
o Changes in face sensation
o Drooling
o Cheek biting
o Dysacusis
o Tinnitus
• Usually the paralysis involves the upper and lower portion of the side
of the face that is affected (peripheral lesion)
• If the paralysis does not involve the forehead, the problem might be
a central lesion because of the distribution of the nerve
• Audiogram as screening for auditory system
• If there is complete paralysis, electrophysiologic test must be done
• CT/MRI not indicated
• Ddx: must be differentiated from Melkersson-Rosenthal
syndrome (peripheral facial paralysis with recurrent swelling of the
face and lips and a fissured tongue)
D. Course and Prognosis
• Partial paralysis always resolves completely within a few weeks
• Complete paralysis recovery takes longer (months) and is complete
in only about 60-70% of cases
o Approximately 15% of patients are left with troublesome
residual palsy/synkinesis
E. Guidelines for Management
• Treatment with corticosteroids, occasionally combined with
rheologic or antiviral agents, is generally recommended although
definite efficacy has not been confirmed
• Complete otologic and audiometric evaluation
• Treated with 10-14 days of tapering systemic steroids and antiviral
medication
• Partial paralysis → observe
• Complete paralysis → determine level of involvement through
electroneurography and electromyography
• Surgical – decompression for cases of total paralysis with evidence
of extensive nerve degeneration
o 71% complete recovery
o 38% has good clinical recovery with mild residual palsy
o 16% fair to poor recovery
NOTES:
“In all cases of Bell’s palsy, the process is self-limiting, non-
progressive, non-life-threatening, and spontaneously
remitting, with typical Bell’s palsy improving within 4 to 6
months, and always by 12 months after onset.” – May and Klein.
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 V. TRAUMATIC FACIAL PARALYSIS Treatment
• CN 7 is the most commonly injured cranial nerve • Systemic steroids and acyclovir
• A complete or partial facial nerve injury, nerve compression (by • Post-herpetic neuralgia is treated with oral analgesics and topical
hematoma or bone fragments), trauma-induced swelling, or thermal capsaicin
injury (from a drill during otosurgery) • Compared to Bell’s palsy, nerve degeneration is worse, hence
• Paralysis may be immediate (complete, instantaneous traumatic worst recovery
lesion) or delayed (progresses over several days following the B. Bacterial
trauma) • Infections from the ear (AOM, COM, mastoiditis, Malignant otitis
• Does not occur with isolated symptoms. It’s often accompanied by externa)
other symptoms relating to the trauma • Dehiscence in the fallopian canal serves as a portal of entry for
bacterial invasion
A. Pathogenesis
• Facial paralysis may be caused by a temporal bone fracture, facial D. Lyme Disease
trauma (sharp or blunt), surgical trauma (surgery of the petrous
• Flu-like symptoms, cutaneous manifestations, erythema
bone or parotid gland), or obstetric trauma
chronicum migrans (most distinct symptom)
• Depending on the degree of trauma, the effects can range from a
• 10% will have facial paralysis
transient conduction block (neurapraxia) or nerve damage with an
intact perineurium (axonotmesis) to a complete nerve transection
E. Guidelines for Management
(neurotmesis)
Acute Otitis Media/Mastoiditis

B. Diagnosis • Myringotomy and tube placement

• Diagnosis is due to mechanism of injury, related injuries, or recent • Systemic and topical antibiotics
surgical history
o That's why you have to know if it’s caused by blunt or Chronic Otitis Media
penetrating trauma • Mastoidectomy if coalescent mastoiditis or associated intracranial
o It can be: extension of infection
▪ Iatrogenic: most common is surgery (mastoidectomy) • Removal of cholesteatoma or granulation tissue, and facial nerve
▪ Intratemporal decompression
▪ Extratemporal
C. Guidelines for Management VII. SYSTEMIC DISEASES
Iatrogenic following ear surgery • Guillain Barre Syndrome
• Mononucleosis
• Rule out effects of local anesthetics and compressive effect
• Sarcoidosis
• EMG testing
• HIV Infection
• Delayed onset (partial or complete) → steroids and observe
• Immediate onset (partial or complete) → explore the nerve
VIII. NEOPLASM
immediately
• Involves the facial nerve itself or originates from surrounding
structures
Trauma (Head Injury)
• In all patients with new-onset paralysis, 5% are due to neoplastic
• Delayed Onset (partial or complete) → observe and steroids unless
process
contraindicated
• Suggestive of tumor involvement:
• Immediate Onset (partial) → observe and steroids unless
o Slowly evolving paresis/paralysis
contraindicated
o Persistent paralysis > 4 months
• Immediate Onset (complete) → explore the nerve when the patient o Ipsilateral recurrence
is stabilized o Concurrent SNHL
o Multiple cranial nerve deficits
VI. INFECTION o History of carcinoma
A. Viral
• Most common agent is  herpes zoster (Herpes Zoster Oticus)
• Aside from paralysis, there is otalgia, vesicular eruptions,
sensorineural hearing loss, tinnitus, and vertigo
• Ramsay Hunt Syndrome (aka Herpes Zoster Oticus)
o Incidence increases after age 60
o REACTIVATION of VZV ( not reinfection) in ganglion cells
o Significant symptom:
▪ Unilateral burning ear pain with CN 7 palsy

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 The following parts are not in the lecturer’s PowerPoint but is found in 2019B trans.
IX. LATEROBASAL FRACTURES
• Temporal bone fractures
• Lateral skull base is a frequent site of occurrence of basal skull
fractures.
• Trauma is associated with fractures of the calvaria and also with
brain injury
A. Complications
• Facial nerve function commonly affected
vestibulocochlear function
1. Cerebrospinal fluid leak
• Due to torn dura mater
• With extensive injuries to the lateral skull base, both the dura and
brain tissue may prolapse into the air cells of the temporal bone
• Manifested by the following clinical signs:
 Pneumocephalus (air in the intracranial cavity)
 CSF otorrhea
 Infection (meningitis or brain abscess)
• Confirmed by laboratory tests, imaging studies, or intraoperatively
2. Cochleovestibular symptoms
• Conductive hearing loss caused by fluid in the tympanic cavity or
by ossicular dislocation
• Sensorineural hearing loss caused by fracture of the labyrinth
o Associated with failure of vestibular organ and is manifested
clinically as severe vertigo, nausea, and vomiting
B. Classifications of Temporal Bone Fracture
1. Transverse Temporal Bone Fracture
• Fracture line runs transversely across the petrous bone or petrous
pyramid, along the internal auditory canal and/or through the
labyrinth
• Caused by a traumatizing force in the frontal plane
• Symptoms:
o Acute vestibular dysfunction, hearing loss, CSF rhinorrhea,
facial paralysis
o Otorrhea is absent.
o No blood or CSF discharge from the ear canal
▪ Fracture line runs medial to the external auditory canal
and tympanic membrane, thus not directly affecting the
structure
• Diagnosis
o Otoscopy: signs of hemotympanum
o Clinical auditory testing: Weber test is lateralized to the
healthy ear and there is spontaneous nystagmus toward
the healthy ear
o Thin-slice CT scanning: to define fracture line
• Course and Complications:
o High risk for meningitis with less likelihood that the fistula will
close spontaneously
o Hearing or vestibular function is extremely unlikely to be
recovered
o Has poorer prognosis than in patients with a longitudinal
fracture
• Treatment:
o CSF leak indicates surgical closure
o Otherwise, treatment is conservative with emphasis placed on
mobilizing the patient and restoring vestibular functions
1.06 FACIAL NERVE AND TRAUMATIC FACIAL PARALYSIS
along with
Figure 21. Temporal Bone Fracture. Typical longitudinal bone fracture
(left) and transverse temporal bone fracture (right).
2. Isolated Meatal Fracture
• Often caused by posterior displacement of the mandibular condyle
3. Squam-mastoid Fracture
• Confined to the temporal squama and mastoid air cell (internal
auditory canal)
• Auditory canal and tympanic cavity may also be involved
4. Longitudinal Temporal Bone Fracture
• Runs along the petrous bone and petrous pyramid
• Typical fracture line runs along the auditory canal, mastoid roof,
tegmen tympani, carotid canal, and sphenoid sinus
•  Most common burst fracture affecting lateral skull base
• Caused by a diffuse, lateral traumatizing force
• May result from a fall in which head is struck without any other
injuries
• Associated with brain trauma in many cases.
• Symptoms:
o Aural discharge (pure blood or blood mixed with CSF
otorrhea)
o Hearing loss
o Facial paralysis
• Diagnosis:
o Otoscopic findings usually establish the diagnosis when
combined with history and auditory tests
o Otoscopy: shows tearing of the meatal skin and tympanic
membrane, with bleeding into the ear canal
o Clinical Auditory Testing: Weber test is lateralized to the
affected ear. Rinne test is usually, but not always, negative.
o Thin-slice CT scanning: To define fracture line
o Neurography: Assess facial nerve function
o Pure tone audiometry: For auditory testing
• Complication:
o Early complications: meningitis in the presence of CSF leak,
otitis media in presence of tympanic membrane perforation
and facial nerve paralysis
o Late complications: Stenosis of the ear canal due to scarring
or a post-traumatic cholesteatoma caused by the ingrowth of
meatal skin into the middle ear through a fracture.
• Treatment:
o Ear should be covered with sterile dressing and left alone
o Corticosteroid for facial paralysis
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 o Surgical exploration if with infectious complications or c. It’s most common in the 5th decade of life
persistent CSF leak and in selected cases of facial paralysis d. Bell’s Palsy has no sexual predilection
7. Which Sunderland nerve injury classification has a transected
perineurium but an intact epineurium?
a. Class I
b. Class II
c. Class III
d. Class IV
8. Which ancillary test is the most accurate?
a. Electromyography
b. Electroneurography
c. Audiogram
d. CT Scan of Temporal Bones
9. What is the most common type of temporal bone fracture?
a. Comminuted fracture
b. Oblique fracture
c. Longitudinal fracture
d. Transverse fracture
10. A 64-year old female came in with a chief complaint of otalgia of
3 days. This was associated with vesicular eruptions on her left
mandible with drooping of her left lower lip. What is your
diagnosis?
a. Ramsay Hunt Syndrome
b. Goldenhar Syndrome
Figure 22. Longitudinal Temporal Bone Fracture. Thin-slice axial CT c. Mobius Syndrome
scans of a longitudinal fracture of the left temporal bone. The mastoid of d. Gardenigo Syndrome
this patient is hypopneumatized (contains few air cells). The scans show
clouding of the mastoid cells, tympanic cavity, and small sphenoid sinus.
Answer key: 1C, 2A, 3B, 4A, 5C, 6D, 7D, 8B, 9C, 10A

REFERENCES
1. Dr. Alonso’s Powerpoint
2. 2019B Trans
3. Probst, R. (2006). Basic Otorhinolaryngology.
4. Cumming’s Otolaryngology. (2006). 6th edition. Pages
2629- 2630.

QUIZ
1. Which of the following conditions may result in CN VII paralysis?
a. Diffuse otitis externa
b. Furuncolosis
c. Herpes Zoster Oticus
d. Eczematous Dermatitis
2. What is the narrowest segment of the facial nerve?
a. Labyrinthe
b. Intracranial
c. Meatal
d. Tympanic
3. What topognostic test of the facial nerve measures the output of
the lacrimal gland?
a. Hitzelberg test
b. Schirmer’s test
c. Gustometry
d. Stapedial test
4. The following are the terminal branches of the facial nerve
EXCEPT:
a. Maxillary
b. Mandibular
c. Buccal
d. Zygomatic
e. Temporal
5. What is the grading system used for the terminated branches of
the facial nerve?
a. Brodsky
b. Brodmann
c. House-Brackmann
d. Lund-McKay
6. Which of the following is TRUE of Bell’s Palsy?
a. It has a sexual predilection for males
b. It most often occurs in children

1.06 FACIAL NERVE AND TRAUMATIC FACIAL PARALYSIS 10 of 11

 APPENDIX

Figure 24. Complex Course of the Facial Nerve

Table 5. Summary of Sunderland Nerve Injury Classification
Wallerian
Grade Presentation Intact/injured Tissue Prognosis Surgery
Degeneration
Neurapraxia I Transient Injured: Myelin
Mildest conduction
block; Intact: Axon, Endoneurium,
• Complete recovery
most common Perineurium, Epineurium; (-)
anticipated
finding is loss however, there is axonal
of motor compression or inflammation
function. resulting in conduction block.
Axonotmesis II Injury to the
• Complete recovery (+) distal to the
nerves of the Injured: Myelin, Axon
anticipated (1 mm/day) site of injury
extremities
III • Unpredictable outcome;
Injured: Myelin, Axon, (+) distal to the
• Risk of synkinesis if Indicated
Endoneurium site of injury
regrowth occurs
IV Injured: Myelin, Axon, • Poor functional outcome;
Required
Endoneurium, Perineurium • Higher risk for synkinesis
V • Recovery is impossible
Neurotmesis without proper surgical
treatment
Complete Injured: Myelin, Axon, • Most of the time, it’s Required
nerve Endoneurium, Perineurium, unsalvageable for
transection Epineurium • Little chance of recovery
Most regeneration
severe • Risk of neuroma
formation

1.06 FACIAL NERVE AND TRAUMATIC FACIAL PARALYSIS 11 of 11