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Clinical CN7 :new_moon_with_face: (:tangerine: Bell’s Palsy (Minimal…
Clinical CN7
:new_moon_with_face:
:<3:
Ddx of Acute Facial palsies
:tangerine:
Infection
Bell’s palsy (Herpes Simplex Mononeuritis) :star:
Ramsay Hunt (Herpes Zoster Oticus) :star:
Otitis media with effusion
Acute suppurative otitis media
Coalescent mastoiditis
Chronic otitis media
Malignant otitis externa
TB
Lyme Disease
AIDS :star2:
Infectious mononucleosis
:fire:
Trauma
Temporal bone Fx :star:
Facial contusions/lacerations
Penetrating wounds
Iatrogenic injury
Neoplasia
Cholesteatoma :star2:
Glomus jugulare or Tympanicum
Carcinoma (Primary or Metastatic)
Facial neuroma
Schwannoma of Lower Cranial nerves
Meningioma
Leukemia
Histiocytes
Rhabdomyosarcoma
Neurological causes
Stroke :star2:
Guillain-Barré syndrome (GBS)
Myasthenia Graves (MG)
:tangerine:
Bell’s Palsy
Def
: Idiopathic Sudden facial weakness with Spontaneous recovery
Incidence
: found 15-40 per 100,000
Epidemiology
10% recurrence
14% positive FxHx
Most prevalent in 3rd decade of life
Minimal criteria
: :keycap_star:must Ddx other serious ds before Dx Bell’s palsy
Paralysis or Paresis of all muscle groups of
one side of face
Sudden onset
Absence
of signs of
CNS
ds
Absence
of signs of
Ear
or
Cerebellopontine angle ds
Etio
Viral infection (Mumps, Rubella, Herpes simplex, EBV)
Ischemic neuropathy
Autoimmune reactions
Entrapment neuropathy
Symptoms
Polyneuropathy :grapes:
Prognosis in 1 yr F/U
Incomplete paralysis ⇨
All = excellent recovery
6% slight residual weakness
Complete paralysis ⇨
71% complete recovery
13% Mild residual palsy
16% Fair recovery
Treatment
Steroid
:stars:main Rx
Helps to Prevent
Denervation
Autonomic dyskinesis
Progression to Complete paralysis
:arrow_down: recovery time
Serves as Analgesia
Dose: 1 mg/kg/day for 7 days
Acyclovir
(gives if เป็นแรกๆ)
at First 72 hrs
Facial nerve decompression
(Drill hole to :arrow_up: space) — still controversial
Suggested when Degeneration > 95%
Suggested when ENoG got degeneration >90%
Method: unroofing Labyrinthine segment via Middle fossa approach
:tangerine:
Ramsay Hunt syndrome
Herpes zoster facial paralysis
Etio: VZV (2nd M/C Facial paralysis)
Symptoms
Skin vesicles on Pinna, Retroauricular area, Face or Mouth
Compared to Bell’s palsy: RHS got
more severe symptoms
higher risk of complete nerve degen
poor prognosis
Triads
:
Ipsilateral facial paralysis
Ear pain
Vesicles on face
Outcomes
Complete recovery 50%
Severe ocular complications as infection along V1⇨
Uveitis, Keratoconjunctivits, Optic neuritis, Glaucoma
Prognosis
Timing of การเกิด vesicular eruption may affect prognosis
Tho most cases Eruption & Paralysis occur simultaneously
! 25% of cases —
Eruption precedes
Paralysis⇨Higher likelihood of recovery
Recurrent paralysis
9.3% of pt with Bell’s palsy had previous paralysis Hx
20% of tumor
PathoPSO
: Varicella or Chicken pox as primary infection ⇨ dorsal root to Extramedullary CN ganglia
Epidemiology: age
>60 y/o
, :arrow_down: cell-mediated immunity (CA, Trauma, RT or CMT)
Treatment
Corticosteroid
to relieve pain, :arrow_down: Vertigo & postherpetic neuralgia
Acyclovir
to lessen pain & promote resolution of vesicles
:fire:
Traumatic Facial paralysis
Temporal bone Fx
:star:
Longitudinal Fx
80%
of temporal bone Fx
Direct force
along
long axis
Symptoms
Skin canal laceration
Otorrhea (Bloody or CSF)
Teared TM or Hemotympanum
Ossicular chain disruption
20% of Facial n injury (Geniculate gg)
Delayed onset of facial weakness
20% of Labyrinthine concussion
Transverse Fx
20%
of temporal bone Fx
Force
across
long axis
Symptoms
Profound
SNHL
(common)
Vertigo (common)
50%
Immediate Facial n injury
90% at Geniculate gg (ตัวระหว่าง genu2&3)
May extend to Carotid & Jugular foramen
Penetrating injuries (bullet)
S&S
Dural tears, CSF liquorrhea, Damage of Optic capsule & vascular injury
Inx
CT, Carotid arteriograpjy, Facial n electrical testing
Iatrogenic injuries (หมอทำ)
Eg ผ่าแล้วไปโดน nerve
Mx
Release tight dressings & packing ทันที
Wait for any local anes effects to dissipate
If Face has not recovered ⇨
Urgent exploration & Decompensation of nerve
Hyperkinetic disorders
Hemifacial spasm
Involuntary twitching
Contraction of one side of face
Starts around mouth ⇨ Involves entire face
Partial destruction of Periphral Facial n
Blepharospasm
Idiopathic, progressive, involuntary spasm of Orbicularis oculus & Upper Face (corrugator and procerus ms)
Mechanism: not yet determined
Selective destruction of peripheral nerve branches innervate Orbicularis oculi ms
Rx
Botulinum A toxin for 11-14 wk: > 90% relieve symptoms