FACIAL NERVE—-DANIEL TODD,MD CAVEATES: DIPLEGIA=PRIMARILY GBS GBS WILL GIVE YOU DISMAL READINGS ON YOUR ELECTROPHYSIOLOGIC TESTS BUT YOU CERTAINLY DO NOT WANT TO OPERATE ON THIS SELF LIMITING ENTITIY DAY 18-21=MAXIMAL AXONAL REGROWTH—-SHOULD REPAIR PRIMARILY BY THEN 72 HOURS WALLERIAN DEGENERATION TRIGEMINAL=BELLS NERVE(MESENCEPHALIC=PROPRIOCEPTION) VIDIAN NEURECTOMY MAY LEAD TO XEROPTHALMIA 90% OF CSF LEAKS CLEAR WITHIN 28 DAYS F.N. MUCH MORE SUPERFICIAL IN CHILDREN(ESPECIALLY < 2) BELLS PHENOM=A TELEOLOGIC PROTECTIVE MECHANISM WHEREBY THE GLOBE ROLLS UP AND OUT WITH EYE CLOSURE(INDICATIVE OF A PERIPHERAL LESION) STRAUS’ SIGN = INJECTION OF PILOCARPINE IS FOLLOWED BY CONTRALAT PERSPIRATION PRIOR TO IPSI PERSIRATION ELECTROTHERAPY HAS NO BENEFIT AND MAY ACTUALLY BE HARMFUL, MAY INDUCE INCREASED SYNKINESIS MEATAL FORAMEN OF THE PERIGENICULATE REGION IS THE NARROWEST REGION OF THE FALLOPIAN CANAL 50% INCIDENCE OF BONEY DEHISCENC IN THE MIDDLE EAR HB GRADING SYSTEM 1-3 CAN CLOSE EYE, 4=SYMMETRY AT REST,5=ASSYMETRY AT REST REPAIR PRIMARILY IF YOU SEVER MORE THAN 50% OF THE NERVE USUALLY UNDERESTIMATE THE DEGREE OF INJURY IN MASTIOD SURGERY BOGARAD SYNDROME=GUSTATORY TEARING (SYNDROME OF CROCADILE TEARS—FROM AFRICAN FOLKLORE)-A SYNKINESIS—-PROBABLY FROM LESSER TO GREATER SUP PETROSAL NERVE—-WOULD HAPPEN IN A T-BONE Fx WITH DAMAGE TO THE PERIGENICULATE REGION BELLS<15% BAD OUTCOMES ZOSTER >40% BAD OUTCOMES UNTIL AGE 2 FACIAL NERVE MUCH MORE SUPERFICIAL(MASTIOD NOT WELL FORMED)—-DO NOT OPERATE AROUND HERE UNTIL AFTER AGE 2 FACIAL NERVE NOT FULL DEV. UNTIL AGE 4 PRIMARY TUMOR CAUSING FP IS SCHWANNOMA, SECOND IS MENINGIOMA PRIMARY CA CAUSING FP IS ADENOID CYSTIC CA OF PAROTID ALL NON-IATROGENIC INTRA-TEMPORAL BONE PATHOLOGY OCCURS WITHIN THE LABYRINTHIAN SEGMENT OF THE PERIGENICULATE REGION OF THE FALLOPIAN CANAL THERE IS ONLY A SINGLE FASCICLE IN THE LABYRINTHIAN PORTION OF FACIAL NERVE WHERE THERE ARE MULTIPLE SEPARATE FASCICLES A 2ND ARCH DERIVATIVE (RIECHERT’S CARTILAGE) FACIAL PARALYSIS=PROSOPLEGIA CENTRAL=SUPRANUCLEAR=UMN(LESION IS IN THE CONTRALATERAL CEREBRAL CORTEX) MAY SPARE INVOLUNTARY-EMOTIONAL IMPUT (INTACT MIMETIC FUNCTION)-EXTRAPYRAMIDAL TRACTS (EPS) ABSENT BELL’S PHENOM INTACT FRONTALIS AND ORBICULARIS OCULI FROM DUAL (CROSS) INNERVATION OF THAT PORTION OF THE NUCLEUS GOOD TONE NUCLEAR FACIAL PAULSEY LOCATED AT PONTOMEDULLARY JUNCTION INTERNAL GENU FACIAL COLLICULUS=BUMP IN THE FLOOR OF THE 4TH VENTRICLE MADE OF FACIAL NERVE FIBERS CIRCLING AROUND THE ABDUCENS NUCLEUS (ACCOUNTS FOR LR PAULSEY SEEN IN MOBIUS SYNDROME) NO TONE A LARGE PONTINE INFARCT COULD GIVE YOU A COMPLETE FACIAL DIPLEGIA PERIPHERAL=LMN BY FAR MOST COMMON (BELLS>TRAUMA>ZOSTER) NO TONE DIVIDED INTO 3 REGIONS BY T-BONE(PRE,INTRA,POST) PRE=INTRACRANIAL SEGMENT—–ABOUT 25 MM INTRA-TEMPORAL BONE PORTION—–ABOUT 25 MM MEATAL SEGMENT 9MM PORUS ACOUSTICUS OF IAC TO MEATAL FORAMEN(THE NARROWEST SEGMENT) OF IAC (WHERE BILL’S BAR IS) LABYRINTHIAN SEGMENT= PREGENICULATE SEGMENT OF PERIGENICULATE REGION 3-6MM (THE NARROWEST) PRIMARY REGION FOR BELLS TO LIGHT UP ON A GAD SCAN—-TEMPORAL BONE Fx’S HERE TYMPANIC SEGMENT=POSTGENICULATE SEGMENT OF PERIGENICULATE REGION 8-11MM—50-66% BONEY DEHISSENCE MASTIOD(VERTICLE) SEGMENT—OUT SMF POST=EXTRATEMPORAL SEGMENT PRE-PES POST-PES
TOPODIAGNOSTIC TESTS CAN HELP IDENTIFY THE LOCATION OF THE LESION BEFORE GSPN(VIDIAN N. OF THE PTERYGOID CANAL) XEROPHTHALMIA HYPERACOUSIS DYSGEUSIA AFTER GSPN EPIPHORA DUE TO HORNER’S M PARALYSIS (DILATES THE NL DUCT ORIFICE) ECTROPIA(MALPOSITION OF THE PUNCTA) ABSENT BLINKING (PUMPING ACTION ON THE JONE’S PUMP) TOPODIAGNOSTIC TESTS—NOT VERY CORRELATIVE SCHIRMER TEST(ESTIMATES THE RISK OF EXPOSURE KERATITIS)—--REALLY THE HALLMARK OF THESE ASSAYS—–TELLS YOU IF THE LESION IS PRE OR POST GENICULATE (WHERE THE GSPN BRANCHES) + IF ONE EYE LESS THAN 25% OF THE OTHER + IF LESS THAN 25 MM IN 5 MIN STAPEDIAL REFLEX (ACOUSTIC REFLEX) COMMONLY ABSENT FOR ABOUT 2 WEEKS IN BELLS “THE OTOLOGISTS EMG” (ELECTRO)GEUSTOMETRY HIGHLY SUBJECTIVE—TENDS TO RECOVER BEFORE THE FACIAL PARALYSIS MIDDLE 1/3 OF THE TONGUE = BEST BECAUSE ANT 1/3 IS HIGHLY BILATERAL SALIVARY FLOW RATES THE FIRST PHYSIOLOGIC TEST TO BECOME ABNL MUST BILAT CANNULATE WHARTON’S (VERY DIFFICULT) A 25% REDUCTION IN FLOW = SIGNIFICANT *MEASURING SALIVARY PH IS AN EASY INDIRECT MEASURE OF FLOW HIGH FLOW = HIGH PH PH < 6.1 CORRESPONDS WITH CHORDA TYMPANI TRANSECTION RAPID BLINK TEST CAN PICK UP SUBTLE DIFFERENCES ELECTROPHYSIOLOGIC TESTS CAN HELP DETERMINE THE SEVERITY OF THE LESION SUNDERLAND’S CLASSIFICATION CLASS I—NEUROPRAXIA CLASS II—AXONOTMESIS THE REST = NEUROTMESIS CLASS III—NEUROTMESIS—-ENDONEURIUM AND AXON DISRUPTED—-CLINICAL SYNKINESIS CLASS IV—PERINEURIUM DISRUPTED CLASS V—EPINEURIUM DISRUPTED (3 IS ALWAYS SYNKINESIS—HB OR SUNDERLAND) CAN BE DIFFICULT TO DISCERN BETWEEN MYOGENIC AND NEUROGENIC INJURIES—-CAN RESORT TO MUSCLE BIOPSY REALLY ONLY TEST COMPLETE ACUTE PARALYSIS ANTIDROMIC = PROX (AFFERENT) SPREAD OF DEPOLARIZATION ORTHODROMIC = DISTAL (EFFERENT) SPREAD OF DEPOLARIZATION 0-3D (REALLY NO TEST APPROPRIATE- MUST WAIT FOR WALLERIAN DEGENERATION–BEGINS IN 12 HOURS-COMPLETE IN 12 DAYS)-CAN DO NET(HILGER) IN A SERIAL FASHION TO DOCUMENT A TREND 3D-3W ENOG BEST 3W- EMG BEST NET(NERVE EXCIT. TEST) “HILGER” NL IN FIRST 72 HOURS CAN DO A CLINIC A COMPARITIVE TEST (OTHER SIDE MUST BE NL) IF DIFFERENCE > 3.5 MAMPS = SIGNIFICANT—CONSIDER DECOMPRESSION (AVOID MASSETER, DIAL TO 0, PLACE PROBE OVER ZYGOMATIC ARCH AND LOWER BORDER OF THE MANDIBLE(1/2 WAY OUT), DO NL SIDE FIRST, START AT 3-4 MAMPS AND THEN DIAL IT DOWN UNTIL THE RESPONS GOES AWAY)
MST (MODIFIED NET) PAINFUL A COMPARITIVE TEST NL IN FIRST 72 HOURS RECRUITS ALL NERVES FOR MOTOR UNITS CRANK IT UP UNTIL IT HURTS- DOCUMENT AND COMPARE EMG CANNOT USE UNTIL 10-14 DAYS POST ONSET COULD USE IN B Dz LIMITED VALUE- NO EVOKING STIM. (JUST A RECORDING) CANNOT QUANTIFY THE TEST FOR NEONATAL (CONG.) FP FIBRILLATION POTENTIALS = DEGEN./DENERVATION = BAD Px (11-14 DAYS) POLYPHASIC ACTION POTENTIAL = REGEN/REINNERVATION = GOOD Px (6-12 WKS)—–IF NONE BY 15 MONTHS YOU ARE S.O.L. MULT. ASYNCHRONOUS ACTION POTENTIALS = PROLONGED TRACTION ENOG REALLY A MST + EMG (AN EVOKED EMG) = EEMG –ALSO PAINFUL A COMPARITIVE TEST FOR UNILATERAL Dz NL IN FIRST 72 HRS HIGH FALSE + AFTER 3 WKS DUE TO DISORDERLY REGENERATION BEST = MOST ACCURATE = TEST OF CHOICE STIM. ELECTRODE TRANSCUTANEOUSLY AT SMF RECORDING ELECTRODE AT NL GROOVE IF LESS THAN 10% OF NL SIDE = BAD Px—DECOMPRESSION–BEWARE BECAUSE GBS COULD GIVE THESE RESULTS DO SERIAL STUDIES TO FOLLOW ANTIDROMIC POTENTIALS, ACOUSTIC REFLEX EVOKED POTENTIAL , MAGNETIC STIMULATION—NOT CLINICALLY USEFUL HOUSE BRACKMAN SCORE (MORE OF A RECOVERY SCORE THAN A DIAGNOSTIC SCORE)—ALLOWS FOR CLINICAL GRADING OF THE SEVERITY OF THE LESION I = NL II = MILD EASY COMPLETE EYE CLOSURE III = MODERATE——ABOUT 75% RECOVERY—THE BEST YOU CAN HOPE FOR WITH AN INTERPOSITION GRAFT COMPLETE EYE CLOSURE WITH EFFORT SLIGHT SYNKINESIS (NEUROTMESIS) IV = MOD/SEVERE NL AT REST INCOMPLETE EYE CLOSURE V = SEVERE ABNL AT REST BARELY PERCEPTIBLE MOTION VI = TOTAL PARALYSIS LAB TESTS GTT, CBC, LYME TITERS, HIV, MONOSPOT, TB, SARCOID, MHATP, AUTOIMMUNE PANEL AUDIOGRAM OC/OP TASTE AND SENSATION EPIGLOTTIS—-TASTE (SVA)-&-SENSATION(GSA)=INT BR OF SLN(ARNOLD’S) BOT——–TASTE(SVA)-&–SENSATION(GSA)==LINGUAL BR OF GLOSSOPHARYNGEAL(JACOBSEN’S) PALATE—–TASTE(SVA)=GSPN(VIDIAN N OF THE PTERYGOPALATINE CANAL=CN7)——–SENSATION(GSA)=GREATER PALATINE NERVE (V2) ORAL TONGUE—-TASTE(SVA)=CHORDAE TYMPANI=CN7——-SENSATION(GSA)=LINGUAL NERVE (V3) V3, 9 AND 10 CAN ALL GIVE YOU REFERRED OTALGIA! TASTE = GUSTATION = THE ABILITY TO DISTINGUISH BETWEEN VARYING GUSTATORY STIMULI (BITTER, SWEET, SALTY, AND SOUR) LIKE AUDITION AN ANALYTICAL SENSE—–VS OLFACTION AND VISIONE = SENTHETIC SENSES FLAVOR = TASTE + OLFACTION (75%) + TACTILE AND CHEMICAL SENSATION CAN STIM A TASTE WITH IV SUBSTANCES—CHEMORECEPTORS VARIOUS DYSGEUSIAS INCLUDE PHANTOGEUSIA, ECT…..HIGH INCIDENCE OF COMORBID DEPRESSSION NO REAL TOPOGRAPHICAL MAP OF TASTE—-HOWEVER SOME PREDILECTIONS BITTER = PRIMARILY BOT—-TRANSECT BOTH CHORDA TYMPANI NERVES AND YOU STILL TASTE BITTER (CN 9) SOUR = SIDES OF TONGUE (FUNGIFORM PAPILLA)
SWEET = DORSAL MID TONGUE SALTY = TIP OF TONGUE FILIFORM PAPILLAE REALLY HAVE NO GUSTATORY FUNCTION! IMAGINING CT FOR TRAUMA- OTHERWISE MRI WITH GADOLINIUM BELL’S PAULSEY CAWTHORNE “ALL THAT PAULSIES IS NOT BELLS”—–A DX OF EXCLUSION SIR CHARLES BELL 1829 IDIOPATHIC (PROBABLY HSV) ->1/2 OF ALL CASES (80%) OF ALL FP 20-30/100,00/YEAR +PTS >65, – PTS <13 MALE=FEMALE DM +4-5X RISK THIRD TRIMESTER +3.3X RISK R=L, <1% B FAMILY Hx 8-10% RECURRENT 9%(30% RECURRENT BELLS=OCCULT CA)—MUST IMAGE—-Rx IS DECOMPRESSION VS INTERMITTENT STEROIDS AND VALTREX WHEN THE PRODROME BEGINS SUDDEN ONSET OF UNILATERAL PARESIS(1/3) OR PARALYSIS (2/3) POSSIBLE VIRAL PRODROME (60%) HERPETIC VIRAL STOMATITIS-FUNGIFORM PAPILITIS-CHORDAE TYMPANI NEURITIS-GENICULATE GANLIONITIS-FACIAL NEURITIS AND PAULSEY PROGRESSION OVER 24-48 HOURS ?EXPOSURE TO COLD AIR SUDDEN PARESIS OF ALL BRANCHES OFTEN OTALGIA OR HITSELBERGER’S SIGN DYS OR HYPERACOUSIS(PHONOPHOBIA) DYSGEUSIA IPSI XEROSTOMIA OR XEROPTHALMIA FACIAL HYPESTHESIA OR DYSESTHESIA EPIPHORA, ECTROPION, NAO, ORAL INCOMPETENCE, SYNKINESIS WITH MASS MOVEMENT OR GUSTATORY SWEATING NO INVOLUNTARY MOVEMENT(EMOTIONAL) + BELL’S PHENOM 100% FUNGIFORM PAPILITIS (A TONGUE BLADE Dx) (PROBABLE ORIGIN) ERYTHEMATOUS CHORDA TYMPANI (NEURITIS) NO OTHER CNS OR OTOLOGIC FINDINGS IF NO RESOLUTION IN 3-4 WEEKS THEN PROBABLY GET AN MRI—- AXIOM GOES— IMAGE IF RECURRENT PARALYSIS, SLOWLY PROGRESSIVE, NO RECOVERY IN 3-6 MO?, PAULSEY ASSOC WITH TWITCHING MRI GADOLINIUM LIGHTS UP MEATAL FORAMEN —(JUNCTION OF IAC AND LABYRINTHIAN PORTION OF THE FACIAL NERVE) IN PERIGENICULATE REGION OF FALLOPIAN CANAL HIGH HSV TITERS—LOW LYME TITERS BELLS NOT RESOVED IN 6 MONTHS THINK CA 71% RECOVER WITHOUT SEQUELAE 13% SLIGHT SEQUELAE 13% INCOMPLETE RECOVERY BAD Px: HYPERACOUSIS, XEROPHTHALMIA, DM, HTN, PAIN BAD SYNDROME: BELLS PHENOM ABSENT ANESTHETIC CORNEA DRY EYE (ALSO BAD ARE ADVANCED AGE, POST AURICULAR PAIN, AND ABSENT STP REFLEX) MOST IMPORTANT Px INDICATOR IS DEGREE OF PARALYSIS 85% BEGIN TO RECOVER WITHIN 3 WKS 15% WITHIN 3 MONTHS CLASSICALLY SAID IF THEY RECOVER WITHIN 3 WEEKS IT WILL RECOVER COMPLETELY IF IT RECOVERS WITHIN 3 MONTHS IT WILL BE PRETTY GOOD RECOVERY OTHERWISE IT MAY NOT BE SO GOOD Rx PT WITH ELECTIC STIM AND FACIAL MASSAGE?—CONTROVERSIAL EYE CARE (MOISTURE CHAMBER) (CHILDREN OFTEN DO NOT REQUIRE) STERIODS (60MG Q D WITH A 15 D TAPER) ACYCLOVIR (400MG 5 X DAY FOR 10 DAYS)—FAMVIR OR VALTREX DECOMPRESSION? RAMSAY-HUNT SYNDROME (HUNT 1907)
HERPES ZOSTER OTICUS 3rd MOST COMMON CAUSE OF FP MANIFESTATION OF DORMANT VARICELLA ZOSTER VIRUS REACTIVATING IN THE EXTRAMEDULLARY CRANIAL NERVE GANGLIA(GENICULATE) DURING PERIODS OF DECREASED CMI MAY PROGRESS FOR 14-21 DAYS SEVERE OTALGIA—-PAIN CHARACTERIZES THE SYNDROME FACIAL PARALYSIS-MORE SEVERE (15-30% FULL RECOVERY) FACIAL HYPESTHESIAS VESICULAR ERUPTION IN CONCHAL BOWL FROM AURICULAR BRANCH OF VAGUS CONVEYING GSV OF 7-(EAC AND PALATE)-SO CHECK PALATE—SOMETIMES THE HERPETIC VESICLES FOLLOW THE PARALYSIS BY 10-14 DAYS! VARYING(10%)SNHL +/-VESTIBULOPATHY OFTEN COMORBID CN DEFICITS! Rx: IV ACYLOVIR (USED TO BE DECOMPRESSION) +/- STERIODS — ROUTINE EYE CARE CONGENITAL/NEONATAL FACIAL PARALYSIS 1/1000 LIVE BIRTHS IMPAIRED EYE CLOSURE, FLATTENED NL FOLD CAN BE VERY DIFFICULT TO SEE—MUST STIMULATE CHILD OFTEN HAVE TO GET AN ENOG OR EMG DIFF Dx = DEVELOPMENTAL VS TRAUMATIC LOOK FOR BELL’S PHENOM, TEAR PRODUCTION, AND CORNEAL SENSATION GET ABR, CT AND ESPECIALLY ENOG IN THE 1ST 2-3 DAYS AFTER BIRTH (NL IN TRAUMA) MUST ADDRESS THE EYE PROTECTION AND THE FEEDING ABILITY OF THE NEONATE TRAMATIC (BIRTH TRAUMA) CONG FACIAL PARALYSIS 85% OF CONG FACIAL PARALYSIS CEPHALOPELVIC DISPROPORTION—->3500 GRAMS FORCEPS (LOOK FOR HEMOTYMPANUM, FACIAL BRUISING, LACERATIONS, PRIMAPARITY, AND SWELLING) >90% RECOVERY ENOG WILL BE NL WITHIN THE FIRST 2-3 DAYS AFTER THE BIRTH TRAUMA DEVELOPEMENTAL LOOK FOR OTHER CRANIOFACIAL ABNL (CLEFT PALATE, HYPOPLASTIC MAXILLA, MICROTIA, AND SNHL) MOBIUS(MOEBIUS) SYNDROME (CONG. FACIAL DIPLEGIA) AUTO D DIPLEGIA UNILAT OR B LR PAULSEY–CLASSICALLY A DIPLEGIA! +/-TRUNCAL,EXTREMITY,AURICULAR ABNL +/- HYPOGLOSSAL DEFICITS——RESULTANT DYSARTHRIA–-AND CANNOT UTILIZE A 12—7 TRANSPOSITION SOME LOWER FACE SPARRING POSSIBLE MR, MIXED HL, MAY HAVE ASSOC. CARDIOFACIAL SYNDROME Bx MIMETIC MUSCLES-+MOTOR ENDPLATES MAY DO CROSSOVER ANASTOMOSIS, IF NO MOTOR ENDPLATES NEED A NEUROMUSCULAR TRANSFER (TEMPORALIS TO UPPER FACE)—–PROBABLY WILL NEED THIS (HOPEFULLY THE MIDFACE WILL BE SPARED) CONG UNILAT LOWER LIP PAULSEY(ASYMMETRIC CRYING FACIES) ONLY NOTED WHEN CRYING L>R APLASIA OF DEPRESSOR ANGULI ORIS(NO EYE OR NL FOLD DEFICITS) MAY BE ASSOC. WITH CARDIOFACIAL SYNDROME ISOLATED RAMUS MANDIBULARIS PARALYSIS AND CARDIAC DEFECTS HEMIFACIAL MICROSOMIA/GOLDENHAR’S SYNDROME (OCULO-AURICULO-VERTEBRAL DYSPLASIA) AUTO r CHARGE SYNDROME CHILDHOOD (NON CONG) FACIAL PARALYSIS 42% BELL’S 21% TRAUMA 13% AOM (+BONEY DEHISSENCE OF HORIZONTAL(TYMPANIC) PORTION OF 7) 8% CONG-LOOK FOR ISOLATED MARGINAL MANDIBULAR DEFICITS 2% NEOPLASM EYE CARE IS SELDOM REQUIRED
BILATERAL FACIAL PARALYSIS (DIPLEGIA) GBS=#1—-PROGRESSIVE ASCENDING MOTOR PARALYSIS LYME’S Dz=#2 SARCOIDOSIS (UVEOPAROTID FEVER OF HEREFORDT)—50% OF THESE PTS=#3 INFECTIOUS MONONUCLEOSIS ACUTE PORPHYRIA(PHOTOPHOBIA/ABD. PAIN) SYPHILIS? BOTULISM(Dx: STOOL SPECIMEN) LEUKEMIA POLYARTERITIS NODOSA ACUTE IDIOPATHIC POLYNEURITIS TRAUMA(10-20% OF T-BONE Fx ARE B) CONG. CENTRAL PONTINE LESION NEOPLASMS CAUSING FACIAL PARALYSIS GRADUAL ONSET(>3 WKS)-10%ACUTE RECURRENT(30% OCCULT CA) FACIAL TWITCHING—–SUBUNIT (BLEPHAROSPASM) VS HEMIFACIAL SPASM YOU WOULD SEE WITH A FACIAL NEUROMA SYNKINESIS PROGRESSION >6 MONTHS PALPABLE MASS MULT. CN NEUROPATHIES INTRACRANIAL PRIMARILY BENIGN–VESTIBULAR SCHWANNOMA, GENICULATE OSSEOUS HEMANGIOMA, CHOLESTEATOMA, MENINGIOMA A FACIAL NEUROMA IS ALSO POSSIBLE–ALWAYS CONSIDER NERVE SPARRING OPTIONS FOR ALL OF THESE (HAMANGIOMAS AND NEUROMAS)—-ANOTHER OTOLOGIST’S DILEMMA–LIKE A CHILD’S RP—OBSERVATION, RT, GAMMA KNIFE—IF YOU DO TAKE IT—-UTILIZE INTRAOPERATIVE FROZEN SECTIONS TO SECURE MARGINS AND IMMEDIATELY GRAFT WITH GREATER AURICULAR NERVE EXTRACRANIAL PRIMARILY MALIGNANT-MUCOEPIDERMOID CA >50% OF PAROTID GLAND CA BUT RARELY PRESENT WITH FACIAL PARALYSIS –ADENOID CYSTIC CA(CYLINDROMA)-20% PRESENT WITH FACIAL PARALYSIS PROBABLY BEST TO GRAFT IMMEDIATELY AFTER RESECTION—-IF YOU DO NOT TAKE THE MIMETIC MUSCULATURE LYME DISEASE—BANNWARTH’S SYNDROME IN EUROPE BORRELIA BURGDORFERI(SPIROCHETE) PRIMARY RESERVOIR=DEER TICK- IXODES DAMMINI PACIFICUS SECONDARY RESERVOIR=WHITE TAILED DEER & WHITE FOOTED MOUSE 3 STAGES STAGE I (FLU LIKE Sx) ERYTHEMA CHROMICUM MIGRANS(RED SPREADING RING) MALAISE, MYALGIAS, FEVER, LAD–CUTANEOUS MANIFESTATIONS SPARE THE PALMS AND SOLES STAGE II (NEURO Sx) WEEKS TO MONTHS LATER–HEADACHE, 15% CNS SIGNS(VARIABLE) 50% FACIAL PARALYSIS(10% OF PTS) STAGE III (ARTHRALGIAS) WEEKS TO YEARS LATER–60% RECURRENT ARTHRALGIAS Dx: WARTHIN STARRY STAIN FOR BORRELIA HIGH ESR, HIGH IgM ANTI-BORRELIA–SEROLOGY POSITIVE AFTER 2 WEEKS 10% OF HEALTHY PEOPLE IN ENDEMIC AREAS HAVE POSITIVE TITERS Rx: TETRACYCLINE P.O. FOR 10 DAYS SECOND LINE=AMOX/PCN OR CEFTRIAXONE 2 G IV QD X 14 MELKERSON-ROSENTHAL SYNDROME (1931) RECURRENT OROFACIAL EDEMA RECURRENT FACIAL PARALYSIS(POSSIBLY PROGRESSIVE) LINGUAL PLICATA(FISSURED TONGUE)–POSSIBLY PERMANENT ORAL CAVITY/LIP DEFORMITY(CHELITIS) +/- MIGRAINE HA
COMPLETE TRIAD IN ONLY 25%–USUALLY SEQUENTIAL TRIAD OF SIGNS USUALLY STARTS IN CHILDHOOD OR 2nd DECADE FEMALE>MALE UNILATERAL ON IPSI SIDE OF SWELLING PROBABLY A LOCALIZED VARIANT OF ANGIONEUROTIC (QUINKE’S) EDEMA VS A VARIANT OF SARCOIDOSIS (HIGH ACE LEVELS/GRANULOMATOUS CHANGES) Dx: LIP BIOPSY-GRANULOMATOUS CHANGES-NON-CASEATING Rx: STEROIDS ACYLOVIR? THALIDOMIDE PROPHYLACTIC DECOMPRESSION(FACIAL PARALYSIS TENDS TO WORSEN) SARCOIDOSIS HEERFORDT’S DISEASE(HEERFORDT-WALDENSTROM SYNDROME) UVEOPAROTID FEVER—-PAROTID ENLARGEMENT, CN PAULSEY, ANDIRIDOCYCLITIS (RESEMBLES SJOGRENS/MIKULICZ SYNDROME ANT. UVEITIS IRIDOCYCLITIS FACIAL PARALYSIS MILD FEVER NON-SUPPURATIVE PAROTIDITIS Dx: HIGH ESR, HIGH LFT’S, HYPERGLOBULINEMIA, B HILAR ADENOPATHY, HYPERCALCEMIA, HIGH ACE LEVELS, ANERGY Rx: STEROIDS T-BONE TRAUMA 30% OF ALL CHI HAVE A SKULL FX 18% OF ALL SKULL FX INVOLVE THE TEMPORAL BONE 50%OF ALL CHI HAVE A SNHL CN 6 IS THE MOST FREQUENTLY INJURED CN (LR PAULSEY) FULL RECOVERY IF ONLY LOW FREQ PARTIAL RECOVERY IF ONLY HIGH FREQ 15% CHI WILL SUFFER A CHL HEMOTYMPANUM TAKES ABOUT 6-8 WKS TO RESOLVE(CHL RESOLVES IN 4WKS) I-S JOINT SEPARATION STAPES CRURA FX MALLEUS IS RARELY INJURED 0.7% CHI RESULT IN FACIAL PARALYSIS T-BONE Fx/BASILAR SKULL Fx REALLY MOST MIXED 1-6% WILL HAVE A CSF LEAK OLD FIGURES FROM IMPACT STUDIES DONE ON THE 40’S 80-90% LONG, 10-20% TRANSVERSE, 8% BILAT STENVER PROJECTION USEFUL RADIOGRAPHICALLY IN ANTIQUITY MUST GET FINE CUT CT OF T-BONES—BOTH AXIAL & CORONAL Hx HL,TINNITUS,AUTOPHONY,VERTIGO,FACIAL WEAKNESS,FACIAL HYPETHESIAS,DIPLOPIA,OTORRHEA,RHINORHEA PE HEMOTYMP,RACOON EYES,BATTLES SIGN,BLOOD IN EAC,TUNING FORKS,NYSTAGMUS,TOPODIAGNOSTIC TESTS,TM STATUS,CN FUNCTION,FISTULA TEST, (B FACIAL PARALYSIS MAY BE HARD TO DETECT) ANCILLARY CT,AUDIO,ENOG HEMOTYMPANUM USUALLY RESOLVES IN 1-3 MONTHS LONGITUDINAL TRIAD:LOC, CHL, BLOODY OTORHEA 80%-90% OF T-BONE Fx’S 20%-25% OF THESE SUFFER FACIAL PARALYSIS(THE OVERALL MAJORITY OF FN PARALYSIS) FROM TEMPERO-PARIETAL TRAUMA(LAT. SKULL)(MINOR TRAUMA) Fx TENDS TO RUN PARALLEL TO THE EAC–THROUGH THE MIDDLE EAR MIDDLE EAR ALMOST ALWAYS INVOLVED HEMOTYMPANUM IF TM INTACT RARELY CSF LEAK OSSICULAR DAMAGE COMMON(I-S JOINT SEPARATION > STAPES INJURY)) ROOF OF THE EAC OFTEN FRACTURED—IMPORTANT TO LOOK FOR TYMPANIC RING Fx AND AVOID GETTING SQUAM IN THE MIDDLE EAR BATTLE’S SIGN(POST AURICULAR A.—–MASTOID ECCYMOSIS) MAY INVOLVE FORAMEN LACERUM (DORELLOS CANAL) OR FORAMEN OVALE (V3) MAY INVOVE EUSTACION TUBE B 10-20%!—B FACIAL PARALYSIS MAY LOOK LIKE LACK OF AFFECT USUALLY ANT. TO THE OTIC CAPSULE CAN HAVE PLF FROM STAPES SUBLUXATION INTO THE O.W.
TRANSVERSE TRIAD:SNHL, SPONT. NYSTAGMUS, FACIAL PARALYSIS 10-20% OF T-BONE Fx’S FROM FRONTAL OR OCCIPITAL TRAUMA(MASSIVE) Fx RUNS FROM THE FORAMEN MAGNUM TANSVERSELY ACROSS THE PETROUS APEX ACROSS THE IAC AND OTIC CAPSULE, ENDING AT THE FORMAMEN SPINOSUM(MMA) OR LACERUM(CN6) OTIC CAPSULE AND IAC RUPTURE COMMON SNHL AND VERTIGO COMMON HEMOTYMPANUM CSF LEAK COMMON(SALTY TASTE WORSE WITH HEAD DOWN) FACIAL NERVE PARALYSIS 50%(DISTAL LABYRINTHIAN SEGMENT) EAC INTACT TM USUALLY INTACT MAY INVOLVE THE JUGULULAR FORAMEN OR FOMAMEN MAGNUM FACIAL NERVE REPAIR EYE IS MOST IMPORTANT IN REANIMATION FOLLOWING TRANSECTION THE DISTAL NERVE WILL STIM FOR 72 HOURS PRIOR TO WALLERIAN DEGENERATION SHOULD EXPLORE AND PERFORM EPINEURIAL REPAIR WITHIN 24 HOURS IF TRAUMA WAS A CLEAN TRANSECTION IF DIRTY TRANSECTION EXPLORE EARLY AND TAG THE ENDS OF THE FACIAL NERVE AND THEN REPAIR AT 18-21 DAYS(OPTIMAL PROTEIN REGENERATION) REPAIR WITHIN DAYS IS BETTER THAN EXTENSIVE WAITING DISTAL TO PES END TO END EPINEURAL REPAIR IS ALWAYS BEST(MUST BE TENSION FREE) NO BENEFIT TO REPAIR INJURIES MEDIAL TO LATERAL CANTHUS PROXIMAL TO PES SHOULD PERFORM INTERFASCICULAR REPAIR CAN MOBILIZE NERVE 1 CM WITH MASTOID RELEASE (THIS MAY BE OUT OF VOGUE DUE TO DEVASCULARIZATION) MUST HAVE NO TENSION ON THE SUTURE LINES (.5CM=70GM FORCE) IF TRANSECTION IS WITHIN T-BONE SHOULD PERFORM INTERFASCICULAR REPAIR WITH EPINEURAL RESECTION AND PERINEURAL REPAIR(EPINEURIUM CAN PROPAGATE SECONDARY SCAR TISSUE FORMATION) CABLE GRAFT IS NEXT BEST OPTION SMALLER DIAMETER AUTOGRAFTS DO BETTER DUE TO THEIR MORE RAPID REVASCULARIZATION GRAFTS SHOULD BE SECURED WITH PERINEURAL SUTURES FOR EXACT APPROXIMATION USING MICROSURGICAL TECHNIQUES(10-0 NYLON) GREATER AURICULAR NERVE(C2-C3) GETS YOU UP TO 10 CM SUPRACLAVICULAR NERVES WORK WELL AND HAVE SOME BIFURCATIONS WHICH MAY BE OF BENEFIT SURAL NERVE GETS YOU UP TO 30-35 CM—1-2 CM POST/LAT TO LAT MALLEOLUS—DEEP TO LESSER SAPHENOUS VEIN SURAL NERVE IS BETTER—-INCREASED DIAMETER AND INCREASED NEURAL POPULATION BEST HOPE FOR INTERPOSITION GRAFT IS HB GRADE III—SYNKINESIS FOR CPA TUMOR(NO VIABLE PROXIMAL STUMP) 12 to 7 CROSSOVER IS BEST CAN ALSO DO 7 TO 7 CROSSOVER MUST WAIT UP TO 12 MONTHS TO SEE FUNCTION YOU HAVE UP TO 18 MONTHS TO REINNERVATE MIMETIC MUSCULATURE AFTER THAT YOU CONSIDER NEUROMUSCULAR TRANSFER WITH MASSETER OR TEMPORALIS MUSCLE SWING AS ALWAYS PROTECT THE EYE V1 INTACT (CORNEAL BLINK) DO GOLDWEIGHT NO CORNEAL SENSATION(V1) = TARSORRAPHY GELPE SPRING FOR LOGOPHTHALMOS—-NOT USED MUCH ANYMORE—-HIGH EXTRUSION RATE A GOLD WEIGHT WILL SHOW THROUGH THIN PALE PALPEBRAL SKIN—GENERALLY A WELL TOLERATED PROCEDURE PLACE UNDER THE MUSCLE ON THE TARSAL PLATE COMBINE WITH TEARS, MOISTURE CHAMBER, AND OTHER CONSERVATIVE MEASURES