supra nuclaer pathway.
Facial nucleus is located in the pons , it is divided into two part . the upper part is supplied by the pyramidal tract of the both side of cerebral hemisphere .and receive another supply from the extra pyramidal fibers . the lower part receive only supply from pyramidal fibers of the opposite side of cerebral hemisphere ,this part supply lower quarter of the face.
The facial nerve is mixed , it has autonomic ,sensory , motor fibers.
1) The autonomic fibers supply two glands:
a- Lacrimal gland.
b- Salivary gland ( sub lingual and sub maxillary gland ).
2) The sensory fibers are responsible for taste sensation of anterior two thirds of the tongue.
3) The motor fibers divide at the parotid gland into five branches , each one supply spcific muscles in the face.
(1) Mandibular branch which supply the following muscles:
(a) Levator libii superioris: this muscle raise upper lip upward (showing your gum).
(b) Depressor libii inferior: pull lower lip down ward.
(c) Resorious: pull angle of the mouth laterally.
(d) Mentalis: raise skin of chin.
(2)Cervical branch supply the following:
(a) Platysma: make tension of the neck.
(b) Stapedius.
(3) Temporal branch supply the following muscles:
(a) Frontalis: pull eye brows upward.
(b)Orbicularis oculi , this muscle has two parts:
a- pulpebral part: do gentile eye closture.
b- orbital part : do firm eye closture.
(c) Corregaror: pull eye brows together.
(4) Zygomatic branch which supply the following muscle:
(a)Buccinator :draw cheeks inward.
(b)Nasalis: widening of one nose strile.
(c) Zygomatic major and minor: pull angle of the mouth upward and outward.
(5) Buccal branch supply thos muscles:
(a)Buccinator.
(b)Orbicularis oris: close lips and protrude them forward.
The facisl ner ve supply also a-posterior belly of digastric muscle.
b-stylohyoid muscle.
Types of the lesion of facial nerve:
(1) Upper motor neuron lesion: it is lesion of the cerebral hemisphere result in contra lateral paralysis of the lower quarter of the face , this paralysis involve voluntary movement but there is spare of the emotional and associative movement which is supplied by extra pyramidal fibers.
this paralysis is associated with hyper tonia and hyper reflexia and there may be associated hemiplegia on the same side of the facial paralysis.
criteria of the affected side.
1-Oblitration of the naso labial fold.
2-Dropping of the angle of the mouth with dribbling of saliva.
3- Accumulation of food behind cheeks.
4-Inability to blow the cheeks.
5-Inability to show teeth.
(2) Lower motor neuron lesion; it is lesion affect facial nucleus or nerve itself.there is paralysis in the upper and lower halves of the face on the same side of the lesion. this paralysis affect voluntary movement and emotional and associative movement . there is hypotonia and hyporeflexia.
Symptoms appear in the affected side:
1-Oblitration of the naso labial fold.
2-Dropping of the angle of the mouth with dribbling of saliva.
3- Accumulation of food behind cheeks.
4-Inability to blow the cheeks.
5-Inability to show teeth.
6-Inability to raise eye brows with absence of wrinkles of the face.
7-Inability to close eye.
Examination of the facial nerve.
(1) Motor part :it is examined through action of the mucles which appear in the facial expression.
a-Upper face :( frontalis and orbicularis oculi)
* Test for raising of the eye brows.
*Test for firm closture of the eye.
b- Lower face:( orbicularis oris , buccinator and retractor anguli).
Look for any symptoms refer to facial paralysis.
*Test for whistiing, blowing of the cheeks and showing of teeth.
(2) Sensory part: examine the taste sensation over anterior two thirds of tongue by drying patient tongue and then applying adrop of sweet or bitter or salty solution on its top see if the patient can properly recognize the taste.
(3)Glabellar reflex: in the normal adult , tapping the glabella(root of the nose) result in blinking ( cotraction of orbicularis oculi muscles) this blinking stops after (2-3) taps due to habituation.
Bell's palsy
Definition: non suppurative inflammation of the motor branch of the facial nerve within stylomastoid foramen. it is a lower motor neuron type.
Etiology
Usually with unknown cuase , but there is related conditions lead to bell's palsy:
a-Air draft.
b-Psychological ststus.
c- Some diseases as diabetes.
d- Loss of immunity.
Clinical presentation
1-Oblitration of the naso labial fold.
2-Dropping of the angle of the mouth with dribbling of saliva.
3- Accumulation of food behind cheeks.
4-Inability to blow the cheeks.
5-Inability to show teeth.
6-Inability to raise eye brows with absence of wrinkles of the face.
7-Inability to close eye.
Bell's phenomena: when patient attempts to close his eye, the eye ball roll upward
Objective diagnostic procedure
a- EMG
b-Nerve conduction study:
Results:increase in the distal latency.
decrease in the conductivity.
Assessment of the bell's palsy:
(1)Test for pain: the test is performed infront of mirror
the therapist stands behind the patient and put his thumb and index on the stylomastoid foramen and do bilateral pressure and move around ears till reach the parotid gland during that the therapist observe facial expression of the patient in the mirror.
(2)Reflexive examination:
a-Conjunctival reflexes:( afferent:cr-5, efferent cr-7)
Ask patient to look outward and inward, then touch corneo-conjunctival junction from the lateral side using thin piece of cotton.normally, stimulation of one side of the eye result in blinking of both eyes. absence of blinking on one side denotes facial paralysis of this side. b-Glabellar reflex: in the normal adult , tapping the glabella(root of the nose) result in blinking ( cotraction of orbicularis oculi muscles) this blinking stops after (2-3) taps due to habituation.
(3) test for adhesion: is applied by circular movement by middle three fingers on the muscles of the face. adhesions are obvious in the ftontalis muscle.
Cuases of adhesion:
a- prolonged abuse of the muscles.
b- prolonged use of galvanic stimulation.
(4) Muscle test: test for facial expression, patient sits infront of mirror and ask patient to do action of each muscle around eye ,mouth and nose.
N.B:In LMNL muscle test for orbicularis oculi muscle is firm closture of the eye as we test the orbital part.
Trearment
1)Acute cases:it treated to be treated by medication as corticosteroid and vitamins B complex with minor role of physiotherapy in the form of:
a-short wave:as it has anti rheumatic and anti inflammatory effect.
Placement of electrode: one is put behind ear and surface electrode at any part of the body.and is applied for 10 minutes.
b-Massage to improve circulation and prevent adhesion.
c- Patient needs to take rest.
2) chronic cases are treated mainly by:
a- facial massage: we can use several forms:
1- friction massage to break down adhesion by finger bads ,it may be:
a- transverse.
b- logitudinal.
c- circular.
2- half circular massage :is applied with one hand under chin on the affected side and the other on the forehead of the sound side.
3-segmental effleurage.
4-whole effleurage.
5- vibration around nose to open the air ways.
Aims of massage:
1-to regain the semetry of face.
2-open air ways.
3-improve the circulation.
4- break down adhesion.
b- Faradic stimulation:use pen electrode for (1-2) minutes put surface electrode on the nervetrunk or on the parptid gland and the other on the motor point of the muscles
c- fascilitation technique : use action of other muscle to fascilitate facial muscle:
resistance to neck muscle fascilitate contraction of frontalis muscle.
d- Active exercise: start exercise when muscles can do flicker contraction.as blowing and chewing gums.
e- splints: they are used in cases of adhesion which develop in the neglected cases .it is used for(7-8) months as hook splint which is applied from the mouth to the ears.
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