Maxilofacial Surgery Facial Neuropathology Question And Answers

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Facial Neuropathology Definition

 Trigeminal neuralgia: It is a sudden, severe, brief, stabbing, recurrent pain along the distribution of the trigeminal nerve

Facial Neuropathology Important Notes

1. Trigger zones for trigeminal neuralgia:

  • Vermillion border of lips
  • Around eyes
  • Ala of nose

2. 5 hypotheses of Bell’s palsy:

  • Rheumatic
  • Cold
  • Ischaemia
  • Immunological
  • Viral

3. Classification of nerve injuries:

  • Seddon’s Classification:
    • Neuropraxia:
    • Axonotmesis
    • Neurotmesis
  • Sunderland’s Classification:
    • First-degree injury
      • Type 1: Mild compression of the nerve trunk
      • Type 2: Moderate compression
      • Type 3: Severe compression
    • Second-degree nerve injury
    • Third-degree nerve injury
    • Fourth-degree nerve injury
    • Fifth-degree nerve injury

Facial Neuropathology Long Essays

Question 1. Describe in detail bout trigeminal neuralgia, its etiology, clinical features & management.
Or
Define trigeminal neuralgia & describe in brief its etiology, clinical signs & symptoms & management.
Or
Tic Dolourex
Answer:

Trigeminal Neuralgia of Definition:

It is a sudden, severe, brief, stabbing, recurrent pain along the distribution of the trigeminal nerve

Etiology of Trigeminal Neuralgia :

  • Pathological:
    • Dental pathosis
    • Allergic
    • Traction on divisions of the trigeminal nerve
    • Irritation to the ganglion
    • Ischaemia
    • Secondary lesions
    • Aneurysm of internal carotid artery

Read And Learn More: Oral and Maxillofacial Surgery Question and Answers

Clinical Features of Trigeminal Neuralgia:

  • AGE: Around 35 years
  • Sex: Common in female
  • Site: Right lower portion of the face, usually unilateral
  • Duration: A few seconds to a few minutes
  • As time passes duration between the cycles decreases
  • Nature: stabbing or lancinating
  • Aggravating factors: Activation of Trigger Zones These are the vermillion border of the lip, around the eyes, ala of the nose

Interference with other activities:

  • The patient avoids shaving, washing their face, and chewing. Brushing, as these may aggregate pain
  • These lead to a poor lifestyle
  • Extreme cases: leads to “Frozen or Mask Like Face”

 Medical management of Trigeminal Neuralgia:

  • Medical:
    • Carbamazepine: Initial dose: 100 mg twice daily until relief is achieved
    • Dilantin: 300-400 mg in single or divided doses
    • Gabapentin: 11200-3600 mg/day TID/QID
    • Baclofen: 10 mg TID
    • Amitriptyline: 25-75 mg/day QID
    • Combination therapy: Dilantin + carbamazepine
  • Surgical:
    • Injection of alcohol in gasserian ganglion
    • Nerve avulsion: Performed on lingual, buccal, or mental nerve
    • Part of the nerve is sectioned
    • Electrocoagulation of gasserian ganglion: Radiotherapyy is done
    • Rhizotomy: Trigeminal sensory root is sectioned
    • Newer technique: Tens
    • Low-intensity current is used at high frequency and is applied to the skin through electrodes attached by a conduction paste

Facial Neuropathology Incision For Mental Neurectomy And Buccal Extension

Facial Neuropathology Neurotmesis Y Shaped Dr Ginwallas Incision

Facial Neuropathology Short Essays

Question 1. Facial nerve palsy. 
Answer:

Etiology of Facial nerve palsy:

  • Congenital
  • Traumatic
  • Infections
  • Inflammation
  • Neoplastic
  • Idiopathic

Clinical Features of Facial nerve palsy:

  • Unable to raise eyebrows
  • Unable to blow cheeks
  • Expressionless face
  • Absence of wrinkling
  • Absence of function of the mandibular nerve
  • Lack of movement of the upper lip
  • Unable to close one eye
  • Absence of nasolabial fold
  • Absence of taste sensation
  • Drooling of the lower lip on the affected side

Bell’s Palsy:

  • Idiopathic paralysis of the facial nerve of sudden onset

Etiology: 5 Hypothesis:

  • Rheumatic
  • Cold
  • Ischaemia.
  • Immunological
  • Viral

Clinical Features of Bell’s Palsy:

  • Pain in post auricular region
  • Sudden onset
  • Unilateral loss of function
  • Loss of facial expression
  • Absence of wrinkling Inability to close the eye
  • Watering of eye Inability to blow the cheek
  • Obliteration of nasolabial fold
  • Loss of taste sensation
  • Hyperacute
  • Slurring of speech

Management Bell’s Palsy:

  1. Physiotherapy
    • Facial exercises
    • Massaging
    • Electrical stimulation
  2.  Protection to the eye:
    • Covering of eye with a bandage
  3. Medical management:
    • Prednisolone – 60-80 mg per day
    • 3 tablets for 1st 4 days
    • 2 tablets for 2nd 4 days
    • 1 tablet for 3rd 4 days
  4. Surgical treatment:
    • Nerve decompression
    • Nerve grafting

Question 3. Diagnosis of trigeminal neuralgia.
Answer:

  • Paroxysmal unilateral facial pain:
    • Distribution of pain along branches of the trigeminal nerve
    • Trigger zones positive
    • Absence of symptoms between attacks
    • No neurological deficit MRI for vascular lesions
  • White & Sweet Criteria:
    • Paroxysmal pain
    • Stimulation of trigger zones causes pain
    • Pain along the distribution of nerve
    • Unilateral pain
    • Normal neurological examination

Question 4. Ginwalla’s technique.
Answer:

Ginwalla’s technique

Used for the management of trigeminal neuralgia

The extent of Incision of Ginwalla’s technique:

  • Anterior border of the ramus up to the retromolar area
  • It is split into 2 halves
  • One extends lingually & the other buccally
  • Results in Y-shaped incision

The technique of Ginwalla’s:

  • Incision is given
  • Expose the ramus
  • Ligate the inferior alveolar nerve at two ends
  • Divide it between ligatures
  • Cauterize superior end
  • Hold the inferior end with a hemostat
  • Similarly, ligate mental nerve
  • Avulse mental nerve
  • Excise the remaining inferior alveolar nerve
  • Closure of wound

The technique of Ginwalla’s

Question 5. Nerve injuries in oral surgery.
Answer:

Seddon’s Classification:

  1. Neuropraxia:
    • Results from mild insult to a nerve
    • No axon degeneration occurs
    • Mild paraesthesia present
  2.  Axonotmesis:
    • Severe injury
    • Degeneration of afferent fibers
    • Severe paraesthesia present
  3. Neuromimesis:
    • Most severe injury of the nerve
    • Complete destruction of nerve structure
    • Anesthesia is present
    • If the nerve is present within the bony canal, recovery can occur by the process of nerve degeneration

Sunderland’s Classification:

1. First-degree injury:

  • Type 1:
    • Mild compression of the nerve trunk
    • Results in ischemia & conduction block
    • No axonal degeneration
    • Recovery within a day
  • Type 2:
    • Moderate compression
    • Results in enema & conduction block
    • Recovery within 1–2 days
  • Type 3:
    • Severe compression
    • Disruption of myelin sheath
    • Sensory loss
    • Recovery in 1-2 months

Facial Neuropathology Neuropraxia First Degree Lesion

2. Second-degree nerve injury:

  • Synonymous with Seddon’s axonotmesis
  • Axonal damage occurs
  • Epineurium, perimetrium & endoneurium is intact
  • Paraesthesia & anaesthesia present
  • Spontaneous recovery

Facial Neuropathology Axonotmesis Second Degree Lesion

3. Third-degree nerve injury:

  • Synonymous with Seddon’s axonotmesis
  • Axonal damage
  • Damage to epineurium
  • Paraesthesia & anesthesia present
  • Regeneration of axon is blocked
  • Incomplete sensory recovery Surgical repair needed

Facial Neuropathology Axonotmesis Third Degree Lesion

4. Fourth-degree nerve injury:

  • Synonymous to Seddon’s axonotmesis Damage epineurium, endoneurium & axons
  • Intact epineurium
  • Sensory impairment
  • Poor recovery
  • Surgical intervention needed

Facial Neuropathology Axonotmesis Fourth Degree Lesion

5. Fifth-degree nerve injury:

  • No conduction of impulses
  • Even epimerism is destroyed
  • Poor prognosis

Facial Neuropathology Axonotmesis Fifth Degree Lesion

Facial Neuropathology Short Question And Answers

Question 1. Bell’s sign.
Answer:

Bell’s sign

  • Seen in Bell palsy
  • The inability to close the eye occurs in it
  • On attempting to close the eye, the eyeballs roll upwards
  • This peculiar sign is called the “Bells Sign”

Question 2. Trigger zones.
Answer:

Trigger zones

  • These are cutaneous zones located along the distribution of divisions of the nerve
  • Stimulation of these zones occurs by the following
  • Shaving, washing face, chewing, brushing, applying lotion, cosmetics, eating, touching, strong breeze
  • Leads to pain

Question 3. Neurectomy.
Answer:

Neurectomy

  • This is palliative treatment in which peripheral branches of the nerve are avulsed
  • This prevents transmission of the peripheral impulses to the central trigeminal system
  • It can be done over
  • Infraorbital nerve
  • Mental nerve
  • Inferior alveolar nerve
  • Lingual nerve

Facial Neuropathology Viva Voce

  1. Classic Bell’s palsy results from a lesion involving the glossopharyngeal nerve
  2. The trigeminal nerve is a mixed nerve
  3. A gasserian ganglion is found in a space known as Merkel’s cavity
  4. The initial stage of paralysis of the facial nerve is the tongue deviates to the same side on the protrusion
  5. Tic douloureux treatment includes carbamazepine
  6. Damage to a seventh cranial nerve is associated with Bell’s palsy
  7. Trigeminal neuralgia is characterized by sharp pain when pressure is applied to the affected area

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