Page Ten P H Y S I O T H E R A P Y September, 1957 FACIAL By Dr. M. JACKSON, IT is not until th e developm ent,of a facial palsy th at the necessity and im portance o f a norm ally functioning facial nerve is realised. This lesion tends n o t only to shatter the m orale o f a patient but seriously affects his economic and social status. U nfortunately no t enough attention is given to this aspect o f th e lesion. I f facial palsy occurs as a com ­ plication o f injury or disease o f the tem poral bone it concerns both the otologist and the physiotherapist; th e latter m ust treat th e end result o f th e paralysis, th at is the muscles, whereas the form er is primarily concerned w ith the cause o f th e paralysis. H e must be prepared to advise w hether operative interference is necessary or not. In this paper I w ant to discuss th e anatom y, pathology and treatm ent o f paralysis o f th e facial nerve. T he facial nerve lies in close association with th e eighth nerve, separated from it by th e sensory division o f the seventh nerve as it enters th e petrous part o f the tem poral bone at th e internal auditory meatus. It appears on the inner wall o f the tym panic cavity and swells out to form the geniculate ganglion. I t then bends sharply backward in the upper p a rt o f th e middle ear, above th e fenestra ovalis or oval window. W hen the nerve reaches a point ju st below the horizontal sem icircular canal it bends downwards and des­ cends vertically to th e stylo-mastoid foram en. In its course through the m iddle ear and vertical portion, the nerve is enclosed in th e bony fallopian canal till it m akes its exit at th e stylo-mastoid foram en. A point o f im portance is that the nerve is firmly attached to the periosteum lining the canal. This fact makes it particularly vulnerable as any swelling o r trau m a could cause pressure on the nerve, and, if sufficiently long m aintained, may lead to degeneration of the nerve fibres. T he canal has the advantage, however, of acting as a splint to support a nerve graft and does away with the need for suture, minimising the form ation o f scar tissue and thus favouring regeneration. From the stylo-mastoid foram en the nerve turns abruptly forward, dividing into term inal branches deep to the parotid gland in front o f the ear. A lesion in this area, for example a tum our or injury, presents no problem in localization. The nerve has a longer course in a bony canal than any other nerve in the body and this probably accounts for the fact th at it is more often paralysed than any o ther n e rv e .' v T he narrow fallopian canal may hinder regeneration, but does not alter the fundam ental process o f degeneration and regeneration. We m ust distinguish between degenerative and non-degenerative lesions. In the latter, where a nerve impulse is tem porarily im paired, paralysis clears up com ­ pletely in a short tim e and, w hat is im portant, is that there is no wasting. In degenerative lesions there may either be an interruption o f axons with preservation o f supporting structures or com plete division of the nerve elements. U nfortunately ap art from operation, there is no certain means o f distinguishing between th e lesions as both show th e reaction o f diegeneration. This accounts for th e confusion when considering the indications for a decompression operation in traum atic palsy. D enervated muscle become flaccid and undergo pro­ gressive atrophy — m ore rapid during growth as in young children. Muscle atrophy an d resultant fibrotic changes following denervation are soon apparent because of the thin m usculature o f th e face, where there is no definite muscle fascia surrounding th e individual muscles. These are in­ serted in subcutaneous tissue o r skin w ithout intervention of any subcutaneous fascia. .G ravity and pull o f muscles are responsible for stretching denervated muscles which leads to characteristic drooping o f the face. W hen denervation has persisted for any length o f time, the fibrotic sheath tends to replace individual muscles which cannot then be m ade to contract, even if continuity o f nerve is restored. T he physio- PALSY F.R.C.S. (Edin.), D.L.O. therapist’s duty is to try and prevent these changes. Obvious­ ly, if th e continuity o f the nerve is n o t re-established, a time ' will com e when the fibrotic changes m ust occur. If there is no sign o f nerve regeneration with spontaneous m uscular movem ent, when is operative interference indi­ cated ? A ccording to Josephine Collier, experim ental evidence suggests th a t waiting for two or three m onths enhances the chances o f successful recovery but th a t intervals o f longer than six m onths tend to produce irreversible- changes. Clinical observation in peripheral nerve injuries points to the fact th a t the rate o f regeneration o f nerve is about 2 m.m. a day. W hat are the com m oner diseases which may affect the nerve whilst in contact with the internal and m iddle ear? (1) Internal E ar: T um ours causing pressure on th e facial nerve in internal auditory m eatus; such as a neurofibrom a o f the eighth nerve. I t is an interesting fact th at pressure to an amazing degree may occur, resulting only in facial paresis. This is due to there being plenty o f room for expansion o f the nerve. (2) Middle E ar: F r o m c h i l d h o o d t o o l d a g e t h e m i d d l e e a r is s u b j e c t t o i n f e c t i o n a n d m a y b e a p o t e n t i a l s o u r c e o f d a n g e r t o t h e f a c i a l n e r v e . (а) In acute infection o f the m iddle ear the facial nerve is rarely involved. Paralysis may be due to vascular congestion and oedem a, probably on account o f there being a dehiscence in the bony fallopian canal. This invariably clears up with resolution o f the infection. In acute m astoiditis pressure from pus in a cell leading on to th e nerve may cause paresis or paralysis. In some cases operation may be indicated. (б) T he incidence o f facial palsy is relatively much higher in chronic suppurative otitis m edia th an in acute conditions, and is chiefly due to cholesteatom a, which has the ability to erode the bony wall o f th e fallopian canal. O peration is im perative in these cases. T he incidence o f facial paralysis produced by acute head injury is high, especially in fractures o f the m iddle and pos­ terior fossa. M ost authorities agree th at between 80 to 90 % o f these cases recover completely, or a t least adequately. Recovery may be expected to follow massage and electricaL treatm ent o f the paralysed muscles. In such cases which show' no sign o f recovery after three m onths operation must be considered. Surgery is feasible w here the injury is distal to the geniculate ganglion. T he site o f injury can be gauged by a careful history and clinical exam ination. X-ray plates are necessary, as well as testing for signs o f injury to th e laby­ rinth. Electrical tests, such as faradic and galvanic stim ula­ tion m ust be done. Tests for lachrym ation, taste and saliva­ tion assist in localising the actual site o f injury. In cases w here repair in continuity is impossible anastom osis with the hypoglossal o r spinal accessory may be required. In 1812, Charles Bell described the m otor supply o f the facial muscles as due to the seventh o r facial nerve. Since then peripheral facial paralysis n o t due to injury o r disease o f the tem poral bone has been comm only know n as “ Bell’s Palsy” . I t is a well established fact that this is the com m onest type o f facial palsy. The actual aetiology o f the condition is obscure. Exposure to cold is usually considered to be the cause but em otional factors and hereditary dispositions may play some part. Occasionally small epidemics o f facial paralysis occur which suggests an infective factor. The con­ sensus o f opinion is th at local ischaemia produces this lesion. T he cause o f th e paralysis m ust be treated im mediately the diagnosis is m ade. Medical treatm ent must be directed R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1957 P H Y S I O T H E R A P Y Page Eleven towards relief of the ischaemia, vaso-dilator drugs being the o b v i o u s choice. T he use o f adrenal cortical horm ones in very early cases o f Bell’s Palsy has given encouraging results. S u p p o r t i v e treatm ent by splints o f th e affected muscles must be undertaken from the onset o f the paralysis. Faradic treatment should only be given 10rl4 days after the paralysis has occurred, earlier than this a. response may-.be present, although the nerve has been divided. .Electrical- treatm ent should now be instituted. ■ It is estimated th at 80% o f cases recover spontaneously. Unfortunately it is n o t possible to tell definitely which cases fall in this category. If after two or three m onths o f supportive treatment, there is no sign o f recovery and th e faradic. re­ sponse is negative then decompressions of the facial nerve should seriously be contem plated. C ertain o ther factors influence this decision. The paralysis is n o t usually ushered in with pain. If, however, pain is present and this is con­ current with the rapidity o f onset and completeness o f the paralysis, then th e prognosis is grave, and may be a potential candidate for operation. The facial-m usculature must re­ spond to galvanic • stim ulation if decompression is to be of any value. R epeated electrom yography m ay assist in ^deciding which cases will recover spontaneously. y t he actual operation is straightforw ard provided the sur­ geon has a good knowledge o f anatom y. A-post-auricular is made. T he facial nerve is exposed, at the stylo-mastoid foramen and the vertical portion followed on to the external semicircular canal., Neurolysis is then perform ed and, in my limited experience, it is quite dram atic to witness the nerve being exposed and bulge through the incision. T he hearing should not be affected and no post-operative complications should occur. A patient who after two m onths showed no sign o f reco­ very, and with , no response to faradic stim ulation, was recently operated on by me. Two. wesks after operation recovery began, and within six weeks was alm ost complete. 1 have been impressed with the.good results where operation has been indicated. Indiscriminate, operation is not recommended and the standard methods o f treatm ent should be adhered to in all cases. O peration must only be considered after a lapse of two o r three m onths if conservative methods have failed. BIRTHS Te Groen, to M r, and Mrs. T e G roen, nee de Jager a son in Pretoria on June 2nd. Norris, to Bill and H eather at M ater D ei H ospital, East London, a daughter W endy Jane, sister to Jennifer and Jparry on June 15th. ENGAGEMENT bteenkamp — Carstens, Miss L. J. R . Steenkam p (Pretoria H ospital Diplom a) to M r. W . Carstens, both o f Pretoria. MARRIAGES Breitschuh — Neuhaus, Miss I. B. Breitschuh, formerly o f Pretoria, to Bob N euhaus a t W indhoek on June 22nd. Winkle — Human, Miss M. W inkle (trained Pretoria H ospi­ tal) to M r. H um an on M ay 29th. Lopis — Dove, Miss B. Lopis (University S tudent and Student M em ber) to Mr: J. Dove on June 2nd. DEATHS Fisher — Mrs. Janette Fisher (B. Sc. R and) N ee M aurer at Brakpan on April 24th. Hahne — Mrs. M. H . H ahne, nee Biggar a t the F a r E ast Rand Hospital on April 30th. Hope — M r. F. W. H ope, husband o f Mrs. H . B. H ope o f W itwatersrand University on June 28th. To their relatives the Society records its sincere sympathy. BRANCH NEWS N O R T H E R N CAPE BRA N CH . Mr. E. N icholson has returned to Kimberley from over­ seas a n d h a s accepted a Physiotherapy post at th e Vocational High School, D isk o b o lo s." ’ The branch has been very active the first h a lf o f this year. R egular monthly G roup-discussion meetings were held which were enthusiastically attended by members. M em bers have found talks given by Mr. N icholson on his recent experiences in the treatm ent o f poliomyelitis at Royal N ational O rthopaedic H ospital, Stanm ore and study- observation visits to many R ehabilitation C entres in Britain, m ost useful and interesting. EAST L O N D O N BRA N CH L EC T U R E BY D R . I. G. FIT Z PA T R IC K O n February 13th, D r. I , G . Fitzpatrick, ,spoke to the B ranch on “ H ypnotism, its use and general acceptance in the field o f M edicine” . D r. Fitzpatrick traced the use o f hypnotism down the ages from th e ‘Sleep Temples’ o f the M iddle East, to th e m ore recent times when it was known as Mesmerism, and accom­ panied by much ‘passing o f hands’ and use o f magnets. H e explained how showmanship, and th e air o f mystery thus created, had. delayed the acceptance of this ancient art by Medical Bodies the world over; and even today left many sceptics and hindered its full and universal acceptance as an asset in the field o f medicine. I t was a little horrifying to hear o f the very rem arkable work and research done in this field during the last Century, that cam e to nought because o f the refusal o f M edical Bodies to recognise H ypnotism as anything but a sort of, ‘Black Magic’; and the exponents o f this art as nothing short of quacks — despite medical qualifications. H ow ever with the form ation o f the ‘British Society o f M edical H ypnotology’ in 1947, a start had been m ade to rem edy this. Whilst showing us that there is a very definite future for the use o f hypnotism in the Medical — Therapeutic world, D r. Fitzpatrick decried its use on the stage or by unqualified persons; for the reasons th at a great deal o f harm can be caused by removing a symptom w ithout getting down to the cause. Even rem oving the desire to smoke from a heavy sm oker could do him infinite harm , unless the cause for th at craving was routed out, and som ething concrete put in its place. T o dem onstrate to us the three stages o f hypnosis (light, som bulant, and deep), D r. Fitzpatrick used a volunteer member o f the branch as a model. H e explained th at the full co-operation o f the subject was essential, and th at she m ust have the pow er to concentrate on what he was saying and asking her to do, to the exclusion o f everything else. (The m odel was glad to learn that it is the most norm al and intelligent who are the easiest subjects). The word sleep he said was a mis-nomer, but it is used as an easy simile for everyday practice — in fact hypnotism was not in any o f its stages a true sleep, but a state o f deep relaxation. Following the very interesting dem onstration an eager discussion ensued. O ne main point forthcom ing being th e realisation, and general acceptance o f the immense value th at lies in the a rt o f Self-Hypnosis — the ability to relax oneself mentally and physically for ten to twenty m inutes at any time. A t the request o f mem bers D r. Fitzpatrick tried mass hypnotism on all present, and succeeded in convincing most o f the mem bers th at they were easy subjects for hypnotism, and all th at they would endeavour to cultivate the art o f self-hypnosis. The talk was so interesting that m em bers forgot th e time to the extent o f concluding the evening at ten thirty p.m., w ithout having conducted any business. It was agreed to leave arrangem ents for the S.A.S.P. conference to be held in E ast L ondon, to the Executive comm ittee, and to discuss them at a later date. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )