Picture 3. Chart segment, function And journey facial nerve

1. The labyrinthine segment is located between the end of the internal acoustic canal and the geniculate ganglion and is 2-4 mm long. The greater superior petrosal nerve exits from the geniculate ganglion and provides stimulation for secretion in the lacrimal gland.

2. The tympanic segment or horizontal segment, is located between the distal part of the geniculate ganglion and runs towards the posterior part of the middle ear, then up towards the oval window and stapes, then down parallel to the horizontal semicircular canal, its length is ± 12 mm. Usually the bony part of the horizontal semicircular canal protrudes laterally from the facial canal, the anterior part is 0.1-1 mm away and the posterior part is 2-3 mm away. Here the stapedius nerve exits which innervates the stapedius muscle.

3. Segmen mastoid or segment vertical, length 15-20 mm. Segmen This starting from the medial and posterior walls of the tympanic cavity. The transition from the tympanic segment to the mastoid segment is called the pyramidal segment or external genu. This section is the most lateral part of the facial nerve so that during surgery it is easily traumatized. The length of the pyramidal segment is approximately 2-6 mm. The wall Laterally it is the lower medial border of the aditus ad antrum . The mastoid segment runs caudally towards the stylomastoid foramen which is located in the digastric cleft. Around the middle of the mastoid segment, the facial nerve branches into the chorda tympani which carries taste fibers to the anterior 2/3 of the tongue, pain, temperature and the posterior wall of the external acoustic meatus. as well as bring fibers secretarial For glandular sub maxillary and sub lingual. After go out from bone mastoid, nerve facialist going to parotid gland and divides to innervate the facial muscles. ^8,9

3. Fracture Bone Temporal

1. Epidemiology

Motor vehicle accidents result in head trauma of various types. level severity. In time Then, 75% from accident vehicle motorized resulting in trauma head, However moment This Already reduce with seat belt usage and the emergence of airbags . Although the force of trauma is not strong enough to break the skull, 14%-22% of sufferers experience temporal bone fractures. It has been reported that up to now 31% of fractures are caused by motor vehicle accidents. Facial nerve paralysis occurs in 20% of sufferers, usually in the form of neuropraxia or partial axonotmesis . Temporal bone fractures have been reported to occur in all age groups. More than 70% occur during the second, third and fourth decades. Fractures mainly occur in men with a ratio of 3:1, due to involvement in risky activities rather than due to structural weaknesses in the male skull. ^6,8,10

According to Bailey ¹¹ , about 6-7% of cases of temporal bone fractures in adults will be accompanied by facial nerve injury. While in children the incidence is around 3-9%. From Hough, 75% of head trauma patients with middle ear damage are men, while women are 25%. ¹⁰

1. Type Fracture Bone Temporal

Temporal bone fractures consist of longitudinal fractures, transverse fractures and fracture mixture or combination. Clash from direction frontal And occipital often causes fracture transversal And clash from lateral cause fracture Longitudinal. Longitudinal fractures are the most common, usually from the mastoid segment across the roof of the Eustachian tube or starting from the foramen magnum and running towards the ear canal. The fracture line is parallel to the axis of the petrous pyramid and usually runs along the anterior wall of the pyramidal pars, so that the labyrinth and facial nerve are often spared from the lesion. These fractures are usually linear, If branching can to be continued to hole ear or mastoid, seldom to inner ear. In other words, this fracture is usually a middle ear fracture. The tensor tympani muscle can be severed, so that incus dislocation is often found. Around 30% sufferer with fracture longitudinal there is disturbance deaf conduction.^2.10- 15

Picture 4. Fracture longitudinal bone temporal (left) And fracture transverse temporal bone (right)

When the impulse is blocked, neuropraxia or conduction block occurs, there is a blockage of the flow of axoplasmic transport in both directions, but some axoplasmic transport continues. The distance between the injury site and the cell body in punch follow determine level injury to overall nerve. If injury occurs in the internal acoustic canal with axons severed, then the lost axoplasm will be quite long and permanent damage will be greater compared to damage that occurs distally, near the motor end plate.

Person Which more young will healed more perfect from injury Which the same when compared to older people. If the magnitude of pressure on the nerve is sufficient to cause complete obstruction of axoplasmic movement through the injury site for several days, then axonotmesis occurs with loss of axonal continuity. As a result, Walleri's degeneration occurs in the distal part.

During a number of day axon Still can responsive in a way electric to external stimuli in the distal part, but not There is voluntary motor movement or electrical conduction through the injury site. Histologically the proximal nerves are still normal but biochemical changes have occurred. ^8,9

Schwann cells swell and are phagocytic, then divide until they completely fill the tubule. connecting network that surrounding each nerve fiber. Neurons that are deprived of nutrients will return to their original size after the axon loses Nissl substance by cytoplasmic swelling or chromatolysis. Three or four days after injury occurs formation tape Bunker. Tape This allegedly provide substance biochemistry for the nerves Which new. When fiber nerve cut off, nerve Which experience repair forms a growth cone at the proximal end of the axon. There are multiple protoplasmic processes in the growth cone and the single regenerating axon grows branching and enters the Schwann cells of various tubules. In the same way growth can occur towards other nerves. ^6,8,9

Facial muscles can undergo wasting away after the loss of motor nerves. facialist pass three stages injury. Stage First in progress until 21 days, involving physiological events where the cell body undergoes metabolic transformation. And start regenerate use to form axoplasm Which will occupying the neurotubules. The second stage lasts up to 2 years, a period during which cells and proximal segments can regenerate using Brugner's bands or endoneurial tube reserves, through which regenerated axons can reach the facial muscles. Therefore, up to 2 years after injury, reanastomosis of the severed nerve can still be considered by placing a connecting graft between the 2 separated points or transferring a functional motor nerve to the distal nerve segment. For this reason, it is believed that facial muscle rehabilitation can be done by nerve transfer or reanastomosis. injury nerve, at least in term time 24 month after injury. The third stage is usually characterized by scarring of the distal nerves and muscle degeneration. ^7,8

Complications other from damage nerve facialist is water eye crocodile​ tears ), Which happen consequence deviation regeneration fiber nerve parasympathetic Which should innervate gland saliva, become deviate to the lacrimal gland. In addition, hyperkinesis can also occur in the stapes tendon, which causes complaints of fullness and rumbling in the ears. The purpose of examining the function of the facial nerve is not only to determine the degree of paralysis, but also to determine the location of the facial nerve lesion. In examining the motor function of the facial muscles, the gradation of facial nerve function according to House-Brackmann and Freys can be used.^7,8

In the Freys grading system, which was first introduced in France, there is a slight difference with House Brackmann. In this system, 4 components are assessed, namely motor function examination, tone, synkinesis and hemispasm. In the motor system examination, the face is divided into 10 areas, based on 10 muscles responsible for facial expressions and facial expressions. The ten muscles examined and how to examine them are explained in table ^2.7,8

Table 3. Method inspection muscle face

In condition normal, Where No there is abnormality nerve facialist, then the value maximum from summation 10 area in face on One side is 30. Inspection facial tone is assessed by dividing the face into 5 areas. According to Freyss, tone testing is important and assessment does not have to be done for every muscle, but rather for each level of facial muscles. Mark For tone worth 0-3, with mark 3 For tone normal And 0 when there is no tone. If there is hypotonus, the value is reduced by 2 for each level depending on the degree. Under normal circumstances the total value for the tonus of the five levels face is 15. Synkinesis is Wrong One complications from facial nerve paresis. To find out whether or not there is synkinesis, the following examination is carried out: a) The patient is asked to close his eyes as strong as possible, Then examiner notice There is whether or not movement muscles in the area corner lips on. Then done evaluation as following: mark 2 if no synkinesis is found. If synkinesis occurs on the paretic side, depending on the degree, the value is reduced by 1 or 2. b) The patient is asked to laugh out loud while showing their teeth, then the examiner observes whether or not there is movement of the muscles in the lower eye corner. Assessments such as (a). c). Synkinesis can also be seen moment somebody speak (movement emotion). Examiner pay attention to the presence or absence of muscle movement around the mouth. If there is no synkinesis, a score of 1 is given. If there is synkinesis on the paretic side, a score of 0 is given. Hemispasm is a unilateral facial nerve hyperactivity. If there is no hemispasm, a score of 0 is given, but if there is hemispasm, a minus one (-1) value is given for each movement. The total value of motor, tone, synkinesis And hemispasm on condition normal is 50. Gradation paresis, assessed based on the total value of the examination results multiplied by 2 to obtain the percentage of facial nerve motor function. good. In this system, topographic assessment and electrophysiological test examination are also carried out, including the Nerve Exitability Test (NET), Maximal Stimulation Test (MST), Electroneurography (EnoG) and Electromyography (EMG). Topographic assessment includes the Schirmer test, stapedius reflex and gustometry. The Schirmer test or nasolacrimal reflex test, to determine function fiber sympathetic nerve facialist through nerve petrosus superficial at the level of the geniculate ganglion. The method is to place litmus paper on the base of the conjunctiva. According to Freys, if there is a difference between the right eye and left, ≥ 50% considered pathological. For evaluate reflex stapedius used electro caustic impedance is by providing a threshold of stimulation on m.Stapedius to determine the function of the stapedius nerve, a branch of the facial nerve. In gustometry, the difference in the threshold of stimulation between the right and left is assessed. Freys determined that a difference of 50% between the two sides is pathological. From this system, the location of the lesion can be reported with the best percentage of motor function along with the possibility of prognosis from the results of NET, MST, EnoG or EMG. ^7,8,9

Picture 5. CT Scan piece Axial, looks fracture bone temporal left

Hearing tests are performed if the patient's condition allows, starting from simple audiological examinations in the form of tuning tests, pure tone audiometry and tympanometry. In addition to functioning to detect the degree of deafness that occurs, this examination is important as a basis for the development of treatment progress after surgical therapy is performed. Electrophysiological tests such as NET, MST, EnoG and EMG are performed to assess the degree of damage, determine the prognosis for facial nerve repair after trauma and plan the therapy to be given. ^7,8,9

7. Management

Management paresis nerve facialist consequence fracture bone temporal Until now it is still a controversial issue. Schematically, the treatment of facial nerve paralysis due to temporal bone fracture is explained in table 4: ⁷

1. Conservative

Conservative treatment given is medication and physiotherapy. Treatment to reduce nerve edema can be given corticosteroids. Neurotonics are given for nerve growth. Physiotherapy also can given covering infra red radiation (IRR), electrical stimulation (ES), deep kneeling exercise and mirror exercise . All of the above efforts aim to maintain muscle contractility. The masses reported that patients with facial nerve paralysis without any poor prognostic factors would experience complete improvement and healing. In patients with facial nerve paralysis nerve level I And II House And Brackman obtained more from 90% of patients experienced improvement approaching normal. ^6,8,19,20

2. Surgery

Some authors recommend observation and symptomatic therapy only. Mainan et al., observed 45 non-operative patients, found that 44 people experienced satisfactory healing and 65% experienced healing that perfect. Like quoted Mattox, from McKennan and Chole, patients with late-onset facial nerve paralysis, continued to experience healing Which Good. When has decided patient with paresis. The facial nerve due to trauma will undergo surgical therapy in the form of decompression, the patient is faced with a situation between rapid onset or slow onset. has long. On onset Which fast, usually condition trauma patient more severe. From Mattox, different from what was obtained by Adegbite et al., said that the prognosis is more determined by the degree of facial nerve damage, not by time or onset. According to Fisch, based on the results of electrophysiological tests (EnoG), degeneration of nerve cells began to occur 6 days after onset.

Ideally, decompression is performed immediately after the trauma occurs. But according to Fisch and Kartush, the best time to perform this decompression surgery is after 3 weeks, because edema and tissue hematoma have been minimal, intraoperative bleeding is minimal so that the surgical field is more clearly visible. Although repair within 30 days after trauma shows the same results. In cases of facial nerve paresis that have lasted a long time, electrical or physiological tests no longer produce valid results. It is recommended to wait up to 12 months, after which surgery is performed if there is no clinical improvement or the EMG results are also not good. Surgical exploration facial nerve post trauma need surgeon who is experienced in mastoid surgery, translabyrinthine, middle fossa exploration and nerve repair. Accuracy during surgery is very necessary, because according to Jones, 14 out of 15 patients with CT scanning bone fracture temporal, also accompanied by ipsilateral temporal lobe contusion. The success of nerve surgery is greatly influenced by knowledge of facial nerve anatomy, the availability of intraoperative electrical monitoring devices and the completeness of the instruments.

Surgery is performed if there is severe hearing loss and disturbances. balance. Procedure operation is to free nerve, nerve decompression or repair in a way anatomy nerve facialist. According to Hough that 66.6% of patients trauma head new found existence line fracture moment operation ongoing, 92.3% happen dislocation incudostapedial as well as 57.1% bone incus has let go from its place. Surgical action can be performed with 3 approaches depending on the type of trauma and the location of the affected facial nerve. The approaches that can be performed are: 1) mastoidectomy or extended mastoidectomy approach, 2) medial cranial fossa approach and 3) transmastoid approach. ^7,15-22

Approach mastoidectomy or extended mastoidectomy done to observe the facial nerve from the geniculate ganglion to the stylomastoid foramen that is on segment timpani And segment mastoid. Approach This can clearly identify the Fallopian canal. The surgical procedure is first a simple mastoidectomy is performed, second a recess is traced and identified. facialist, third identification segments nerve And network canal facialist, fourth remove bone wrapping nerve And fifth If indicated to perform nerve sheath opening.

To observe the facial nerve section from the distal geniculate ganglion properly, a wide mastoidectomy can be performed. The medial cranial fossa approach is performed to observe the entire labyrinthine segment of the facial nerve from the geniculate ganglion to the internal auditory canal. This procedure is used not only for facial nerve exploration, but also for small intracanalicular acoustic neuromas and to explore the vestibular nerve. Procedure action This combined with approach trans mastoid then done exploration on area process cochleariform with petrous nerve superficial major as landmarks . Difficulty approach This is

1) existence leakage dura mater with herniation And damage bone temporal, 2) avulsion nerve petrosus superficial major, 3) bleeding artery meningitis medial, and 4) cochlear trauma or superior semicircular canal trauma.

This transmastoid approach can expose 60% of the labyrinthine segment. In addition, according to May, the rate of facial nerve paresis improvement is also higher, namely 84-85%. The transmastoid approach itself has 2 methods, namely 1) transmastoid epitympany where the incus is removed during surgery and then reinstalled. 2) transmastoid epitympany and otoendoscopy where the incus is only shifted up or down.

Following is step – step decompression nerve facialist transmastoid ^23.24

• Drill the mastoid cortex with the landmarks of Mc Ewen's triangle, identifying the posterior wall of the ear canal, the temporal line and the spine of Henle. Clean and remove all air cells from the antrum. to the mastoid tip and digastric ridge found. Identification tag mastoid, sine sigmoid, semicircular canals lateral, adit ads antrum, fossa incudis, solid angle. Aircell in the area The zygoma root is also removed until identified. upper edge of the incus and the horizontal part of the facial canal. Landmarks for N. Facialis pars vertical is the posterior tip of the incus at the top and the anterior end of the digastric groove at the bottom. lower. Drill until foramen stylomastoid. Bone between foramen stylomastoid And canal semicircular lateral thinned out And until N.facialis appears pink. If there is pathological tissue/granulation tissue, it is cleaned.

• If the horizontal segment of N.VI is affected, decompression is performed through the triangle (posterior tympanotomy) formed by the medial N.VII. , cord timpani And annulus timpani in lateral and short process incus in superior part. Identify the incus, incudimalleolar joint and malleus and check the mobility of the ossicles and patency of the aditus ad antrum. If the entire horizontal segment must be decompressed, the incus must also be disarticulated.

  • Open Channel facialist And sheath nerves

    • Landmarks of the external genu, chorda tympani and facial recess are visible. Thinning of the facial canal is done using a diamond drill so as not to injure the facial nerve. From the external genu to the stylomastoid foramen.

      • After the facial nerve pars tympani and pars mastoid are exposed, identify the damage to the nerve according to the topography of the lesion. Thin the bone on canal facialist until bone thin the can lifted using a micro elevator.

      • Done appointment bone thin along nerve facialist on 3 aspect : 1) descending portion of the mastoid segment between the stylomastoid foramen and the external genu on the posterior aspect, 2) the external genu and facial recess portion on the lateral aspect and 3) the horizontal segment to the inferior edge of the cochleariform process .

      • With the facial nerve landmark, open the sheath of the nerve, carefully. sharp sheath incision with technique atraumatic and preservation of the entire nerve fascicle. Ziegler ophthalmic knife can be used for nerve sheath incision.

      • Identification nerve facialist : clean up hematoma, flakes bone or nerve damage to the lesion topic. So that there is no pressure on the facial nerve. Cover with fascia graft.

• Placed tampon hole ear Which Already coated by ointment antibiotics.

  • Wound operation closed with stitches layer layer by layer

    • When need installed pipe Salir in the area incision

Decompression procedures can be used to repair damaged nerve tissue. disconnected with method connect back to continuous axon nerve. If the nerve damage is not extensive, the edges of the nerve can be sharply divided and then repositioned. anatomically nerve. If the edge nerve No can taken or if the nerve part No can renovated so graph nerve can installed. If nerve facialist Severe damage can be treated by grafting or cable grafting or by complete end-to-end anastomosis . Nerve grafts can be taken from the matrix. or part axon nerve Which installed from proximal until the part distal nerve. Grafts that are often used are from the branches of the superficial cervical plexus, especially the greater auricular nerve, because the grafts are easily obtained around the surgical site and the size is suitable. ^5,7,16-22

Procedure taking auricle graft major is as following: perpendicular line marker to the line between the mastoid tip and the angle of the mandible. It is located just below the platysma muscle, above the sternocleidomastoid muscle. Then an incision is made on the skin that has been marked, followed by careful release of the graft. The graft is cut after the facial nerve preparation is complete .

Another location for nerve grafting is the sural nerve graft. The procedure is almost the same as the auricle graft, but what needs to be considered is the location of the graft and patient preparation. Nerve identification is estimated 2 cm behind And 1-2 cm proximal from lateral malleolus. The dissection of the medial sural nerve is proximal below the popliteal fossa. There is a nerve of 30-35 cm for grafting. Next, the nerve is transected proximally and wrapped with a moist gauze swab . ^23.24

The most important aspect of nerve repair is ensuring that the endoneurial segments are aligned as this will promote regeneration. The nerve ends should be sutured using 9-0 or 10-0 monofilament suture to connect the epineurium or perineurium. Complications of action operation can happen bleeding. Bleeding the can overcome with cautery and covered with bone wax .

According to Salinas JD, that giving injection corticosteroids on joints and soft tissue due to trauma will accelerate healing. Corticosteroids work by limiting capillary dilation and permeability of vascular structures, so that the inflammatory process can be inhibited. Corticosteroids also inhibit the formation of arachidonic acid as a material for making prostaglandins. As a result of the action decompression nerve happen lost hearing type conduction more from

15 dB which occurs in 14% of cases. Conductive hearing loss is caused by by fixation stapes Because fraction bone, herniation dura mater affecting the top of the malleus head or due to disarticulation of the incudomaleus joint.

8. Prognosis

The prognosis of facial nerve paralysis due to temporal bone fracture depends on the type of fracture, clinical symptoms that arise, the time of trauma and its management. Factors that cause a poor prognosis are acute symptoms or paralysis occurring immediately after trauma, complete paralysis in the form of neurotmesis where the nerve is severed during trauma. In facial nerve paralysis, if there is improvement in the first 3 weeks, the prognosis is expected to be ^good.8

According to May and Shambaugh, in grade 1 trauma, facial nerve repair begins to occur within 1-4 weeks and spontaneous healing is possible. 1 year after trauma. Trauma degrees 2 will healed with satisfying or happen symptom remainder minimum, start happen repair in 1-2 month. Degrees 3 no experience healing that perfect, start happen repair in 2-4 months. Degrees 4 happen process repair start 4-18 month And degrees 5 No healing occurs. Most deaths in temporal fractures are caused by increased pressure intra cranial in a way I. Three principle treatment paresis Acute facial nerve is physical therapy, drug therapy and psychophysical therapy. Patients are still advised to check at 1 week, 3 months, 6 months and 1 year after surgery to examine the function of the facial nerve. ^5,6,8,9,25

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