Botox-like Drug The aesthetics

RED HERRING | Medicis Eyes Botox-like Drug Thursday, January 26, 2006 Advanced Search -- -- Log in | Join the RH community - it's FREE -- Capital Industries Biosciences Communications Computing Energy Entertainment & Media Internet & Services Security & Defense Venture Capital Profiles Q&A Regions Briefings Metrics Research Newsletters Events RSSfeeds -- Subscribe Now Customer Service Advertisement - MARKETS - Industries Medicis Eyes Botox-like Drug The aesthetics products maker hopes to get marketing rights to cosmetic drug Reloxin. January 10, 2006 Facial cosmetic medicine maker Medicis Pharmaceutical said Tuesday it’s seeking a commercial partnership to market Reloxin, a potential competitor to blockbuster drug Botox, now that the marketing rights for the cosmetic drug may be up for grabs. The current holder of the Reloxin rights, breast implant maker Inamed , said during December it planned on terminating them to avoid any regulatory issues as it goes forward with its $3.2-billion acquisition by Botox-maker Allergan (see Allergan Bids $3.2B for Inamed ). Medicis, which makes acne treatments, had been set to acquire Inamed after making a more than $2.8-billion bid in March 2005, but the deal was called off after Allergan came in with a higher offer (see Inamed Favors Allergan Bid ). Medicis received a $90-million breakup fee (see Inamed OKs $3.2B Allergan Bid ). Medicis said its desire to add the experimental product to its business was among the main reasons the company wanted to acquire Inamed. Like Botox, Reloxin is a botulinum toxin that is used to smooth lines on the face. ‘We aspire to be… the commercial arm of Reloxin.’ -Jonah Shacknai, Medicis “Reloxin was the most important component of the transaction,” said Medicis CEO Jonah Shacknai at the JPMorgan Annual Healthcare conference in San Francisco . Mr. Shacknai said Medicis had the opportunity to increase its offer but declined. He said Medicis was certain Reloxin would fall out of the mix if Inamed and Allergan merged. Aesthetics Powerhouse “Our original goal in the transaction was never to be a breast implant company,” he said. “It was rather to be an aesthetics powerhouse.” Medicis was right. Inamed said last month it would hand its rights back to Europe-based Ipsen, the company it partnered with during 2001 to develop the rival product. Now Medicis has its eye on Ipsen. “We aspire to be their partners, be the commercial arm of Reloxin,” Mr. Shacknai said. Mr. Shacknai said Medicis is prepared to step into Inamed’s shoes, which would mean branching out into other markets beyond the United States and Canada . But it’s likely that other companies will also be eyeing Reloxin if it comes into play and Medicis may have to persuade Ipsen that it’s the right partner. Shares of Medicis closed down $0.54 to $32.42. RELATED ARTICLES Inamed OKs $3.2B Allergan Bid The breast implant maker accepts offer from the manufacturer of Botox after rival suitor Medicis drops out. Biomedical M&A Heats Up Cephalon bids $360M for Zeneus; J&J still wants Guidant; Inamed’s board favors bid by Allergan. RECENT ARTICLES • Drugs & Devices: Varian Deal • Amgen’s Silence Hurts Stock • China Pleads Poverty on Flu • Guidant Picks Boston for $27B • Video Game Fights Fat • Workers Roll Over for Dogs RED HERRING Sponsors Articles | Blog | Research | Newsletters | Events New User Registration | Search | About Us | Letter from the Editor | Advertising Info | Magazine Customer Service | Contact Us | Careers | RSS feeds © 1993-2006 Red Herring, Inc. All rights reserved.

skin cream for six

New cream reduces skin damage from sun - HealthLINK (Women) - Yale-New Haven Hospital Can we help? Follow up on this month's He@lthLINK He@lthLINKs Cancer Cardiac Mental health Pediatrics Women's health Archive Search this site for: Site Contents Patients & visitors Medical professionals Yale-New Haven Children's Hospital Yale-New Haven Psychiatric Hospital General information Calendar Online resources Press information Phone Numbers Directory assistance (203) 688-4242 Patient information (203) 688-4177 Adult emergency (203) 688-2222 Children's emergency (203) 688-3333 Admitting (203) 688-2221 Children's admitting (203) 688-3331 Mailing address: Yale-New Haven Hospital 20 York Street New Haven, CT 06510-3202 Search this site for: Site Contents Patients & visitors Medical professionals Yale-New Haven Children's Hospital Yale-New Haven Psychiatric Hospital General information Calendar Online resources Press information March 17, 2003 News this month New cream reduces skin damage from sun A daily application of a new skin cream for six months may reduce the fine wrinkling and skin discoloration caused by years of sun exposure. Researchers say the cream, which contains 0.1 percent of a substance called tazarotene, reduces the effects of ultraviolet light exposure and minimizes wrinkles, discoloration and roughness. The study appeared in The Archives of Dermatology . Daily application of a new skin cream may reduce fine wrinkling and skin discoloration caused by years of sun exposure. Part of the Retin-A family Tazarotene is among the vitamin A derivatives known as retinoids. It is part of the same group of compounds as the widely used Retin-A ® and Renova ® , both of which contain the same active ingredient, tretinoin. These prescription products are known to build collagen, regenerate the elastin that lets skin stretch and reverse abnormal pigmentation. Much of what is known about Retin-A is based on its 30-year track record as an acne treatment. Creams and gels containing tazarotene are used to treat acne as well as some types of psoriasis. In October 2002, the FDA approved a request from the manufacturer to market the tazarotene cream, sold as Avage ® , to fight wrinkles. Initial studies of the cream indicate it could reduce signs of sun damage when used daily for 12 weeks. In this study, Tania J. Phillips, MD, of the Boston University School of Medicine studied whether using the cream longer would produce similar results. Study results promising More than 500 patients with sun-damaged skin applied either Avage or a placebo cream to their faces once a day for 24 weeks. After 24 weeks, all patients who remained in the study used the Avage cream for an additional 28 weeks. The average age of the participants was 56. More patients who used the tazarotene cream experienced at least 50 % improvement in skin appearance. After 24 weeks, researchers found significantly more patients who used the tazarotene cream experienced a more than 50 percent overall improvement in skin appearance compared to those who received the placebo. The Avage users also reported less wrinkling, mottled pigmentation and skin roughness. Even more benefits were seen among those who used the cream for up to 52 weeks. Researchers say the improvements did not taper off by week 52, which suggests that the benefits may continue to increase over time. Twenty of the 283 Avage-treated patients in phase one of the study dropped out due to adverse effects, including skin burning, itching, redness, dryness and irritation. Physician Referral Online A free and confidential service of Yale-New Haven Hospital. Physician Referral Online Using your own criteria, you can request information from a database of 900 area physicians who have registered to participate. Request an appointment We would be happy to assist you in scheduling an appointment with a member of the hospital's medical staff. Use the link above or call: 203-688-2000 or toll free 1-888-700-6543 to talk with a referral coordinator. For the 12th year in a row, Yale-New Haven has been highly ranked by U.S. News & World Report for its programs in gynecology. Variety of options for sun damage Lines, wrinkles, uneven pigmentation and age spotsthese are the signs of aging on our skin and most of them are a direct result of exposure to the sun. Photoaging of the skin is a common problem. Anyone who is exposed to sun gets it; and the more sun exposure, the more damage. “Lines, wrinkles, uneven pigmentation and age spots…are…most[ly]…a direct result of exposure to the sun.” There are some things you can do to improve that damage, but the best thing is to prevent further damage by wearing sunscreen every day, winter and summer, with a minimum SPF of 15. Cigarette smoking also contributes to aging effects by the biochemical changes it brings about in skin tissues. Chemicals inhaled from cigarette smoke constrict tiny blood vessels in the skin, reducing the oxygen and nutrient supply to delicate facial tissues. Blood-vessel constriction lasts at least an hour after a cigarette has been snuffed out. Over many years of smoking, the oxygen and nutrient deficiencies cause skin to wrinkle prematurely and lose elasticity. So, heres another reason to stop smoking. Retinoids If you already have sun damage, there are ways you can improve how your skin looks. The results of this latest study of tazarotene cream are similar to those of other retinoids. Extensive studies have been done of Retin-A and Renova, and the results, as in this study, indicate a statistical benefit in terms of improving fine wrinkling, irregular pigmentation and coarse texture. It is unrealistic to expect dramatic changes, however. The improvement is usually relatively subtle, but noticeable in the double-blind studies that have been conducted. Many patients do experience some irritation, redness, dryness or flaking when beginning a regimen of retinoids. A small percentage of patients find the irritation serious enough to cause them to discontinue the products, but most find that these symptoms abate within a few weeks. Retinoids work by sloughing off the dead outer layers of the skin, exposing the skin underneath and promoting the growth of collagen, which thickens the skin fibers that preserve moisture. By removing dead surface cells that become harder to shed as we age, and by thinning and flattening the outer layer of skin, retinoids give skin that much-valued “rosy glow.” Other options for photoaged skin? OTC products Hundreds of over-the-counter (OTC) preparations are advertised as having anti-aging benefits. They vary in price from reasonable to very expensive. Many of these products may be effective moisturizers, but none has any proven benefit to sun-damaged skin. AHAs Also widely hyped are alpha hydroxy acids (AHAs). Theyre less irritating than the retinoids, but they dont penetrate as deeply. Be aware that it's the prescription creams that have been found effective. The small amount of AHAs in over-the-counter moisturizers and facial treatments may not make much difference to your skin. Stronger solutions can have a significant impact, but they must be administered by a physician. At concentrations of 30 percent and higher, glycolic acid is known to increase collagen production and skin elasticity and to thicken the epidermis. Laser skin resurfacing New-age lasers burn off top skin layers in lined areas and injure the dermis so collagen will reform. Healing takes a week or more; redness persists for weeks to months. The newer “laser facial” or “photo-facial” procedures bypass the skin surface and go straight to the dermis, where theyre said to encourage collagen production, but this can take months. Laser skin resurfacing is expensive and long-term studies on the outcomes of laser work are not available. Microdermabrasion This popular procedure is essentially a mild sanding of the skins surface, a kind of mechanical acid peel with a bit of vacuum effect. Some patients report good results after multiple treatments. It has been shown to be effective for post-acne scarring. Injected fillers These substances, most often collagen or fat, are injected directly into the wrinkle to plump up creased and sunken areas of the face. The effect is temporary, and some people can have allergic reactions. Chemical peels Peels tighten the skin by promoting growth of collagen and elastin; they also remove fine lines and wrinkles. The stronger the acid used, the more dramatic the improvement. Mild peels cause the outer layer of skin to slough off in two to three days. Medium-strength peels create enough crusting, scaling and oozing to remove deeper scars and wrinkles, but theyll keep you out of circulation for a week to 10 days. Deep phenol peels can eliminate major sun damage and wrinkles, but the patient is out of commission for a couple of weeks, and the resulting redness takes months to fade. If youre considering any of these treatments, be sure to consult with a medical specialist and fully understand the risks as well the benefits you may realistically expect. Dr. Savin is a dermatologist and founder of the Savin Center in New Haven. He is an attending physician at Yale-New Haven Hospital and a clinical professor of dermatology at the Yale University School of Medicine. For more information on this topic: “ Efficacy of 0.1% tazarotene cream for the treatment of photodamage: A 12-month multicenter randomized trial ,” Archives of Dermatology , v. 138, no. 11, November 2002 [abstract] Chemical peels , Yale New Haven Health Information Library Skin protection , Yale New Haven Health Information Library Keeping your skin healthy as you age , Yale New Haven Health Information Library Laser resurfacing , Yale New Haven Health Information Library Dermabrasion , Yale New Haven Health Information Library Other women's health resources Maternity Services , Yale-New Haven Hospital Women's Heart Advantage , Yale-New Haven Hospital Women's health news and information , Yale New Haven Health Previous issues of HealthLINK — Women's health December 2002- NIH guidelines for gastric bypass surgery September 2002- Womens Health Initiative study on HRT stopped July 2002- Strength training boon for aging women May 2002- Yeast infections: Dangers of self diagnosis March 2002- Uterine fibroid embolization reduces pain March 2002- Uterine fibroid embolization reduces pain November 2001- Risk of uterine tears higher after C-section August 2001- Association issues PMS guidelines June 2001- High heels dangerous to your health April 2001- Study finds common drug ingredient linked to increased stroke risk March 2001- Younger women fare worse after heart attacks Archive Home page Staff directory Directions and parking Online resources Yale New Haven HealthSystem Need a doctor? Search Comments Top of page Yale-New Haven MedicalCenter Home page URL: http://www.ynhh.org All information is intended for your generalknowledge and is not a substitute for medical advice or treatment for specific medicalconditions. You should seek prompt medical care for any specific health issues andconsult your physician before starting a new fitness regimen.

Sensitive Skin Set for

Amazon.com: Bullie Close Shave/Post Shave Dry/Sensitive Skin Set for Men: Beauty Your Store Beauty See All 32 Product Categories Your Account | Cart | Wish List | Help | Browse Brands & Products | Free Gifts & Special Offers | Fragrance | Makeup | Skin Care | Bath & Shower | Hair Care | Men's Grooming Search Amazon.com Beauty Skin Care Makeup Fragrance Bath & Shower Hair Care Men's Grooming Health/Personal Care Web Search This item is not eligible for Amazon Prime, but over a million other items are. Join Amazon Prime today. Already a member? Sign in . or Sign in to turn on 1-Click ordering. A9.com users save 1.57% on Amazon. Learn how . See larger image Share your own customer images Bullie Close Shave/Post Shave Dry/Sensitive Skin Set for Men Other products by Bullie More about this product Price: $29.00 Availability: Usually ships in 1-2 business days. Ships from and sold by Bullie . Product Features Non Foaming Prevents Irritation Effortless Glide Cruelty Free Product Description Product Description The perfectly simple shaving set. Includes One Close Shave 7.5oz and One Post-Shave+Toner 6oz each formulated for the particular needs of your skin type. The everyday retail price of each item purchased separately is $35.00. Important Information Directions Close Shave- Apply a layer of gel onto a damp face, shave and rinse. This gel does not foam or lather.Post Shave- After shaving wipe over face and neck avoiding eye area. Product Details Product Dimensions: 5.2 x 2.5 x 7.0 inches ; 1.0 pounds Shipping Information: View shipping rates and policies Note: Gift-wrapping is not available for this item. ASIN: B0009QU7E4 Amazon.com Sales Rank: #15,156 in Beauty (See Top Sellers in Beauty ) Yesterday: #14,965 in Beauty This page was created by a seller. Customer Reviews Be the first person to review this item . Look for similar items by category Beauty > Products > Men's Grooming > Grooming Kits > Shaving Kits Beauty > Products > Men's Grooming > Shaving > Shaving Kits Beauty > Products > Shaving & Hair Removal > Hair Removal > Kits & Sets This Item and You Write a Review | Write a So You'd Like To... Guide | Tell a Friend About This Item | Rate This Item Suggestion Box Your comments can help make our site better for everyone. If you've found something incorrect, broken, or frustrating on this page, let us know so that we can improve it. Please note that we are unable to respond directly to suggestions made via this form. If you need help with an order, please contact Customer Service . Please mark as many of the following boxes that apply: Product information is missing important details. Product information is incorrect. The page contains typographical errors. The page takes too long to load. The page has a software bug in it. Content violates Amazon.com's policy on offensive language . Product offered violates Amazon.com's policy on items that can be listed for sale. Comments or Examples: Examples: Missing information such as dimensions and model number, typos, inaccuracies, etc. Bullie Privacy Statement Bullie Shipping Information Bullie Returns & Exchanges Where's My Stuff? • Track your recent orders . • View or change your orders in Your Account . Shipping & Returns • See our shipping rates & policies . • Return an item (here's our Returns Policy ). Need Help? • Forgot your password? Click here . • Redeem or buy a gift certificate. • Visit our Help department . Search Amazon.com Books Popular Music Music Downloads Classical Music DVD VHS Apparel Yellow Pages Movie Showtimes Toys Baby Computers Video Games Electronics Camera & Photo Software Tools & Hardware Office Products Magazines Sports & Outdoors Outdoor Living Kitchen Jewelry & Watches Beauty Gourmet Food Musical Instruments Health/Personal Care Pet Supplies Travel Cell Phones & Service Outlet Auctions zShops Everything Else Automotive for Amazon.com Home | Directory of All Stores Our International Sites: Canada | United Kingdom | Germany | Japan | France | China Help | Shopping Cart | Your Account | Sell Items | 1-Click Settings Investor Relations | Press Room | Careers Conditions of Use | Privacy Notice © 1996-2006, Amazon.com, Inc. or its affiliates

Retinal Cream

Ryerson Sports & Recreation: Fat Soluble Vitamins CONTACT | A - Z | SEARCH Student Services : Sports & Rec : Recreation : Personal Training : Nutrition : Fat Soluble Vitamins Memberships Hours and Location Mascot Staff Job Postings Varsity Teams Intramurals Day Camps Facilities Clubs Staff Job Postings Fitness Classes Certification Courses Personal Training Events Facilities Staff Nutrition General Info Water and Hydration Trans Fats Fat Soluble Vitamins Obesity Low Carb Craze Supplements Diabetes Labels Unhealthy Habits Questions & Answers Personal Training General Info Programs General Info Weight Room Intro Fitness Assessment B.I. Analysis Nutrition Consultation Training Packages General Info Personal Training Trim 'N' Tone Private Swim Lessons Personal Trainers Nutrition General Info Water and Hydration Trans Fats Fat Soluble Vitamins Obesity Low Carb Craze Supplements Diabetes Labels Unhealthy Habits Questions & Answers Muscle of the Month General Info Abdominals Biceps Rhombs, Traps, & Lats Quadriceps Pectoralis Major Hot Topics General Info Adventure Sports About Spinning Fit in the Winter What is Stress? What is Cellulite? What's New? Winter prgram registration starts December 1st! RAC now hiring part-time staff Awards Announced Search Fat Soluble Vitamins Vitamin A Retinol; Retinal; Retinoic acidMain precursor: Betacarotene Function Vision: health of cornea· Skin health· Bone and skin growth· Reproduction· Hormone synthesis and regulation· Immunity· Beta-carotene: antioxidant Deficiency Anemia (small cell type)· Cessation of bone growth; painful joints; impaired enamel formation; cracks in teeth; tendency towards tooth decay· Depression; frequent respiratory, digestive, bladder and vaginal infections· Diarrhea· Night blindness· Kidney stones; impaired growth· Keratinization; corneal degeneration leading to blindness; rashes Toxicity Red blood cell breakage; nosebleeds· Bone Pain; growth retardation; increased pressure inside skull mimicking brain tumor; headaches· Abdominal cramps and pain; nausea; vomiting; diarrhea; weight loss; loss of appetite· Over-reactivity of the immune system· Blurred vision · Pain in calves· Fatigue; loss of appetite; irritability· Dry skin; rashes; loss of hair· Cessation of menstruation· Liver and spleen enlargement Food Source Retinal - Fortified milk; cheese; cream; butter; fortified margarine; eggs; liver Beta-carotene - Spinach; dark leafy greens; broccoli; deep orange fruits (apricots, cantaloupe) and vegetables (squash, carrots, sweet potatoes, pumpkin Vitamin D Calciferol; Cholecalciferol; Dihydroxy Vitamin D Main precursor: Cholesterol Function Mineralization of bones (raises blood calcium and phosphorus via absorption from digestive tract and by withdrawing calcium from bones and stimulating retention by kidneys Deficiency Abnormal growth; misshapen bones (bowing of legs); soft bones; joint pain; malformed teeth· Muscle spasms Toxicity Raised blood calcium· Excessive thirst; headaches; irritability; loss of appetite; weakness; nausea· Kidney stones; stones in arteries; mental and physical retardation Food Source Self-synthesis with sunlight; fortified milk or margarine; eggs; liver; sardines Vitamin E Alpha-tocopherol; Tocopherol Function Antioxidant (detoxification of strong oxidants)· Stabilization of cell membranes· Regulation of oxidation reactions· Protection of PUFA (partially unsaturated fatty acids) and vitamin A Deficiency Red blood cell breakage; anemia· Degeneration of nervous and muscular systems; weakness; difficulty walking; leg cramps· Fibrocystic breast disease Toxicity Augments the effects of anti-clotting medication· General discomfort Food Source Polyunsaturated plant oils (margarine, salad dressings, shortenings); green and leafy vegetables; wheat germ; whole-grain products; nuts; seeds Vitamin K Phylloquinone; Naphthoquinone Function Synthesis of blood-clotting proteins and a blood protein that regulates blood calcium Deficiency Hemorrhage Toxicity Interference with anti-clotting medication; vitamin K analogues may cause jaundice Food Source Bacterial synthesis in the digestive tract; liver; green leafy vegetables; cabbage-type vegetables; milk Back to Nutrition ©2005 Sports & Recreation, Ryerson U. unless otherwise noted. All rights reserved. Content produced in accordance with the Policy on Ryerson's Official Web Page.

facial nerve and fallopian

Core Curriculum Syllabus: Facial Paralysis Core Curriculum Syllabus: Facial Paralysis Anatomy of the 7th Cranial Nerve Anatomy of the facial nerve and fallopian canal Intracranial nerve arises near pons and courses 12mm to porus acousticus. Meatal portion (10 mm) is anterior to the superior vestibular nerve and superior to the cochlear nerve. Intratemporal portion Labyrinthine segment (3-4 mm) passes through narrowest part of the fallopian canal. Common site of pathology: temporal bone fractures and Bell's palsy. Tympanic segment runs from geniculate ganglion to pyramidal turn (11 mm). Mastoid segment descends 13 mm to exit the stylomastoid foramen. Extracranial portion Nerve extends 15-20 mm from stylomastoid foramen to pes anserinus. Variable branching patterns. Clinical comment: The course of the facial nerve through the posterior fossa, temporal bone, and parotid gland renders this cranial nerve vulnerable to many neoplastic, traumatic, and infectious events. Disorders of the nerve provoke some interest in other medical specialties, but because of his background in head and neck anatomy and pathology and skill in temporal bone surgery, the otolaryngologist is most qualified to diagnose and manage paralysis of the facial nerve. Nevertheless, all clinicians should be able to recognize a peripheral paralysis and initiate proper evaluation. Anomalous Courses Most common anomaly: dehiscence of facial canal. Common sites: oval window and geniculate ganglion. Exposed nerve is more susceptible to injury during otologic surgery. Most course anomalies are within temporal bone: Prolapse of nerve against stapes Bifurcation around stapes Deviation across promontory Knuckle at the pyramidal (second) turn Duplication variants Anomalies are more common in malformations of the ear. II. Pathophysiology of the Facial Nerve Mixed Motor-Sensory Nerve Efferent fibers from the motor nucleus innervate muscles of facial expression, post-auricular, stylohyoid, posterior digastric, and stapedius muscles. Superior salivary nucleus projects efferent (parasympathetic preganglionic) fibers to sphenopalatine ganglion where postganglionic fibers then innervate lacrimal glands and mucinous glands of the nose. Another set of parasympathetic fibers synapse at the submandibular ganglion. Postganglionic fibers connect the submandibular and sublingual glands. Afferent fibers convey taste from anterior two-thirds of tongue to nucleus tractus solitarius via lingual nerve, chorda tympani, and nervus intermedius. Afferent fibers mediate sensation from posterior external auditory canal, concha, ear lobe, and deep parts of face. Projections unknown. Nerve Injury and Regeneration Sunderland classification of nerve injury: Neuropraxia: reversible conduction block (1° damage). Axonotmesis: loss of structural continuity of axon with intact endoneurial sheath (2° damage). Neurotmesis: 3°: loss of continuity of axons and endoneurial sheaths; 4°: loss of continuity of axons, sheaths, funiculus; 5°: complete loss of nerve continuity. Degeneration Interruption of the continuity of the axon separates the distal axon from its metabolic source, the neuron or cell body. Wallerian degeneration of the distal axon and myelin sheath begins within 24 hours. Macrophages phagocytose degraded myelin and axons. Regeneration Neuron metabolism leads to increases in mRNA, enzymes, and structural proteins. Axonal stumps swell with axoplasm and proliferation of neurofilaments. Conditions at the site of injury govern the fate and organization of the sprouts. Simple misdirection: the entry of one axon into a tubule destined for a muscle other than the one previously innervated. Clinical expression: synkinesis or associated movement . Complex misdirection: a single axon through branching innervates tubules to different muscles. Clinical expression: mass movement . Other sequelae of faulty regeneration: tics, spasms, contractures, weakness, and gustatory lacrimation. II. Differential Diagnosis of Peripheral Facial Paralysis Extracranial Traumatic Facial lacerations Blunt forces Penetrating wounds Mandible fractures Iatrogenic injuries Newborn paralysis Neoplastic Parotid tumors Tumors of the external canal and middle ear Facial nerve neurinomas Metastatic lesions Congenital absence of facial musculature Intratemporal Traumatic Fractures of petrous pyramid Penetrating injuries Iatrogenic injuries Neoplastic Glomus tumors Cholesteatoma Facial neurinomas Hemangiomas Meningiomas Acoustic neurinomas Squamous cell carcinomas Rhabdomyosarcoma Arachnoidal cysts Metastatic Infectious Herpes zoster oticus Acute otitis media Chronic otitis media Malignant otitis externa Idiopathic Bell's palsy Melkersson-Rosenthal syndrome Congenital: osteopetroses Intracranial Iatrogenic injury Neoplastic Congenital Mobius syndrome Absence of motor units IV. Evaluation of Facial Paralysis Examination The presence of a peripheral facial paralysis demands a complete head and neck examination with otoscopy and cranial nerve evaluation. Characteristics of a peripheral paralysis: At rest: less prominent wrinkles on forehead of affected side, eyebrow droop, flattened nasolabial fold, corner of mouth turned down. Unable to wrinkle forehead, raise eyebrow, wrinkle nasolabial fold, purse lips, show teeth, or completely close eye. Bell phenomenon: visible vertical rotation of globe on closing affected eye. Characteristics of a central facial paralysis: Because of uncrossed contributions from ipsilateral supranuclear areas, movements of the frontal and upper orbicularis oculi mm. tend to be spared. Facial movement may be present on affected side during emotional expression. Involvement of tongue. Presence of lacrimation and salivation. Electrodiagnostic Testing Expediency of management of acute paralysis may prevent conversion of minor injury into a more severe form with resulting sequelae. Nerve Excitability Test Technique: Using a stimulating electrode (square pulse of 0.3 msec duration) over the terminal ramifications of the facial nerve, one increases the current (milliamperes) until movement in the appropriate muscle group is just visible. Normal values (unaffected side of face) are compared to the side of paralysis. Interpretation: A difference of 3.5 mamp or more indicates an unfavorable prognosis. Electroneurography (Evoked Electromyography) Technique: Square wave impulses of 0.2 msec duration and 50-100 volt amplitude with a frequency of 1/sec are delivered with a bipolar electrode in front of the tragus while a second bipolar electrode captures the compound action potentials of underlying facial muscles in the nasolabial fold. Interpretation: The difference in amplitude of the potentials of the intact and involved side of the face correlate with the percentage of degenerated motor fibers (denervation). Advantage: Quantitative analysis of amount of degeneration. Disadvantage: Amplitudes are a 24-48 hour delayed representation of actual events occurring at site of lesion. Clinical applications: Facial nerves subjected to traumatic injuries of a magnitude requiring surgical repair undergo 90% degeneration within six days of injury. In cases of Bell's Palsy, a poor prognosis can be anticipated in patients reaching 95% or more degeneration within 14 days of onset of the palsy. Topographic Diagnosis - Topographic testing to determine the anatomical level of a peripheral lesion is possible because of the mixed function of the nerve and the branching pattern within the temporal bone. Larger, labelled illustration Tests of clinical value include: Petrosal nerve Schirmer test: quantitative evaluation of tear production Interpretation: When unilateral wetness is reduced by more than 30% of the total amount of both eyes after 5 minutes or when bilateral tearing is reduced to less than 25 mm after a 5-minute period, the Schirmer test is considered clinically significant and implies a lesion at or proximal to the geniculate ganglion. Stapedius nerve Impedance audiometry can record the presence or absence of stapedius muscle contraction to sound stimuli 70 to 100 dB above hearing threshold. Interpretation: Absence of the reflex is due to a lesion proximal to stapedius nerve (vertical segment of facial nerve). (Caution: The Schirmer's test can give false negative results.) Diagnostic Studies Audiometry Pure tone audiometry records cochlear nerve function. Stapedial reflex is part of topographic testing. Speech discrimination, tone decay, auditory evoked potentials are used to screen for retrocochlear lesions, e.g., tumors of the cerebellopontine angle. X-ray Computed tomography with and without contrast (radiopaque and air) is preferred for lesions of IAC, posterior fossa, and brain stem. High resolution scans needed for base of skull lesions. MRI is best for soft tissue assessment and tumors of the facial nerve. V. Management of Facial Paralysis Extracranial Etiologies Traumatic injuries: lacerations, gunshot wounds, iatrogenic. Most important areas to repair: main trunk, temporofacial and cervicofacial divisions. When immediate repair in contaminated or extensive wounds is not feasible, proximal and distal stumps should be tagged. The transected ends lose response to electrical stimulation within 72 hours. If not properly identified, these endings may become involved in scar tissue. Anastomosis or grafting in such cases may be impossible. Methods of repair: direct end-to-end anastomosis and interpositional grafting. Do not approximate ends under tension! Iatrogenic injury Complication of parotid surgery. Tumors are best managed by the experienced otolaryngologist-head and neck surgeon. Integrity of nerve should be ascertained prior to closure. Immediate repair indicated. Neoplasia A mass in the parotid associated with facial paralysis is a sign of malignancy. Two most common cell types: adenoid cystic and undifferentiated. Sacrifice of involved nerve and nerve adjacent to tumor indicated in high-grade malignancies: adenoid cystic, high-grade mucoepidermoid carcinoma, ex-pleomorphic adenoma, etc. Reconstruction: interpositional grafting and 7-12 cranial nerve crossover. Intratemporal Etiologies Temporal bone fractures Signs: bleeding from the external canal, hemotympanum, step-deformity of the osseous canal, conductive hearing loss (longitudinal fracture), sensorineural hearing loss (transverse fracture), CSF otorrhea, and facial nerve involvement (20% of longitudinal fractures and 50% of transverse fractures). In general, paralysis of immediate onset carries a poor prognosis and paralysis of delayed onset has a more favorable recovery. All paralysis should be followed with electrical testing, as exceptions to the maxim exist. Timely exploration and repair ensure better quality of return of function. Types of pathology: intraneural hematoma, impingement of bone and transection of nerve. Most common site of injury: adjacent to geniculate ganglion. Surgical approaches: Longitudinal fractures are explored through the middle fossa, and mastoid, if necessary. Facial nerve is examined via transmastoid, translabyrinthine approach in transverse fractures. Iatrogenic injury Incidence 0.6-3.7% Most common areas: pyramidal turn and the tympanic segment over the oval window. Neoplasia The primary tumor of the facial nerve per se is the facial neurinoma. Weakness of the face is the most common symptom. Treatment is surgical removal with grafting of the involved segment of nerve. Many benign and malignant masses may involve the facial nerve in its course through the temporal bone: glomus tumors, meningiomas, cholesteatomas, squamous cell carcinoma, rhabdomyosarcoma, etc. Surgical removal is necessary in most cases. Radiation therapy may be palliative depending on cell type, size, and location. If the nerve cannot be spared at the time of resection, interpositional grafting is warranted. Idiopathic facial palsy (Bell's Palsy) Bell's Palsy is the most common cause of facial paralysis (greater than 50% of cases of acute palsy). Unfortunately, this leads to over-diagnosis of the condition and a false sense of security. Every patient with a facial paralysis needs a complete evaluation. When the diagnosis of Bell's palsy is made (by exclusion), the patient must be followed 6 - 9 months or until recovery of facial movement. Failure of any return of function implies an etiology other than Bell's palsy. Re-evaluation is mandatory in such cases, as the most commonly overlooked diagnosis is one of neoplasia. Etiology is still unknown. Entrapment theory: an inflammatory response leads to compression and ischemia of the nerve in the narrowest part of the fallopian canal, the meatal foramen and labyrinthine segment. Electrical testing follows the degeneration of the motor fibers. Decompression of the nerve is indicated when 90-94% degeneration occurs within 2 weeks of onset. Steroids are indicated early in the course of the disease. The use of acyclovir is under investigation. Surgical decompression is accomplished via the middle fossa by an otologist-neurotologist. Transmastoid decompression is no more efficacious than steroid therapy. Infection Acute suppurative otitis media is caused by gram-positive cocci and Hemophilus influenza. Invasion into the facial canal through a dehiscence may evoke an inflammatory response with edema, compression, and ischemia resulting in facial weakness. Treatment includes myringotomy, appropriate antibiotics, and transmastoid decompression if degeneration progresses. Facial paralysis due to chronic otitis media requires tympanomastoidectomy for eradication of infection or cholesteatoma. Otalgia, facial weakness and a vesicular eruption on the concha or external canal (sensory distribution of 7th cranial nerve) characterize herpes zoster oticus (Ramsay-Hunt Syndrome). Site of pathology: labyrinthine segment of nerve. Acyclovir is treatment of choice. Malignant otitis externa is due to Pseudomonas invasion of soft tissue, cartilage, and bone. Treatment includes debridement of infected tissue, decompression of facial nerve when involved, and six weeks of semi-synthetic penicillin in combination with an aminoglycoside. Cipro may have a role in long-term therapy. Other Etiologies Congenital Mobius syndrome: hypoplasia of 6th and 7th cranial nerve nuclei. Birth trauma: due to forceps compression or compression of side of face against sacrum during labor. Osteopetroses: hereditary bone diseases. May result in bony obliteration of foramina with compression of cranial nerves. Decompression is indicated on rare occasion. Intracranial: Most common causes are neoplastic and iatrogenic . References Coker NJ and Fisch U: Disorders of the Facial Nerve. Otolaryngology , English GM (ed)Harper and Row, Hagarstown, 1984. Miehlke A: Surgery of the Facial Nerve , W.B. Saunders, Philadelphia, l973. Fisch U: Facial Nerve Surgery , Aesculapius, Birmingham, l977. Coker NJ: Facial Reanimation. Operative Challenges in Otolaryngology - Head and Neck Surgery , Pillsbury HC and Goldsmith MM (eds), pp. 688-694. Year Book Medical Publishers, Chicago, 1990. Coker NJ: Management of Traumatic Injuries to the Facial Nerve. Otolaryngol Clinics North Am , Weisman RA and Stanley Jr. RB (eds), 24:215-227. W.B. Saunders Co., Philadelphia, 1991. Coker NJ: Acute Facial Paralysis. Head and Neck Surgery - Otolaryngology , Bailey BJ (ed), 1992. Next | Core Curriculum Table of Contents | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery Mail: One Baylor Plaza, NA102, Houston, TX 77030 Phone : 713-798-5906 E-mail: oto@bcm.edu Last modified: Jan. 23, 2006