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Paralysis of the Portio Dura

nerve, bone, fallopian, children, facial, mouth, palate, child and skull

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PARALYSIS OF THE PORTIO DURA.

paralysis from affection of the portio Jura of the seventh nerve may be a mild• or severe complaint according to the cause on which the paralysis depends. It is common enough in children, and in them is fre quently a sign of severe and perhaps incurable disease.

It will be remembered that the facial nerve rises in the floor of the fourth ventricle from a nucleus common to it and the sixth nerve. Thence it passes outwards with the auditory nerve, enters the internal auditory meatus, and is conveyed by the Fallopian aqueduct' to its foramen of exit from the skull. It is important to bear in mind the principal branches given off by the nerve in the Fallopian canal, as the seat of the lesion is determined by the extent and distribution of the paralysis. Shortly after entering the aqueduct, the facial nerve is joined by the large superficial petrosal branch of the Vidian nerve. It is by this channel that it conveys nervous influence to the velum ; for the Vidian nerve is united with el's ganglion, from which branches descend to supply the muscles of the uvula and soft palate. Soon afterwards it is joined by the small super ficial petrosal branch from the tympanic nerve ; and a little farther on it gives off the chorda tympani, which joins the gustatory branch of the fifth nerve, and is distributed to the tongue.' Causation.—The function of the facial nerve may be interfered with by a lesion at any part of its course, from its origin in the floor of the fourth ventricle to its periphery. The cause of the paralysis may therefore lie in side the skull cavity, in the Fallopian aqueduct, or outside the temporal bone.

Inside the skull the nerve may be injured by extravasation of blood or be compressed by tumours, inflammatory thickenings of the Jura water, and by exudations. In the Fallopian canal the nerve may be damaged by fracture at the base of the skull, or be destroyed by caries of the petrous bone. After leavino. the temporal bone the nerve may be injured by the forceps during delivery ; or by blows upon the face ; or by inflammation set up in its sheath by extension from neighbouring parts, as in parotid itis ; or by an impression of cold, causing rheumatic inflammation of the sheath of the nerve.

The two chief causes which give rise to this condition in children are, no doubt, carious disease of the petrous bone, and exposure of the face to a current of cold air. Of these the first is a very serious disease, the sec ond a comparatively trifling one.

Caries of the petrous part of the temporal bone is a common conse quence of neglected otitis in the child. According to Von Treltsch, it is far from uncommon to find the mastoid cells, with the tympanic cavity, and the Eustachian tube the seat of suppurative catarrh in a child who had lived and died without the disease having been suspected. This con

dition may exist without external discharge, without pain, or any symptom by which its presence may be revealed (see Otitis).

In children under three years of age facial paralysis is not rare. At this time of life it is due almost invariably to otitis and caries of bone, with suppuration in the sheath of the nerve. Older children may suffer from paralysis arising from the same cause, but in them there is increasing prob ability that the loss of power is the consequence of a chill.

Symptoms.—The first s).L.uptom usually noticed by the mother is that the child's mouth is drawn to one side when he laughs, or cries. On care ful inspection it will be found that the absence of movement involves the whole side of the face. While the features are at rest, the eye on the af fected side is incompletely closed ; the nostril is flattened ; the cheek may hang a little, although this is not easy to detect in babies ; and the angle of the mouth is slightly lowered. It is when the child cries that the great difference between the two sides is seen. Then, on the healthy side the eyebrow contracts ; the forehead wrinkles ; the eye closes ; the ala of the nose and the mouth are drawn upwards ; and the middle line of the lips is pulled fax out of the centre of the face. On the affected side, on the con trary, the muscles are motionless ; the eye is open ; and the skin remains smooth. If the nerve is affected in the Fallopian canal, the paralysis af fects the soft palate. On looking into the throat, it will be seen that on the side of the lesion the arch of the palate is flattened, and that the uvula is curved to the sound side ; for the motor fibres which pass through the large superficial petrosal nerve and the Vidian nerve to Meckel's ganglion, from which the palatine branches proceed, contract the azygos uvulae only on the sound side. For the same reason children may complain that their mouth is dry and their taste impaired—the chorda tympani, which erects the papilla of the tongue and promotes secretion of saliva, no longer con veying the nervous influence. Sensibility is not affected, but babies often seem to have a difficulty in swallowing their food ; and if there should be loss of power on one side of the soft palate,. some of the milk may be oc casionally returned through the nose. An older child complains of great inconvenience from food collecting between the gums and the cheek, through the action of the buccinator being paralysed. He can no longer whistle, and even his speech may be impaired. The half-open eye is apt to become inflamed from exposure ; and there may be a flow of tears over the cheek as a consequence, according to Duchenne, of paralysis of the tensor tarsi muscle, which no longer retains the puncta in its normal posi tion.

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