FACIAL NERVE

Anatomy

MEGHANA PATIL
ROLL NO 121
 CONTENTS
Introduction

Nucleus

Course

Branches

Blood Supply

Surgical Landmarks

Variation and Anomalies

Severity of Nerve Injury

 Introduction
Runs from Pons to Parotid

Mixed nerve; Sensory root is called Nerve of Wrisberg

2 afferents: SVA, GSA

2 efferents: SVE, GVE

 Nucleus
GVE
GVE
SVE
SVA
GSA
Receives fibres from PRE CENTRAL GYRUS

Upper Part: fibres from both Cerebral Hemispheres

Lower Part: Supplies lower face and gets only crossed

fibres from one hemisphere.

Fibres from Thalamus: alternate route, hence emotional

movements are preserved in Supra Nuclear Palsies.
 Course
Motor fibres take origin from nucleus of VII nerve after
going around the nucleus of VI nerve and then joined by
sensory root.

Leaves brainstem at PONTO MEDULLARY

JUNCTION.

Travels through Post. Cranial Fossa and enters Int. Acoustic

Meatus.

At the fundus of the meatus (lateral most part of meatus), the

nerve enters the bony facial canal, traverses the temporal
bone and comes out of the stylomastoid foramen. Here it
crosses the styloid process and divides into terminal
branches.
1. Intracranial Part: From pons to
internal acoustic meatus (15–17 mm).

2. Intratemporal Part: From internal

acoustic meatus to stylomastoid foramen.
It is further divided into:

Meatal segment (8–10 mm): Within

internal acoustic meatus.

Labyrinthine segment (4.0 mm):

From fundus of meatus to the
geniculate ganglion where nerve takes
turn posteriorly forming a “Genu.” The
nerve in the labyrinthine segment has
the narrowest diameter (0.61–0.68 mm)
and the bony canal in this segment is
also the narrowest. Thus oedema or
inflammation can easily compress the
nerve and cause paralysis. This is also
the shortest segment of the nerve.
 Tympanic or horizontal
segment (11.0 mm): From
geniculate ganglion to just above
the pyramidal eminence. It lies
above the oval window and below
the lateral semicircular canal.

Mastoid or vertical segment

(13.0 mm): From the pyramid to
stylomastoid foramen. Between
the tympanic and mastoid
segments is the Second Genu of
the nerve.

3. Extracranial Part: From

stylomastoid foramen to the
termination of its peripheral
branches.
 D: Ipsilateral Facial Paralysis +
Loss of Saliva Secr. + Loss of Taste
from ant. 2/3rd of tongue +
hyperacusis ( inc. sensitivity to
sounds) + loss of lacrimation
C: Ipsilateral Facial Paralysis +
Loss of Saliva Secr. + Loss of Taste
from ant. 2/3rd of tongue +
hyperacusis ( inc. sensitivity to
sounds)
B: Ipsilateral Facial Paralysis +
Loss of Saliva Secr. + Loss of Taste
from ant. 2/3rd of tongue
A: Ipsilateral Facial Paralysis

Crocodile Tears (Gustatory

Lacrimation). There is
Unilateral lacrimation with
Mastication. This is due to
faulty regeneration of
parasympathetic fibres which
now supply lacrimal gland
instead of the salivary
glands. It can be treated by
section of Greater Superficial
Petrosal Nerve or Tympanic
Neurectomy.
 Branches
1. Greater Superficial Petrosal Nerve: It arises from Geniculate Ganglion and carries
secretomotor fibres to lacrimal gland and the glands of nasal mucosa and palate.

2. Nerve to Stapedius: It arises at the level of Second Genu and supplies the Stapedius muscle.

3. Chorda Tympani: It arises from the middle of vertical segment, passes between the incus
and neck of malleus, and leaves the tympanic cavity through Petrotympanic Fissure. It carries
secretomotor fibres to Submandibular and Sublingual glands and brings taste from Anterior two-
thirds of Tongue.

4. Communicating Branch: It joins Auricular branch of Vagus and supplies the Concha,
Retroauricular groove, Posterior Meatus and the outer surface of Tympanic Membrane.

5. Posterior Auricular Nerve: It supplies muscles of Pinna, Occipital belly of

Occipitofrontalis and communicates with Auricular branch of Vagus.

6. Muscular Branches: To Stylohyoid and Posterior belly of Digastric.

7. Peripheral Branches: The nerve trunk, after crossing the styloid process, forms two
divisions, an upper Temporofacial and a lower Cervicofacial, which further divide into
smaller branches. These are the temporal, zygomatic, buccal, mandibular and cervical and
together form PES ANSERINUS (goose-foot). They supply all the muscles of facial
expression.
 Blood Supply
It is derived from four blood vessels:

Anterior-Inferior Cerebellar Artery:

supplies the nerve in Cerebellopontine angle;

Labyrinthine Artery: branch of Anterior-

Inferior Cerebellar Artery (Basilar A), which
supplies the nerve in internal auditory canal;

Superficial Petrosal Artery: branch of

Middle Meningeal Artery (Maxillary A),
which supplies Geniculate Ganglion and the
adjacent region; and

Stylomastoid Artery: branch of Posterior

Auricular Artery (ECA), which supplies the
Mastoid and Tympanic Segment.

All the arteries form an External Plexus

which lies in the Epineurium and feeds a
deeper Intraneural Internal Plexus
 Surgical Landmarks
For Middle Ear and Mastoid Surgery
Processus cochleariformis: It demarcates the geniculate
ganglion which lies just anterior to it. Tympanic segment of the
nerve starts at this level.
Oval Window and Horizontal Canal: The facial nerve runs
above the oval window (stapes) and below the horizontal canal.
Short process of Incus: Facial nerve lies medial to the short
process of incus at the level of aditus.
Pyramid: Nerve runs behind the pyramid and the posterior
tympanic sulcus.
Tympanomastoid suture: In vertical or mastoid segment,
nerve runs behind this suture. 5-8mm deep to the suture.
Digastric Ridge: The nerve leaves the mastoid at the anterior
end of digastric ridge. Antero-medial to mastoid segment of
nerve.
For Parotid Surgery
Cartilaginous pointer: The nerve
lies 1 cm deep and slightly anterior
and inferior to the pointer.
Cartilaginous pointer is a sharp
triangular piece of cartilage of the
pinna and “points” to the nerve.
Tympanomastoid suture: Nerve
lies 6–8 mm deep to this suture.
Styloid process: The nerve crosses
lateral to styloid process.
Posterior belly of Digastric: If
posterior belly of digastric muscle is
traced backwards along its upper
border to its attachment to the
digastric groove, nerve is found to lie
between it and the styloid process.
 Variation and Anomalies
Bony dehiscence: This is the most common anomaly. Dehiscence (absence of bony cover)
occurs most commonly in tympanic segment over the Oval Window. It also occurs near the
region of Geniculate Ganglion or in the region of Retrofacial Mastoid cells. A dehiscent nerve
is prone to injury at the time of surgery or gets easily involved in Mastoid and Middle ear
infections.

Prolapse of nerve: The dehiscent nerve may prolapse over the Stapes and make Stapes
Surgery or Ossicular Reconstruction difficult.

Hump: The nerve may make a hump posteriorly near the Horizontal canal making it
vulnerable to injury while exposing the antrum during mastoid surgery.

Bifurcation and Trifurcation: The Vertical part of facial nerve divides into two or three
branches, each occupying a separate canal and exiting through individual foramen.

Bifurcation and Enclosing the stapes: The nerve divides proximal to Oval Window—one
part passing above and the other below it and then reuniting.

Between Oval and Round Windows: Just before Oval Window the nerve crosses the
middle ear passing between oval and round windows.

Anomalies of the nerve are more common in congenital ears; utmost care should be taken while
operating cases of microtia or other congenital conditions of the ear.
 Severity of Nerve Injury
Degree of nerve injury will determine the Regeneration of nerve and its function. Earlier nerve injuries were
divided into:

Neurapraxia: a Conduction Block, where flow of axoplasm through the axons was partially obstructed.

Axonotmesis: Injury to Axons.

Neurotmesis: Injury to Nerve.

Sunderland classified nerve injuries into five degrees of severity based on Anatomical structure of the nerve
and this classification is now widely accepted.

1°= Partial block to flow of axoplasm; no morphological changes are seen. Recovery of function is complete
(Neurapraxia).

2°= Loss of axons, but endoneurial tubes remain intact. During recovery, axons will grow into their respective
tubes, and the result is good (Axonotmesis).

3°= Injury to Endoneurium. During recovery, axons of one tube can grow into another. Synkinesis can occur
(Neurotmesis).

4°= Injury to Perineurium in addition to above. Scarring will impair regeneration of fibres (Partial
Transection).

5°= Injury to Epineurium in addition to above (Complete Nerve Transection).

The first three degrees are seen in Viral and Inflammatory disorders while fourth and fifth are seen in Surgical
or Accidental Trauma to the nerve or in Neoplasms.
References:
P99-102, Diseases of Ear, Nose and Throat & Head and Neck
Surgery, PL Dhingra, Shruthi Dhingra, 7E

Thank You