PEER-REVIEW REPORTS

The Nervus Intermedius: A Review of Its Anatomy, Function, Pathology, and Role
in Neurosurgery
R. Shane Tubbs1, Dominik T. Steck1, Martin M. Mortazavi1, Aaron A. Cohen-Gadol 2

Key words
䡲 Anterior inferior cerebellar artery
䡲 Cranial nerve
䡲 Facial nerve
䡲 Intermediate nerve
䡲 Microvascular decompression
䡲 Neuralgia
䡲 Nervus intermedius
䡲 Vestibulocochlear nerve
䡲 Wrisberg nerve
Abbreviation and Acronym
MRI: Magnetic resonance imaging
From 1Pediatric Neurosurgery, Children’s
Hospital, Birmingham, Alabama; and
2
Goodman Campbell Brain and Spine, Department of
Neurological Surgery, Indiana University, Indianapolis,
Indiana, USA
To whom correspondence should be addressed:
Aaron A. Cohen-Gadol, M.D., M.Sc.
[E-mail: acohenmd@gmail.com]
Citation: World Neurosurg. (2013) 79, 5/6:763-767.
http://dx.doi.org/10.1016/j.wneu.2012.03.023
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter © 2013 Elsevier Inc.
All rights reserved.
PAIN
䡲 BACKGROUND: Geniculate neuralgia, although uncommon, can be a debili-
tating pathology. Unfortunately, a thorough review of this pain syndrome and the
clinical anatomy, function, and pathology of its most commonly associated nerve,
the nervus intermedius, is lacking in the literature. Therefore, the present study
aimed to further elucidate the diagnosis of this pain syndrome and its surgical
treatment based on a review of the literature.
䡲 METHODS: Using standard search engines, the literature was evaluated for
germane reports regarding the nervus intermedius and associated pathology. A
summary of this body of literature is presented.
䡲 RESULTS: Since 1968, only approximately 50 peer-reviewed reports have been
published regarding the nervus intermedius. Most of these are single-case
reports and in reference to geniculate neuralgia. No report was a review of the
literature.
䡲 CONCLUSIONS: Neuralgia involving the nervus intermedius is uncommon, but
when present, can be life altering. Microvascular decompression may be
effective as a treatment. Along its cisternal course, the nerve may be difficult to
distinguish from the facial nerve. Based on case reports and small series,
long-term pain control can be seen after nerve sectioning or microvascular
decompression, but no prospective studies exist. Such studies are now neces-
sary to shed light on the efficacy of surgical treatment of nervus intermedius
neuralgia.

INTRODUCTION
The nervus intermedius was first identified
in 1563, and it was Heinrich August Wris-
berg who named it the “portio media inter
comunicantem faciei et nervum auditorium” in
1777 (1). This nerve (Figure 1), often re-
ferred to as the Wrisberg nerve, carries
parasympathetic fibers to the lacrimal and
nasopalatine glands and transmits sensory
information from the tongue and various
skin areas of the nose and concha of the
ear (8, 20, 22, 28). A cutaneous branch
arises near the origin of the chorda tym-
pani nerve and joins with the auricular
branch of the vagus nerve to supply the
external auditory canal and concha of the
external ear. It is this innervation that al-
lows herpetic vesicles to be identified in
the ear with viral infection of the genicu-
late ganglion, the so-called Ramsay-Hunt
syndrome (20).
ANATOMY AND FUNCTIONS
The nervus intermedius consists of fibers
derived from the superior salivary nucleus
whose stimulation results in secretion of
the lacrimal and submandibular and sub-
lingual glands (4). Traveling along this
nerve are sensory fibers derived from the
gustatory receptors destined for the supe-
rior pole of the solitary nucleus in the me-
dulla and fibers for cutaneous sensation of
parts of the ear destined for the dorsal part
of the trigeminal tract (31). The course of
the nervus intermedius and the motor root
of the facial nerve can be divided into cister-
nal, meatal, labyrinthal, and extracranial
parts. Rhoton et al. (20) found that, on av-
erage, the length of all 3 segments was 22
mm. The nerve takes its name from its in-
termediate position between the facial and
superior portion of the vestibular nerves
(20). The average length of adherence,
which is often crescent shaped, of the ner-
vus intermedius to the vestibulocochlear
nerve has been found to be approximately 8
mm (11, 20). Inside the meatus, the motor
root of the facial nerve and the nervus inter-
medius are usually bound together as a sin-
gle structure.
In the temporal bone, the facial nerve
continues its course through the facial ca-
nal. The nerve is supplied from branches of
the middle meningeal, maxillary, and pos-
terior auricular arteries. Between the co-
chlea and the semicircular canals, it runs
laterally above the vestibule. Reaching the
medial wall of the epitympanic recess, the
geniculum (external genu) is formed. This
point, above the base of the cochlea, is the
location of the geniculate ganglion (14).
Here the nerve gives rise to the greater
petrosal nerve (greater superficial petrosal
nerve), which carries parasympathetic fi-

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R. SHANE TUBBS ET AL.
PAIN
Figure 1. Cadaveric dissection of the right
porus acousticus noting the facial, nervus
intermedius, and vestibulocochlear nerves.
bers supplying the lacrimal, nasal, and pal-
atine glands (22, 29). The tympanic cavity
and the nerve are separated only by a thin
layer of bone and this layer might be absent,
so in some individuals, there is only the mu-
cosa between the nerve and the cavity of the
middle ear, and therefore the nerve might
be easily affected by infections of the middle
ear. Possible anomalies include the nerve
lying in the wall of the mastoid antrum with
the nerve emerging from the mastoid pro-
cess and division of the nerve within the
facial canal (branches leave the temporal
bone through different foramina in this
case). An anterolateral turn toward the pa-
rotid gland describes the extracranial
course of the facial nerve after it emerges
from the stylomastoid foramen (14, 31).
Rhoton et al. (20) and Oh et al. (16) found
up to 4 to 5 roots that made up the nervus
intermedius, although a single root was the
most common. Additionally, Rhoton et al.
(20) stated that in approximately 20% of
cases, it is impossible to identify the nervus
intermedius along its intracisternal course
because it is intimately attached to the ves-
tibular part of the vestibulocochlear nerve
and does not separate from it until the inter-
nal acoustic meatus.
Preganglionic fibers from the superior
salivatory nucleus in the pons travel to the
pterygopalatine ganglion in the greater
petrosal nerve, and the postganglionic fi-
bers innervate the lacrimal gland as well as
the glands of the nose and palate. Pregan-
glionic parasympathetic fibers from the
pons travel to the submandibular ganglion
in the chorda tympani and innervate the
submandibular, the sublingual, and the ac-
cessory salivary glands.
764 www.SCIENCEDIRECT.com
Section of the nervus intermedius may
decrease the cutaneous sensitivity in the
area around the concha of the external ear,
sensation from anterior nasopharynx and
tympanic membrane, part of the external
auditory canal, and the area behind the ear
and over the mastoid process (11, 22). Stim-
ulation of the nervus intermedius can cause
referred pain to the ear, and the projection
of fibers from this nerve might also explain
referred pain to the face after irritation of
the nervus intermedius (20). Therefore, the
nervus intermedius plays an important role
in the surgical treatment of neuralgia of the
external auditory canal (see later) (20). In-
terestingly, Ashram et al. (6) described elec-
tromyography activity in the orbicularis oris
muscle after stimulation of the nervus inter-
medius.
Burmeister et al. (8) conducted a study in
which they tried to identify the nervus inter-
medius with 3-T magnetic resonance imag-
ing (MRI). Their conclusion was that the
nervus intermedius can be depicted reliably
with MRI, which might be helpful, espe-
cially in the diagnosis of the source of tu-
mors in this region.
GENICULATE NEURALGIA AND ITS
SURGICAL TREATMENT
Although nervus intermedius (geniculate)
neuralgia is rare and difficult to diagnose, a
number of different surgical treatment op-
tions have evolved, leading to more confu-
sion about the most appropriate approach.
The International Headache Society (10) de-
fines nervus intermedius neuralgia as inter-
mittent episodes of pain located deep in the
ear that last for seconds or minutes; the
posterior wall of the auditory canal may be a
trigger zone. The pain can be accompanied
by disorders of lacrimation, salivation, and
taste (10). In 1909, Clark and Taylor (9) were
the first to report success in treating facial
pain with resection of the geniculate gan-
glion. Of note, some have advocated tran-
section of the nervus intermedius for
chronic cluster headaches (15, 22). In fact,
Rowed (22) reported a 75% success rate us-
ing this technique in such patients. Paren-
thetically, this investigator found that hear-
ing impairment was the most frequent
serious complication after sectioning of the
nervus intermedius (22).
Sachs (24) followed up four patients
after section of the nervus intermedius,
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2012.03.023
PEER-REVIEW REPORTS
THE NERVUS INTERMEDIUS
two of them for more than 10 years. The
first patient, a 43-year-old woman, suf-
fered from attacks of right-sided face and
head pain for 7 years that later became
associated with severe pain in the right
ear. During surgery and under local anes-
thesia, the facial, vestibulocochlear, and
glossopharyngeal nerves, including the
nervus intermedius, were explored; stim-
ulation of the nervus intermedius resulted
in pain in the ear and right face. The same
symptoms could be produced when stim-
ulating the vestibulocochlear nerve. The
facial (inadvertently) and vestibuloco-
chlear nerves and the nervus intermedius
were sectioned. No recurrence was noted
at 15 years of follow up. The second pa-
tient, a 56-year-old man with attacks of
left-sided facial pain that were associated
with ipsilateral lacrimation and nasal
congestion, underwent left greater petro-
sal neurectomy, which brought relief for 3
years. A third patient, a 65-year-old man
who suffered from attacks of pain on the
left side of the face without lacrimation,
nasal congestion, or ear pain, also under-
went sectioning of the nervus interme-
dius. Lacrimation was lost, but no loss of
taste occurred, and the patient became
pain-free postoperatively. The fourth pa-
tient, a 36-year-old man, complained of
daily headaches for 6 to 8 weeks per year.
The pain was in the right cheek, eye, fore-
head, temple, and behind the right ear. In
this case, a large internal auditory artery
was seen between the facial and vestibu-
locochlear nerves. Sectioning of the ner-
vus intermedius caused decrease of lacri-
mation and loss of taste on the anterior
two-thirds of the tongue and immediate
relief of pain (24). There is some variation
in the distribution of pain among the
above patients (some suffering from fa-
cial pain) making it difficult to assess who
reliably harbored geniculate neuralgia.
Lovely and Janetta (13) reported 14 cases
of patients with the primary complaint of
deep inner ear pain, often in combination
with atypical facial pain or throat pain. Vas-
cular compression of the trigeminal, glos-
sopharyngeal, or vagus nerve or the nervus
intermedius was observed in almost every
case and was assumed to be a cause of the
primary or secondary complaints in these
patients (Figures 2 and 3A).
These cases emphasize the importance
of the nervus intermedius in otalgia. Four
 PEER-REVIEW REPORTS
R. SHANE TUBBS ET AL. THE NERVUS INTERMEDIUS

Rupa et al. (23) reported 14 patients with
geniculate neuralgia who underwent nervus
intermedius sectioning. This cohort was in-
cluded among 18 cases of primary otalgia
with additional procedures, including
resection of the geniculate ganglion,
sented with both trigeminal and nervus
intermedius neuralgia (touching the nose
and the external auditory meatus caused
pain in the second/third divisions of the
trigeminal nerve and ear, respectively).
During surgery, the anterior inferior cer-

Figure 2. Schematic drawing of the surgical
approach to the nervus intermedius for
microvascular decompression or sectioning.
patients had to undergo multiple proce-
dures, and in two of them, lasting relief was
not obtained before the nervus intermedius
was sectioned. The sectioning of the nervus
intermedius was well tolerated in all pa-
tients, and no neurologic deficits or altera-
tions in taste or lacrimation were reported
(13). The efficacy of pain relief through mi-
crovascular decompression or sectioning of
the nervus intermedius cannot be reliably
established by this study. Some patients
suffered from atypical face pain as well, and
therefore, a heterogeneous group of pa-
tients was analyzed.
glossopharyngeal, vagus, tympanic, and
chorda tympani nerves. Among all pa-
tients, pain relief was achieved in 72.2%
(23). Reported side effects of nervus in-
termedius sectioning included decreased
lacrimation, salivation, and taste (23).
Pulec (18) has also reported good results
after nervus intermedius sectioning for
geniculate neuralgia.
Sakas et al. (26) reported a case of a 52-
year-old woman with episodes of pain of
the right auditory canal, pinna and retro-
mastoid area, as well as right-sided tinni-
tus, hearing loss, imbalance, and vertigo.
Neuroimaging demonstrated a tortuous an-
terior inferior cerebellar artery compress-
ing the facial and vestibulocochlear nerves
at the internal auditory meatus. During sur-
gery, the artery was mobilized and sepa-
rated from the nerves. All symptoms,
including pain, tinnitus, vertigo, and
hearing loss, improved during the follow-
ing months (26). Belloti et al. (7) dis-
cussed a 65-year-old patient who pre-
PAIN
ebellar artery was found adherent to the
facial and vestibulocochlear nerves and
the root of the trigeminal nerve was com-
pressed by three large veins and a branch
of the superior cerebellar artery. After de-
compressing the nerves from the vessels
and rhizotomy of the sensory root of the
trigeminal nerve, the patient became pain
free (7). Saers et al. (25), Younes et al.
(30), and Özer et al. (17) reported similar
cases of suspected nervus intermedius
neuralgia in which the anterior inferior
cerebellar artery compressed the nervus
intermedius and mobilization of the ar-
tery cured the pain. Such neurovascular
compression led to demyelination at the
root entry zone (25). Interestingly, some
have questioned vascular compression as
a cause of geniculate neuralgia (5).
Alfieri et al. (2) found that the mean dis-
tance laterally from the brain stem of cen-
tral myelin for the nervus intermedius was
0.5 mm on the medial side of the nerve and
0.33 on its lateral side. The Obersteiner-
Redlich zone or glial-Schwann cell junction
for the medial and lateral sides of the nerve
was 0.279 mm and 0.33 mm, respectively
(2). With these data, it appears that the ner-
vus intermedius is closer to the brain stem
compared with other cranial nerves (2).
Riederer et al. (19) described an inter-
esting case of familial geniculate neural-
gia and concluded that an X-linked domi-
nant inheritance was most likely the cause
of the occurrence of nervus intermedius
neuralgia in the family. In some cases, a
genetic susceptibility for cranial neural-
gias might be present (32), and one theory
suggested a mutation of the Nav 1.7 so-
dium channel with resultant nerve hyper-
excitability (3).

PERSPECTIVES ON SURGICAL
TREATMENT OF GENICULATE
NEURALGIA
The previously discussed studies regard-
ing the surgical treatment of geniculate
Figure 3. Intraoperative images of the surgical approach (A) to the nervus intermedius in a patient neuralgia suffer from similar limitations.
with geniculate neuralgia. Note the surrounding nerves (B). An offending vessel was identified and The studied patients suffered from heter-
pulled away (C) from the nerve and held in place with a Teflon implant (D).
ogeneous pain syndromes that included

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R. SHANE TUBBS ET AL.
poorly described face pain. The number
of patients mentioned in the individual
studies and the follow-up durations are
also limited.
The efficacy of exploratory surgery with
transection of nervus intermedius for long-
PAIN
term relief of geniculate neuralgia remains
unconvincing. Therefore, patient selection
remains especially important, and the risk
of vestibulocochlear nerve dysfunction and
resultant persistent dizziness and balance
dysfunction should be carefully considered
during manipulation of the VII/VIII com-
plex. Glossopharyngeal neuralgia with a
primarily otitic component may mimic
geniculate neuralgia; this overlap in presen-
tation should be considered during explora-
tion of the posterior fossa cranial nerves
because the glossopharyngeal nerve may be
involved in vascular compression.
TUMORS INVOLVING THE
NERVUS INTERMEDIUS
Scheller et al. (27) reported a possible case
of case of nervus intermedius schwannoma
that presented with progressive left-sided
hearing loss and dizziness. Rizer et al. (21)
reported a 38-year-old man with left-sided
hearing loss and tinnitus. MRI demon-
strated a lesion in the lateral end of the left
internal auditory canal. During surgery, a
tumor was found that attached only to part
of the facial nerve and was removed with
nervus intermedius sectioning. Kudo et al.
(12) reported a patient who presented with
left hemifacial spasm. A small mass (later
found to be a schwannoma) arising from
the nervus intermedius, adhering to and
compressing the facial nerve, was found.
The nervus intermedius was sectioned and
the patient was free of spasms after surgery
and at long-term follow-up.
CONCLUSIONS
Neuralgia involving the nervus intermedius
is uncommon, but when present, it can be
life altering. Microvascular decompression
may be effective as a treatment. Along its
cisternal course, the nerve may be difficult
to distinguish from the facial nerve. Based
on case reports and small series, long-term
pain control can be seen after nerve section-
ing or microvascular decompression, but
no prospective studies exist. Such studies
766 www.SCIENCEDIRECT.com
are now necessary to shed light on the effi-
cacy of surgical treatment of nervus inter-
medius neuralgia. A thorough knowledge
of the anatomy of this nerve is necessary
when treating patients presenting with
symptoms due to pathology along its
course.
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Early versus Delayed Endoscopic Surgery for Carpal Tunnel Syndrome: Prospective
Randomized Study
P. Sarat Chandra, Pankaj Kumar Singh, Vinay Goyal, Avnish Kumar Chauhan, Nirmal Thakkur, Manjari Tripathi
Key words
䡲 Carpal tunnel release
䡲 Carpal tunnel syndrome
䡲 Endoscopic surgery
䡲 Flexor retinaculum
Abbreviations and Acronyms
APB: Abductor pollicis brevis
CTS: Carpal tunnel syndrome
EP: Electrophysiology
ICMR: Indian Council for Medical Research
NSAIDs: Nonsteroidal antiinflammatory drugs
Department of Neurosurgery, All India Institute
of Medical Sciences, New Delhi, India
To whom correspondence should be addressed:
Manjari Tripathi, D.M.
[E-mail: manjari.tripathi1@gmail.com]
Citation: World Neurosurg. (2013) 79, 5/6:767-772.
http://dx.doi.org/10.1016/j.wneu.2012.08.008
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter © 2013 Elsevier Inc.
All rights reserved.
INTRODUCTION
Carpal tunnel syndrome (CTS) is the most
common nerve entrapment syndrome oc-
curring in the upper extremity, with a prev-
alence of up to 9% (18). Classic symptoms
of CTS include pain, paresthesia (character-
istically worse during the night, termed bra-
chialgia paresthetica nocturna), and hypoesthe-
sia in the hand. Weakness and atrophy of
the abductor pollicis brevis (APB) and mus-
cles innervated by the median nerve may
also be observed. The characteristic prolon-
gation of distal motor latency confirms the
diagnosis (1, 25). Initially, a conservative
approach to treatment is preferred for per-
sisting symptoms; however, the treatment
WORLD NEUROSURGERY 79 [5/6]: 767-772, MAY/JUNE 2013
PEER-REVIEW REPORTS
THE NERVUS INTERMEDIUS
32. Wang Y, Yu CY, Huang L, Riederer F, Ettlin D: Fa- Received 17 November 2011; accepted 29 March 2012
milial neuralgia of occipital and intermedius nerves
PERIPHERAL NERVE
Citation: World Neurosurg. (2013) 79, 5/6:763-767.
in a Chinese family. J Headache Pain 12:497-500,
http://dx.doi.org/10.1016/j.wneu.2012.03.023
2011.
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
Conflict of interest statement: The authors declare that the
1878-8750/$ - see front matter © 2013 Elsevier Inc.
article content was composed in the absence of any
All rights reserved.
commercial or financial relationships that could be
construed as a potential conflict of interest.
䡲 OBJECTIVE: To compare the effects of early versus delayed endoscopic
surgery in patients with moderately severe carpal tunnel syndrome (CTS).
䡲 METHODS: The study included 100 patients with CTS. Investigations per-
formed before surgery excluded secondary causes. Patients with moderately
severe CTS (grade 3– 4) were randomly assigned. Bland’s neurophysiologic
grading scale for CTS was used to assess the patients. Patients underwent an
endoscopic carpal tunnel release using an indigenously designed instrument.
䡲 RESULTS: Following a course of conservative treatment, surgical treatment
was offered in two groups: early surgery (n ⴝ 51; <1 week after diagnosis) and
delayed surgery as per the usual waiting list (n ⴝ 49; >6 months after diagnosis).
Improvement in both groups was significant (P < 0.001). When both groups were
compared, improvement was better for the early surgery group (P < 0.001;
confidence interval 6.35–9.12).
䡲 CONCLUSIONS: On the basis of this study, early endoscopic surgery is
proposed in patients with moderately severe CTS.
of choice is surgical dissection of the trans- ance. Generally, most reviews state that
verse carpal ligament (flexor retinaculum) both endoscopic and open techniques are
with decompression of the nerve (16, 18). safe and equally effective in relieving the
Open dissection of the transverse carpal symptoms of CTS.
ligament has been the standard procedure The timing of surgery (early or delayed) is
performed for ⬎50 years (5, 21). Endo- also important. Most patients who are rou-
scopic surgical techniques were developed tinely considered for surgery are usually
and introduced to ameliorate the inconve- given a trial of conservative treatment, fol-
niences and adverse events of open dissec- lowed by surgery after 3– 6 months. Earlier
tion. Endoscopic carpal tunnel release was studies have shown that both conservative
introduced by Okutsu et al. in 1987 (15). and surgical treatments lead to improved
Subsequently, several other clinicians de- outcomes. However, the improvement has
veloped endoscopic techniques for dissec- been shown to be better in patients who
tion of the transverse carpal ligament (3, underwent surgery (20, 21).
12-23). These techniques were introduced Treatment for moderately severe (Bland
with the presumed advantage of being min- score 3– 4 [defined subsequently]) (25) CTS
imally invasive with decreased surgical du- is controversial. Few studies favored both
ration, resulting in better patient compli- surgery and conservative treatment. How-
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