Moderator: Presenter:

Dr k ranganath Dr prashanth l
P G Trainee
CONTENTS :
Introduction
Embryology
Origin
Functional components
Course and relations









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Communications
Branches
Vascular supply
Facial nerve paralysis
References

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introduction
The facial nerve is the seventh (VII) of twelve
paired cranial nerves.
It is the nerve of facial expression.
The facial nerve is composed of approximately
10,000 neurons, 7,000 of which are myelinated
and innervate the nerves of facial expression and
3000 of the nerve fibres' are somatosensory and
secretomotor and make up the nervus intermedius
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EMBRYOLOGY OF FACIAL NERVE
Tissue which will become the facial nerve is first
identifiable at the end of 3
rd
week of gestation
when the entire embryo is 3mm long.
At this stage, a collection of neural crestal cells
appears dorsolateral to rhombencephalon and just
rostral to otic (acoustic) placode.

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These cell collection also gives rise to 8
th
(acoustic)
cranial nerve, therefore it is called as
fascioacoustic (or acousticofacial) primordium
or crest.
By the end of 4
th
week , the facial and acoustic
portions of primordium become more distinct.
The facial portion of the primordium is a narrow
cell column which extends to a thickened area of
surface ectoderm called a placode.
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This placode is located on the surface of upper
portion of second pharyngeal arch.
During early 5
th
week, the geniculate ganglion
begins as a collection of neuroblasts in the facial
portion of primordium.
Proximal segment of primordium becomes less
cellular and more fibrous in appearance.
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Distal segment is ill-defined but separates into
two almost equal branches:
i. one courses caudally into dense mesenchyme of
second pharyngeal arch and represents future
main trunk of facial nerve.
ii. the other curves down to the first arch to
become the chorda tympani nerve.
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origin of facial nerve
DEEP/NUCLEAR ORIGIN:
1. Facial/motor nucleus
2. Superior salivatory
nucleus
3. Upper part of nucleus of
tractus solitarius
4. Upper part of the spinal
nucleus of trigeminal nerve


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1. Facial/Motor Nucleus
It lies deep in the reticular formation
of lower pons, below and in front of
abducent nucleus.
It represents special visceral efferent
column which supplies muscles of
face.
At the cranial end of abducent
nucleus , the fibres bend abruptly
downwards and forwards forming an
internal genu and emerge at the
lower border of the pons through the
motor root.


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2. Superior Salivatory Nucleus
It is situated dorso lateral
to the caudal part of motor
nucleus.
It represents general
visceral efferent column.
Gives origin to the
preganglionic secretomotor
fibres which emerge
through the sensory root.

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3. Nucleus Of Tractus
Solitarius
It represents special visceral
afferent and possibly general
visceral afferent column.
It receives taste sensation
from anterior 2/3
rd
of tongue
via chorda tympani nerve,
and from soft palate through
greater petrosal nerve.

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4. Spinal Nucleus Of
Trigeminal Nerve
Possibly it receives
cutaneous sensations from
auricle through auricular br
of vagus, and cell bodies of
these fibres are located in
geniculate ganglion of facial
nerve.
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SUPERFICIAL ORIGIN:
The facial nerve consists of a
motor and a sensory part
(nervus intermedius)
The two parts emerge at the
lower border of the pons in the
recess between the olive and the
inferior peduncle, the motor part
being the more medial,
immediately to the lateral side of
the sensory part is the acoustic
nerve.


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Functional components of facial
nerve
1. Branchiomotor- motor fibres:
supply the muscles which are
derived from second arch.
2. Preganglionic secretomotor fibres:
for submandibular ,sublingual,
lacrimal glands and glands of soft
palate and nasal cavity.
3. Special sensory fibres: from
anterior 2/3
rd
of tongue and soft
palate.
4. General sensory fibres: from
concha of auricle.

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Course and relations
Course of the facial nerve
may be divided by
stylomastoid foramen
into
Intracranial part
Extracranial part


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Intracranial part:
The facial nerve emerges from the brainstem with the
nerve of Wrisberg, i.e. the nervus intermedius.
The nervus intermedius gained its name from its
position as it courses across the cerebellopontine angle
(CPA) between the facial nerve and the
vestibulocochlear nerves.




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The average distance between
the point where the nerves exit
the brainstem and the place
where they enter into the
internal auditory canal (IAC) is
approximately 15.8 mm.
The facial nerve and the nervus
intermedius lie above and
slightly anterior to CN VIII.
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At the fundus of the
meatus, the two roots,
sensory and motor roots
fuse to form a single trunk,
which lies in the petrous
temporal bone.
Within the canal, course of
the nerve can be divided
into three parts by two
bends.

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First part, is directed laterally
above the vestibule.
Second part, runs backwards
along the medial wall of the
middle ear, above the
promontory.
Third part, is directed vertically
downwards behind the
promontory.

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First bend, at the junction of first and second parts is
sharp. it lies over the anterosuperior part of the
promontory, and is called as genu.
The geniculate ganglion of the nerve is so called
because it lies on the genu.
Second bend is gradual and lies b/w promontory and
aditus to the mastoid antrum.
Finally the nerve passes vertically downwards along the
posterior wall of the tympanic cavity and leaves the
temporal bone through the stylomastoid foramen.
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Extracranial part:
At its exit from the foramen the
facial nerve changes the
direction, passes forward
superficial to the styloid process
of temporal bone and pierces the
posteromedial surface of parotid
gland.

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Within the gland the nerve runs forward for about 1cm
superficial to the retromandibular vein and external
carotid artery, and then divides into: temporo-facial
trunk and cervico-facial trunk.
Temporo-facial trunk turns abruptly upwards and
subdivides into temporal and zygomatic branches.
Cervico-facial trunk passes downwards and forward &
subdivides into buccal, marginal mandibular and
cervical branches.



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The five terminal branches radiate like the gooses foot
through the anterior border of the gland and supply the
facial muscles. Such patterning is called pes anserinus
The trunks branch further to form a parotid plexus (pes
anserinus), which exhibits variations in branching pattern.
They leave the parotid gland by its anteromedial surface,
medial to its anterior margin and supply the muscles of
facial expression.


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Communications of the facial nerve
In the internal acoustic meatus:
a. communicates with the vestibulocochlear nerve.
At the geniculate ganglion:
a. communicates with pterygopalatine ganglion through the
greater petrosal nerve.
b. communicates with otic ganglion by a branch which joins
with lesser petrosal nerve.
c. communicates with sympathetic plexus around middle
meningeal artery by a branch called as external petrosal n.

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In the facial canal:
a. With the auricular branch of vagus nerve, through
which facial nerve possibly conveys cutaneous
sensations from concha.
Below the stylomastoid foramen:
a. With glossopharyngeal nerve
b. With vagus nerve
c. With auriculotemporal nerve
d. With greater auricular nerves
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Behind the ear:
a. With lesser petrosal nerve
In the face:
a. With the branches from trigeminal nerve
In the neck:
a. with the transverse cervical cutaneous nerve
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Branches of facial nerve
In the facial canal
a. Nerve to the stapedius:
it arises from the facial nerve opposite the pyramidal
eminence and supplies the stapedius muscle.
paralysis of this nerve causes hyperacusis.
b. Chorda tympani nerve:
It arises from the facial nerve about 6cm above the
stylomastoid foramen.

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It conveys taste fibers from the anterior 2/3
rd
of the
tongue except vallate papillae.
It also gives preganglionic secretomotor fibres for
submandibular and sublingual glands along with
lingual nerve.
Chorda tympani nerve represents pretrematic nerve of
the first branchial arch.
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Below the stylomastoid foramen
Posterior auricular nerve:
It passes upwards and backwards behind the auricle.
Supplies the intrinsic muscle of cranial surface of
auricle , auricularis posterior and occipital belly of
occipito-frontalis.
Nerve to the posterior belly of digastric
Supplies posterior belly of digastric muscle.
Nerve to the stylohyoid muscle
Sometimes these two branches arises as a common
trunk.

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In the face
Temporal branch
Zygomatic branch
Buccal branch
Marginal mandibular
branch
Cervical branch
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Temporal branch:
Passes upwards in front of auricle and across the
zygomatic arch.
Supplies intrinsic muscle of lateral surface of auricle,
auricularis anterior & superior muscles, upper part of
orbicularis oculi, frontalis and corrugator supercilli.
Zygomatic branch:
runs along the zygomatic arch
Supplies the lower part of orbicularis oculi muscle.
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Buccal branch:
Consists of superficial and deep parts
Superficial branches supply procerus.
Deep branches subdivide into upper and lower sets.
Upper buccal passes forwards above the parotid duct
and supplies zygomaticus major and minor, levator
anguli oris, levator labii superioris, levator labii
superioris alaque nasi and muscles of the nose.
Lower buccal passes below the parotid duct and
supplies buccinators and orbicularis oris.
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Marginal mandibular branch:
Appears first in the neck and then curves upwards and
forwards across the lower border of the mandible.
Appears in the face after crossing superficial to the
facial artery and vein.
Supplies risorius, depressor anguli oris, depressor labii
inferioris and mentalis.
Cervical branch:
Appears in anterior triangle of neck.
Supplies the platysma.
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Vascular supply of facial nerve
The cortical motor area of the face is supplied by the
Rolandic branch of the middle cerebral artery.
Within the pons, the facial nucleus receives its blood
supply primarily from the anterior inferior cerebellar
artery (AICA).
The AICA, a branch of the basilar artery, enters the
internal auditory canal (IAC) with the facial nerve.
The AICA branches into the labyrinthine and cochlear
arteries.
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35
The superficial petrosal branch of
the middle meningeal artery is the
second of 3 sources of arterial
blood supply to the intrapetrosal
facial nerve.
The posterior auricular artery
supplies the facial nerve at and
distal to the stylomastoid foramen.
Venous drainage parallels the
arterial blood supply.


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facial nerve paralysis

Facial nerve paralysis may be:
1. Supranuclear paralysis
2. Nuclear paralysis
3. Infranuclear paralysis
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Supranuclear Facial Paralysis
Supranuclear facial paralysis involving upper motor
neuron pathways is usually a part of hemiplegia
caused by the occlusion of a blood vessel supplying
the internal capsule or motor cortex.
This results in impairment or loss of movements of
lower facial muscles of the contra lateral side, but the
upper facial muscles are escaped.
This is due to bilateral control of motor cortex to the
subgroups of motor nuclei which supply the upper
facial muscles.
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Voluntary movements are of lower
part of the face are more affected
than emotional movements due to
interruption of cortico-bulbar and
cortico-reticular fibres.
Occasionally supranuclear lesions
may abolish or weaken emotional
movements but not voluntary
movements.
Electrical reaction of affected
muscles are unaltered.


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Nuclear Facial Paralysis
A lesion in the pons may involve motor nucleus of the facial
nerve along with abducent nucleus around which motor root
makes a loop.
This results in lower motor neuron paralysis producing loss
of movements of all facial muscles on the affected side
associated with internal strabismus due to involvement of
lateral rectus muscle of the eyeball.
Sometimes a pontine lesion affects the pyramidal tract and
the facial nucleus and is expressed as millard gublar
syndrome which is characterized by contra lateral
hemiplegia and ipsilateral facial palsy.
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Infranuclear Facial Paralysis
A lesion interrupting the peripheral
part of the facial nerve is known as
bells palsy.
Bells palsy when complete,
produces lower motor neuron
paralysis of all facial muscles on the
affected side with abolition of both
voluntary and reflex movements.
The manifestations of peripheral
injury vary according to the site of
involvement.
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Lesion in the internal acoustic meatus produces bells
palsy and deafness due to involvement of the
vestibulocochlear nerve.
Lesion at the genu, produces:
a. Diminished lacrimation.
b. Diminished submandibular secretion.
c. Reduced taste sensation on the anterior 2/3
rd
of the
tongue.
d. Hyperacusis due to involvement of nerve to the
stapedius.
e. Along with the signs of bells palsy on the affected
side.
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During the recovery from an injury proximal to the
genicular ganglion, some regenerating salivary fibres
may pass through greater petrosal nerve and reach
pterygopalatine ganglion.
This is manifested by paroxysmal lacrimation during
eating and is known as crocodile tears syndrome.
A lesion of the facial nerve between the genu and
pyramidal eminence produces:
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a. Diminished submandibular secretion.
b. Hyperacusis due to involvement of nerve to the
stapedius.
c. Along with the signs of bells palsy on the
affected side.
An injury to the facial nerve below the
stylomastoid foramen produces bells palsy
without affecting other functions.
In typical facial paralysis, following
manifestations are observed on the affected side.

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Transverse wrinkles of the forehead
disappear and the eye brow droops.
Palpebral fissure is wider than normal
side due to unopposed action of
levator palpebrae superioris.
Patient is unable to close his eyelids
and the tears roll over the cheek.
Corneal reflex is disturbed which may
culminate into corneal ulcers and
blindness.
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When an attempt is made to close the
eyelids, the eye ball on the affected side may
be seen to roll upward, this is known as
bells phenomenon.
Nasolabial fold disappears, ala does not
move and the tip of the nose is deviated to
the unaffected side.
During smiling the angle of the mouth
remains motionless on the affected, where as
the other angle moves upwards and laterally.
This makes the oral fissure triangular in
shape.
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Due to paralysis of the buccinator, food accumulates in
the vestibule of the mouth and occasionally dribbles
out between the paralyzed lips.
Pursing of the whistle is disturbed and labial speech
may be affected.

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Other causes of facial nerve paralysis:
Trauma
Herpes zoster infection
Otitis media
Neurosarcoidosis
Moebius syndrome
Tumors

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Trauma
Physical trauma, especially fractures of the temporal
bone, may also cause acute facial nerve paralysis.
Most commonly, facial paralysis follows temporal bone
fractures, though the likelihood depends on the type of
fracture.
Traumatic injuries can be assessed by computed
tomography (CT) and nerve conduction studies (ENoG).

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Herpes zoster infection
Herpes zoster infection that affects cranial nerves VII
(facial nerve) and VIII (vestibulocochlear nerve).
Patients present with facial paralysis, ear
pain, vesicles, sensory neural hearing loss, and vertigo.
Management includes Antiviral drugs and
oral steroids.

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Otitis Media
Otitis media is an infection in the middle ear, which
can spread to the facial nerve and inflame it, causing
compression of the nerve in its canal.
Antibiotics are used to control the otitis media, and
other options include a wide myringotomy (an incision
in the tympanic membrane) or decompression if the
patient does not improve.

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Neurosarcoidosis
Facial nerve paralysis, sometimes bilateral, is a
common manifestation of neurosarcoidosis
(sarcoidosis of the nervous system).
It is a rare condition.

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Moebius syndrome
Moebius syndrome is a bilateral facial paralysis
resulting from the underdevelopment of the VII cranial
nerve (facial nerve), which is present at birth.
The VI cranial nerve, which controls lateral eye
movement, is also affected,
So people with Moebius syndrome cannot form facial
expression or move their eyes from side to side.
Moebius syndrome is extremely rare, and its cause or
causes are not known.

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Tumors
A tumor compressing the facial nerve anywhere along
its complex pathway can result in facial paralysis.
Common culprits are facial neuromas,
congenital cholesteatomas, hemangiomas, acoustic
neuromas, parotid gland neoplasms, or metastases of
other tumours.
Patients with facial nerve paralysis resulting from
tumours usually present with a progressive, twitching
paralysis,

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Computed tomography (CT) or magnetic resonance
(MR) imaging should be used to identify the location of
the tumour, and it should be managed accordingly.

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DIFFERENTIAL DIAGNOSIS OF FACIAL
NERVE PARALYSIS

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Grade Descriptions Characteristics
I Normal Normal facial function in all areas
II Mild dysfunction Slight weakness noticeable on close
inspection; may have very slight synkinesis
III Moderate
dysfunction
Obvious, but not disfiguring, difference
between 2 sides; noticeable, but not severe,
synkinesis, contracture, or hemifacial spasm;
complete eye closure with effort
IV Moderately
severe
dysfunction
Obvious weakness or disfiguring asymmetry;
normal symmetry and tone at rest; incomplete
eye closure
V Severe
dysfunction
Only barely perceptible motion; asymmetry at
rest
VI Total paralysis No movement
House-Brackmann Facial Nerve Grading System
Treatment of facial paralysis

Steroids
Corticosteroid such as prednisone significantly
improves recovery at 6 months and are thus
recommended.
Early treatment (within 3 days after the onset) is
necessary for benefit with a 14% greater probability of
recovery.

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Antivirals
Antivirals (such as acyclovir) are ineffective in
improving recovery from Bell's palsy beyond steroids
alone.
They were however commonly prescribed due to a
theoretical link between Bell's palsy and the herpes
simplex and varicella zoster virus.

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Physiotherapy
Physiotherapy can be beneficial to some individuals
with Bells palsy as it helps to maintain muscle tone of
the affected facial muscles and stimulate the facial n.
It is important that muscle re-education exercises
& soft tissue techniques be implemented prior to
recovery in order to help prevent
permanent contractures of the paralyzed facial
muscles.
To reduce pain, heat can be applied to the affected side
of the face.

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Surgery
Surgery may be able to improve outcomes in facial nerve
palsy that has not recovered.

A number of different techniques exist.

Smile surgery or smile reconstruction is a surgical procedure
that may restore the smile for people with facial nerve
paralysis.
It is unknown if early surgery is beneficial or harmful.
Adverse effects include hearing loss which occurs in 3-15%
of people.
As of 2007 the American Academy of Neurology did not
recommend surgical decompression.


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Complementary therapy
The efficacy of acupuncture remains unknown because
the available studies are of low quality (poor primary
study design or inadequate reporting practices)
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references
1. Facial nerve, schaitkin barry, may mark.
2. Grays anatomy, 39
th
edition.
3. Essentials of human anatomy [ head and neck]- A K
Datta , 3
rd
edition.
4. Human anatomy- B D Chaurasia 4
th
edition.
5. Internet
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