ANATOMY OF THE FACIAL NERVE

03 JUN 2011

PRESENTED BY Maj A SITARAMAN

History
Friedreich- Paralysis may occur when local causes act on the facial nerve 1821- Sir Charles Bell-

First Dissection of the facial nerve on a cadaver

1829- Bells Palsy named 1932- Balance and Duel-

Nerve graft for Repair

Embryology
Nerve of 2nd branchial arch 3rd wk Fibro Acoustic

Crest (Dorso Lateral aspect of hindbrain , cranial to otic placode) 4th wk Distinct Facial Nerve

Cont
5th wk Geniculate Ganglion formed

Facial Nerve divides(main trunk & Chorda Tympani) 7th wk 5 branches appear in parotid bud 8th wk Sulcus in posterior Otic capsule(primitive Facial Canal) 16th wk Neural communications with Facial Muscles is complete

Cont
Facial nucleus Neuroblasts in PONS with 6th Nerve nucleus in close

proximity As brain develops pons expands INTERNAL GENU

Surg imp : any inflammatory event in this part both Nerves involved

Congenital Anomalies
Moebius Syndrome(Congenital Facial diplegia)

Abnormal VI ,VII,XII Nerve nuclei Facial Nerve absent / smaller Congenital Extra ocular muscle & facial palsy
Treacher Collins Syndrome (Mandibulo Facial Dysostosis) Goldenhars Syndrome (Oculoauriculo Vertebral Dysplasia)

Introduction
VII Cranial Nerve ; Mixed Nerve

10,000 Motor , Sensory , parasympathetic fibers

Motor root 7000 Special Visceral Efferent Fibers Sensory & Parasympathetic 3000 carried by NERVUS INTERMEDIUS(Nerve of Wrisberg) Nervus Intermedius consists of General visc. Eff.

Special visc. Aff.

Somatic Aff.

Facial Nerve Nuclei

3 nuclei 1) Motor nucleus Lower

Pons below 4th Ventricle 2) Superior salivatory Nucleus dorsal to Motor Nucleus 3) Nucleus of Tractus Solitarius Medulla Oblongata

Central Connections of FN
Dorsal part of Nucleus B/L

supra nuclear innervation

Lower part of Nucleus

Contra Lateral innervation

Imp Clinical varieties of VII

Nerve Lesions

Cont
Facial Nerve course unusual Fibers course towards floor of IV Ventricle Wrap around VI Nerve nucleus

Facial Colliculus
Retrace along pons Exits Ponto medullary jn.

Course

Intra cranial portion

From brainstem to fundus of IAM Length 24mm Facial Nerve crosses CP

angle with 8th CN & NI Devoid of epineurium Thin layer of pia mater
Surg imp : 1) Iatrogenic trauma in CP angle

tumour surgery 2) Difficult to identify in schwannoma(no connective tissue)

Meatal Segment
Enters in anterosuperior

segment of IAC Length 5 12 mm Crista Falciformis Bills bar No separate sheath Shares with NI & 8th CN Facial Nerve merges with NI at Fundus

Intra Temporal Region

From Fundus to Stylomastoid Foramen Length 28 to 30 mm Fallopian canal Longest bony canal 3 segments by 2 genus

Labyrinthine Segment & Narrowest(0.68mm)

Shortest(3-5mm) No anastamosing arteries Periostium is thicker Postero Superior to cochlea Antero Medial to SSCC Posterior to vestibule Distal end Geniculate ganglion;1st genu

 Surgical importance: 1) Anatomical bottle neck Ischemia in oedema 2) Part most vulnerable for Ischemia(no arterial anastamosis) 3) Temporal bone # - Most Commonly injured

Geniculate ganglion: Bipolar ganglion cells Aff. input somatic & special visceral afferent Secretomotor Fibres to lacrimal gland(without synapse)

Tympanic Segment
Horizontal segment
From Geniculate Ganglion to 2nd genu Length 8 to 11mm Lies beneath LSCC & above Oval Window above & medial to Processus cochleariformis

Cont
Nerve lies lateral & posterior to Pyramidal process Creates 2 Recesses
1. Facial recess (lateral) 2. Sinus tympani(medial)

2nd Genu

 Surgical importance:

Cont

Processus Cochleariformis(consistent landmark) Imp landmark for 2nd genu

-LSCC -Pyramidal eminence -B/w short process of incus(L) & LSCC(M)

Mastoid Segment
Vertical Segment From 2nd genu(PM) to Stylomastoid Foramen (AL) Longest (13mm) Landmark Digastric Ridge FN leaves FC via Stylomastoid Foramen(b/w mastoid tip & styloid process)

Extra Temporal Region

From Stylomastoid Foramen to terminal branches Runs in substance of parotid Main trunk divides

- upper Temporofacial - lower Cervicofacial Pes anserinus Superficial to Retromandibular Vein

Branches
Intra temporal region : 1) Greater Superficial Petrosal Nerve 2) Nerve to Stapedius 3) Chorda Tympani 4) Sensory Auricular

branch

Greater Superficial Petrosal Nerve

From Geniculate Ganglion 2 types of fibers Pregang para symp Pterygopalatine gang. Post gang Lacrimal Gland

Sensory fibers to nasal & palatine glands

Joins deep petrosal N

N to pterygoid canal

 GSPN
MIDDLE CRANIAL

FOSSA
FORAMEN LACERUM DEEP PETROSAL PTERYGOPALATINE

GANGLION
NERVE OF PTERYGOID

NERVE

CANAL

 Nerve to stapedius 6mm above

Stylomastoid Foramen Supply stapedius

Sensory auricular Br
Joins auricular br of vagus

Supply retro auricular groove & concha

Chorda Tympani
4mm above Stylomastoid Foramen Lateral & Anterior to Facial Nerve Posterior Canaliculus Lateral to Long Process of Incus &

Medial to Malleus Ant canaliculus(Canal of huguier) 2 types of fibers Pre G parasym sub mand Gang Post G submand & subligual G Special sensory ant 2/3rd of tongue

 CHORDA TYMPANI POST. CANALICULUS CANAL OF HUGUIER

INFRATEMPORAL FOSSA
LINGUAL NERVE SUBMANDIBULAR GANGLION

 Surgical importance:
1) Greater Superficial Petrosal Nerve

- landmark in middle cranial fossa approach

1) Chorda Tympani
- Landmark in Posterior Tympanotomy -Lateral margin of Facial Recess -Medial limit for Facial Ridge reduction

 Extra temporal region

1) Post.auricular

Nerve(Occipito frontalis &muscles of pinna) 2) Muscular Branches(post belly of digastric &stylohyoid)

Terminal Branches

 Temporal :

Cross zygomatic arch

TEMPORAL ZYGOMATIC

Auricularis ant & sup;frontalis;orb oculi &

MANDIBULAR corrugator supercilii

BUCCAL

ZygomaticCERVICAL :

Cross zygomatic bone

Orbiculatis oculi

 Marginal mandibular : 1-2cm below inferior ramus of mandible Muscles of lower lip&chin Cervical : Platysma &depressor anguli oris Buccal : 1 cm below zygomatic

BUCCAL

MANDIBULAR

CERVICAL

arch Along parotid duct

 Buccal branch supplies : 1) Risorius (smirk) 2) Buccinator (aids chewing) 3) Levator Labii Superioris 4) Levator Labii Alaque Nasi

(snarl) 5) Levator Anguli Oris(soft smile) 6) Nasalis (Flare Nostrils) 7) Orbicularis Oris (Purse Lips)

Anatomical Relationship
Child Adult

CT may exit thru SMF

CT exits prox to SMF

2nd genu is more acute & 2nd genu less acute &

lateral more medial N trunk on exit from SMF N trunk is less anterior & is more ant & lat deeper N very superficial over N superficial over angle angle of mandible of mandible

Blood Supply

Surgical Landmarks
Ear surgery: 1) Geniculate Ganglion lies superior to Processus cochleariformis 2) 2nd genu hugs inferior aspect of LSCC 3) Lies above Oval Window Niche 4) Incus lies lateral to Facial Nerve 5) Runs behind Pyramid 6) Lies 6-8mm inferior to Tympano Mastoid suture 7) Digastric ridge mastoid segment 8) Blood vessels

Cont
Parotid surgery

Tragal pointer 1cm deep & inferior Tympanomastoid suture Lies lateral to Styloid process Superficial to Retromandibular vein Bisects angle b/w Posterior belly of digastric & ear canal Retrograde dissection

Variations
Most Common variations

1. Facial Nerve displacements

2. Dehiscence of Fallopian canal Dehiscence in Tympanic Segment (35-55%) Vertical segment variations 1. Bipartite Nerve 2. Ant displaced Nerve 3. With post hump

Cont
Nerve to stapedius & Chorda Tympani variation Large Chorda Tympani can be real Facial Nerve (shouldnt sacrifice)

Rohrt & Lorentzen classification:

1. 2. 3. 4.

Nerve partially obliterating stapes footplate Bifurcation of Nerve Nerve rests on foot plate Nerve rests on promontory

 Katz & Catalano classification: 1. Type I (25%) 2. Type II (14%) 3. Type III(44%) 4. Type IV(14%) 5. Type V(3%)

Cont

References
Scott-Browns Otorhinolaryngology, Head and Neck Surgery.7th ed. Ballengers Otorhinolaryngology ,Head and Neck Surgery. 17th ed. Internet References

Otology could be a dull way of life without the 7th cranial N arrogantly swerving through the temporal bone to the muscles of facial expression JOHN GROVES

THANK YOU