Presenter : Dr. Neha Goel Moderator : Dr.

Arjun Dass

Embryonic Development :
Facial

nerve course, branching pattern, and anatomical relationships are established during the first 3 months of prenatal life nerve is not fully developed until about 4 years of age nerve tissue is seen at the third week of gestationfacioacoustic primordium or crest

The

The first identifiable facial

Chorda tympani is the first branch to appear.

Applied Anatomy :
Facial nerve lies just beneath the skin near the mastoid tip at birth

and is vulnerable to post auricular skin incision. As the mastoid tip forms and elongates, facial nerve assumes its more medial and protected position Individual axons of facial nerve also undergo myelination until the age of 4 years, an important consideration during electrical testing of facial nerve at this age Facial nerve develops within second brachial arch during the time that closely adjacent external and middle ear region. Anomalies of facial nerve should be anticipated whenever there is an associated malformation of external or middle ear

Facial Nerve :
Facial nerve is a mixed nerve Motor root : muscles of 2nd

brachial arch. Sensory root nerve of Wrisberg carries taste fibers from the anterior 2/3 of the tongue and general sensation from the concha and retroauricular skin. Also it carries secretomotor fibers to the lacrimal, submandibular and sublingual glands as well as those in the nose and palate.

Anatomic segments of facial nerve

Intracranial (15-17 mm): brainstem

to IAM Meatal (8-10mm): fundus of IAM to meatal foramen Labyrinthine (3-5 mm): meatal foramen to GG Tympanic/horizontal (8-11 mm): ganglion adj to oval window pyramidal eminence of stapedius tendon Mastoid/vertical (10-15 mm): second genu to SMF Extratemporal (15-20 mm): SMF to facial muscles

Hiatus of canal of greater superficial petrosal nerve

Inferior Orbital Fissure Lacerate foramen

Posterior Cranial Fossa (PCF)

Internal Acoustic Meatus Facial canal

Greater superficial Petrosal nerve (GSPN)

Pterygoid canal

Greater and lesser palatine canals

Petrotympanic fissure

Facial nerve Chorda tympani nerve

Stylomastoid Foramen
Facial nerve Posterior auricular N.

Overview of Facial Nerve anatomy in the skull

Supranuclear Part :
Primary somatomotor cortex : precentral gyrus (area

4,6,8) internat capsule via cortico bulbar tract pyramidal tracts pons In basal pons most of the facial nerve fibres cross the midbrain to reach the contralateral facial nerve nucleus Some fibres innervate ipsilateral facial nerve nucleus, majority of which are destined for temporal branch Extrapyramidal cortical input from hypothalamus, globus pallidus and frontal lobe -involuntary facial expressions with emotions Visual system : blink reflex Trigeminal nerve : corneal reflex Auditory nuclie : response to loud sound

Applied Anatomy
Central nervous system lesion spare forehead muscle

since they receive input from both cerebral cortices, whereas peripheral lesions involve all branches of facial nerve

Facial Nucleus and Brainstem:

Facial nerve originates from facial

motor nucleus which lies in lateral portion of pons. Facial nerve hooks around the nucleus of sixth nerve.
Facial nerve exits the brainstem at

pontomedullary junction caudal to fifth nerve and 1.5mm anterior, medial and superior to eighth cranial nerve.

Cerebello pontine Angle

Facial nerve leaves brainstem at

pontomedullary junction , lies in close relation to vestibulocochlear nerve and nerve of wriseburg Trigeminal nerve lies superiorly and cranial nerve IX X XI XII lie inferiorly

Applied Anatomy :
Vestibular schwanomma in CPA

jeopardises facial nerve during its growth and attempted surgical removal due to intimate relation. In CPA, facial nerve is covered with pia, is placed in CSF, and is devoid of epineurium, leaving it susceptible to manipulation trauma during intracranial surgery

Meatal Part :
Facial nerve passes through the

porus of IAC.
Superior and inferior vestibular

nerves lie posterior and inferoposterior to facial nerve in IAC. Cochlear nerve lies caudal to facial nerve.
The length of IAC portion of nerve

is around 8-10mm.

Fallopian Canal :
Subsequently

fallopian canal takes a long tortuos course through temporal bone ~ 30 mm It provides a bony covering for facial nerve longer than that of any other nerve Protects the facial nerve but also renders it vulnerable to certain diseases and disorders

Labyrinthine Segment :
Facial nerve enters the labyrinthine

segment of facial nerve through the meatal foramen

the narrowest (0.68 mm in diameter )

and lined by fibrous annular ligament

the shortest portion of the canal. (4

mm in length)
A dense arachnoid band encircles the

nerve at lateral end of IAC.

Posterocephalad to cochlea Anteromedial to ampulla of SCC Posterior to vestibule

Applied Anatomy :
Bottle

neck at the entrance of facial nerve predisposes it to strangulation in cases of edematous swelling This is the only segment of facial nerve in which there are no anastomosing arterial arcades

Geniculate Ganglion :
On entering the facial canal there is

an angulation of 132 degree as well as downward inclination of 3-5mm.

At the GG Facial nerve

takes 75 degree turn posteriorly at first genu. arises from GG and emerges through facial hiatus onto the floor of MCF

Greater superficial petrosal nerve

Contains

sensory intermedius

bipolar ganglions for function of nerves

Tympanic segment
From

the GG facial nerve courses in tympanic segment and measures approx 10-12mm in length. Anteriorly it lies above and medial to Processus cochleariformis Slopes downward at an angle of 30 degree to horizontal In middle part it runs over the oval window (superior margin) It then runs under Lateral semicircular canal Nerve then takes a second turn Angle between 2nd and 3rd part varies from 95-125 degree.

Mastoid Segment :
Approx

midway in mastoid segment facial nerve gives off chorda tympani. Gives rise to Branch to stapedius Facial nerve leaves the temporal bone at SMF.As the nerve approaches the SMF it becomes encircled by fibrous tendon of digastric muscle which becomes part of nerve sheath.

ac

Extratemporal Part:
As it emerges from

SMF, extratemporal FN runs anteriorly in the substance of parotid gland ,crosses the external carotid artery and divides at the posterior border of ramus of mandible 2 divisions : temporofacioal and cervicofacial

Functional components of the Facial Nerve (CN VII)

1.

striated muscles derived from the 2nd branchial arch. 2. GVA (General Visceral Afferent) Sensory from visceral touch, temperature, and 3. pain. SVA (Special Visceral Afferent) Taste 4. GVE (General Visceral Efferent) Autonomic innervation to mucosal, lacrimal, and salivary glands. 5. GSA (General Somatic Afferent) Sensory from somatic touch, temperature, and Click on numbers for functional components pain.

SVE (Special Visceral Efferent) Motor to

SVE Component of the Facial Nerve

The next slides demonstrate innervation to muscles derived from the 2nd branchial arch: 1. Stapedius muscle -- dampens movement of the ossicles (inserts on stapes of middle ear) 2. Posterior auricular muscle -- posterior movement of pinna 3. Stylohyoid muscle -- elevates hyoid bone 4. Posterior belly of digastric -- elevates hyoid bone, depresses mandible 5. Muscles of facial expression -- blinking, smiling, frowning, facial movements
Click here to start Animation of SVE component

Summary of SVE

Internal Acoustic Meatus

Facial nucleus

Facial canal

Stapedius muscle dampens movement of ossicles.

Facial nerve Stylomastoid Foramen Posterior auricular N. Posterior auricular muscle responsible for posterior displacement of pinna. Stylohyoid muscle elevates hyoid bone.

Facial nerve Temporal-orbicularis oculi closes eyelids. Zygomatic-zygomaticus major partly responsible for smiling. Buccal-buccinator tenses cheek Mandibular-depressor angularis oris responsible for frowning. Cervical- platysma helps lower mandible and tightens skin of neck.

Posterior belly of digastric elevates hyoid bone.

Click here to start

GVA Component of the Facial Nerve

The next slide demonstrates that GVA is responsible for providing: 1. Light touch, temperature, and pain sensation from the soft palate via the greater superficial petrosal nerve (GSPN).
Click here to start GVA

Summary of GVA
Through the internal acoustic meatus

Through the Pterygoid canal Through the hiatus of canal of GSPN

GSPN

Pterygoid canal

Through the lesser palatine canal

Facial canal

Facial nerve

Light touch, temperature, and pain from the soft palate

Click here for animation

SVA Component of the Facial Nerve

The next two slides demonstrate that SVA is responsible for providing: 1. Taste from the hard and soft palate via the greater superficial petrosal nerve (GSPN). 2. Taste from the anterior 2/3 of the tongue via the chorda tympani nerve.
Click here for animation

Summary of SVA
Internal Acoustic Meatus

Hiatus of canal of greater superficial petrosal nerve

Lacerate foramen

GSPN

Pterygoid canal

Greater and lesser palatine canals

Facial canal

Petrotympanic fissure

Chorda tympani Taste from hard and soft palate. Taste from anterior 2/3 tongue.

Stylomastoid Foramen

Click here to start animation

GVE Component of the Facial Nerve

1. Via the pterygopalatine ganglion GVE provides: A. Lacrimation (tearing of the eye) B. Mucus secretions of the nasal cavity C. Mucus secretions of the oral cavity 2. Via innervation of the submandibular ganglion GVE provides: A. Salivation of the oral cavity
Click to start Animation of GVE component

Summary of GVE
Internal Acoustic Meatus

Hiatus of canal of greater superficial petrosal nerve

Inferior Orbital Fissure Lacerate foramen

GSPN

Pterygoid canal

Greater and lesser palatine canals

From the pterygopalatine ganglion postganglionic GVE fibers provide lacrimation of the eyes and mucus secretion of the nasal cavity and oral cavity.

Facial canal

Petrotympanic fissure

Superior salivary and lacrimal nucleus

Chorda tympani

From the submandibular ganglion postganglionic GVE fibers provide salivation in the oral cavity.

Click here to start animation

GSA Component of the Facial Nerve

GSA is responsible for providing: 1. Touch, temperature, and pain sensation from part of the external acoustic meatus via the posterior auricular nerve.

Click here to start GSA

Summary of GSA

Foramen Rotundem

Inferior Orbital Fissure

Internal Acoustic Meatus

Facial canal

Facial nerve Stylomastoid Foramen

Facial nerve

Touch, temperature, and pain sensation from the external acoustic meatus. Posterior auricular nerve

Click here to start animation

Blood Supply
Middle cerebral artery supplying the motor cortex. The facial nucleus in the pons is supplied by the anterior

inferior cerebellar artery and the short and long circumferential arteries. The facial nerve proper is then supplied by the 1) labyrinthine branch of anterior inferior cerebellar artery 2) superior petrosal branch of the middle meningeal artery 3) the stylomastoid branch of the postauricular artery These tend to overlap; however, the region just proximal to the geniculate ganglion is thought to be somewhat susceptible to vascular compromise secondary to the poorer redundancy present there compared with other areas.

Radiological appearance :

Landmarks For Facial nerve During Mastoid Surgery

LSCC Nerve lies inferior Short process of Incus nerve is just medial to it Oval window niche nerve lies superior Chorda tympani nerve nerve arises from vertical

segment 4 mm above SM foramen Processus cochleariformis nerve lies superior and medial Cog : bony prominencce from roof of epitympanum 7th nerve - LSCC 1.77 mm 7th nerve - SPI 2.36 mm LSCC - SPI 1.25 mm

Landmarks For Facial nerve During Parotid Surgery

Tragal pointer nerve is 1cm deep and below to tip of tragal cartilage. Not reliable Tympano-mastoid suture line nerve lies 6-8mm deep to suture line Post belly of Diagastric nerve is just superior to ant border Stylomastoid Foramen

Retrograde 1. Marginal mandibular nerve - nerve crosses superficial to facial v. 1cm anterior to angle of mandible 2. Buccal branch nerve is 1cm above and parallel to parotid duct 3. Temporal-bisects line from tragus to lateral canthus.

Anatomic variations
Congenital bony dehiscence in facial canal (50 % temporal bones )

- Horizontal part (91 %) - Vertical Part

Aberrations along tympanic segment

- the superior aspect of LSC - the oval window (below it or partly above and partly below) - the stapedial arch
Aberrations along vertical segment

- Abn posterior,lateral course - Bifurcation,trifurcation posterior to OW - Hypoplasia of facial nerve

Causes of facial paralysis

Investigations
Through history and physiological examination Laboratory studies Audiometry In selected cases in which either the location or site

of injury is unknown, both CT scanning and MRI may be helpful. High-resolution CT scanning of the temporal bone provides the best imaging of the bony confines of the facial nerve and may reveal the site of pathology at any point along its course. MRI is superior in delineating the details of the soft tissues, including the nerve itself. Thus it is the study of choice to diagnose acoustic neuromas and facial nerve schwannomas. Electrophysiological & topodiagnostic tests

ELECTROPHYSIOLOGICAL TESTS

Nerve Excitability Test (NET) Maximal Stimulation Testing (MST) Electromyography (EMG) Electroneurography (ENoG)
The two most helpful are the ENoG and EMG.

Nerve Excitability Test (NET)

Most predictive prognostic factor for recovery of

facial nerve function* Takes 3 4days for test to become positive Useful during first 2 3 weeks of complete paralysis Unnecessary in cases of incomplete paralysis A difference of 3.5 mA or more between two sides is significant and an indicator for facial nerve decompression Hilger nerve stimulator over stylomastoid foramen Reflects elevated thresholds for neuromuscular stimulation due to degeneration / disruption of axons (comparison to contralateral side)

Nerve Excitability Test (NET)

Benefits:
Easy to perform More comfortable for patient

Drawbacks
Subjectivity (relies on operators

visual detection of response) May exclude smaller fibers (current thresholds are likely to selectively activate larger fibers with lower thresholds and smaller fibers closer to stimulating electrode)

Maximal stimulation test (MST)

Measures greatest amplitude of facial movement

on maximal or supramaximal stimuli ( up to 5mA or discomfort) expressed as percentage be estimated so can guide prognosis and treatment

Proportions of fibres that have degenerated can

Takes 3 4days for test to become positive

Maximal Stimulation Test

Electrical impulse administered to saturate the nerve

with current and to compare it to contralateral side Test is repeated periodically until definitive response Response Equivalent to contralateral side
Minimally diminished (<50% of normal) Markedly diminished (< 25% of normal)

Absent Symmetric response within first ten days complete recovery in > 90% No response within first ten days incomplete recovery with significant sequelae Superior to NET - test becomes abnormal sooner, but drawback is subjectivity

Evoked electromyography (EEMG) or Electroneuronography (EnoG)

Records

compound muscle action potential (CMAP) with surface electrodes placed transcutaneously in the nasolabial fold (response) and stylomastoid foramen (stimulus) Waveform responses are analyzed to compare peak-to-peak amplitudes between normal and uninvolved sides where the peak amplitude is

Evoked electromyography (EEMG) or Electroneuronography (EnoG)

Most reliable in first 2-3 weeks post event (as neuropraxic fibers

recover or regenerate, they discharge asynchronously and the response is subsequently diminished) Response < 10% of normal in first 3 weeks poor prognosis Response > 90% of normal within 3 weeks of onset 80-100% probability of recovery Testing every other day Advantages: Reliable Disadvantages: Uncomfortable Cost Test-retest variability due to position of electrodes

EMG
Measured by electrodes inserted in to orbicularis oris

and orbicularis occuli muscles

EMG can be used to determine if a nerve in question is

in fact in continuity (volitional activity recorded), shows evidence of Wallerian degeneration (fibrillation potentials), or has signs of reinnervation (polyphasic innervation potentials). injury

Fibrillation potentials typically arise 2-3 weeks following Polyphasic reinnervation potentials may precede clinical

signs of recovery by 6-12 weeks.

No potential muscle not viable

Acoustic Reflex Evoked Potential

Scalp recorded potential at 12 15 ms in response to

acoustic stimulation C/L to recording site Doubtful value

Magnetic stimulation test

Noninvasive No pain/discomfort Transcranial stimulation can be done May not be useful for prognostic purpose

Muscle biopsy
Useful adjunct to EMG in long standing facial

paralysis and in congenital facial paralysis with suspected U/L absence of facial nerve Deciding factor for reanimation procedures Muscle viable dynamic procedures Muscle not viable static procedures

Topodiagnostic Tests
1. Lacrimal functions(GSPN) 2. 3. 4. 5.

Schirmers test Stapedius reflex (N. to Stapedius) Taste and electrogustometry (Chorda Tympani N.) Salivary flow (Chorda Tympani N.) Salivary pH (Chorda Tympani N.)

Schirmer Test
Greater superficial petrosal nerve Filter paper is placed in the lower conjunctival fornix

bilaterally5x35mm filter paper hooked in lower fornix for 5 min.

not affected by corneal anesthesia

Modified Schirmers test ammonium inhalation. Test is

3- 5 minutes Value of 25% or less on the involved side or total lacrimation <25 mm is considered abnormal.

Stapedial Reflex
Stapedius branch of the facial nerve Most objective and reproducible A loud tone is presented to either the ipsilateral or

contralateral ear evokes a reflex movement of the stapedius muscle changes the tension on the TM (which must be intact for a valid test) resulting in a change in the impedance of the ossicular chain If intact stapedial reflex, complete recovery can be expected to begin within six weeks absent reflex or reflex < 50% of amplitude of C/L side is abnormal Absence of the stapedial reflex during the first two weeks in Bells Palsy is common

Taste Testing
Chorda tympani Extremely subjective Papillae generally disappear within 10 days post

injury - middle 1/3 of the tongue is most indicative, because the anterior 1/3 may receive bilateral input.
Electrogustometry positive if >25% difference on two

sides

Salivary flow rates

Chorda tympani Cannulation of Wharton's ducts bilaterally 5 minute measurement of output Significant if 25% reduction in flow of the

involved side as compared to the normal side Salivary pH Flow Rate ( 6.1 incomplete recovery) Salivary flow of submandibular gland (< 45% of the healthy side poor prognosis)

House Brackmann nerve grading system For recovery from facial paralysis