HEAD

AND

NECK RADIOLOGY

Joel

D. Swartz,

M.D.

The Facial Nerve Analysis Tympanic

Canal:

CT

of the Protruding Segment

The development and subsequent course of the facial nerve canal are complex. High resolution computed tomography
(HRCT) provides an opportunity for the

HE

study of this often perplexing structure. Normal anatomy and normal variations of the facial nerve canal must be considered when examining patients who have facial nerve palsy referrable to the temporal bone. The author recommends direct axial and coronal imaging supplemented by sagittal and possibly oblique reformations.
Index terms: tomography, Radiology Ear, anatomy, 2123.1211 1984; 153: 443-447 2123.92
#{149} Ear,

logic mography normal normal pontant ennable

facial nerve canal has been the subject of considerable radioand clinical controversy. High resolution computed to(HRCT) now provides a modality with which to study the appearance of the canal. Knowledge of normal anatomy and variations in the facial nerve canal becomes particularly imwhen evaluating patients who have a facial nerve palsy refto the temporal bone. MATERIALS AND METHODS
in all patients have facial being palsy lo-

The studied calizable targeted the the the level

facial for to for

nerve middle

canal is carefully ear disease and

evaluated with CT in all patients who

the temporal bone. One and one-half maximal bony detail, are scanned in anterior turns of the cochlea to the of the material mngin contrast

millimeter-thick the coronal mastoid internal is used

sections, position from process, and canal patients in to

computed

of the

axial position from the superior mastoid process. Intravenous

auditory in those

who have facial palsy.

(1 mm)
is performed

Axial sections
to permit
to evaluate

are scanned
image
the second

at contiguous
Sagittal
Coronal genu.

or overlapping
reformation
reformation is

regular

intervals
routinely

reformation. the coronal

necessary

in patients

who

cannot

assume

position.

DISCUSSION The superior

tremity,

canalicular aspect
it

portion of the facial of the internal auditory

with the intermediate

nerve canal.
nerve

courses in the antenoAt its most lateral exof Wrisberg and is

courses

separated by the falciform crest from the more inferior cochlear nerve. A vertical crest separates it from the more posteriorly located superior vestibular nerve. The facial nerve and the intermediate nerve then enter the facial nerve canal (1). The facial nerve canal has three segments (labyninthine, tympanic, mastoid) and two genus (Figs. 1 and 2). The labyrinthine segment
describes a gentle curve with a medial concavity in the intervesti-

From

the

Department

of Radiologic

Sciences,

The

Medical College of Pennsylvania, Philadelphia, Pennsylvania. Received April 10, 1984; accepted and revision requested May 18; revision received May 29. #{176}RSNA,l984. ahr

bulocochlear groove as it courses anterolaterally to the geniculate fossa (Fig. 3). This is the shortest (3-5 mm), narrowest (.68 mm), and subsequently most vulnerable segment (2). The apex of the first cochlean turn lies medial to it. Transverse temporal bone fractures commonly compromise this segment (2). At the geniculate fossa, the canal forms an acute angle of 75 degrees on less and then courses posteriorly and laterally to become the tympanic segment (Fig. 3). This angle is referred to as the first genu. In the small wedge-shaped space formed by this angle, there is compact bone encasing the anterior aspect of the vestibule (i). The geniculate fossa, a bulbous enlargement of the facial canal, contains the geniculate ganglion. The intermediate nerve of Wrisberg previously described terminates in the ganglion and continues as the greaten and lesser superficial petrosal nerves to the lacrimal and panotid glands respectively (1, 3). The anterior epitympanic sinus is related to the geniculate fossa externally (Fig. 3). Its medial wall is in contact

443

Figure

Illustration

from

above

(right)

indicating
[modified

planes

5, 7, 9, ii

and slightly lateral of section for Figures from (13)].

Figure

with the ganglion and the nerve may be dehiscent at this point. This may be of considerable surgical importance. The size and configuration of the labyninthine segment and first genu can vary considerably. One asymptomatic patient had an unusually prominent geniculate fossa (Fig. 4). The tympanic segment of the facial nerve canal is straight and measures approximately iO-i2 mm in length (1). It extends from the geniculate fossa to the posterior wall of the tympanum and runs along the superior portion of the internal wall of the tympanic cavity (Fig. 5). This segment of the canal is usually inclined slightly infenionly to the plane of the horizontal semicircular canal which it runs beneath (Fig. 6). It forms an angle of approximately 37 degrees with the horizontal plane. Anteriorly it lies above and medial to the cochleariform process that is an important surgical landmark (Fig. 7) (i). The normal non-protruding middie portion nuns above the oval window. The tympanic segment of the facial nerve canal is densely concealed by bone only at its most anterior and postenon extremities, and between them the wall is made of very thin bone that could easily be fractured at surgery.
This segment of the canal is especially

on an obliquely reconstructed image (Fig. 8). The concavity of this turn is in the posterior superior region of the tympanic cavity and faces the portion of the promontory that separates the round and oval windows (Fig. 9). Latenally this concavity is separated from the ampulla of the posterior semicinculan canal by the sinus tympani (Fig. 10) (i). The mastoid segment of the facial nerve canal extends from this second turn to the stylomastoid fonamen, which is usually a distance of approximately 13 mm (Figs. ii, i2). Air cells
usually separate it from the posterior

fossa
ially

by a distance
this mastoid

of 4-i2
segment

mm.
is related

Medto

the jugular bulb (Figs. 1 1, 13). The facial canal may be dehiscent in the jugular fossa on may be as fan away as 8 mm. This distance from the fossa is inversely related to the size of the fossa

itself. The superior portion of the mastoid segment is related to the postenon wall of the tympanum. Only 3
mm separates the facial nerve canal

from the tympanic ring at the level of the round window (Figs. 10, i3). More inferionly, there is more deviation. The mastoid segment can almost always be identified on axial section because there is usually better contication than that which surrounds the individual
mastoid air cells may be difficult (Fig. in i3). Identification a hyperpneuma-

susceptible to erosions due otympanic diseases (1, 3). The extremity of the short process incus marks the point where canal begins its second turn styloid complex to become the segment (Fig. 6). The motor the stapedius muscle arises distal portion of the tympanic
(3). The facial recess is

to tubposterior of the the facial into the mastoid nerve to from the segment

tized
tion
short

mastoid.
of this
process

The
segment
is of

most
just
particular

proximal
inferior
concern

porto the
to

the surgeon mastoidectomy

who (4).

performs Variation

revision has been

noted

in the

cross

sectional

size

(Fig.

immediately

Right
section

lateral
for

illustration
Figures

indicating
13,

planes
15 [modified

of

3, 6, 10,

from

(3)].

lateral to the facial canal in this location (i). The second genu of the facial nerve canal between the tympanic and mastoid segments forms an angle of between 95#{176} i25#{176}, and seen with CT only

i4). The chonda tympani nerve usually arises from the distal third of this segment and courses upward and antenionly (3). The stylomastoid foramen is

located

antenomedial

to the

mastoid
stylthe milli-

process and oid process

postenomedial to the (Fig. 1 i). Occasionally,

nerve
on axial

can be identified
sections obtained

in cross
a few

section (Fig. 15)

meters
Figure 3 Figure 4 (5).

inferior

to the

foramen

Because the facial canal has complicated derivation from both the pnimondial otic capsule and from the Reichert cartilage (second bnanchial arch), it is often defective (6, 7). These congenital bony dehiscences in the facial canal are encountered in 55% of
temporal complete bones closure of the (8) and of the result canal wail from during may be inits ob-

development.
nuity

Such
osseous

gaps

in the

conti-

3.

Axial

4.

section at level of first genu. LABY. SEG. labyninthine segment; GF geniculate fossa; TYMP. SEG. = proximal tympanic segment; ANT. EPI. CELL. anterior epitympanic air cell. Axial section. Unusually prominent geniculate fossa at first genu (arrow).

served in any portion of the facial canal. Already discussed are dehiscences into the anterior epitympanic air cell and into the jugular fossa. The vast majority (90%), however, are in the
tympanic usually segment; involve the such dehiscences infenolatenal or

PROX.

444

#{149}

Radiology

November

1984

medial

wall

(80%).

Inferior

protrusion

sions

have

been

confused
(iO). CT this latter

with

facial
a

tympanic truding inferior

segment nerve bony is not margin

without possible of the

the

pro-

of the nerve in this tympanic segment occurs through these dehiscences in 25% of patients (7). This protrusion may

nerve neuromas diagnosis from

differential entity in

as the middle is canal have

patient

who
The

has facial
CT nerve density

palsy

may

not be

vary

from

a slight

bulge

through

small opening to a situation where the nerve has emerged from the canal and has come to lie upon the superior aspect of the crural arch of the stapes (5-iO). This protrusion may cause a conductive hearing loss. This prolapse may conceal a portion or all of the oval window and it is therefore of considenable surgical importance, particularly for a fenestration procedure (ii). Especially prominent neural protru-

possible. protruding soft tissue

appearance of the is that of a smooth with inferior con-

portion of the tympanic normally extremely thin. Anomalies of the facial are common in patients

segment nerve who

vexity emanating from the face of the lateral semicircular the level of the oval window

undensurcanal at on coro-

congenital and second ence with

atnesia

disorders branchial external

that

involving arches. auditory

an anteriorly

the first Expenicanal

lo-

nal section (Figs. 16, i7). The CT diagnosis of this entity is possible only in the absence of excessive debris within

indicates

the
margin

middle
of the

ear Diagnosis

because
must

the
be

inferior
outlined

nerve

by

air.

of

the

dehiscent

cated mastoid segment is the most common anomaly encountered (12). Knowledge of the course of the canal must precede any surgical reconstruction.

Figure

Figure

Figure

5. 6.
7.

SPI short process of incus. LSC lateral semicircular canal; FN (TYMP) section); INCUS BODY, LP = long process; LEN P = lenticular process. Direct coronal section at level of cochlea. DLS distal labyrinthine segment (cross-section); CP & TTT = cochleaniform process and tensor tympani tendon; HM head of malleus.

Axial section. TYMP. SEG. tympanic Coronal section of level of oval window.

segment;

tympanic PTS proximal

segment

of facial

nerve

canal

(cross-

tympanic

segment

(cross-section);

Figure

Figure

Figure

10

Direct nerve lateral sinus

coronal section. FN (2nd) G canal at level of second genu; semicircular canal; V vestibule; tympani; RW round window.

facial LSC ST

Axial
=

view

at level

of sinus

tympani.

FN

(sec-

ond) G = facial nerve canal just beneath second genu (3 mm below Figure 6); S. TYMP sinus tympani; PSC = posterior semicircular canal; RW = round window.

-4

Obliquely reconstructed of tympanic segment. cated (arrow).

image Second

through genu

plane is mdi-

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445

Figure

Ii

Figure

12

a. Direct coronal section at level of mastoid segment. FN (M) mastoid segment of facial nerve canal; SMF stylomastoid foramen; JF = jugular fossa; HC hypoglossal canal. a and b. Sagittal reconstruction. Mastoid Segment of facial nerve canal mdicated (arrows). smf = stylomastoid foramen

b.

Figure

13

Figure

14

Figure

15

13.

Axial section. FN tympanic annulus;

(M) JF

mastoid jugular

segment of facial fossa (prominent);

nerve CC

canal carotid

(cross-section); canal.

T. ANN

14.

Axial
duct.

section.

FN (M)

unusually

prominent

mastoid

segment;

C. AQ

cochlear

aque-

Axial arrow exiting

section at level of stylomastoid foramen, indicates facial nerve (in cross-section) foramen.

Figure

16

Figure

17

16.

17.

old woman has an unsually shaped segment of the facial nerve (long-stemmed is noted on this coronal section at the level of the round window. Protruding tympanic segment following radical mastoidectomy. Residual debris in the mastoid bowl (double arrows). The soft tissue density with inferior convexity, at the level
tympanic

Protruding auditory

tympanic segment. This canal. A protruding tympanic

35-year

external arrow) is noted noted

of the oval window

segment of the facial

(long-stemmed
nerve.

arrow),

proved

at surgery

to be a protruding

446

#{149}

Radiology

November

1984

Acknowledgement The author appreciates the assistance of Joan Colombaro in manuscript preparation; Ira A. Grunther for illustrations; and George L. Popky, M.D., Professor and Chairman of the Department of Radiologic Sciences at The Medical College of Pennsylvania, for advice and encouragement. Joel D. Swartz, M.D. Department of Radiologic Sciences The Medical College of Pennsylvania 3300 Henry Avenue Philadelphia, Pennsylvania 19129

2.

3.

4.

5.

References
.

6.

1.

Proctor B, Nager GT. The facial canal: normal anatomy, variations, and anomalies. Ann Otorhinolaryngol 88, Supplement I, 1978:33-44.

7.

JE, Altenau MM, Schaefer SD. Bilongitudinal temporal bone fractures: a retrospective review of seventeen cases. Laryngoscope 1979; 89:1432-1435. Shambaugh GE, May M. Facial nerve paralysis in Paparella MM and Shumnick DM Otolaryngology, Volume II, The Ear, W.B. Saunders Co., Philadelphia, 1980:16801704. DonaldsonjA, Anson BJ. Surgical Anatomy of the Facial Nerve in Symposium on Disease and Injury of the Facial Nerve, Otolaryngologic Clinics of North America, June, 1974:289-308. Curtin HD, Wolfe P. May M. Malignant external otitis: CT evaluation. Radiology i982; 145:383-388. Mayer GG, Crabtree JA. The facial nerve coursing inferior to the oval window. Arch Otolaryngol 1976; 102:744-746. Nager GT, Proctor B. II: Anatomical vaniations and anomalies involving the facial nerve canal. Ann Otorhmnolaryngol 88,

Griffin

lateral

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ii.

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13.

Supplement 1:45-61, 1978. Baxter A. Dehiscence of the fallopian canal: an anatomical study. J Laryngol and Otol 1971; 85:587-594. Schuknecht H. Anatomical variants and anomalies of surgical significance: J Lanyngol and Otol 1971; 85:1238-1241. Johnsson LG, Kingsley TC. Herniation of the facial nerve in the middle ear. Arch Otolaryngol 1970; 91:598-602. SwartzJD, Faerber EN, Wolfson RJ, Marlowe FJ. Fenestral otosclerosis: significance of preoperative CT evaluation. Radiology, 1984; 151:703-707. Swartz JD, Faerber EN. Congenital malformation of the external and middle ear: high resolution CT analysis with emphasis on findings of surgical import. Am J Neuroradiol, in press. Guinto EJ, Himadi GM. Tomographic Anatomy of the Ear. Radiologic Clinics of North America, Volume XII, Number 3, 405-417.

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