Facial Nerve

Overview
• The facial nerve is associated with the derivatives of
the second pharyngeal arch (also called nerve of 2nd BA:
• Motor – muscles of facial expression, posterior belly of the
digastric, stylohyoid and stapedius muscles.
• Sensory – a small area around the concha of the external ear.
• Special Sensory – provides special taste sensation to the
anterior 2/3 of the tongue via the chorda tympani
• Parasympathetic – supplies many of the glands of the head
and neck, including:
– Submandibular and sublingual salivary glands.
– Nasal, palatine and pharyngeal mucous glands.
– Lacrimal glands.
 Anatomical Course
• The course of the facial nerve is very complex.
• There are many branches, which transmit a
combination of sensory, motor and
parasympathetic fibres.
• Anatomically, the course of the facial nerve can be
divided into two parts:
– Intracranial – the course of the nerve through the
cranial cavity, and the cranium itself.
– Extracranial – the course of the nerve outside the
cranium, through the face and neck.
 Intracranial
• The nerve arises in the pons.
• It begins as two roots; a large motor root, and
a small sensory root (Intermediate nerve)
• The two roots travel through the internal
acoustic meatus, a 1cm long opening in the
petrous part of the temporal bone.
 Cont…
• Within the temporal bone, the roots leave the internal acoustic
meatus, and enter into the facial canal. The canal is a ‘Z’ shaped
structure. Within the facial canal, three important events occur:
• Firstly the two roots fuse to form the facial nerve.
• Next, the nerve forms the geniculate ganglion.
• Lastly, the nerve gives rise to:
– Greater petrosal nerve – parasympathetic fibres to mucous glands and
lacrimal gland.
– Nerve to stapedius – motor fibres to stapedius muscle of the middle
ear.
– Chorda tympani – special sensory fibres to the anterior 2/3 tongue and
parasympathetic fibres to the submandibular and sublingual glands.
• The facial nerve then exits the facial canal (and the cranium) via
the stylomastoid foramen.
 Extracranial
• After exiting the skull, the facial nerve turns superiorly to run just
anterior to the outer ear.
• The first extracranial branch to arise is the posterior auricular
nerve. It provides motor innervation to the some of the muscles
around the ear.
• Immediately distal to this, motor branches are sent to the
posterior belly of the digastric muscle and to
the stylohyoid muscle.
• The main trunk of the nerve, now termed the motor root of the
facial nerve, continues anteriorly and inferiorly into the parotid
gland (note – the facial nerve does not contribute towards the
innervation of the parotid gland, which is innervated by
the glossopharyngeal nerve).
 Motor Functions
• Branches of the facial nerve are responsible for innervating many of the
muscles of the head and neck. All these muscles are derivatives of
the second pharyngeal arch.
• The first motor branch arises within the facial canal; the nerve to
stapedius. It passes through the pyramidal eminence to supply the
stapedius muscle in the middle ear.
• Between the stylomastoid foramen, and the parotid gland, three more
motor branches are given off:
– Posterior auricular nerve – Ascends in front of the mastoid process, and
innervates the intrinsic and extrinsic muscles of the outer ear. It also supplies
the occipital part of the occipitofrontalis muscle.
– Nerve to the posterior belly of the digastric muscle – Innervates the posterior
belly of the digastric muscle (a suprahyoid muscle of the neck). It is responsible
for raising the hyoid bone.
– Nerve to the stylohyoid muscle – Innervates the stylohyoid muscle (a
suprahyoid muscle of the neck). It is responsible for raising the hyoid bone.
• Within the parotid gland, the facial nerve terminates
by bifurcating into five motor branches. These
innervate the muscles of facial expression:
– Temporal – Innervates the frontalis, orbicularis oculi and
corrugator supercilii.
– Zygomatic – Innervates the orbicularis oculi.
– Buccal – Innervates the orbicularis oris, buccinator and
zygomaticus.
– Marginal mandibular – Innervates the depressor labii
inferioris, depressor anguli oris and mentalis.
– Cervical – Innervates the platysma
• Special Sensory Functions
– The chorda tympani branch of the facial nerve is
responsible for innervating the anterior 2/3 of the
tongue with the special sense of taste.
• Parasympathetic Functions
– The parasympathetic fibres of the facial nerve are carried by the greater
petrosal and chorda tympani branches.
• Greater Petrosal Nerve
– The greater petrosal nerve arises immediately distal to the geniculate ganglion within
the facial canal. It then moves in anteromedial direction, exiting the temporal bone
into the middle cranial fossa. From here, its travels across (but not through) the
foramen lacerum, combining with the deep petrosal nerve to form the nerve of the
pterygoid canal.
– The nerve of pterygoid canal then passes through the pterygoid canal (Vidian canal) to
enter the pterygopalatine fossa, and synapses with the pterygopalatine ganglion.
Branches from this ganglion then go on to provide parasympathetic innervation to
the mucous glands of the oral cavity, nose and pharynx, and the lacrimal gland.
• Chorda Tympani
– The chorda tympani also carries some parasympathetic fibres. These combine with
the lingual nerve (a branch of the trigeminal nerve) in the infratemporal
fossa and form the submandibular ganglion. Branches from this ganglion travel to the
submandibular and sublingual salivary glands.
 Clinical Relevance: Damage to the Facial
Nerve
• Intracranial Lesions
• Intracranial lesions occur during the intracranial course of
the facial nerve (proximal to the stylomastoid foramen).
– The muscles of facial expression will be paralysed or severely
weakened.
– The other symptoms produced depend on the location of the
lesion, and the branches that are affected:
• Chorda tympani – reduced salivation and loss of taste on the ipsilateral
2/3 of the tongue.
• Nerve to stapedius – ipsilateral hyperacusis (hypersensitive to sound).
• Greater petrosal nerve – ipsilateral reduced lacrimal fluid production.
• The most common cause of an intracranial lesion of the
facial nerve is infection related to the external or middle ear.
If no definitive cause can be found, the disease is termed
• Extracranial Lesions
• Extracranial lesions occur during the extracranial course of the
facial nerve (distal to the stylomastoid foramen).
• Only the motor function of the facial nerve is affected, therefore
resulting in paralysis or severe weakness of the muscles of facial
expression.
• There are various causes of extracranial lesions of the facial nerve:
– Parotid gland pathology – e.g a tumour, parotitis, surgery.
– Infection of the nerve – particularly by the herpes virus.
– Compression during forceps delivery – the neonatal mastoid process is
not fully developed and does not provide complete protection of the
nerve.
– Idiopathic – If no definitive cause can be found then the disease is
termed Bell’s palsy.
 Pathology of FN
• Congenital
– External auditory canal (EAC) atresia: presents as
hypoplastic auricle, stenotic or aplastic EAC with bony
or membranous covering, hypoplastic middle ear
with fused and malrotated ossicles, and anteriorly
displaced tympanic and mastoid segments of CN VII.
– Congenital facial nerve dehiscence is typically a
sporadic anomaly in which there is deficiency of bone
overlying the facial nerve canal. In rare cases, the
nerve can prolapse through the defect and mimic a
mass.
• Infection and Inflammation
– The most common cause of acute facial nerve
paralysis is known as Bell’s palsy.
– The cause is unknown, although a possible
association with herpes simplex virus (HSV-1) has
been described.
– The majority of cases are self-limited, with symptoms
peaking after several days (up to 2 weeks)
– Pt presents with facial palsy involving the whole
facial muscles
 • Ramsay-Hunt syndrome (varicella zoster virus): previously
inactive (dormant) varicella-zoster virus is reactivated and
spreads to affect the facial nerve.
• Patient presents with rash around the EAC and pina, facial
nerve paralysis and Otalgia.
– Treatment of Bells palsy and RHS includes PO steroid,
topical antibiotics and Eye care to prevent exposure
keratitis
• Benign neoplasms
– Benign neoplasms of the facial nerve include
schwannoma.
– Schwannoma is a tumor of the Schwann cells lining the
nerve. This rarely involves CN VII in the geniculate,
tympanic, or mastoid segments.
– There is characteristic fusiform nerve enlargement and
smooth bone erosion.
• Trauma and Iatrogenic Causes
– Temporal bone fracture is another common cause
of FN paralysis
– Transverse TB fracture involves 50% FN palsy and
longitudinal fracture involve 20% FN palsy.
– Transverse fracture is due to antero posterior
trauma and longitudinal fracture is due to lateral
blow trauma.
– Pt present with otorhea, hemotympanum, FN
palsy EAC laceration
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