2. Introduction :
VII Cranial Nerve - Mixed N
10,000 Motor , Sensory , parasympathetic fibers
Motor root – 7000 special visceral efferent fibers
Sensory & Parasympathetic – 3000 fibers carried by
“NERVUS INTERMEDIUS” (Nerve of Wrisberg)
3. Structure of nerve :
From inside out Nerve fibre consists of axon, myelin
sheath, neurilemma & endoneurium
A group of nerve fibre is enclosed in a sheath called
perineurium to form a fascicle
The fascicles are bound together by epineurium
4. Components of a Nerve :
Endonerium
Surrounds each nerve fiber
Provides endoneural tube for regeneration
Much poorer prognosis if disrupted
Perinerium
Surrounds a group of nerve fibers
Provides tensile strength
Protects nerve from infection
Pressure regulation
Epinerium
Surrounds the entire nerve
Provides nutrition to nerve
9. Facial nerve: Types of fibers
Special Visceral Efferent/Branchial Motor
General Visceral Efferent/Parasympathetic
General Sensory Afferent/Sensory
Special Visceral Afferent/Taste
10. Special Visceral Efferent/Branchial Motor :
Premotor cortex
Motor cortex
Corticobulbar tract
bilateral facial motor nuclei (pons)
facial muscles
• Stapedius
• Stylohyoid
• Posterior belly of Digastric
• Buccinator
15. Central Connections of FN Nucleus
Upper part of Nucleus – B/L supranuclear (cortical)
innervation
Lower part of Nucleus– C/L supranuclear innervation
Imp – function of forehead preserved in supranuclear
lesions
16.
17. DIVISIONS OF FACIAL NERVE
Divided into 3 parts:-
Intracranial
Intratemporal
Extracranial
18. Intracranial Course:
length 23-24mm
Motor fibers hook around Nucleus of VI CN and joins the
Sensory root (N of Wrisberg)
FN (+ VC N + Abdu N) leaves brainstem at Ponto-medullary
junction
F N passes through CP angle with VC N & Nervus Intermedius
At the fundus of IAC, FN enters fallopian canal
Devoid of epineurium - thin layer of pia mater surrounds it and
continues into the meatal segment
Surg imp :
Iatrogenic trauma in CP angle tumour surgery
Difficult to identify in schwannoma (no connective tissue)
19.
20.
21. Intra Temporal Course:
From IAC to SMF
Length – 28 to 30 mm
Longest bony canal
3 segments by 2 genus
25. Meatal Segment
Lies in IAC
Enters in ant. sup. segment of IAC
Length 5 – 12 mm
No separate sheath
Shares with NI & VIII CN
Baths in CSF
27. *Bill’s Bar & Falciform Crescent
Bill's bar was named after Dr William House
It divides the superior compartment of the internal acoustic meatus
into an anterior and posterior compartment.
Anterior to Bill's bar, in the anterior superior quadrant are the facial
nerve (CN VII) and nervus intermedius
Posterior to it in the posterior superior quadrant is the superior division
of the vestibular nerve
The falciformcrescent is a horizontal ridge that divides the internal
acoustic meatus into superior and inferior portions.
Superior - The facial nerve and superior vestibular nerve (SVN) travel
in the superior portion of the IAM with the facial nerve anterior to the
SVN and separated from it in the lateral portion by Bill's bar, a vertical
ridge of bone.
Inferior - The cochlear nerve and inferior vestibular nerve (IVN) run
inferior to the falciform crescent with the cochlear nerve situated more
anteriorly.
28. Labyrinthine Segment
Narrowest(0.68mm) & Shortest(3-5mm)
From Meatal foramen to Geniculate Ganglion (1st Genu)
No anastomosing arteries
Periostium is thicker
Relations :- the segment is
Posterocephald (Posterosuperior) to cochlea
Anteromedial to Sup SCC
Cephald (Superior) to vestibule
Continuation of Internal auditory canal
29. Surgical importance:
Anatomical “bottle neck” – ischemia in oedema resulting in
BELL’S PALSY, Part most vulnerable for ischemia (no arterial
anastomosis & surrounded by dense arachniod band)
Temporal bone # - MC injured
Geniculate ganglion :(distal end)
Bipolar ganglion cells - Afferent input pain & taste fibres
Secretomotor fiber to lacrimal gland by GSPN
30. Tympanic Segment
From Geniculate ganglion to 2nd genu
Length – 8 to 11 mm
Lies beneath LSCC & above OW
At its proximal end above & medial to Processus
cochleariformis & TT muscle.
Creates 2 recesses
Facial recess (lat)
Sinus tympani(med)
31. Facial recess and sinus tympani relations with facial
nerve and pyramidal eminence
32. Surgical importance:
Processus cochleariformis (consistant landmark)
Imp landmark for 2 nd genu
Hug the inf. LSCC
Pyramidal eminence
B/w short process of incus(L) & Lat SCC(M)
33. Mastoid Segment
From 2 nd genu (PM) to SMF(AL)
Longest (13mm)
Landmark – “ Digastric Ridge” identified by medial
aspect of mastoid tip
FN leaves FC via SMF (b/w mastoid tip & styloid
process)
Has 3 brances
Chorda Tympani
N to stapedius
sensory auricular branch
34. Review of the Intra Temporal part of Facial
Nerve, its branches and communications
39. Extra Cranial Course
From SMF to Terminal branches
Runs in substance of parotid
Main trunk divides forming “Pes anserinus”
upper temperofacial
lower cervicofacial
Superficial to Retromandibular vein & Ext. carotid art
42. Branches of Facial N:
Intra temporal region :
GSPN
N to Stapedius
Chorda Tympani
Sensory Auricular branch
Extra temporal region
Posterior Auricular Nerve
Muscular branches
Stylohyoid
Post. belly of Diagastric
Terminal Branches
Temporal
Zygomatic
Buccal
Marginal Mandibular
Cervical
43. Intra temporal region:
GSPN:
From Geniculate ganglion 2 types of fibers arise
Preganglionic parasympathetic
Pterygopalatine gang. Postganglionic lacrimal gland
Sensory fibers to nasal & palatine glands
joins Deep Petrosal N N of pterygoid canal
Nerve to Stapedius:
6mm above SMF
Supply - Stapedius
44. Sensory Auricular Br:
Joins auricular br of vagus
Supply retro-auricular groove & concha
Chorda tympani Br:
4-5mm above SMF
Lat & ant to Facial N
Passes b/w long process incus & upper part of handle of
malleus
2 types of fibers
Preganglionic parasympathetic Submandibular Ganglion
Postganglionic submandibular & sublingual gland
Special sensory ant 2/3 rd of tongue
45. Surgical importance:
GSPN - landmark in middle cranial fossa approach
CT – landmark in posterior tympanotomy
CT – lateral margin of facial recess
CT – medial limit for facial ridge in CWD
46. Extratemporal region:
The stylomastoid foramen
medial aspect of mastoid tip
FN exit from Stylomastoid Foramen
below tympanic plate & Lat to the base of styloid
nonvascular area Lateral to base of carotid sheath &
behind the parotid gland
Post. Auricular N
Muscles of pinna
Occipitofrontalis
Muscular Branches
Post. belly of digastric
Stylohyoid
47. Terminal branches :
Temporal :
Comes out through the upper pole of parotid gland
Cross zygomatic arch
Muscles supplied
Auricularis anterior & superior
Frontalis
Corrugator supercilii
Procerus
Upper orbicularis oculi
Action – Raising eyebrows
48. Zygomatic :
Also called Upper Zygomatic
Cross zygomatic bone
Muscles supplied
Lower Orbicularis oculi
Action – Tight shutting of eye
54. Pattern of branching of Terminal branches of Facial Nerve
(Classification & Branching pattern by Davis et al - Gray’s ANATOMY)
55. Katz & Catalano classification:
Type I (25%)no anastomic links bet the 2 branches
Type II (14%) buccal branch subdivided
Type III(44%)
Type IV(14%)
Type V(3%)
56. Anatomical Relationship of FN in Adults & Children:
Child
• Absent mastoid
process & incomplete
tympanic ring. CT
may exit thru SMF
• 2nd genu is more
acute & lateral
• N trunk on exit from
SMF is more anterior
& lateral
• N very superficial
over angle of
mandible
Adult
• Mastoid process &
complete ring . CT
exits separately prox
to SMF
• 2nd genu less acute
& more medial
• Parotid is more post.
N trunk is less
anterior & deeper
• N superficial over
angle of mandible
58. Facial Nerve embryonic development:
Facial nerve course, branching pattern, and
anatomical relationships are established during the
first 3 months of prenatal life
The nerve is not fully developed until about 4 years of
age
The first identifiable FN tissue is seen at the 3rd week
of gestation- facioacoustic primordium or crest
59. Facial nerve embryology - 4th week
By the end of the 4 th week, the facial and acoustic
portions are more distinct
The facial portion extends to placode
The acoustic portion terminates on otocyst
Facial nerve embryology - 7th week
Early 7 th week, geniculate ganglion is well-defined and
facial nerve roots are recognizable
The nervus intermedius arises from the ganglion and
passes to brainstem.
Motor root fibers pass mainly caudal to ganglion
60. Facial nerve embryonic development:
Extratemporal segment – FN branches:
Proximal branches form - First 6th week,
Posterior auricular branch > branch of digastric - Early 8th week,
Temporofacial and Cervicofacial divisions - Late 8 th week (5 major
peripheral subdivisions present)
Extratemporal segment – other nerves :
Facial nerve communicates with
peripheral branches of CN V, IX, X,
cervical cutaneous nerves
greater auricular nerve
transverse cervical branches of the cervical plexus (C2, C3)
Trigeminal nerve: auriculotemporal , infraorbital , buccal , mental
branches
All connections are complete by week 12, except for connections to
branches of CN V at orbit periphery - these are completed at 4.5
months
61. Surgical Landmarks :
Ear & Mastoid surgery
Geniculate ganglion lies behind & superior to Processus
cochleariformis
2nd genu hugs inferior aspect of LSCC
Facial N lies above OW niche
Incus lies lateral to Facial N
Facial N runs behind Pyramid
Facial N lies 6-8mm inferior to Tympano-mastoid suture
Digastric ridge – mastoid segment
Parotid surgery
Tragal pointer – Fn lies 1cm deep to it
FN lies 1cm inferior to Tympanomastoid suture
N bisects angle b/w Post belly of digastric & ear canal
Buccal br 1 cm below & parallel to zygomatic arch
N lies lateral to Styloid process & Superficial to Retromandibular vein
62. Variations:
MC variations
Facial N displacements
Dehiscence of fallopian canal 50% -MC
Dehiscence in tympanic/horizontal seg (91%)
Vertical seg. variations
Bifurcation/ Trifurcation of the N
Ant displaced N With post hump
63. THANK YOU…
REFERENCES:-
GRAY’s Anatomy - 29th Edition
Scott Brown’s Otorhinolaryngology & Head and Neck Surgery – 7th Edition
Cumming’s Otolaryngology & Head and Neck Surgery -5th Edition
Glasscock-Shambaugh Surg. of EAR – 6th Edition
Mohan Bansal – 2nd Edition
BD Chaurasia’s – Human Anatomy 3rd Edition