MITHILA MINORITY DENTAL COLLEGE AND HOSPITAL

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

TOPIC :- FACIALNERVE

DATE OF PRESENTATION:- 09-07-2019

MODERATOR: SUBMITTED BY:

AMIT KUMAR SINGH

PG TRAINEE

SIGNATURE OF HOD:
 CONTENTS

 Introduction

 Embroyology

 Functional components

 Ganglions

 Course and relations

 Branches of distribution

 Applied anatomy

 Studies

 Conclusion

 References
 INTRODUCTION

• It is the 7th cranial nerve

• It is the nerve of 3rd branchial arch

• It is both motor and sensory.

EMBROYOLOGY

 The facial nerve is developmentally derived from the hyoid arch, which is
the second branchial arch
 The motor division of facial nerve is derived from the basal plate of the
embryonic pons
 The sensory division originates from the cranial neural Crest
 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 Facial Nerve tissue is seen at the third week of
gestation- facioacoustic primordium or crest
 By the end of the 4th week,the facial and acousticportions are more
distinct
 The facial portion extends to placode
 The acoustic portion terminates on otocyst
 Early 5th week, the geniculate ganglion forms from distal part of
primordium
 It separates into 2 branches: main trunk of facial nerve and chorda
tympani
 Near the end of the 5th week, the facial motor nucleus is recognizable
 The motor nuclei of VI and VII cranial nerves initially lie in close
proximity.
 The internal genu forms as metencephalon, it elongates and CN VI
nucleus ascends
 Early 7th 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
 Proximal branches form in the 6th week, posterior auricular branch,
branch of digastric
 temporofacial and cervicofacial divisions present
 5 major peripheral subdivisions present

FUNCTIONAL COMPONENTS

1. Special visceral or branchial efferent, to muscles responsible for facial

expression and for elevation of the hyoid bone.

2. General visceral efferent or parasympathetic. These fibers are

secretomotor to the submandibular and sublingual salivary glands, the
lacrimal gland and gland of the nose , the palatal, and the pharynx
3. General visceral afferent component carries afferent impulses from the
above mentioned glands.
4. Special visceral afferent fibers carry taste sensations from the palate and
from anterior two third of the tongue except from vallate papillae.
5. General somatic afferent fibers probably innervate a part of skin of the
ear. The nerve doesnot give any branchs to the ear , but some fibers may
reach it through communications with vagus nerve. Proprioceptive
impulses from muscles of the face travel through the branches of the
trigeminal nerve to reach the mesencephalic nucleus of the nerve.
NUCLEI
The fibers of the nerve are connected to four nuclei situated in the lower
pons.
 Motor nucleus or branchiomototr.
 Superior salviatory nucleus or parasympathetic.
 Lacrimatory nucleus is also parasympathetic.
 Nucleus of the tractus solitarius which is gustatory. It also receives
afferent fibers from the glands.
 The motor nucleus lies deep in reticular formation of the lowar pons.
The part of the nucleus that supplies muscles of the upper part of the
face receives corticonuclear fibers from the motor cortex of both the
right and left sides.
 In contrast, the part of nucleus that supplies muscles of the face
receives corticonuclear fibers only from the opposite crerbral
hemisphere

COURSE AND RELATIONS

 The facial nerve is attached to the brainstem by two roots, motor and
sensory. The sensory root is called the nervus intermedius.
 The two roots of the facial nerve are attached to the lateral part of the
lower border of the pons just medial to eight cranial nerve.
 The two roots run laterally and forwards , with the eight nerve to reach
the internal acoustic meatus.
 In the meatus , the motor root lies in a groove on the eight nerve, with
the sensory root intervening. Here the seventh and eight nerves are
accompanied by the labyrinthine vessels.
 At the bottom or fundus of the meatus , the two roots , sensory or
motor, fuse to form a single trunk, which lie in the petrous temproal
bone .
 Within in the canal the course of the course of the nerve can be
divided into three parts by two bends.
 The first part is directed laterally above the vestibule;the seconds part
runs backwards in relations to the medial wall of the middle ear ,
above the promontory .
 The third part is directed vertically downwards behind the
promontory. The third part is directed vertically downwards behind
the promontory.
 The first bend at the the junction of the first and second parts is sharp.
 It lies over the anterosuperior part of the promontory, and is also
called the genu.the geniculate ganglion of the nerve is so called
because it lies on the genu.
 The second bend is gradual ,and lies between the promontory and
aditus to the mstoid antrum.
 The facialnerve leave the skull bypassing through the stylimastoid
foramen.
 In its extracranial course, the facialneve crosses the lateral side
of the base of the styloid process.
  It enters the posteromedial surface of the parotid glands , runs
forward through the gland crossing the retromandibular veins
and external carotid artery.
 Behind the neck of the mandible .it divide into its five terminal
branches which emerge along the anterior border of the parotid
gland.
Branches and distributions
 within the canal:
A. Greater petrosal nerve
B. The nerve to the stapedius
C. The chorda tympani
 At its exist from the stylomastoid foramen
A. Posterior auricular
B. Digastric
C. Stylohyoid
 Terminal branches within the parotid gland
A. Temporal
B. Zygomatic
C. Buccal
D. Marginal mandibular
E. Cervical
 Communnicating branches with adjacent cranial and spinal nerve

A. Greater petrosal nerve

B. The nerve to the stapedius:-

  The nerve to the stapedius arises opposite the pyramid of the
middle ear, and supplies the stapedius muscle.
 The muscle dampens excessive vibrations of the stapes
caused by high-pitched sounds. In paralysis of the muscle,
even normal sounds appear too louds and is known as
hyperacusis.
C. The chorda tympani
 The chorda tympani arises in the vertical part of the
facial canal about 6mm above the stylomastoid
foramen.
 It runs upwards and forewards iin a bon canal. It
enters the middle ear and run forewards in close
realations to the tympanic memberane.
 It leaves the middle ear by passing through the
pertrotympanic fissure.
 It then passes medial tolthe spine of the sphenoid and
enters the infratemporal fossa.here it joins the lingual
nerve through which it is distributed.
 It carries:
a. Preganglionic secretomotor fibers to the submandibular
ganglion for the supply of the submandibular and sublingual
salivaray glands.
b. Taste fibers from the anterior two –thirds og the tounge except
circumvallate papillae.
2. At its exist from the stylomastoid foramen:-
A. Posterior auricular:-
 The posterior auricular nerves arises just below the stylomastoid foramen.
 It ascends between the mastoid process and the external acoustic meatus,
and supplies
a. Auricular posterior
b. Occipitalis
c. Intrinsic muscles on the bac of auricle
B. The digastric branch:-
 The digastric branch, arises close to the previous nerve .it is
short and supplies the posterior belly of digastric.
C. The stlohyoid branch:-
The stylohyoid branch, arises with the diagestric branch, is long
and supplies the stylohyoid muscle.
3. Terminal branches within the parotid gland

A. The temporal branch cross the zygomatic arch and supply:

a. Auricularies anterior
b. Auricularies superior
c. Intrinsic muscle on the lateral side of the eaar
d. Frontalis
e. Orbicularies oculi
f. Corrugator supercilli
B. The zygomatic branches run across the zygomatic bone and
supply the orbicularis oculi.
C. The buccal branches are to in number . the upper branch run
above the parotid duct and the lower buccal branch below the
duct. They supply muscles in that vicinity especially in
buccinators.
D. The marginal mandibular runs below the angle of the mandible
deep to the platysma. It crosses the body of the mandible and
supply muscles of lip and chin.
 E. The cervical branch emerges from the apex of the parotid
gland , and runs downward and forewards in the neck to supply
the platysma
4. Communicating branches , for effective coordinaton between the
movements of the muscles of the first, second and third branchial
arches , the motor nerves of the three arches communicate with each
other.the facial nerve also communicates with sensory nerves
distuributed over its motor territory.

GANGLIONS

The ganglia associated with the facial nerve are as follows:-

1. The geniculate GANGLION-

 The geniculate ganglion is located on the first bend of the
facial nerve,in relation to the medialwallof the middle ear.
 It is a sensory ganglion . the taste fibers present in the nerve
are peripherl process of the pseudounipolar neurons present
in the geniculate ganglion.
2.The sub mandibular ganglion :
 the submandibular ganglion is a papasympathitic ganglion for relay
of secretomotar fibers to the submandibular and sublingual glands.
 The pre ganglion fibers comes from the chord tympani nerve.
3 The pterygopalatine nerve:-
  The pterygomandibular nerve is also aparasympathe tic ganglion.
Secretomotor fibers are meant for lacrimalgland relay on this
ganglion .
 The fibers reach he ganglion from the erve to the pterygoid canal
APPLIED ANATOMY
Facial Nerve Lesions

1. Supra nuclear type:

Features:
a) Paralysis of lower part of face (opposite side)
b) Partial paralysis of upper part of face
c) Normal taste and saliva secretion
d) Stapedius not paralysed

2. Nuclear type:
Features:
a) Paralysis of facial muscle (same side)
b) Paralysis of lateral rectus
c) Internal strabismus

3. Peripheral lesion
a) At internal acoustic meatus
Features:
i. Paralysis of secretomotor fibers
ii. Hyper acusis
iii. Loss of corneal reflex
iv. Taste fibers unaffected
v. Facial expression and movements paralysed
b) Injury distal to geniculate ganglion
Features:
i. Complete motor paralysis (same side)
ii. No hyper acusis
iii. Loss of corneal reflex
iv. Taste fibers affected
v. Facial expression and movements paralysed
vi. Pronounced reaction of degeneration

c) Injury at stylomastoid foramen

• Condition known as Bell’s Palsy
 Background of BELL’S PALSY
 First described more than a century ago by Sir Charles Bell Yet much
controversy still surrounds its etiology and management. Bell palsy is
certainly the most common cause of facial paralysis worldwide
Demographics of Bells palsy
 Race: slightly higher in persons of Japanese descent.
 Sex: No difference exists
 Age: highest in persons aged 15-45 years.
 Bell palsy is less common in those younger than 15 years and in those
older than 60 years.
 Pathophysiology of Bells palsy
 Main cause of Bell's palsy is latent herpes viruses(herpes simplex virus
type 1 and herpes zoster virus), which are reactivated from cranial nerve
ganglia
 Polymerase chain reaction techniques have isolated
 herpes virus DNA from the facial nerve during acute palsy
 Inflammation of the nerve initially results in a reversible neurapraxia
  Herpes zoster virus shows more aggressive biological behaviour than
herpes simplex virus Type1
 Bell's phenomenon is the upward diversion of the eye ball on attempted
closure of the lid is seen when eye closure is incomplete.
Features of Bell’s Palsy
I. Unilateral involvement
II. Inability to smile, close eye or raise eyebrow
III. Whistling impossible
IV. Drooping of corner of the mouth
V. Inability to close eyelid (Bell’s sign)
VI. Inability to wrinkle forehead
VII. Loss of blinking reflex
VIII. Slurred speech
IX. Mask like appearance of face
X. Loss/ alteration of taste

Medical treatment
 Corticosteroids :
 Prednisolone 1 mg/kg/day 7-10 days
 Corticosteroids combine with antiviral drug is better
 Acyclovir 400 mg 5 times/day
 Famciclovir and valacyclovir 500 mg bid
 Surgical treatment
 Facial nerve decompression
 Indication:
 Completely paralysis
 ENoG less than 10% in 2 weeks
 Appropriate time for surgery is 2-3 weeks after paralysis
  FREY’S SYNDROME

Frey’s syndrome was described by Frey. He reported the incidence of localized

gustatory sweating and flushing following a gun shot wound and suppurative
parotitis. This auriculotemporal nerve syndrome may follow the surgery of the
parotid gland and TM joint, a facial wound or parotid abscess.
1. It is characterized by pain in the auriculo temporal nerve distribution.
2. Associated gustatory sweating and occasionally erythema is seen.
3. There is flushing on the affected side of the face accompanied by sweating
within the hairline, the periauricular region and beneath the pinna.
4. A minor starch iodine test is positive in these patients (The skin is painted
with a solution of iodine, castor oil and absolute alcohol. Corn starch
is dusted onto the dried, painted area. A positive test will be evoked after the
patient chewed a lemon wedge for 5 minutes).
 Preauricular incision :-
Incision is taken in the skin. Platysma and superficial fascia dissected. The duct
is identified at the anterior border of the gland. The duct is followed backwards
through the substance of gland until the calculus; identified and recovered.
Extreme caution should be exercised for the preservation of branches of facial
nerve, particularly the lower zygomatic branch, which lies on the surface of the
duct just below the accessory parotid. The fascial sheath encasing the gland is
closed completely. This prevents saliva leaking into the tissues. A piece of
corrugated rubber drain is placed, and the wound is closed over the drain in
layers. A pressure dressing is applied over the site of surgery.
RAMSAY-HUNT SYNDROME:-
  Involvent of geniculate ganglia by herpes zoster results in this syndrome.
 It shows following symptoms:
a. Hyperacusis
b. Loss of lacrimation
c. Loss of sensatation of taste in anterior two- third of tounge
d. Bell’s palasy and lackof salivation
e. Vesicles on the auricle

CASE STUDIES

VARIATIONS IN THE BRANCHING PATTERN OF FACIAL NERVE

 The Aim of this report is to describe the variations in the complex

network of terminal branches of facial nerve in the face.

 This study includes fifty fetal parotid glands in 25 foetuses and 8 adult
parotid glands of 4 cadavers.

 In the foetal specimens the facial nerve divides into 2 main divisions in
88% of glands. The remaining 12% fetal specimens the facial nerve
divides directly into 5 terminal branches.

 The variations noted are: In the fetal specimens the facial nerve divides
into two main divisions in 88% and in all adult specimens. In 12% of
foetal specimens direct five terminal branches are given
 Intraparotid facial nerve schwannoma

 The aim of this was to assess and describe the pathological characteristics
of intraparotid facial nerve schwannoma.

 A classification is proposed, based on anatomical and pathological

evaluations.

 two important characteristics of facial nerve schwannoma emerged:-

 1) capable of surgical dissection

 2)it is tightlybound to the nerve

 The extent of the neoplasm and the involvement of different branches of

the facial nerve are very important elements to consider when evaluating
prognosis and therapy.

 To emphasise the usefulness of a classification, based on anatomical and

pathological evaluation, which can supply information about post-
operative facial function.

Conclusion

 The most impotant thing about the intracranial course of Facial nerve is
its relationship to the middle ear.

 The most important thing about the extracranial course is Its relationship
to the parotid gland.

Hence a complete understanding of its anatomy is essential and care should be

taken during surgical procedures.

References
 Grays Anatomy : 39th Edition

 Netters : Colour Atlas of Anatomy

 Fonseca & Walker : Maxillo FacialTrauma 2nd EditionVol 1 & 2

 Text of human anatomy(volume 3)-B D CHAURASIA

 International journal of Oral & maxillofacial Surgery