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Overview
The facial nerve, or cranial nerve (CN) VII, is the nerve of facial expression. The pathways of the facial nerve are variable, and knowledge of the key intratemporal and extratemporal landmarks is essential for accurate physical diagnosis and safe and effective surgical intervention in the head and neck. (See the image below.)
The facial nerve is composed of approximately 10,000 neurons, 7,000 of which are myelinated and innervate the nerves of facial expression. Three thousand of the nerve fibers are somatosensory and secretomotor and make up the nervus intermedius. The course of the facial nerve and its central connections can be roughly divided into 6 segments, as shown in Table 1, below. Table 1. Segmental Description of the Facial Nerve and Central Connections (Open Table in a new window) Length, Segment Location mm NA 13-15 3-4 8-11 10-14 15-20
Supranuclear Brainstem Meatal segment Labyrinthine segment Tympanic segment Mastoid segment
Cerebral cortex Brainstem to internal auditory canal (IAC) Fundus of IAC to facial hiatus Geniculate ganglion to pyramidal eminence Pyramidal process to stylomastoid foramen
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The objective of this article is to briefly review the anatomy of the facial nerve in each of these segments and to follow the nerve from its most proximal origin to its end organ, ie, the muscles of facial expression.
Central Connections
Crosby and DeJonge, along with Nelson, have provided 2 of the most complete descriptions of the facial nerve's central connections. The reader is referred to these references for a more detailed description of the supranuclear and nuclear organization of the facial nerve.
[1, 2]
This homunculus illustrates the location on the motor strip of facial areas relative to the hand and upper extremities. The lower half of the figure depicts the anatomy of the pyramidal system.
Discharges from the facial motor area are carried through fascicles of the corticobulbar tract to the internal capsule, then through the upper midbrain to the lower brainstem, where they synapse in the pontine facial nerve nucleus. The pontine facial nerve nucleus is divided into an upper and a lower half, bilaterally. The corticobulbar tracts from the upper face cross and recross en route to the pons; the tracts to the lower face cross only once. In 1987, Jenny and Saper performed an extensive study of the proximal facial nerve organizations in a primate model and found evidence that in monkeys, upper facial movement is relatively preserved in upper motor neuron injury, because these motor neurons receive relatively little direct cortical input. In contrast, the lower facial muscles are more severely affected, because their motor neurons depend on significant cortical innervation. The authors believe
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In their study, Jenny and Saper found that the descending corticofacial fibers in monkeys innervated the lower facial motor nuclear region bilaterally but with contralateral predominance. The upper facial motor nuclear regions received scant direct cortical innervation on either side of the brain. The deficits observed with unilateral ablation of the corticobulbar fibers reflect the fact that upper facial motor neurons do not receive significant cortical innervations and that lower facial motor neurons contralateral to the lesion have functional loss because of their dependence on direct contralateral cortical innervation and because the remaining ipsilateral cortical projections are not sufficient to drive them. These findings may explain why a focal lesion in the facial area on one side of the motor cortex in humans spares eyelid closure and forehead movement but results in paralysis of the lower face. Table 2. Summary of Innervation and Actions of Facial Mimetic Muscles (Open Table in a new window) Branch of CN VII Posterior auricular Temporal Location of Lesion Posterior auricular Occipitofrontalis, occipital belly Anterior auricular Superior auricular Occipitofrontalis, occipital belly Corrugator supercilii Procerus Temporal and zygomatic Zygomatic and buccal Buccal Orbicularis oculi Zygomaticus major Zygomaticus minor Levator labii superioris Levator labii superioris alaeque nasi Risorius Buccinator Levator anguli oris Orbicularis Nasalis, dilator naris Nasalis, compressor naris Buccal and marginal mandibular Marginal mandibular Cervical Depressor anguli oris Depressor labii inferioris Mentalis Platysma Pulls ear backward Moves scalp backward Pulls ear forward Raises ear Moves scalp forward Pulls eyebrow medially and downward Pulls medial eyebrow downward Closes eyelids and contracts skin around eye Elevates corners of mouth Elevates upper lip Elevates upper lip and midportion nasolabial fold Elevates medial nasolabial fold and nasal ala Aids smile with lateral pull Pulls corner of mouth backward and compresses cheek Pulls angles of mouth upward and toward midline Closes and compresses lips Flares nostrils Compresses nostrils Pulls corner of mouth downward Pulls lower lip downward Pulls skin of chin upward Pulls down corners of mouth Actions
Caution is advised in using preservation of forehead function to diagnose a central lesion. Patients may have sparing of forehead function with lesions in the pontine facial nerve nucleus, with selective lesions in the temporal bone, or with an injury to the nerve in its distribution in the face. An accurate neurologic diagnosis is best made by examining deficits in conjunction with "the company they keep." A cortical lesion that produces a lower facial deficit is usually
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associated with a motor deficit of the tongue and weakness of the thumb, fingers, or hand on the ipsilateral side (see the image above). Nerve fibers influencing emotional facial expression are thought to arise in the thalamus and globus pallidus. Supranuclear pyramidal lesions spare movements of the face initiated as emotional responses and reflexes. With nuclear and infranuclear lesions, loss of involuntary and voluntary facial movement occurs. The facial nerve nuclei also receive afferent input from other brainstem nuclei. Input from the trigeminal nerve and nucleus form the basis of the trigeminofacial reflexes, eg, the corneal reflex. Input from the acoustic nuclei to the facial nerve nucleus forms part of the stapedial reflex response to loud noises.
Extrapyramidal system
The extrapyramidal system consists of the basal ganglia and the descending motor projections other than the fibers of the pyramidal or corticospinal tracts. This system is associated with spontaneous, emotional, mimetic facial motions. The interplay between the pyramidal and extrapyramidal systems accounts for resting tone and stabilizes the motor responses. The masked facies associated with Parkinsonism are known to be the result of destruction of the extrapyramidal pathways. The facial dystonia seen in Meige syndrome is thought to be due to basal ganglion disease.
Lower midbrain
A lesion in the lower midbrain above the level of the facial nucleus may cause contralateral paresis of the face and muscles of the extremities, ipsilateral abducens muscle paresis (due to effects on the abducens nerve), and ipsilateral internal strabismus. If the lesion extends far enough laterally to include the emerging facial nerve fibers, a peripheral type of ipsilateral facial paralysis might be apparent.
Pons
The facial motor nucleus is located in the lower third of the pons, beneath the fourth ventricle. The neurons leaving the nucleus pass around the abducens nucleus as they emerge from the brainstem. Involvement of the facial nerve nucleus and VI nerve nucleus are suggestive of a lesion near the fourth ventricle. A lesion near the ventricle at the level of the superior salivatory nucleus may result in a dry eye in addition to a peripheral facial paralysis and abducens paresis. Many syndromes are known to result from pontine lesions, some of which are summarized in Table 3. Table 3. Syndromes Associated with Central Lesions (Open Table in a new window) Syndrome Foville syndrome Millard-Gubler syndrome Moebius syndrome Parkinson disease Pseudobulbar palsy Fundus of IAC to facial hiatus Extrapyramidal pathways Pontine Location of Lesion Lateral pons Characteristic Feature Ipsilateral facial paresis, ipsilateral facial analgesia, ipsilateral Homer syndrome, ipsilateral deafness Facial dystonia Unilateral sixth nerve palsy, ipsilateral seventh nerve palsy, contralateral hemiparesis
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Ipsilateral facial paresis, ipsilateral abducens (CN VI) palsy Masked facies Bilateral facial paresis with other CN defects, hyperactive gag reflex, hyperreflexia associated with hypertension, emotional lability
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Weber syndrome
Upper midbrain
Ipsilateral loss of direct and consensual pupillary light reflexes, ipsilateral external strabismus, oculomotor paresis
This drawing shows the contents of the right internal auditory canal. Note the relationship between the nervus intermedius (ie, nerve of Wrisberg) and the facial nerve. Also note the superior location of the facial nerve relative to the vestibulocochlear nerve.
The nervus intermedius conveys (1) afferent taste fibers from the chorda tympani nerve, which come from the anterior two thirds of the tongue; (2) taste fibers from the soft palate via the palatine and greater petrosal nerves; and (3) preganglionic parasympathetic innervation to the submandibular, sublingual, and lacrimal glands. The fibers for taste originate in the nucleus of the tractus solitarius (NTS), and the fibers to the lacrimal, nasal, palatal mucus, and submandibular glands originate in the superior salivatory nucleus. Fibers to the lacrimal gland are carried with the greater superficial petrosal nerve until it exits the skull, where they branch off as the Vidian nerve, as shown in the image below.
Schematic illustration shows the facial nerve and its peripheral connections. Note the interconnections of cranial nerve (CN) VII with CN V, CN IX, and CN X.
The nervus intermedius also has a small cutaneous sensory component from afferent fibers originating from the skin of the auricle and postauricular area. The close anatomic association between the facial nerve, the nervus intermedius, and the vestibulocochlear nerve at the level of the CPA and in the IAC may result in disturbances in tearing, taste, salivary gland flow, hearing, balance, and facial function as a result of lesions at this level. Common examples are the symptoms of tinnitus, unilateral hearing loss, and balance disturbances often associated with acoustic schwannomas. Large acoustic schwannomas may progress to involve the facial nerve and even CN V, CN IX, CN X, and CN XI.
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The facial nerve and the nervus intermedius enter the IAC with the vestibulocochlear nerve. The gross and microscopic anatomic relationships among the locations of CN VII, CN VIII, and the nervus intermedius, shown in the image below, are of surgical importance. The vestibulocochlear nerve enters the IAC inferiorly (caudad). The facial nerve runs superiorly (cephalad) along the roof of the IAC. A useful mnemonic for remembering this relationship is "Seven-up over Coke." At the fundus of the IAC, the falciform crest (crista falciformis) divides the IAC into superior and inferior compartments. The facial nerve passes along the superior part of the ledge, separated from the superior vestibular nerve by a vertical bony ridge named the Bill bar (after the esteemed Dr William House).
Spatial anatomic relationship between the nerves traveling through the internal auditory canal is shown. Note the changing spatial relationship between the facial nerve (cranial nerve [CN] VII) and the vestibulocochlear nerve (CN VIII).
The transtemporal course of the facial nerve is shown. Note the vascular arcades feeding the facial nerve throughout its course in the bony fallopian canal.
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tongue are added to the geniculate ganglion from the chorda tympani. Three nerves branch from the geniculate ganglion: the greater superficial petrosal nerve, the lesser petrosal nerve, and the external petrosal nerve. The greater petrosal nerve emerges from the upper portion of the ganglion and carries secretomotor fibers to the lacrimal gland. The greater petrosal nerve exits the petrous temporal bone via the greater petrosal foramen to enter the middle cranial fossa. The nerve passes deep to the Gasserian ganglion (ie, trigeminal ganglion) to the foramen lacerum, through which it travels to the pterygoid canal. In the pterygoid canal, the greater petrosal nerve joins the deep petrosal nerve to become the nerve of the pterygoid canal. Axons from this nerve synapse in the pterygopalatine ganglion; postganglionic parasympathetic fibers, which are carried via branches of the maxillary (V2) divisions of the trigeminal nerve (CN V), innervate the lacrimal gland and mucus glands of the nasal and oral cavities. The external petrosal nerve is an inconstant branch that carries sympathetic fibers to the middle meningeal artery; however, it is not as well known. The lesser petrosal nerve carries secretory fibers to the parotid gland. This nerve carries parasympathetic contributions from the tympanic plexus (from CN IX) and the nervus intermedius.
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Exposure of the facial nerve after a cortical mastoidectomy. The facial recess has been opened by thinning of the posterior canal wall. The recess is identified using the incus, chorda tympani, and horizontal semicircular canal as landmarks.
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Mastoid segment
The second genu marks the beginning of the mastoid segment. The second genu is lateral and posterior to the pyramidal process. The nerve continues vertically down the anterior wall of the mastoid process to the stylomastoid foramen. The mastoid segment is the longest part of the intratemporal course of the facial nerve, approximately 10-14 mm long. During middle ear surgery, the facial nerve is most commonly injured at the pyramidal turn. The 3 branches that exit from the mastoid segment of the facial nerve are (1) the nerve to the stapedius muscle, (2) the chorda tympani nerve, and (3) the nerve from the auricular branch of the vagus. The auricular branch of the vagus nerve arises from the jugular foramen and joins the facial nerve just distal to the point at which the nerve to the stapedius muscle arises. Pain fibers to the posterior auditory canal may be carried with this nerve. The chorda tympani is the terminal branch of the nervus intermedius. The chorda runs laterally in the middle ear, between the incus and the handle of the malleus. The nerve crosses the middle ear cavity and exits through the petrotympanic fissure (ie, canal of Huguier) to join the lingual nerve. The chorda tympani nerve carries preganglionic secretomotor fibers to the submaxillary and sublingual glands. The chorda also carries special sensory afferent fibers (ie, taste fibers) from the anterior two thirds of the tongue and fibers from the posterior wall of the external auditory canal responsible for pain, temperature, and touch sensations. The facial nerve exits the fallopian canal via the stylomastoid foramen. The nerve travels between the digastric and stylohyoid muscles and enters the parotid gland. A sensory branch exits the nerve just below the stylomastoid foramen and innervates the posterior wall of the external auditory canal and a portion of the tympanic membrane.
The topographic trajectory of the frontal and/or marginal branches should be identified during a rhytidoplasty, submandibular gland excision, and/or neck dissection. The frontal branch can be roughly located along a line extending from the attachment of the lobule (approximately 5 mm below the tragus), anterior and superiorly to a point 1.5 cm above the lateral aspect of the ipsilateral eyebrow.
[6, 7]
Surgical landmarks to the facial nerve include the tympanomastoid suture line, the tragal pointer, and the posterior belly of the digastric muscle. The tympanomastoid suture line lies between the mastoid and tympanic segments of the temporal bone and is approximately 6-8 mm lateral to the stylomastoid foramen. The main trunk of the nerve can also be found midway between (10 mm posteroinferior to) the cartilaginous tragal pointer of the external auditory canal and the posterior belly of the digastric muscle. The nerve is usually located inferior and medial to the pointer.
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During surgical dissection, the surgeon may encounter a branch from the occipital artery that lies lateral to the facial nerve. Brisk bleeding at this time may be a sign that the nerve is in close proximity; hemostasis should be obtained using bipolar electrocautery, and further dissection should proceed cautiously. The styloid process is deep to the main trunk of the nerve. In the infant and young child, these landmarks are not applicable because of differences in the rate of anatomic development of the parotid gland and mastoid. The modified Blair incision most commonly used in adults is often avoided in children because the facial nerve is located more superficially, and the risk of injury is increased with elevation of the skin flaps. Many textbooks on pediatric otolaryngology provide detailed descriptions of the safe placement of surgical incisions for exposing the facial nerve and its branches in children. Once it has exited the fallopian canal at the stylomastoid foramen, the facial nerve gives off several rami before it divides into its main branches. Below the stylomastoid foramen, the posterior auricular nerve leaves the facial nerve and innervates the postauricular muscles. Two small branches innervate the stylohyoid muscle and posterior belly of the digastric muscle. The facial nerve crosses lateral to the styloid process and penetrates the parotid gland. The nerve lies in a fibrous plane that separates the deep and superficial lobes of the parotid gland. In the parotid gland, the nerve divides at the pes anserinus into 2 major divisions, the superiorly directed temporal-facial and the inferiorly directed cervicofacial branches. After the main point of division, 5 major branches of the facial nerve exist, as follows: Temporal (ie, frontal) Zygomatic Buccal Marginal mandibular Cervical The facial nerve innervates 14 of the 17 paired muscle groups of the face on their deep side. The 3 muscles innervated from other sources are the buccinator, levator anguli oris, and mentalis muscles. Frequent connections between the buccal and zygomatic branches exist. The temporal and marginal mandibular branches are at highest risk during surgical procedures and are usually terminal connections without anastomotic connections.
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Temporal branches
The relationships of the temporal branch are complex and only briefly described in this article. Refer to Larrabee and Makielski for a more complete anatomic description. The temporal branch of the facial nerve exits the parotid gland and runs within the SMAS over the zygomatic arch into the temple region. The frontal branch enters the undersurface of the frontalis muscle and lies superficial to the deep temporalis fascia. To avoid injury to the frontal branch during elevation of facial flaps, the surgeon should elevate either in a subcutaneous plane or deep to the SMAS.
[7]
Marginal branches
The mandibular (or marginal) division lies along the body of the mandible (80%) or within 1-2 cm below (20%). This is a critical landmark in head and neck surgery. The marginal branch lies deep to the platysma throughout much of its course. It becomes more superficial approximately 2 cm lateral to the corner of the mouth and ends on the undersurface of the muscles. Injury to the marginal branch results in paralysis of the muscles that depress the corner of the mouth.
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Origin, American College of Surgeons, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons Disclosure: Nothing to disclose. Coauthor(s) Neil Tanna, MD, MBA Resident Physician, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine Neil Tanna, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Medical Society of the District of Columbia Disclosure: Nothing to disclose. Specialty Editor Board Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery Disclosure: American biloogical group Royalty Other Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Gerard J Gianoli, MD Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society Disclosure: Vesticon, Inc. None Board membership Christopher L Slack, MD Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association Disclosure: Nothing to disclose. Chief Editor Arlen D Meyers, MD, MBA Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting
References
1. Crosby ED, DeJonge BR. Experimental and clinical studies of the central connections and central relation of the facial nerve. 1963;72:735 - 755. 2. Nelson JR. Facial paralysis of central nervous system origin. Otolaryngol Clin North Am. Jun
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1974;7(2):411-24. [Medline].
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3. Jenny AB, Saper CB. Organization of the facial nucleus and corticofacial projection in the monkey: a reconsideration of the upper motor neuron facial palsy. Neurology. Jun 1987;37(6):930-9. [Medline]. 4. Mavrikakis I. Facial nerve palsy: anatomy, etiology, evaluation, and management. Orbit. 2008;27(6):466-74. [Medline]. 5. May M, Schaitkin B. May M, Schaitkin B, eds. The Facial Nerve, 2nd Edition. New York, NY: Thieme; 2000. 6. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg. Oct 1966;38(4):352-6. [Medline]. 7. Larrabee WF Jr, Makielski KH. Surgical Anatomy of the Face. New York: Raven Press; 1993. Medscape Reference 2011 WebMD, LLC
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