In

this tutorial you will learn about the anatomy of the facial nerve. This nerve
supplies the muscles of the face that are concerned with facial expressions. Smiling,
frowning, blinking the eye and whistling are just some of the movements that the
facial nerve allows us to do.

The importance of the facial nerve to us as clinicians is that diseases of the ear may
damage it and cause paralysis. The clinician must, therefore, recognize the
presence of paralysis as it implies serious ear disease such as cholesteatoma. The
state of facial nerve function should always be noted when we examine an ear.

ANATOMICAL OVERVIEW

The facial nerve is one of the cranial nerves. Cranial nerves are nerves that come
directly out of the brain. These are different to the nerves that move our arms or
legs as those nerves come out of the spinal cord.

There are twelve cranial nerves and they do jobs like moving the eyes, moving the
face, moving the tongue and shoulders, feeling pain in the face, detecting light,
balance and sound and many other jobs. There is a list of the cranial nerves in the
table below. You dont have to worry about them all at this time although they will
become important in the future. For now just take a look at the sorts of things that
cranial nerves do.

Cranial Nerve number and List of functions
name


1 Olfactory nerve
Detects smells
2 Optic nerve
Detects light for seeing
3 Oculomotor nerve
Moves the eyes (up, down)
4 Trochlear nerve
Moves the eyes (in)
5 Trigemminal nerve
Gives sensation to the face
Helps with chewing
Contracts tensor tympani muscle in the middle ear
6 Abducent nerve
Moves the eyes (out)
7 Facial nerve
Moves the face
Contracts the stapedius muscle in the middle ear
Gives taste sensation
8 Vestibulocochlear nerve Hearing and balance
9 Glossopharyngeal nerve Moves the throat on swallowing
Senses taste
Gives middle ear sensation
10 Vagus nerve
Does many different things all through the body
11 Accessory nerve
Raises the shoulder
12 Hypoglossal nerve
Moves the tongue

Table of cranial nerves and their functions.

The next few pictures show the cranial nerves as they appear under the brain and
in real life.

This is a view of the

underside of the brain
(inferior side). It shows the
cranial nerves.

Notice that the nerves are
paired that is that there is
one on each side of the
brain.

All of the nerves come
directly out of the brain but
only one does not leave the
skull. It is the olfactory
nerve.

All of the others leave the
skull through holes in the
bone of the skull called
foramina.

http://en.wikipedia.org/wiki/File:Brain_human_normal_inferior_view_wit
h_labels_en-2.svg#filelinks

This is the inferior surface

of an actual human brain. It
shows the cranial nerves
emerging from the brain.
They are white in colour.

http://www.sci.uidaho.edu/med532/cranialnervestartpage.htm

The course of the facial nerve (the pathway that it follows from the brain into the
facial muscles) is very complicated. However, what is important for us is that it
passes with the vestibulocochlear nerve into the inner ear (cranial nerve 8), it then
passes through the middle ear and mastoid before leaving the skull. Once out of the
skull it travels inside the parotid salivary gland to get to the muscles in the face.

In other words the facial nerve travels through areas of the body that ear clinicians
examine and test every day. Diseases such as cholesteatoma, acute otitis media and
acoustic neuroma can affect the facial nerve so we must know about the nerve and
be able to examine it.

The anatomy of the Facial nerve (Cranial nerve 7).

When we describe the course of the facial nerve we divide it into segments1. We
will look at three of these: the intracranial segment, the intratemporal segment and
the extratemporal segment.

The intracranial segment.

This segment is that part of the nerve that lies inside the skull itself before it passes
into the middle ear. Once the nerve has left the brain it passes into the internal
acoustic meatus (IAM). In the IAM it runs with the cochlear nerve and the
vestibular nerves.

This is a picture looking up

through the internal acoustic
meatus on the right side.

Imagine that you are standing
inside the head looking out into it.

Superiorly there are two holes. The
anterior one takes the facial nerve
and the posterior one takes the
superior vestibular nerve.

Inferiorly and anteriorly is the
spiral foramina that takes the
cochlear nerve while posteriorly is
the foramen for the inferior
vestibular nerve.

This diagram is a simpler way of
looking at the anatomy.

S, I, A, and P are superior, inferior,
anterior and posterior.

VII is Cranial nerve 7 the facial
nerve.
SV and IV are the superior and
inferior vestibular nerves

C is the cochlear nerve

Figure: Two pictures that show the IAM and how the nerves pass through it.

Acoustic neuromas and fractures of the temporal bone can damage the nerve in this
segment.

1 The facial nerve is a long nerve that travels through many anatomical areas. This is just like the
Mekong: it starts in China then travels through Burma, Laos and Thailand. Then it travels through
Cambodia and at the end it travels through Vietnam. Its the same river in every place but we can
think of it in shorter segments just like the facial nerve.

Once the nerve passes into its foramen it leaves the intracranial segment and
enters the intratemporal segment.

The intratemporal segment.

This is the segment of the nerve that lies inside the middle ear and mastoid. This is
a very important part of the nerve because it is the part that is affected by middle
ear diseases such as otitis media and cholesteatoma. These are diseases that you
see all of the time.

In the middle ear the facial nerve starts anteriorly and then runs posteriorly and
then inferiorly. It is a complicated course that passes by the promontory, the tensor
tympani, the stapes, and the pyramid of the stapedius muscle. You only need to
know all of this when you are actually operating on the ear so dont worry too
much about all of these new names.


You saw this picture in the tutorial
on the middle ear. It shows the
middle ear seen without a
tympanic membrane and with the
scutum removed.

The following picture is similar but
it has also had the ossicles
removed so that all you can see is
the medial wall of the middle ear.

The picture below shows a facial nerve in the middle ear in a yellow colour. The
facial nerve enters the middle ear just superior to the cochlea at A. It then passes
posteriorly in the middle ear to lie just superior to the oval window (B). At this
point it turns inferiorly so that it comes to lie posterior to the oval window and the
round window (C).


While in the middle ear the facial nerve gives off two special nerves. One is the
nerve to stapedius and the other is the chorda tympani. The nerve to stapedius is
responsible for making stapedius muscle contract when the ear is exposed to very
loud sound (acoustic reflex). The chorda tympani carries taste information from
the tongue to the brain.

From posterior to the oval window the nerve travels inferiorly and out of the
temporal bone at the stylomastoid foramen. It is then in its extratemporal segment.

The extratemporal segment.

This is where the nerve divides into five branches. Each of these is responsible for
moving a part of the face. In the image below you can see these branches on the
side of the face. The ones that move the muscles in the face are shown in yellow.

You can see that they supply
muscles around the eye so
that you can raise your
eyebrows or close your eyes.

They go to the muscles
around the lips and allow you
to smile and keep your lips
closed.

They also go into the neck
muscles.

Facial Palsy

If a disease within the middle ear (such as cholesteatoma) damages the nerve the
face will become weak because the muscles will not move. Below is a picture of a
patient trying to smile.

Notice how the right side of his face
moves normally but that the left side
does not move at all. He has a
weakness of the left facial nerve of the
type that could be caused by middle
ear disease.

The medical term for this weakness is
palsy.

Patients with complete facial nerve palsy cannot blink and this means that their
eyes can become damaged and may even become blind. Looking after the eye is
important and it must be kept closed with an eye patch until the nerve starts to
recover its function. Eye drops are also useful to prevent drying of the eyes surface.

There are many diseases that can cause facial nerve palsy apart from middle ear
diseases. A list of the diseases that you may encounter is shown in the table but
there are many other rarer causes.


Infections
1 Acute otitis media
Bacterial infection
2 Cholesteatoma
Skin growing into ear and getting infected with
bacteria
3 Ramsay Hunt Syndrome
Varicella zoster virus infection
4 Bells Palsy
Herpes Simplex virus (probably)
5 Malignant otitis externa
Bacterial infection
6 Leprosy
Bacterial infection - Mycobacterium leprae
7 HIV
Virus
8 Tuberculosis
Bacterial infection mycobacterium tuberculosis
9 Malaria
Parasite infection




Tumours
1 Cancers in parotid gland

2 Acoustic neuroma





Others
1 Cerebrovascular incidents (stroke)
2 Fractured temporal bone
3 Pregnancy and diabetes


A stroke looks different to the other causes because the forehead can move even on
the weak side of the face. Look at the patient below. He has weakness on the left

side of his face. In the left picture he has an asymmetric smile and weaker closure
of the left eye. However, he can raise his eyebrows on the left (right picture). In
other words his forehead has been spared any weakness. This is characteristic of
strokes.

http://www.gla.ac.uk/ibls/US/cal/anatomy/calfacialnerve/clinicalfeat.htm

Examining the facial nerve

Examining the face is easy. Ask the patient to raise their eyebrows, close their eyes
tightly, to smile and to whistle or puff their cheeks out. Look at both sides of the
face when they are doing this and compare them. Make a record of what you see.

Learning points

1. Whenever you see a patient with ear disease you should examine the facial
nerve. This is particularly true of patients with perforations and
cholesteatomas
2. The opposite is also true; whenever you see a patient with a facial palsy you
must examine the ear because the cause of the palsy may be an ear disease
3. Always keep a written record of what you see
4. If you see a patient with middle ear disease and a facial palsy they need to
see an ear surgeon as an emergency
5. Always protect the eye while a facial palsy is present because blindness is a
possibility due to scarring of the eyes surface
6. A stroke can look very similar but the forehead will not be weak