100 SECTION I — Diseases of Ear

6. MUSCULAR BRANCHES. To stylohyoid and posterior

belly of digastric.

7. PERIPHERAL BRANCHES. The nerve trunk, after cross-

ing the styloid process, forms two divisions, an upper
temporofacial and a lower cervicofacial, which further di-
vide into smaller branches. These are the temporal, zygo-
matic, buccal, mandibular and cervical and together form
pes anserinus (goose-foot). They supply all the muscles of
facial expression.

BLOOD SUPPLY OF FACIAL NERVE

It is derived from four blood vessels: (i) Anterior-inferior
cerebellar artery supplies the nerve in cerebellopontine
angle; (ii) labyrinthine artery, branch of anterior-inferior
cerebellar artery, which supplies the nerve in internal
Figure 14.1. Forehead receives bilateral innervation and is thus auditory canal; (iii) superficial petrosal artery, a branch of
saved in supranuclear paralysis. Emotional movements controlled by
middle meningeal artery, which supplies geniculate gan-
thalamo-nuclear fibres are also preserved.
glion and the adjacent region; and (iv) stylomastoid artery,
branch of posterior auricular artery, which supplies the
mastoid and tympanic segment. All the arteries form an
external plexus which lies in the epineurium and feeds a
deeper intraneural internal plexus (Figure 14.3).

SURGICAL LANDMARKS OF FACIAL NERVE

For middle ear and mastoid surgery
1. Processus cochleariformis. It demarcates the genicu-
late ganglion which lies just anterior to it. Tympanic
segment of the nerve starts at this level.
2. Oval window and horizontal canal. The facial nerve
runs above the oval window (stapes) and below the
horizontal canal.
3. Short process of incus. Facial nerve lies medial to the
short process of incus at the level of aditus.
4. Pyramid. Nerve runs behind the pyramid and the pos-
terior tympanic sulcus.
5. Tympanomastoid suture. In vertical or mastoid seg-
ment, nerve runs behind this suture.
6. Digastric ridge. The nerve leaves the mastoid at the
anterior end of digastric ridge.
For parotid surgery (Figure 14.4)
1. Cartilaginous pointer. The nerve lies 1 cm deep and
slightly anterior and inferior to the pointer. Cartilagi-
nous pointer is a sharp triangular piece of cartilage of
the pinna and “points” to the nerve.
2. Tympanomastoid suture. Nerve lies 6–8 mm deep to
this suture.
3. Styloid process. The nerve crosses lateral to styloid
Figure 14.2. (A) Course of facial nerve. Intratemporal part consists of
process.
four segments: meatal (1), labyrinthine (2), tympanic (3) and mastoid 4. Posterior belly of digastric. If posterior belly of di-
(4). (B) Branches of facial nerve on face. gastric muscle is traced backwards along its upper bor-
der to its attachment to the digastric groove, nerve is
found to lie between it and the styloid process.
4. COMMUNICATING BRANCH. It joins auricular branch of
vagus and supplies the concha, retroauricular groove, pos-
VARIATION AND ANOMALIES OF FACIAL
terior meatus and the outer surface of tympanic membrane.
NERVE (FIGURE 14.5)
5. POSTERIOR AURICULAR NERVE. It supplies muscles of 1. Bony dehiscence. This is the most common anom-
pinna, occipital belly of occipitofrontalis and communi- aly. Dehiscence (absence of bony cover) occurs
cates with auricular branch of vagus. most commonly in tympanic segment over the oval

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