Facial Nerve – Anatomy, Origin, Insertion, Functions

The facial nerve is the seventh cranial nerve (CN VII). It arises from the brain stem and extends posteriorly to the abducens nerve and anteriorly to the vestibulocochlear nerve. It courses through the facial canal in the temporal bone and exits through the stylomastoid foramen after which it divides into terminal branches at the posterior edge of the parotid gland. The facial nerve provides motor innervation of facial muscles that are responsible for facial expression, parasympathetic innervation of the glands of the oral cavity and the lacrimal gland, and sensory innervation of the anterior two-thirds of the tongue.

Anatomy of the Facial Nerve

The course of the facial nerve can roughly divide into three portions – origin, intertemporal, and extratemporal.

(a) Origin 

The motor nucleus of the facial nerve originates within the lower pons and emerges via the cerebellopontine angle (anterior to the anterior inferior cerebellar artery). Here in its intracranial course, it is joined by the nerves intermedius, which consists of the sensory and autonomic fibers of the facial nerve, which originate from the tractus solitaries and superior salivatory nucleus respectively.

The facial nerve then inserts into the internal acoustic meatus (IAM) to begin its meatal segment. The IAM is in the petrous part of the temporal bone between the posterior cranial fossa and the inner ear.

Within the intracranial and meatal segments, no branches are given off.

At the IAM, the facial nerve runs in the anterosuperior compartment. Important structures within the IAM are:

  • Superior vestibular nerve
  • Inferior vestibular nerve
  • Facial nerve
  • Cochlear nerve
  • Labyrinthine artery
  • Vestibular ganglion    

(b) Intratemporal

1. Labyrinthine segment – between the IAM+ the geniculate ganglion/first Genu. 

  • This area forms the narrowest portion of the facial nerve (and consequently vulnerable to compromise). At the level of the geniculate ganglion, the facial nerve undergoes the first of two sharp bends (first genu).
  • At this genu, the greater petrosal nerve branches off from the main trunk. The greater petrosal nerve provides preganglionic parasympathetic fibers to the pterygopalatine ganglion (also known as the vidian nerve). The pterygopalatine ganglion provides postganglionic parasympathetic fibers to the lacrimal, nasal and palatine glands. Proximal lesions are associated with impaired lacrimation, hyperacusis, and loss of taste on the anterior two-thirds of the tongue.

2. Tympanic segment – between the geniculate ganglion and the second genu.

The facial nerve traverses the bony fallopian canal on the medial aspect of the tympanic cavity before its second sharp bend (genu). Important relations of the facial nerve at this point include:

  • Anteriorly – Processus cochleariformis (where tensor tympani tendon gets directed to the malleus).
  • Posteriorly – oval window (inferiorly) and the lateral semi-circular canal (superiorly). The facial nerve runs between the malleus and incus (running medial to the malleus and lateral to the incus).

3. Mastoid segment – from the second genu to the stylomastoid foramen. 

  • After its second genu, the nerve now runs on the posterior aspect of the tympanic cavity. It runs in front and lateral to the ampulla of the posterior semicircular canal and medial to the tympanic annulus.
  • Both the nerve to stapedius and chorda tympani leave at this segment. The chorda tympani runs anteriorly across the tympanic cavity to provide preganglionic parasympathetic fibers to the submandibular ganglion, which then provides parasympathetic innervation to the submandibular and sublingual glands.
  • To summarise the three important branches of the facial nerve given off before the nerve leaving the stylomastoid foramen are (GCS):
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Branch Segment of facial nerve Target

  • Greater petrosal nerve Labyrinthine Pterygopalatine Ganglion (palatine, nasal and lacrimal glands)
  • Chorda Tympani Mastoid Submandibular Ganglion (submandibular and sublingual glands)
  • Stapedius Mastoid Stapedius

(c) Extratemporal – The nerve travels inferiorly and laterally around the styloid process. Prior to entering the parotid gland, it gives off branches to the three following muscles:

  • Occipitalis
  • Stylohyoid
  • Posterior belly of digastric

Within the parotid gland, the nerve divides the gland into superficial and deep parts. It lies the most superficial structure traversing the parotid gland. Ordered from superficial to deep, the structures within the parotid gland are:

The facial nerve (superficial) —> Retromandibular vein —> External Carotid Artery —> Auriculotemporal Nerve (deep)

Within the substance of the parotid gland, it divides into two trunks (cervicofacial and temporofacial) and then five main branches which each are responsible for innervation of the muscles of facial expression. The five branches with their target muscle and action are below :

Branch of facial nerve Primary target muscle Clinical assessment

  • Temporal Frontalis Raise eyebrows
  • Zygomatic Orbicularis oculi Close eyes
  • Buccal Puff cheeks out
  • Mandibular Depressor anguli oris Show bottom teeth
  • Cervical Platysma Clench neck

To summarise, the facial nerve innervates the following muscles

  • Stapedius
  • Stylohyoid
  • Posterior belly of digastric
  • Occipitalis
  • Muscles of facial expression

The most important factor when considering the differential diagnosis of facial nerve palsy is whether the lesion is a lower motor neuron or upper motor neuron.

Due to bilateral cortical innervation of the muscles of the upper face (in particular orbicularis oculi and frontalis), only lower motor neuron lesions will result in complete facial paralysis, although this is not always the case. Consequently, the most clinically useful assessment of UMN vs. LMN facial nerve palsy is raising of the eyebrows which assess the frontalis and orbicularis oculi.

Upper motor neuronal lesions that are responsible for causing facial nerve palsy include stroke, multiple sclerosis, subdural hemorrhage, and intracranial neoplasia.

Functions

  • Facial expressionThe main function of the facial nerve is motor control of all of the muscles of facial expression. It also innervates the posterior belly of the digastric muscle, the stylohyoid muscle, and the stapedius muscle of the middle ear. All of these muscles are striated muscles of branchiomeric origin developing from the 2nd pharyngeal arch.
  • Facial sensation – In addition, the facial nerve receives taste sensations from the anterior two-thirds of the tongue via the chorda tympani. The taste sensation is sent to the gustatory portion (superior part) of the solitary nucleus. The general sensation from the anterior two-thirds of the tongue is supplied by afferent fibers of the third division of the fifth cranial nerve (V-3). These sensory (V-3) and taste (VII) fibers travel together as the lingual nerve briefly before the chorda tympani leaves the lingual nerve to enter the tympanic cavity (middle ear) via the petrotympanic fissure. It joins the rest of the facial nerve via the canaliculus for chorda tympani. The facial nerve then forms the geniculate ganglion, which contains the cell bodies of the taste fibers of chorda tympani and other taste and sensory pathways. From the geniculate ganglion, the taste fibers continue as the intermediate nerve which goes to the upper anterior quadrant of the fundus of the internal acoustic meatus along with the motor root of the facial nerve. The intermediate nerve reaches the posterior cranial fossa via the internal acoustic meatus before synapsing in the solitary nucleus.
  • The facial nerve – also supplies a small amount of afferent innervation to the oropharynx below the palatine tonsil. There is also a small amount of cutaneous sensation carried by the nervus intermedius from the skin in and around the auricle (outer ear).
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Others

The facial nerve also supplies parasympathetic fibers to the submandibular gland and sublingual glands via chorda tympani. Parasympathetic innervation serves to increase the flow of saliva from these glands. It also supplies parasympathetic innervation to the nasal mucosa and the lacrimal gland via the pterygopalatine ganglion. The parasympathetic fibers that travel in the facial nerve originate in the superior salivatory nucleus. The facial nerve also functions as the efferent limb of the corneal reflex.

Functional components

The facial nerve carries axons of type GSA, general somatic afferent, to the skin of the posterior ear.

  • The facial nerve also carries axons of type GVE, general visceral efferent, which innervate the sublingual, submandibular, and lacrimal glands, also mucosa of the nasal cavity.
  • Axons of type SVE, special visceral efferent, innervate muscles of facial expression, stapedius, the posterior belly of digastric, and the stylohyoid.

The axons of type SVA, special visceral afferent, provide taste to the anterior two-thirds of the tongue via chorda tympani.

Nerves

The facial nerve exits the brain stem from its ventrolateral surface at the cerebellopontine angle. It consists of two parts: a proper facial nerve and the intermediate nerve. The proper facial nerve contains only a motor component and very small general somatic afferent component, whereas the intermediate nerve carries sensory and parasympathetic visceromotor components.

The facial nerve anatomy can be divided based on its relation to the cranium and the temporal bone into intracranial, intratemporal, and extratemporal parts.

Intracranial Part

The upper motor neuron (UMN) of the facial nerve is located in the primary motor cortex of the frontal lobe. UMN axons descend ipsilaterally as the corticobulbar tract via the genu of the internal capsule and reach the facial nucleus in the pontine tegmentum. The facial nucleus is divided into a dorsal and ventral region. It contains the cell bodies of the facial nerve lower motor neurons (LMN). The dorsal region supplies innervation of the muscles of the upper face, whereas neurons in the ventral region innervate muscles of the lower face. The dorsal aspect of the facial nucleus receives input from both the left and right cerebral hemispheres. This results in both hemispheres having control over the muscles of the upper face. The ventral aspect of the facial nucleus receives mainly contralateral inputs. As a result, the left hemisphere partially controls partially the upper left and right side of the face, and fully the lower right side of the face.

The intermediate nerve carries descending parasympathetic GVE fibers from the superior salivatory nucleus and ascending GVA, GSA, and SVA fibers from the geniculate ganglion.

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The Intrtemporal Part

The infratemporal part of the facial nerve begins when the facial nerve, together with the intermediate nerve, passes through the internal auditory meatus of the temporal bone to enter the facial canal within the petrous part of the temporal bone. After synapsing on the geniculate ganglion, the facial nerve gives rise to the first branch; the greater petrosal nerve, which carries visceromotor parasympathetic fibers (GVE) to the lacrimal gland and GVA from the nasal cavity, paranasal sinuses, and part of the soft palate. The greater petrosal nerve joins the deep petrosal nerve which carries sympathetic postganglionic fibers from the superior cervical ganglion. Together they form the nerve of the pterygoid canal that innervates the pterygopalatine ganglion in the pterygopalatine fossa.

The second branch of the facial nerve running in the facial canal is the nerve to the stapedius muscle, which provides motor (SVE) innervation to the stapedius muscle of the inner ear.

The chords tympani nerve is the last branch of the facial nerve within the facial canal and at the same time, the terminal extension of the intermediate nerve. It runs through the ossicles in the middle ear and exits the tympanic cavity at the petrotympanic fissure where it joins the lingual nerve, which is itself a branch of the trigeminal nerve. The chords tympani nerve carries two kinds of fibers: parasympathetic  GVE to the submandibular ganglion and SVA fibers from the anterior two-thirds of the tongue. Fibers from the submandibular ganglion later innervate the submandibular and sublingual glands.

The Extratemporal Part

The extratemporal part of the facial nerve begins when the facial nerve leaves the cranium through the stylomastoid foramen. As the facial nerve exits, it gives GSA fibers to the pinna of the ear and external auditory meatus and SVE fibers to the posterior belly of digastric, stylohyoid, the superior and inferior auricular, and occipitalis muscles. Thereafter, the facial nerve divides at the end of the posterior edge of the parotid gland into the terminal branches. Usually, five branches can be identified:

  • The temporal branch – innervating the frontalis and orbicularis oris muscles and the muscles in the upper part of the face.
  • The zygomatic branch – innervating the middle part of the face
  • The buccal branch – innervating the cheek muscles, including the buccinator muscle
  • The mandibular branch – innervating muscles of the lower part of the face
  • The cervical branch – innervating the muscles below the chin and, among others, the platysma muscle

Muscles

As stated, the facial nerve innervates the following:

  • The muscles of facial expression – responsible for the expression of emotions by changing facial expression
  • The stylohyoid muscle – draws the hyoid bone backward, which initiates a swallowing action and elevates the tongue
  • The posterior belly of the digastric muscle – together with the anterior belly of the digastric muscle, elevates  the hyoid bone and is involved in any complex movements involving the jaw
  • The stapedius muscle of the middle ear – stabilizes the stapes, preventing excessive movement in response to loud sounds

References