HEAD AND NECK RADIOLOGY

Joel D. Swartz, M.D.

The Facial Nerve Canal: CT
Analysis of the Protruding
Tympanic Segment’

The development and subsequent course T HE facial nerve canal has been the subject of considerable radio-
of the facial nerve canal are complex. logic and clinical controversy. High resolution computed to-
High resolution computed tomography mography (HRCT) now provides a modality with which to study the
(HRCT) provides an opportunity for the normal appearance of the canal. Knowledge of normal anatomy and
study of this often perplexing structure. normal variations in the facial nerve canal becomes particularly im-
Normal anatomy and normal variations pontant when evaluating patients who have a facial nerve palsy ref-
of the facial nerve canal must be consid- ennable to the temporal bone.
ered when examining patients who have
facial nerve palsy referrable to the tem-
MATERIALS AND METHODS
poral bone. The author recommends di-
rect axial and coronal imaging supple- The facial nerve canal is carefully evaluated with CT in all patients being
mented by sagittal and possibly oblique studied for middle ear disease and in all patients who have facial palsy lo-
reformations. calizable to the temporal bone. One and one-half millimeter-thick sections,
targeted for maximal bony detail, are scanned in the coronal position from
the level of the anterior turns of the cochlea to the mastoid process, and in
Index terms: Ear, anatomy, 2123.92 Ear,
#{149} computed
the axial position from the superior m’ngin of the internal auditory canal to
tomography, 2123.1211
the mastoid process. Intravenous contrast material is used in those patients
Radiology 1984; 153: 443-447 who have facial palsy. Axial sections are scanned at contiguous or overlapping
(1 mm) regular intervals to permit image reformation. Sagittal reformation
is performed routinely to evaluate the second genu. Coronal reformation is
necessary in patients who cannot assume the coronal position.

DISCUSSION
The canalicular portion of the facial nerve courses in the anteno-
superior aspect of the internal auditory canal. At its most lateral ex-
tremity, it courses with the intermediate nerve of Wrisberg and is
separated by the falciform crest from the more inferior cochlear nerve.
A vertical crest separates it from the more posteriorly located superior
vestibular nerve. The facial nerve and the intermediate nerve then
enter the facial nerve canal (1).
The facial nerve canal has three segments (labyninthine, tympanic,
mastoid) and two genus (Figs. 1 and 2). The labyrinthine segment
describes a gentle curve with a medial concavity in the intervesti-
bulocochlear groove as it courses anterolaterally to the geniculate
fossa (Fig. 3). This is the shortest (3-5 mm), narrowest (.68 mm), and
subsequently most vulnerable segment (2). The apex of the first co-
chlean turn lies medial to it. Transverse temporal bone fractures
commonly compromise this segment (2). At the geniculate fossa, the
canal forms an acute angle of 75 degrees on less and then courses
posteriorly and laterally to become the tympanic segment (Fig. 3). This
angle is referred to as the first genu. In the small wedge-shaped space
formed by this angle, there is compact bone encasing the anterior
aspect of the vestibule (i).
The geniculate fossa, a bulbous enlargement of the facial canal,
contains the geniculate ganglion. The intermediate nerve of Wrisberg
I From the Department of Radiologic Sciences, The
previously described terminates in the ganglion and continues as the
Medical College of Pennsylvania, Philadelphia, Penn-
greaten and lesser superficial petrosal nerves to the lacrimal and panotid
sylvania. Received April 10, 1984; accepted and revi-
sion requested May 18; revision received May 29. glands respectively (1, 3). The anterior epitympanic sinus is related
#{176}RSNA,l984. ahr to the geniculate fossa externally (Fig. 3). Its medial wall is in contact

443
Figure 1 with the ganglion and the nerve may on an obliquely reconstructed image
be dehiscent at this point. This may be (Fig. 8). The concavity of this turn is in
of considerable surgical importance. the posterior superior region of the
The size and configuration of the lab- tympanic cavity and faces the portion
yninthine segment and first genu can of the promontory that separates the
vary considerably. One asymptomatic round and oval windows (Fig. 9). Lat-
patient had an unusually prominent enally this concavity is separated from
geniculate fossa (Fig. 4). the ampulla of the posterior semicin-
The tympanic segment of the facial culan canal by the sinus tympani (Fig.
nerve canal is straight and measures 10) (i). The mastoid segment of the fa-
approximately iO-i2 mm in length (1). cial nerve canal extends from this sec-
It extends from the geniculate fossa to ond turn to the stylomastoid fonamen,
the posterior wall of the tympanum which is usually a distance of approxi-
and runs along the superior portion of mately 13 mm (Figs. ii, i2). Air cells
the internal wall of the tympanic cavity usually separate it from the posterior
(Fig. 5). This segment of the canal is fossa by a distance of 4-i2 mm. Med-
usually inclined slightly infenionly to ially this mastoid segment is related to
the plane of the horizontal semicircular the jugular bulb (Figs. 1 1, 13). The facial
canal which it runs beneath (Fig. 6). It canal may be dehiscent in the jugular
forms an angle of approximately 37 fossa on may be as fan away as 8 mm.
degrees with the horizontal plane. This distance from the fossa is in-
Anteriorly it lies above and medial to versely related to the size of the fossa
the cochleariform process that is an itself. The superior portion of the
Illustration from above and slightly lateral important surgical landmark (Fig. 7) mastoid segment is related to the pos-
(right) indicating planes of section for Figures (i). The normal non-protruding mid- tenon wall of the tympanum. Only 3
5, 7, 9, ii [modified from (13)]. die portion nuns above the oval win- mm separates the facial nerve canal
dow. The tympanic segment of the fa- from the tympanic ring at the level of
cial nerve canal is densely concealed by the round window (Figs. 10, i3). More
bone only at its most anterior and pos- inferionly, there is more deviation. The
Figure 2 tenon extremities, and between them mastoid segment can almost always be
the wall is made of very thin bone that identified on axial section because
could easily be fractured at surgery. there is usually better contication than
This segment of the canal is especially that which surrounds the individual
susceptible to erosions due to tub- mastoid air cells (Fig. i3). Identification
otympanic diseases (1, 3). The posterior may be difficult in a hyperpneuma-
extremity of the short process of the tized mastoid. The most proximal por-
incus marks the point where the facial tion of this segment just inferior to the
canal begins its second turn into the short process is of particular concern to
styloid complex to become the mastoid the surgeon who performs revision
segment (Fig. 6). The motor nerve to mastoidectomy (4). Variation has been
the stapedius muscle arises from the noted in the cross sectional size (Fig.
distal portion of the tympanic segment i4). The chonda tympani nerve usually
(3). The facial recess is immediately arises from the distal third of this seg-
lateral to the facial canal in this location ment and courses upward and anteni-
(i). only (3). The stylomastoid foramen is
The second genu of the facial nerve located antenomedial to the mastoid
Right lateral illustration indicating planes of canal between the tympanic and mas- process and postenomedial to the styl-
section for Figures 3, 6, 10, 13, 15 [modified toid segments forms an angle of be- oid process (Fig. 1 i). Occasionally, the
from (3)]. tween 95#{176}
and i25#{176},
seen with CT only nerve can be identified in cross section
on axial sections obtained a few milli-
meters inferior to the foramen (Fig. 15)
Figure 3 Figure 4 (5).
Because the facial canal has compli-
cated derivation from both the pni-
mondial otic capsule and from the
Reichert cartilage (second bnanchial
arch), it is often defective (6, 7). These
congenital bony dehiscences in the
facial canal are encountered in 55% of
temporal bones (8) and result from in-
complete closure of the canal during its
development. Such gaps in the conti-
nuity of the osseous wail may be ob-
served in any portion of the facial
canal. Already discussed are dehis-
cences into the anterior epitympanic
air cell and into the jugular fossa. The
3. Axial section at level of first genu. LABY. SEG. labyninthine segment; GF geniculate fossa; vast majority (90%), however, are in the
PROX. TYMP. SEG. = proximal tympanic segment; ANT. EPI. CELL. anterior epitympanic
tympanic segment; such dehiscences
air cell.
4. Axial section. Unusually prominent geniculate fossa at first genu (arrow). usually involve the infenolatenal or

444 Radiology
#{149} November 1984
medial wall (80%). Inferior protrusion sions have been confused with facial tympanic segment without the pro-
of the nerve in this tympanic segment nerve neuromas (iO). CT differential truding nerve is not possible as the
occurs through these dehiscences in diagnosis from this latter entity in a inferior bony margin of the middle
25% of patients (7). This protrusion may patient who has facial palsy may not be portion of the tympanic segment is
vary from a slight bulge through a possible. The CT appearance of the normally extremely thin.
small opening to a situation where the protruding nerve is that of a smooth Anomalies of the facial nerve canal
nerve has emerged from the canal and soft tissue density with inferior con- are common in patients who have
has come to lie upon the superior as- vexity emanating from the undensur- congenital disorders involving the first
pect of the crural arch of the stapes face of the lateral semicircular canal at and second branchial arches. Expeni-
(5-iO). This protrusion may cause a the level of the oval window on coro- ence with external auditory canal
conductive hearing loss. This prolapse nal section (Figs. 16, i7). The CT diag- atnesia indicates that an anteriorly lo-
may conceal a portion or all of the oval nosis of this entity is possible only in cated mastoid segment is the most
window and it is therefore of consid- the absence of excessive debris within common anomaly encountered (12).
enable surgical importance, particularly the middle ear because the inferior Knowledge of the course of the canal
for a fenestration procedure (ii). margin of the nerve must be outlined must precede any surgical reconstruc-
Especially prominent neural protru- by air. Diagnosis of the dehiscent tion.

Figure 5 Figure 6 Figure 7

5. Axial section. TYMP. SEG. tympanic segment;SPI short process of incus.

6. Coronal section of level of oval window. LSC lateral semicircular canal; FN (TYMP) tympanic segment of facial nerve canal (cross-
section); INCUS BODY, LP = long process; LEN P = lenticular process.
7. Direct coronal section at level of cochlea. DLS distal labyrinthine segment (cross-section); PTS proximal tympanic segment (cross-section);
CP & TTT = cochleaniform process and tensor tympani tendon; HM head of malleus.

Figure 8 Figure 9 Figure 10

Direct coronal section. FN (2nd) G = facial Axial view at level of sinus tympani. FN (sec-
nerve canal at level of second genu; LSC = ond) G = facial nerve canal just beneath sec-
lateral semicircular canal; V vestibule; ST ond genu (3 mm below Figure 6); S. TYMP
sinus tympani; RW round window. sinus tympani; PSC = posterior semicircular
canal; RW = round window.

-4

Obliquely reconstructed image through plane

of tympanic segment. Second genu is mdi-
cated (arrow).

Volume 153 Number 2 Radiology 445

#{149}
Figure Ii Figure 12

a.

Direct coronal section at level of mastoid seg- a and b. Sagittal reconstruction. Mastoid
ment. FN (M) mastoid segment of facial Segment of facial nerve canal mdi-
nerve canal; SMF stylomastoid foramen; JF cated (arrows). smf = stylomastoid
b.
= jugular fossa; HC hypoglossal canal. foramen

Figure 13 Figure 14 Figure 15

13. Axial section. FN (M) = mastoid segment of facial nerve canal (cross-section); T. ANN =

tympanic annulus; JF jugular fossa (prominent); CC carotid canal. Axial section at level of stylomastoid foramen,
14. Axial section. FN (M) unusually prominent mastoid segment; C. AQ cochlear aque- arrow indicates facial nerve (in cross-section)
duct. exiting foramen.

Figure 16 Figure 17

16. Protruding tympanic segment. This 35-year

old woman has an unsually shaped external
auditory canal. A protruding tympanic segment of the facial nerve (long-stemmed arrow)
is noted on this coronal section at the level of the round window.
17. Protruding tympanic segment following radical mastoidectomy. Residual debris is noted
in the mastoid bowl (double arrows). The soft tissue density with inferior convexity, noted
at the level of the oval window (long-stemmed arrow), proved at surgery to be a protruding
tympanic segment of the facial nerve.

446 Radiology
#{149} November 1984
 Acknowledgement The author appreciates the 2. Griffin JE, Altenau MM, Schaefer SD. Bi- Supplement 1:45-61, 1978.
assistance of Joan Colombaro in manuscript lateral longitudinal temporal bone fractures: 8. Baxter A. Dehiscence of the fallopian canal:
preparation; Ira A. Grunther for illustrations; and a retrospective review of seventeen cases. an anatomical study. J Laryngol and Otol
George L. Popky, M.D., Professor and Chairman Laryngoscope 1979; 89:1432-1435. 1971; 85:587-594.
of the Department of Radiologic Sciences at The 3. Shambaugh GE, May M. Facial nerve pa- 9. Schuknecht H. Anatomical variants and
Medical College of Pennsylvania, for advice and ralysis in Paparella MM and Shumnick DM anomalies of surgical significance: J Lanyn-
encouragement. Otolaryngology, Volume II, The Ear, W.B. gol and Otol 1971; 85:1238-1241.
Saunders Co., Philadelphia, 1980:1680- 10. Johnsson LG, Kingsley TC. Herniation of
Joel D. Swartz, M.D. 1704. the facial nerve in the middle ear. Arch
Department of Radiologic Sciences 4. DonaldsonjA, Anson BJ. Surgical Anatomy Otolaryngol 1970; 91:598-602.
The Medical College of Pennsylvania of the Facial Nerve in Symposium on Dis- ii. SwartzJD, Faerber EN, Wolfson RJ, Marlowe
3300 Henry Avenue ease and Injury of the Facial Nerve, Otolar- FJ. Fenestral otosclerosis: significance of
Philadelphia, Pennsylvania 19129 yngologic Clinics of North America, June, preoperative CT evaluation. Radiology,
1974:289-308. 1984; 151:703-707.
5. Curtin HD, Wolfe P. May M. Malignant 12. Swartz JD, Faerber EN. Congenital mal-
external otitis: CT evaluation. Radiology formation of the external and middle ear:
i982; 145:383-388. high resolution CT analysis with emphasis
References 6. Mayer GG, Crabtree JA. The facial nerve on findings of surgical import. Am J Neu-
coursing inferior to the oval window. Arch roradiol, in press.
. 1. Proctor B, Nager GT. The facial canal: Otolaryngol 1976; 102:744-746. 13. Guinto EJ, Himadi GM. Tomographic
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Volume 153 Number 2 Radiology . 447