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CRANIAL NERVE VII (FACIAL NERVE)

Introduction
Functional components
Deep/nuclear origin
Central connections
Superficial origin
Course
Relations
Branches of communication
Branches of distribution
Applied aspects

Cranial Nerve VII - Facial Nerve


Component overview
Branchial motor component
Origin and central course
Intracranial course
Intracranial course, cont'd
Extracranial course & final innervation
Voluntary control of facial muscles
Voluntary control of facial muscles, cont'd
Lower motor neuron lesion (LMN)
Bell's palsy
LMN lesions of the facial nerve
LMN lesions, acoustic neuromas
Upper motor neuron (UMN) lesions
Overview, visceral motor component
Origin and central course
Intracranial course
Greater petrosal nerve
Chorda tympani
Overview, special sensory component

Peripheral course
Central course
Central course, cont'd
Overview of general sensory component
Central course
Central course, cont'd
Central course, cont'd
Peripheral lesions of the facial nerve
Peripheral lesions of the facial nerve, cont'd
Cranial Nerve VII - Facial Nerve

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Component Overview
The facial nerve has four components with distinct functions:
Branchial motor
(special visceral efferent)

Supplies the muscles of facial expression;


platysma, posterior belly of digastric muscle;
stylohyoid, and stapedius.

Visceral motor
(general visceral efferent)

Parasympathetic innervation of the lacrimal,


submandibular, and sublingual glands, as well as
mucous membranes of nasopharynx, hard and soft
palate.

Special sensory
(special visceral afferent)

Taste sensation from the anterior 2/3 of tongue; hard


and soft palates.

General sensory
(general somatic afferent)

General sensation from the skin of the external auditory


meatus and from a small area behind the ear.

Branchial motor fibers constitute the largest portion of the facial nerve.
The remaining three components are bound in a distinct fascial sheath from the
branchial motor fibers. Collectively these three components are referred to as the
nervus intermedius.
Component Overview

Last revised: March 22, 1998

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Branchial Motor Component


The largest component of the facial nerve.
Provides voluntary control of the muscles of facial expression (including
buccinator, occipitalis and platysma muscles), as well as the posterior belly of the
digastric, stylohyoid and stapedius muscles.
Note the branchial motor components of the facial nerve:

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Origin and Central Course


The branchial motor component originates from the motor nucleus of CN VII in
the caudal pons.
Fibers leaving the motor nucleus of CN VII initially travel medially and dorsally to
loop around the ipsilateral abducens nucleus (CN VI) producing a slight bulge in
the floor of the fourth ventricle - the facial colliculus.
Fibers then course so as to exit the ventrolateral aspect of the brainstem at the
caudal border of the pons in conjunction with the nervus intermedius components
of CN VII.

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Intracranial course
Upon emerging from the ventrolateral aspect of the caudal border of the pons, all
of the components of CN VII enter the internal auditory meatus along with the
fibers of CN VIII (vestibulocochlear nerve).
The fibers of CN VII pass through the facial canal in the petrous portion of the
temporal bone. The course of the fibers is along the roof of the vestibule of the
inner ear, just posterior to the cochlea.

Figure 7-4. Intracranial course- branchial motor


components of the facial nerve. Facial nerve origin
and inner ear anatomy.

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Intracranial Course, cont'd


At the geniculate ganglion the various components of the facial nerve take
different pathways.
Fibers of the branchial motor component pass through the geniculate ganglion
without synapsing, turn 90 degrees posteriorly and laterally before curving
inferiorly just medial to the middle ear to exit the skull through the stylomastoid
foramen.
The nerve to the stapedius muscle is given off from the facial nerve in its course
through the petrous portion of the temporal bone.

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Extracranial Course and Final Innervation


The posterior auricular nerve, nerve to the posterior belly of the digastric and the
nerve to the stylohyoid muscle are given off upon the facial nerve's exit from the
stylomastoid foramen.
The remaining fibers enter the substance of the parotid gland and divide to form
the temporal, zygomatic, buccal, mandibular, and cervical branches to innervate
the muscles of facial expression.

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Voluntary Control of the Muscles of Facial Expression


Signals for voluntary movement of the facial muscles originate in the motor cortex
(in association with other cortical areas) and pass via the corticobulbar tract in the
posterior limb of the internal capsule to the motor nuclei of CN VII.
Fibers pass to both the ipsilateral and contralateral motor nuclei of CN VII in the
caudal pons:

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Voluntary Control of the Muscles of Facial Expression


The portion of the nucleus that innervates the muscles of the forehead receives
corticobulbar fibers from both the contralateral and ipsilateral motor cortex.
The portion of the nucleus that innervates the lower muscles of facial expression
receives corticobulbar fibers from only the contralateral motor cortex.
This is very important clinically as central (upper motor neuron) and peripheral
(lower motor neuron) lesions will present differently.

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Lower Motor Neuron (LMN) Lesion


Results from damage to the motor nucleus of CN VII or its axons.
A LMN lesion results in the paralysis of all muscles of facial expression (including
those of the forehead) ipsilateral to the lesion.

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Clinical Correlation - Bell's Palsy


A LMN lesion of CN VII which occurs at or beyond the stylomastoid foramen is
commonly referred to as a Bell's Palsy.
Characteristic indications of a LMN lesion or Bell's Palsy include the following, on
the affected side:

Marked facial asymmetry

Atrophy of facial muscles

Eyebrow droop

Smoothing out of forehead and nasolabial folds

Drooping of the mouth corner

Uncontrolled tearing

Loss of efferent limb of conjunctival reflex (cannot close eye)

Lips cannot be held tightly together or pursed

Diificulty keeping food in mouth while chewing on the affected side

Clinical Correlation - LMN Lesions of Facial Nerve (VII)

A LMN lesion of CN VII in conjunction with deficits associated


with CN VI (abducens nerve) indicate a lesion in the
brainstem which affects both the motor nucleus of CN VII
and the abducens nucleus. Clinical Correlation - LMN
Lesions of Facial Nerve (VII)
A LMN lesion of CN VII in conjunction with deficits associated
with CN VIII (vestibulocochlear nerve) are characteristic of a
lesion in the region of the internal acoustic meatus.
An example of this type of lesion is an acoustic neuroma:
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Clinical Correlation - Upper Motor Neuron (UMN) Lesion


Results from damage to neuronal cell bodies in the cortex or their axons that
project via the corticobulbar tract through the posterior limb of the internal capsule
to the motor nucleus of CN VII.
With an UMN lesion, voluntary control of only the lower muscles of facial
expression on the side contralateral to the lesion will be lost.
Voluntary control of muscles of the forehead will be spared due to the bilateral
innervation of the portion of the motor nucleus of CN VII that innervates the upper
muscles of facial expression.
UMN lesions are usually the result of a stroke.

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Overview of Visceral Motor Component


Parasympathetic component of the facial nerve.
Consists of efferent fibers which stimulate secretion from the submandibular,
sublingual, and lacrimal glands, as well as the mucous membranes of the
nasopharynx and hard and soft palates.

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Origin and Central Course


The visceral motor component originates from a diffuse collection of cell bodies in
the caudal pons just below the facial nucleus known as the superior salivatory
nucleus.
Fibers course so as to exit the ventrolateral aspect of the brainstem at the caudal
border of the pons as part of the nervus intermedius portion of CN VII. these fibers
donot loop around the abducens nucleus.
The nervus intermedius exits the brainstem just lateral to the branchial motor
component.

Intracranial Course
Upon emerging from the ventrolateral aspect of the caudal border of the pons, all
of the components of CN VII enter the internal auditory meatus along with the
fibers of CN VIII (vestibulocochlear nerve).
Within the facial canal the visceral motor fibers divide into two groups to become
the greater petrosal nerve and the chorda tympani:
The greater petrosal nerve supplies the lacrimal, nasal, and palatine glands.
The chorda tympani supplies the submandibular and sublingual glands.

Course of the Greater Petrosal Nerve


At the geniculate ganglion the greater petrosal nerve turns anteriorly and medially
exiting the temporal bone via the petrosal foramen and entering the middle cranial
fossa.

Figure 7-15a. Course of the greater petrosal nerve through the temporal bone.

The greater petrosal nerve passes deep to the trigeminal ganglion to enter the
foramen lacerum. The nerve traverses the foramen and enters a canal at the base of
the medial pterygoid plate in conjunction with sympathetic fibers (deep petrosal
nerve) branching from the plexus following the internal carotid artery. The
parasympathetic and sympathetic fibers together make up the nerve of the
pterygoid canal.
Upon exiting the pterygoid canal, pre-ganglionic parasympathetic fibers of CN VII
synapse in the pterygopalatine ganglion which is suspended from the fibers of the
maxillary division of the trigeminal nerve (V2) in the pterygopalatine fossa.

Post-ganglionic parasympathetic fibers then follow the fibers of V2 to reach the


lacrimal gland (via the lacrimal nerve) and the mucous membranes of the nasal and
oral pharynx.

Course of the Chorda Tympani


The pre-ganglionic fibers of the chorda tympani branch from the other fibers of CN
VII as they pass through the facial canal just posterior to the middle ear.
The fibers pass through the middle ear in close relationship with the tympanic
membrane and exit the base of the skull to enter the inferotemporal fossa:

Figure 16a. Course of the chorda tympani, inner ear.

In the inferotemporal fossa the chorda tympani joins the fibers of the lingual
branch of the mandibular division of CN V (V3).
CN VII pre-ganglionic fibers synapse in the submandibular ganglion suspended
from the lingual nerve (V3). Post-ganglionic fibers then either enter the
submandibular gland directly or again follow the lingual nerve before branching to

innervate the sublingual gland:

Overview of Special Sensory Component


Consists of afferent fibers which convey taste information from the anterior 2/3 of
the tongue and the hard and soft palates.

Peripheral Course
Chemoreceptors of the taste buds located on the anterior 2/3 of the tongue and hard
and soft palates initiate receptor (generator) potentials in response to chemical
stimuli.
The taste buds synapse with the peripheral processes of special sensory neurons

from CN VII. These neurons generate action potentials in response to the taste
bud's receptor potentials. The peripheral processes of these neurons follow the
lingual nerve and then chorda tympani to the petrous portion of the temporal bone
(similar to the path followed by the efferent visceral motor fibers).

Figure 7-18a. Chorda tympani and the lingual nerve.

The cell bodies of these primary afferent neurons reside


in the geniculate ganglion:

Figure 7-18b. Geniculate ganglion.

Central Course
The central processes of the special sensory neurons pass from the geniculate
ganglion through the facial canal and enter the brainstem as part of the nervus
intermedius portion of CN VII.
The fibers then join the caudal portion of tractus solitarius and ascend to synapse in
the rostral portion of the nucleus solitarius - also referred to as the gustatory
nucleus:

Central Course
Ascending secondary neurons originating from nucleus
solitarius project both ipsilaterally and contralaterally to the
ventral posteromedial (VPM) nucleus of the thalamus.
Tertiary neurons from the thalamus project via the posterior
limb of the internal capsule to the area of the cortex
responsible for taste.
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Overview of General Sensory Component


A minor component of CN VII.
The general sensory component consists of afferent fibers which convey general
sensory information from the skin of the concha of the external ear and from a
small area of skin behind the ear. It may also supplement the mandibular division
of CN V in providing sensation from the wall of the acoustic meatus and the outer
surface of the tympanic membrane.

Cranial Nerve VII - Facial Nerve


Central Course

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The cell bodies of these primary sensory neurons reside in the geniculate
ganglion. The peripheral processes of these neurons pass from the skin of
the external ear and small region of skin behind the ear through the
stylomastoid foramen in conjunction with the fibers of the branchial motor
component of CN VII.
They then course through the petrous portion of the temporal bone to the
geniculate ganglion.
From the geniculate ganglion, the central processes of these general sensory
fibers travel through the facial canal of the petrous portion of the temporal
bone and exit the internal acoustic meatus.

Central Course
The central processes of the general sensory neurons enter
the brainstem as part of the nervus intermedius portion of
CN VII. The fibers then descend in the spinal tract of the
trigeminal nerve to synapse in the spinal nucleus CN V.
Central Course
Ascending secondary neurons originating from the spinal nucleus of CN V project
to the contralateral ventral posteromedial (VPM) nucleus of the thalamus via the
anterolateral system.
Tertiary neurons from the thalamus project via the posterior limb of the internal
capsule to the sensory cortex of the post-central gyrus.

Peripheral Lesions
By using your knowledge of the anatomy of the facial nerve, the location of a lesion can be
determined by the presence or absence of certain deficits.
A lesion in the facial canal proximal to the branching of the greater petrosal nerve and chorda
tympani is characterized by the following:

Paralysis of all the muscles of facial expressionipsilateral to the lesion (LMN lesion
of the branchial motor component of CN VII).

Loss of secretion from lacrimal gland and mucous membranes of nasal and oral
pharynx ipsilateralto the lesion (lesion of the greater petrosal nerve, visceral motor
component of CN VII).

Loss of secretion from submandibular and sublingual glands ipsilateral to the lesion
(lesion of the chorda tympani, visceral motor component of CN VII).

Loss of taste from anterior 2/3 of tongueipsilateral to the lesion (lesion of the chorda
tympani, special sensory component of CN VII).

Loss of general sensation from concha of external ear and small area of skin behind
the ear (general sensory component of CN VII).

Deficits in hearing and/or vestibular functionsipsilateral to the lesion (associated with


CN VIII).

Intact general sensation to the tongue (supplied by CN V3).

If the lesion was distal to the greater petrosal nerve but proximal to the chorda tympani the
patient would present as above, except that secretory functions of the lacrimal, nasal, and
palatine glands would be intact.

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Peripheral Lesions
A lesion which affected the lingual nerve just distal to its junction with the chorda
tympani would present as follows:

Figure 7-25. Lingual nerve lesion.

Loss of secretion from submandibular and sublingual glands ipsilateral to the lesion
(visceral motor component of CN VII) Loss of taste from anterior 2/3 of tongue
ipsilateral to the lesion (special sensory component of CN VII) Loss of general
sensation from the tongue (general sensory component of CN V3).

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Introduction

OLFACTORY NERVE

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TROCHLEAR NERVE & ABDUCENT NERVE

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FRIDAY, NOVEMBER 6, 2009

FACIAL NERVE:
It is the 7th Cranial Nerve.
It has a medial motor root and a lateral sensory root, the nervous intermedius.

FUNCTIONAL COMPONENTS
Special Visceral (brachial) Efferent
Nucleus of the facial nerve lies in the lower part of Pons supplies various muscles
innervated by facial nerve. The part of nucleus that supplies muscles of the upper part of the
face receives corticonuclear fibers from the motor cortex of both the right and left sides. In
contrast the part of nucleus that supplies muscles of the lower part of the face receive
corticonuclear fibers only from the opposite side of cerebral hemisphere.

General Visceral efferent (parasympathetic)


Superior salivatory nucleus lies in lower part of pons. It sends fibers through the facial
nerve and its chorda tympani branch to the Submandibular ganglion for the supply of
Submandibular and sublingual salivary glands.
Lacrimatory nucleus lies near the salivatory nuclei gives fibers that pass through facial
nerve and its branches relay in the pterygopalatine ganglion and supply the lacrimal gland.

Special Visceral afferent


Nucleus of tractus solitarius (gustatory) carries taste sensation from anterior 2/3rd
of the tongue and from the palate.

General Somatic Afferent fibers


They probably innervate a part of skin over the ear. The nerve does not give any direct
branches to the ear but some fibers may reach it through communication with vagus nerve.
Proprioceptive impulses from muscles of the face are believed to travel through branches of
trigeminal nerve to reach the mesencephalic nucleus of the nerve

MOTOR ROOT
Supplies Muscles of face, scalp, auricle, buccinator, platysma, Stapedius, stylohyoid &
posterior belly of diagastric
SENSORY ROOT
It carries the taste fibers from anterior two thirds of tongue, floor of mouth and palate.
It also conveys parasympathetic secretromotor fibers to Submandibular and sublingual
salivary glands, lacrimal gland and glands of nose and palate.

ORIGIN

The two roots of facial nerve emerge from the anterior surface of brain between the pons and
medulla oblongata. They pass laterally forward in the posterior cranial fossa with the
Vestibulocochlear nerve to the opening of internal acoustic meatus. At the bottom of the
meatus the nerve enters the facial canal runs laterally above the vestibule of labyrinth until it
reaches the medial wall of tympanic cavity. (Middle ear)Here the nerve expands to form
sensory Geniculate ganglion. The nerve then bends sharply backwards above the
promontory, on arriving at the posterior wall of the middle ear, it curves downward. On the
medial side of the aditus of the mastoid antrum. It descends in the posterior wall of middle
ear, behind the pyramid and finally emerges through the stylomastoid foramen.

IMPORTANT BRANCHES OF INTRAPETROUS PART OF FACIAL NERVE:

GREATER PETORSAL NERVE


It arises from facial nerve at the geniculate ganglion. It contains preganglionic
parasympathetic fibers that pass to the pterygopalatine ganglion and are there relayed
through the zygomatic & lacrimal gland; other post ganglionic fibers pass through nasal &
palatine nerves to the glands of mucous membrane of nose and palate. It also contains taste
fibers from the nose and palate. It also contains many taste fibers from the mucous
membrane of the palate.
The nerve emerges on the superior surface of petrous part of temporal bone and runs
forward in a groove. It runs below the trigeminal ganglion and enters the foramen lacerum.
It is here joined by the deep petorsal nerve from sympathetic plexus on the Internal Carotid
Artery and forms nerve of pterygoid canal. This passes forward and enters the
pterygopalatine fossa where it ends in the pterygopalatine ganglion.
THE NERVE TO STAPEDIUS
It arises from the facial nerve as it descends in the facial canal behind the pyramid. It
supplies the muscle with in the pyramid.
CHORDA TYMPANI
It arises from the facial nerve above the stylomastoid foramen. It enters the middle ear close
to posterior border of tympanic membrane. It then runs forward over the tympanic
membrane and crosses the root of the handle of the malleus. It lies in the interval between
the mucous membrane and the fibrous layer of tympanic membrane.
Taste fibers
The nerve leaves the middle ear through petrotympanic fissure and enters infratemporal
fossa where it joins the lingual nerve. Chorda tympani contain many taste fibers from the
mucous membrane covering the anterior two thirds of tongue. (not the vallate papillae)
Taste fibers are the peripheral processes of the cells in the Geniculate ganglion.
Parasympathetic secretomotor fibers
The nerve also contains pre ganglionic parasympathetic secretomotor fibers that reach the
Submandibular ganglion and are there relayed to the Submandibular and sublingual salivary
gland.
As the nerve runs forward in the substance of parotid gland. It divides into 5 terminal
branches

BRANCHES AT ITS EXIT FROM THE STYLOMASTOID FORAMEN

THE POSTERIOR AURICULAR NERVE:


It arises just below the stylomastoid foramen. It ascends between the mastoid process and
the external acoustic meatus and supplies the
Auricularis posterior
The Occipitalis
Intrinsic muscles on the back of the auricle

THE DIAGASTRIC BRANCH


It arises close to the previous nerve. It is short and supplies the posterior belly of diagastric
muscle.
THE STYLOHYOID BRANCH
It may arise with the diagastric branch. It is long and supplies the stylohyoid muscle.

TERMINAL BRANCHES WITH IN THE PAROTID GLAND


THE TEMPORAL BRANCH
It emerges from the upper border of the gland and supplies
The anterior and superior auricular muscles
The frontal belly of occipitofrontalis
The orbicularis occuli
The corrugator supercilli
THE ZYGOMATIC BRANCH
It emerges from the anterior border of the gland and supplies the orbicularis occuli
THE BUCCAL BRANCH
It emerges from the anterior border of gland below the parotid duct and supplies the
buccinator muscle and muscles of upper lip and nostril.
THE MANDIBULAR BRANCH
It emerges from the anterior border of the gland and supplies the muscles of lower lip.
THE CERVICAL BRANCH
It emerges from the lower border of the gland and passes forward in the neck below the
mandible to supply depressor anguli oris muscle.
The facial nerve is the nerve of second arch and supplies all muscles of facial expression. It
does not supply skin but its branches communicate with branches of trigeminal nerve.

EXAMINATION
Routinely only the motor function of the 7th nerve is tested.

MOTOR FUNCTION
When 7th nerve is paralyzed, the patient may complain of inability to close the eyelid,
collection of food in the mouth and dribbling of saliva on the affected side of the mouth and
deviation of the angle of the mouth towards the opposite side.

On inspection, palpebral fissure may be wide and nasolabial fold may be flattened on
theparalyzed side.
Ask the patient to frown or wrinkle the forehead.

There would be no wrinkling on the affe

cted side.

Ask the patient to close the eyes; the affected side will remain open and there will be
brisk upward rolling of the eye ball (Bells phenomenon). To test the power of orbicularis
occuli ask the patient to close the eyes as strongly as possible while you try to open the upper
eyelids. The affected side will be weak.
Ask the patient to inflate the cheek and tap on both sides with finger. The weak
side will be deflated easily.
Ask the patient to show the teeth. The angle of mouth will be deviated towards the
healthy side.
The patient cannot whistle as air escapes from the paralyzed side.
The patient will complain of unusually loud sounds on paralyzed if nerve to Stapedius is

involved.
TASTE
Test taste of the anterior two third of the tongue by following technique.
Get solutions of four common tastes- sweet, salt, sour and bitter.
Instruct the patient to identify the taste, either by writing or raising fingers, e.g. one finger
if taste is sweet, two fingers if salty and so on.
Ask the patient to protrude the tongue. Hold it with a gauze, dry it and test each side
separately.
Put a drop of each solution one by one and ask for response.
Test bitter at the end.
SECRETOMOTOR FUNCTION
Lacrimation and salivation can be tested by various tests but it is not done routinely.
INTERPRETATION
The facial nerve is the most commonly affected cranial nerve by lesion of both upper motor
neuron and lower motor neuron.
UPPER MOTOR NEURON LESION
Manifestations are on the opposite side. Upper half of the face (wrinkling of the forehead,
closure of the eyelid) is less severely affected because the part of the facial nerve nucleus
which supplies muscles of the upper half of the face is connected with both cerebral
hemispheres; the part of the facial nerve nucleus which supplies muscles of lower half of the
face is connected only with the contra lateral cerebral hemispheres. Smiling and other
emotional movements are usually preserved in UMN lesion because there is a separate path
for these movements.
LOWER MOTOR NEURON LESION
Whole of the ipsilateral half of the face is affected. Bells palsy is the most common cause of
isolated lower motor neuron facial palsy. Etiology is unknown. The lesion is in the facial
canal.
As facial nerve has a long route and gives off branches at various sites, the site of lesion can
be localized with considerable precision.
If the lesion is after the nerve exits from the skull, there is only weakness of the
facial muscles.
If the lesion is in the facial canal, between the chorda tympani and branch to
Stapedius, in addition to motor weakness, there is loss of taste as well.
If the lesion is between the branch to Stapedius and internal auditory meatus,
there is hyperacusis on the affected side, in addition to motor weakness and loss of taste.
Geniculate ganglion can be affected by herpes zoster(Ramsay Hunt syndrome). In
addition to other features of facial palsy, there are vesicles in that part of external auditory
meatus which gets sensory supply from the facial nerve.
If the lesion is in the internal auditory meatus, in addition to the features of facial
nerve palsy, 8th nerve is also paralyzed.

If the lesion is in the cerebello-pontine angle, there are signs of cerebellar


dysfunction and 5th, 6th, 7th, and 8th nerves are also involved.
In pontine lesion, along with the facial nerve, the 6th nerve is also paralyzed and there is
upper motor neuron hemiplagia on the opposite side.

Posted by Amber Munir at 12:20 PM

3 comments:

1.
Dr.ShireenOctober 25, 2011 at 6:16 AM

Very helpful post.Thanks a lot!


Reply
Replies

1.
Amber MunirJune 26, 2012 at 8:04 AM

ur welcum :)
Reply

2.

Richelle YeexinDecember 9, 2013 at 10:49 PM

Thank you this is a good explanation!


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