HEAD AND NECK RADIOLOGY

Hugh D. Curtin, M.D.

Patrick Wolfe, M.D.
The Facial Nerve Between the
Nancy Snyderman, M.D.
Stylomastoid Foramen and the
Parotid: Computed Tomographic
Imaging”

A small segment of the facial nerve be- T HE FACIAL nerve follows a tortuous course through the temporal
tween its exit from the stylomastoid fora- bone, exits the skull at the stylomastoid fomamen, and enters the
men and its entrance into the parotid is panotid gland. Radiologic assessment of peripheral facial nerve
surrounded by fat and, therefore, can be problems has focused primarily on the intratempoma! and intrapamotid
imaged well using modern computed to- segments of the nerve (1-7). There is a short segment of the nerve
mography. A small dot can be seen sur- distal to the stylomastoid fomamen and proximal to the panotid gland
rounded by fat just beneath the stylomas- that passes through the fat between the stemnocleidomastoid and di-
toid foramen on computed tomographic gastric muscles (Fig. 1). Within this fat, just inferior to the sty!omastoid
scan. To verify that this indeed represent- foramen, a small “dot” of soft-tissue density can consistently be
ed the facial nerve, tissue sections and an identified on axial computed tomographic (CT) sections. We believe
injection into the mastoid segment of the this dot represents the facial nerve and accompanying vessels (Fig.
intratemporal facial nerve were per- 2). To confirm the identity of this dot, correlation was made both with
formed. The anatomic correlation and gross cadaver sections and with CT sections of a cadaver obtained
clinical material demonstrating involve- before and after injection of contrast material directly into the sheath
ment of the facial nerve in this region are of the facial nerve. This anatomic correlation is presented along with
presented. examples of pathologic processes involving this area of the nerve,
either as an isolated finding or by extension from the temporal bone
Index terms: Nerves, facial #{149}(Infratemporal brain, on parotid gland.
computed tomography, 1[5].121l)

Radiology 149: 165-169, October 1983 MATERIALS AND METHODS

The intratemponal segment of the facial nerve of a cadaver was
exposed using a mastoidectomy approach but taking came to avoid
entry into the stylomastoid fonamen. A small cannula was placed in
the nerve sheath and water-soluble contrast material was slowly in-
jected. The 1 .5-mm axial sections were obtained using a GE-8800
scanner before and after injection. Tissue sections were made from
separate cadaver material using unembalmed frozen specimens.

RESULTS
Following contrast matenia! injection into the facial nerve just su-
periom to the stylomastoid fomamen, a small amount of contrast ma-
terial, presumably limited by the facial nerve sheath, is demonstrated
just beneath the foramen (Fig. 3). This is between the styloid process
and the mastoid tip and conforms to the position of the dot on normal
CT scans (Fig. 4).
On the anatomic section obtained at the same level, the facial nerve
is identified, with its companion vascular supply, surrounded by a
small ring of fat between the mastoid tip and the styloid process im-
mediately inferior to the stylomastoid fomamen (Fig. 5).
1 From the Departments of Radiology (H.D.C., P.W.)
and Otolaryngology (N.S.), University of Pittsburgh,
Eye and Ear Hospital, Pittsburgh, PA. Presented at the DISCUSSION
Sixty-eighth Scientific Assembly and Annual Meeting
The facial nerve exits the brain stem at the pontomedullary junc-
of the Radiological Society of North America, Chicago,
IL, Nov. 28-Dec. 3, 1982. Received Dec. 9, 1982; accept- tion, crosses the cerebellopontine angle cistern and enters the internal
ed March 30, 1983. ht auditory canal. At the fundus of the internal auditory canal, the facial

165
 Figure 1 nerve enters the facial nerve canal,
which carries it on a tortuous course
through the temporal bone to its exit at
the stylomastoid foramen. CT evalua-
tion of these proximal segments of the
nerve has been described, as has ma-
diologic assessment of the parotid
gland and the intraparotid facial nerve.
The short segment of the nerve be-
, tween the temporal bone and the par-
Vi! otid can also be evaluated using the
Parofjd capabilities of recent-generation CT.
Styloid process
gland The facial nerve in this area is seen on
CT as a small dot surrounded by fat
between the mastoid tip and the root of
The facial nerve leaves the temporal bone and enters the
the styloid (Figs. 2 and 4).
parotid. The parotid has been partially dissected from the fa-
Malignant tumors can involve the
cial nerve and reflected anteriorly. The dot referred to in this
article represents a cross-section of the nerve immediately facial nerve in the subtemponal area by
inferior to the stylomastoid foramen. posterior extension from the parotid
(Fig. 6), inferior extension from the
temporal bone (Fig. 7), on by medial
extension from the external auditory
canal on skin (Fig. 8). Usually the tumor
Figure 2 is known clinically and CT shows its
relationship to the facial nerve. Iden-
tification of the normal “bullseye” of
the facial nerve surrounded by fat in
cases of panotid on temporal bone pa-
thology is a good indication that the
process does not extend past this point
(Fig. 9). This may not be true in pen-
neural spread where tumor cells travel
along the nerve without necessarily
enlarging the nerve. Penineural spread
is most commonly seen in adenocystic
canciflQma. More study would be
needed to determine if penineunal
invasion has any characteristic CT
findings.
Inflammatory processes can infil-
Axial CT scan just beneath the stylomastoid foramen. The facial nerve tnate the soft tissues at the skull base
is seen bilaterally (arrow on left). and obliterate the fat planes. Malignant

Figure 3

C.

a. Contrast material (arrow) surrounded by fat between styloid root (S) and mastoid tip (M).
b. CT section immediately inferior to a. Dot (arrow) represents contrast material in facial nerve. Compare with c.
C. Same area as in b, before injection of contrast material.

166 Radiology
#{149} October 1983
Figure 4

a. b. C.

a. CT section through temporal bone. Lucency (arrow) is cross-section through facial nerve canal immediately above stylomastoid foramen.
M = mastoid; arrowhead mandibular condyle.
b. CT section through root of styloid (5) and mastoid (M). Nerve (arrow) is seen emerging into the fat below the stylomastoid foramen.
C. CT section slightly inferior to b. Arrow = facial nerve.

external otitis, a slowly progressive density around the facial nerve in pa- In summary, the segment of the fa-
pseudomonas infection, often extends tients with facial paralysis (8). cia! nerve between the stylomastoid
infemiomly through the floor of the ex- The position of foreign bodies with foramen and the parotid gland can be
temnal ear canal into the subtempoma! respect to the facial nerve in this area identified using CT. Various pathologic
space where the facial nerve can be can also be useful. The pathway of a processes affecting the facial nerve in
involved immediately inferior to the bullet can often be shown both by the this area can thus be studied.
stylomastoid foramen . Involvement disruption of bony structures and by
here is indicated by obliteration of the small metallic flecks the bullet leaves
fat planes around the mastoid, includ- as it tracks through the tissues.
ing that around the facial nerve (Fig. The relationship of the predicted Department of Radiology
University of Pittsburgh
10). We have previously reported four pathway to the position of the facial
Eye and Ear Hospital
cases of malignant external otitis where nerve can be useful in predicting the 230 Lothrop Street
CT demonstrated obliteration of the fat site of injury. Pittsburgh, PA 15213

Figure 5

I nt.

a. b.
a. Anatomic cross-section, similar to CT section, shows nerve (arrowheads) in fat between mastoid and styloid.
b. Line drawing of a.

Volume 149 Number 1 Radiology 167

#{149}
 Figure 6 Figure 7

a. b.
Fifty-five-year-old man with squamous cell carcinoma of the external auditory canal extending
into the mastoid, involving the facial nerve both in its bony portion and subtemporal seg-
CT parotid sialogram in a 67-year-old woman men t.
with acinic cell carcinoma of the parotid and a. Tumor in mastoid (arrowheads) right side.
facial paralysis. Tumor involves the intrapar- b. Tumor obliterates fat planes beneath the temporal bone between styloid (S) and mastoid
otid portion of the facial nerve and extends (M). Compare with normal side.
posteriorly to obliterate the fat density inferior
to the stylomastoid foramen. M = mastoid;
S = styloid; arrowheads tumor.

Figure 8

References
1. Shaffer KA, Haughton VM, Wilson CR.
High resolution computed tomography of the
temporal bone. Radiology 1980; 134:409-
414.
2. Stone DN, Mancuso AA, Rice D, Hanafee
WN. Parotid CT sialography. Radiology
1981; 138:393-397.
3. Taylor S. The petrous temporal bone (in-
cluding the cerebellopontine angle). Radiol
Clin North Am 1982; 20:67-86.
4. Valvassori GE. Radiography of the facial
nerve canal. In: Fisch U, ed. Proceedings of
the 3rd symposium on facial nerve surgery.
Zurich, Switzerland, 1976:174.
S. Wilbrand HF. Multidirectional tomography
of the facial canal. Acta Radiol (Diagn) 1975;
16:654-672.
6. Wright JW, Taylor CE. Facial nerve abnor-
a. b. malities revealed by polytomography. Ar-
chives Otolaryngol 1972; 95:426-430.
Fifty-eight-year-old man with recurrent poorly differentiated squamous cell carcinoma of the
7. Wright JW, Taylor CE. Polytomography of
postauricular area and no facial paralysis. CT shows tumor extending medially toward the sty- the temporal bone. St. Louis, MO: Warren H.
lomastoid foramen. Tumor was adjacent and adherent to the facial nerve, necessitating sacrifice Green,Inc., 1973.
of the nerve. 8. Curtin HD, Wolfe P, May M. Malignant ex-
a. Axial scan showing tumor (arrowheads). ternal otitis: CT evaluation. Radiology 1982;
b. Coronal scan. M mastoid; arrowhead = tumor. 145:383-388.

168 Radiology
#{149} October 1983
Fifty-nine-year-old woman with breast cancer Figure 9
metastasis to the temporal and occipital bones
and facial nerve paralysis. Tumor involves the
intratemporal facial nerve canal. The facial
nerve below the temporal bone is spared.
a. Axial CT scan of the temporal bone
showing tumor (arrowheads).
b. Axial CT scan just beneath the stylomas-
toid foramen showing normal facial nerve
(arrowhead).

a. b.

Figure 10
Malignant external otitis. Sixty-two-year-old
diabetic with pseudomonas infection of the
external auditory canal and recent facial pa-
ralysis.
a. Fat planes around mastoid (M) tip and
between mastoid and styloid (S) are
obliterated.
b. Normal fat density between mastoid tip
and styloid.

Volume 149 Number 1 Radiology 169

#{149}