The Lal:yiigoscope
Lippinrott Williams & Wilkins, Inc., Philadelphia
0 1999 The American Laryngological,
Rhinological and Otological Society, Inc.
Relationship of the Facial Nerve to
the Tympanic Annulus: A Direct
Anatomic Examination
~- ~~
Basil Adad, MD; Barry M. Rasgon, MD; Lynn Ackerson, PhD
Objectiue: To examine the relation of the facial
nerve to the only identifiable surgical landmark in
the external auditory canal. Institution: Community-
based teaching hospital. Study Design: Examination
of formalin-fixed human temporal bones. Buck-
ground. The transcanal approach is often used in
tympanoplasty, canaloplasty, hypotympanotomy, and
removal of tumors of the external auditory canal
(EAC),such as exostoses and osteomas. Surgery of the
EAC places the facial nerve at risk for injury as the
nerve courses vertically in the posterior canal wall.
Few articles have described the relation of the facial
nerve’s course to the tympanic annulus, the only iden-
tifiable landmark in the EAC. This study is the first to
document the relationship of the course of the facial
nerve with respect to the tympanic annulus by direct
anatomic measurement of the temporal bone. Meth-
ods: Thirty-seven formalin-fixed cadaver temporal
bones were studied after skeletonization of the facial
nerve and tympanic annulus. Results: The facial
nerve coursed lateral to the plane of the annulus in
7w0of specimens, always in the posteroinferior quad-
rant. The nerve also coursed anterior to a plane
through the most posterior point of the annulus in
73.1%~ of specimens, also exclusively in the posteroin-
ferior quadrant. The course of the nerve was quite
variable with respect to the annulus. Conclusions:
The facial nerve is most vulnerable to injury in the
posteroinferior quadrant in transcanal surgery. The
annulus is not a reliable landmark for the facial
nerve. Anecdotal evidence is cited and recommenda-
tions are offered. Key Words: Ear, external auditory
canal, EAC, facial nerve, mastoid, temporal bone.
Laiyngoscope, 1091189-1192,1999
I’rcscnted a t the Meeting of the Western Section of the American
Laryngological, Rhinological and Otological Society, Inc., Denver, Colo-
rado, January 9, 1999 (recipient of the Vice-president’s Award) and the
Annual Meeting of the Pacific Coast Oto-ophthalmological Society, Victo-
ria, British Columbia, June 21, 1999.
From the Department of Head and Neck Surgery (B.A., B.M.R.) and
the Division of Research (L.A.), Kaiser Permanente Medical Care Program,
Oakland. California.
Mitor’s Note: This Manuscript was accepted for publication May 6,
1999.
Send Reprint Requests to Barry M. Rasgon, MD, Department of
Head and Neck Surgery, Kaiser Permanente Medical Center, 280 West
MacArthur Boulevard, Oakland, CA 94611-5693, U S A .
Laryngoscope 109: August 1999
INTRODUCTION
The transcanal approach is often used in tympano-
plasty, canaloplasty, hypotympanotomy, and removal of
tumors of the external auditory canal (EAC), such as ex-
ostoses and osteomas. Surgeons performing these proce-
dures must realize that surgery of the EAC places the
facial nerve at risk for injury as the nerve courses verti-
cally in the posterior canal wall. One reason for this is the
lack of consistently identifiable surgical landmarks in the
EAC with respect to the facial nerve. In fact, the only
landmark available is the annular sulcus.1
In 1969, Litton et a1.2 reported use of the annular
sulcus as a reference from which to describe the course of
the horizontal and vertical segments of the facial nerve.
The course of the facial nerve with respect to this land-
mark was documented by plain radiographic films taken
in anteroposterior, lateral, and inferosuperior views. In
that study,z the investigators reported that the facial
nerve coursed lateral to the plane of the annulus in 33 of
50 human temporal bones studied.
Thus, a popular admonition to surgeons has been to
take particular care in the posterior EAC. In their Atlas of
Ear Surgery, Miglets et al.3 advised against the use of a
mallet and osteotome when removing exostoses because
“. . . the posterior wall of the ear canal may . . . crack, and
there is danger of injury to the facial nerve.” Glasscock
and Shambaugh 4 recommended using an otologic drill for
this procedure and recommended hollowing out the tumor
before complete removal. Their recommendation was
based on the belief that without the plane of the annular
sulcus in view, removal of bone perpendicular to its most
posterior extent could lead to inadvertent injury of the
facial nerve. Confirmation of vulnerability of the facial
nerve to injury in transcanal procedures is documented by
Green et al.,5 who found 4 of 22 injuries t o the facial nerve
that occurred during transcanal surgery. For this reason,
these authors advocated the postauricular approach for
removal of exostoses and warned of the possibility of in-
juring the facial nerve in transcanal ~ u r g e r y . ~
Despite this potential for injury during transcanal
surgery, very few articles have described the relation of
the course of the facial nerve to the only identifiable land-
mark in the EAC.1,2,6,7In our literature search7we found
Adad et al.: Relationship of Facial Nerve to Tympanic Annulus
1189
no direct examination of the distance between the facial
nerve and the annular sulcus. We therefore performed a
study in which the relationship of the course of the facial
nerve with respect to the tympanic annulus was noted after
the annulus and facial nerve were skeletonized (Fig. 1).

MATERIALS AND METHODS

Thirty-seven apparently normal, formalin-fixed human ca-
daver temporal bones from the temporal bone bank at our insti-
tution were available for study. A simple mastoidectomy was A
done on each bone to identify the facial nerve. An extended facial
recess approach was next used to access the entire length of the
horizontal and vertical portions of the nerve. The facial nerve was
then skeletonized with a 1-mm diamond burr. Next, the posterior Superior
external auditory canal was drilled away until a thin ring of
annular bone remained from 1 o’clock to 6 o’clock (positions 1-6)
(Fig. 1). Direct measurements of the shortest distance from the
lateral edge of the annular sulcus to the facial nerve were then
made with a fine caliper at 6 points: at 1, 2 ,3, 4, 5, and 6 o’clock
(positions 1-6) in left temporal bones and at l l , l O , 9, 8, 7, and 6 Fig. 2. Medial-lateral orientation of facial nerve to annulus: Ant. and
o’clock (positions 1- 6) in right temporal bones. The lateromedial post. = anterior and posterior annulus (black ring); SMF = stylo-
orientation of the facial nerve was noted with respect to the mastoid foramen; FN = facial nerve (hatched line); LSCC = lateral
annular plane (Fig. 2). We also noted the anteroposterior orien- semicircular canal.
tation of the nerve in relation to a plane perpendicular to the most
posterior point of the annular sulcus (Fig. 3).
Measurements at positions 1 through 6 were then averaged. nerve to the annulus are listed in Table I. Mean distance
The variances were compared using Bartlett’s test of homogene- from the annular sulcus to the nerve was 4.7 mm at
ity of variances. Temporal bones were then grouped into those in position 1, 4.2 mm at position 2, 3.8 mm a t position 3, 3.6
which the nerve traveled lateral to the plane of the annulus mm at position 4, 3.9 mm at position 5, and 5.6 mm a t
(group 1)and those in which the nerve remained medial to the position 6. As is evident, the shortest distance measured
plane of the annulus (group 2). Mean distances at positions 3, 4, between the annulus and the facial nerve was 1.9 mm.
5, and 6 were compared between groups 1 and 2 using a two- The overall test for equality of the variances was not
sample t test with the Bonferroni adjustment for level of signifi- significant ( P = .92). The most variable distance was from
cance (i.e., adjusting the type I error rate from 0.05 to 0.0125 to position 1 to the facial nerve.
account for multiple comparisons).

RESULTS
Of the 37 temporal bones available for study, 23 were
right temporal bones and 14 left temporal bones. Mini-
mum, maximum, and mean distances from the facial
A PSQ
cc

Anterior
Edge of *
Annulus
- Posterior
Edge of
Annulus

Fig. 1. Photographshowing example of (right)temporal bone spec-
imen with skeletonized annulus and facial nerve. External posterior
auditoty canal drilled away until thin ring of annular bone is evident
at 1 o’clock through 6 o’clock position.
A PIC --
Fig. 3. Relation of facial nerve to posteriormost point (dot) on an-
nulus (black ring): ASQ = anterosuperior quadrant; PSQ = postero-
inferior quadrant; AIQ = anteroinferior quadrant; PIQ = posteroin-
ferior quadrant.

Laryngoscope 109: August 1999 Adad et al.: Relationship of Facial Nerve to Tympanic Annulus
1190
 -____ -.

TABLE I.
___ ___
Distance of Facial Nerve to Annulus.
Positions*

1 2 3 4 5 6
~

Group 1 (n = 26)
Mean 4 79 4.30 3.82 3.50 3.83 5.48
SD 1.12 1.01 0.90 0.90 0.76 0.87
Range 2.8-6.8 2.5-6.2 2.5-5.3 1.9-5.3 2.5-5.4 4.0-6.8
Group 2 (n = 11)
Mean 4.61 4.09 3.70 3.74 4.04 5.72
SD 0.71 0.67 0.83 0.72 1.07 1.04
Range 3.7-6.0 2.9-5.0 2.1-4.9 2.8-5.0 2 .O-5.9 4.6-7.3
Total Group (n = 37)
Mean 4.74 4.24 3.78 3.57 3.89 5.55
SD 1.01 0.92 0.87 0.85 0.86 0.92
Range 2.8-6.8 2.5-6.2 2.1-5.3 1.9-5.3 2.0-5.9 4.0-7.3
_ _ _ _ _ -~ -
~

*All positions measured in millimeters and are related to clockface (e.g., position 1 is at 1 o’clock).

Group 1, consisting of specimens in which the facial
nerve coursed lateral to the plane of the annulus, included
26 bones (70%).The transition from lateral to medial
occurred most frequently a t position 5 (53.8%;14/26) but
also occurred at positions 3 (8%), 4 (12%),and 6 (27%).In
group 1 temporal bones, the nerve also coursed anterior to
a plane through the most posterior point of the annulus in
19 cases (73.1%).The transition from posterior to anterior
occurred at position 5 in 47.4% of cases (9/19) and at
position 6 in 52.6%of cases (10/19) (data not shown).
Comparisons of temporal bones in which the facial
nerve coursed lateral to the plane of the annulus (group 1)
versus those in which the nerve remained medial to the
annular plane (group 2) did not show statistically signifi-
cant differences between the groups (Table I). For posi-
tions 3, 4, 5, and 6, the P values for the comparisons of
means in the two groups were 0.68, 0.37, 0.52, and 0.44,
respectively.
DISCUSSION
The transcanal approach is used for many common
otologic procedures, including middle ear exploration,
tympanoplasty, canaloplasty, hypotympanotomy, and re-
moval of exostoses and osteomas of the EAC. However, the
facial nerve traverses the bone of the posterior EAC wall,
making it theoretically vulnerable to injury in transcanal
procedures in which posterior EAC bone is removed. In
the EAC the only identifiable landmark for the facial
nerve is the tympanic annulus.7 In their radiographic
study of 50 fresh human temporal bones, Litton et a1.2
appreciated several aspects of the facial nerve course with
relation to the annular sulcus. First, the horizontal and
vertical course of the nerve varies in relation to the annu-
lus; they found that the vertical course varied more than
the horizontal course. Second, the facial nerve can travel
lateral to the tympanic annulus, as they documented in 33
of 50 bones. Further, when the facial nerve courses lateral
to the annulus, the nerve can also travel anterior to the
most posterior aspect of the tympanic ring in the postero-
inferior quadrant; the authors established this equally
important finding in some specimens. These findings led
Litton et a1.2 to admonish otologic surgeons regarding the
dangers of bone removal in that region of the EAC.
In our review of the biomedical literature in English,
we found no studies in which the distance from the facial
nerve to the tympanic annulus was directly measured
from human temporal bone specimens. In the current
study, the facial nerve was skeletonized along its horizon-
tal and vertical portions and the bone of the posterior EAC
was removed, leaving the bony rim of the annular ring
intact (Fig. 1). Measurements were made from the lateral
annular sulcus to the facial nerve. Our direct measure-
ments for the most part agree with the findings of Litton
et a1.2
Vulnerability
Although many agree that the facial nerve can travel
lateral to the annulus,l*3.4Jj~7some may not appreciate
that it can concurrently travel anteriorly, making it vul-
nerable to injury even when the whole tympanic ring is
apparent. In 70% of the temporal bones dissected in this
study, the nerve coursed lateral to the plane of the annu-
lus. Of these, the nerve was found anterior to the most
posterior point along the tympanic ring in 73.1%. The
shortest distance measured between the sulcus and the
facial nerve was 1.9 mm. In all these cases, the course of
the nerve crossed the posterior and lateral planes in the
posteroinferior quadrant of the EAC. These data lead us to
conclude that the facial nerve is most vulnerable to injury
in that quadrant.
These findings differ somewhat from those of Litton
et a1.,2 who documented the facial nerve coursing lateral to
the plane of the annulus in the posterosuperior quadrant
in 17 of 50 specimens, the posteroinferior quadrant in 16
of 50 bones, and remaining medial to this plane in 17 of
bones. These finding were based on relative positions of
the fallopian canal and annulus observed on plain film
radiographs taken of temporal bone in the anteroposterior

Laryngoscope 109: August 1999 Adad et al.: Relationship of Facial Nerve to Tympanic Annulus
1191
view. By contrast, our data derive from direct visualiza-
tion of the facial nerve, which was observed to travel
medial t o the plane of the annulus until reaching the
posteroinferior quadrant (positions 3-6); in this quadrant,
the facial nerve was seen crossing the lateral plane of the
annulus in 70% of specimens. On the other hand, Litton et
a1.2 did not comment on where the nerve moved anterior to
the posterior annular plane in cases when it was found
lateral to the annulus. In the present study, these mea-
surements lead us to believe that the facial nerve is most
vulnerable to injury in the posteroinferior quadrant.
This is anecdotally supported by the review of Green
et al.,5 in which 1 patient presented with facial nerve
injury after posterior and anterior bony overhang was
removed during tympanoplasty.
Variability
In this present study, we found that the course of the
facial nerve in relation to the annulus varied greatly. The
difference between the smallest measured distance from
points on the annulus to the largest measured distance
ranged from 3.2 mm to 4 mm. Because of the variable
course with respect to the planes of the annulus, this
provides a potentially large volume of space in which the
facial nerve may be found. By statistical comparison of the
variances, no one measurement stood out as more variable
than another. This finding disagrees with the report of
Litton et a1.,2 who wrote that the most variable portion of
the nerve in relation to the annulus was the vertical
portion. Our finding also disagrees with Proctor,G who
described an overall posterior deviation of the course of
the vertical segment and stated that “. . . the tympanic
ring thus is a good landmark for the facial canal, with 3
mm separating them constantly.”
In contrast, Nager and Proctors underscored variabil-
ity of the course of the vertical portion of the facial nerve
by writing that the vertical segment varies in length from
9 to 16 mm and can move anteriorly, medially or posteri-
orly when viewed laterally. This variability was docu-
mented clinically by Green et al.,5 who reported three
iatrogenic facial nerve injuries, presumably secondary to
removal of bony exostoses in the EAC.
Thus, although the annulus is the only landmark in
the EAC for the facial nerve, the variability of the rela-
tionships of these two structures is such that the nerve
still remains vulnerable to injury in transcanal surgery
when removal of bone in the posteroinferior quadrant is
necessary. For this reason, Green et ale5and Parisier et
al. advocated the postauricular or endaural-postauricular
approach for the removal of exostoses.
Laryngoscope 109: August 1999
1192
Also available to the surgeon are computed tomogra-
phy and magnetic resonance imaging. Both are useful for
defining the course of the facial nerve. A computed tomog-
raphy scan of the temporal bone using 2-mm-thick slices
in the axial plane may be most useful for defining the
course of the nerve and its relationship to the bone of the
EAC.9 Finally, the surgeon may elect before or during
surgery to place a facial nerve integrity monitor on the
patient when considering bone removal in the posteroin-
ferior quadrant.
CONCLUSION
Although the tympanic ring is a landmark for the
course of the facial nerve, the nerve’s variable position in
relation to the tympanic ring leads us to conclude that it is
not a reliable landmark. Because the facial nerve fre-
quently courses lateral to the annulus and in some in-
stances moves anteriorly in the posteroinferior quadrant
of the EAC, the nerve is most vulnerable to injury there.
Caution is therefore advocated when removing bone in the
posteroinferior quadrant. The surgeon might also consider
obtaining preoperative imaging studies. Further, placing
a facial nerve integrity monitor seems prudent before an
operation in which removal of bone in the posteroinferior
quadrant is a possibility.
ACKNOWLEDGMENT
The Medical Editing Department, Kaiser Foundation
Research Institute, provided editorial assistance.
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Adad et al.: Relationship of Facial Nerve to Tympanic Annulus