title: Relationship of the facial nerve to the tympanic annulus: a direct anatomic examination.
abstract: OBJECTIVE
  To examine the relation of the facial nerve to the only identifiable surgical landmark in the external auditory canal.
  
  
  METHODS
  Community-based teaching hospital.
  
  
  METHODS
  Examination of formalin-fixed human temporal bones.
  
  
  BACKGROUND
  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 identifiable 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.
  
  
  METHODS
  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 70% of specimens, always in the posteroinferior quadrant. 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 posteroinferior 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 recommendations are offered.
authors.affiliation: Department of Head and Neck Surgery, Kaiser Permanente Medical Care Program, Oakland, California 94611-5693, USA.
authors.forename: B
authors.initials: B
authors.lastname: Adad
authors.forename: B M
authors.initials: BM
authors.lastname: Rasgon
authors.forename: L
authors.initials: L
authors.lastname: Ackerson
mesh_terms: D046508:Culture Techniques; D004424:Ear Canal / Q000033:anatomy & histology; D005154:Facial Nerve / Q000033:anatomy & histology*; D020220:Facial Nerve Injuries; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis; D013701:Temporal Bone / Q000033:anatomy & histology; D014432:Tympanic Membrane / Q000033:anatomy & histology*; D014947:Wounds and Injuries / Q000175:diagnosis