Surgical anatomy of the facial nerve: from middle cranial fossa approach to endoscopic approach. A pictorial review

Purpose: The pathology of the facial nerve is extremely varied and extensive knowledge of the surgical anatomy in different approaches is required to manage it. During the last 15 years, the development of endoscopic ear surgery has significantly changed anatomical concepts, introducing new surgical approaches. The aim of this review is to illustrate five different surgical approaches to the facial nerve: the endoscopic approach, the middle cranial fossa approach, two translabyrinthine approaches (one simple and one endoscopic-assisted) with decompression of the whole petrous portion of the facial nerve, and a transotic approach with temporal craniotomy. Methods: Representative cases of middle and/or inner ear pathologies, surgically treated at our ENT Department, were selected to illustrate each of the five different approaches involving the facial nerve throughout its course. Results: In all cases, the pathology was removed with effective decompression of the facial nerve. The surgical anatomy in each surgical approach is described and illustrated. Conclusions: Facial nerve surgery is challenging for ENT specialists. An excellent knowledge of facial nerve anatomy is needed to eradicate pathology, avoiding nerve injuries and providing a good outcome after surgery.