Abstract
The technical advances in sonography of the past decade have supported the rapid improvement of high-resolution imaging, which enables the quick visualization of peripheral nerves at relatively limited costs. Recently, the possibility of visualizing the extratemporal facial nerve (FN) has been considered. This manuscript describes the first systematic evaluation in cadavers, of a novel ultrasonographic approach with this specific aim. Eight cadaveric hemifaces were evaluated by means of high-frequency ultrasound with two linear (13 and 22 MHz) and a convex transducer (6.6 MHz), to detect the extratemporal course of the FN starting from its exit at the stylomastoid foramen: the main trunk, the parotid plexus between the two parts of the parotid gland, the distal branches terminating into the orbicularis oculi and the zygomatic major muscle. Ultrasound-guided color injections and FN dissection were performed to confirm the results. The main trunk of the FN, as it exits the stylomastoid foramen, was correctly stained in 6/8 cases, the parotid plexus in 8/8 cases. The branches innervating the orbicularis oculi muscle were stained in 7/7 and the branches innervating the zygomatic major muscle in 6/7 hemifaces, after 1 was withdrawn due to insufficient image quality. Through our novel approach of high-resolution ultrasonography we could identify the various portions of the extratemporal FN, including its main trunk leaving the stylomastoid foramen, in an accurate and reproducible way. Further in vivo animal and clinical studies have been planned to confirm these initial results from cadavers.
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Acknowledgements
The presented results have been generated within the diploma thesis of Hannes Wegscheider. We thank Julia Messner for language editing on an earlier version of this manuscript. The authors wish to thank individuals who donated their bodies and tissues for the advancement of education and research.
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Orlando Guntinas-Lichius wrote the first draft of the manuscript. No honorarium, grant, or other form of payment was given to anyone to produce the manuscript. Each author listed in the manuscript has seen and approved the submission of this version of the manuscript and takes full responsibility for the manuscript.
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Supplemental Digital Content 1. Cadaver setting. Lateral positioning of the cadaveric head with a hook between nose and mandible and another hook fixating the earlobe; transparent white box shows transducer position to image the main trunk. (JPG 86 KB)
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Supplemental Digital Content 2. Cadaver preparation. Right side of cadaveric head; green color solution found on the main trunk of FN (arrow) right after exiting the stylomastoid foramen (SMF); 1) indicating the anterior border of the sternocleidomastoid muscle (SCM). (JPG 129 KB)
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Supplemental Digital Content 3. Cadaver preparation. Left side of cadaveric head; 3 steps (A-C) of dissection to get to the main trunk of the facial nerve (FN): A – incision of the skin, B – raised skin flap and mobilization of the connective tissue, C – main trunk of the FN after its exit from the SMF; white box shows the dissected area. (JPG 253 KB)
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Supplemental Digital Content 4. Cadaver setting. Position of the 13 MHz linear probe, to visualize the parotid plexus on the left side in transverse view and an IP approach of the needle. (JPG 59 KB)
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Supplemental Digital Content 5. Cadaver preparation. Right side of cadaveric head; 3 steps (A-C) of dissection to show parts of the parotid plexus: A – parotid gland with the raised flap fixated downwards with a pin, B – further dissected superficial part of the parotid gland being held inferiorly, C - color solution at the parotid plexus in the interlobular space; white box shows the dissected area. (JPG 157 KB)
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Supplemental Digital Content 6. Cadaver setting. 22 MHz linear transducer position at the outer rim of the orbicularis oculi muscle (OOM) on the left side of the cadaveric head, to visualize an innervating branch longitudinally; out-of-plain (OOP) technic of needle approach. (JPG 96 KB)
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Supplemental Digital Content 7. Cadaver preparation. Right side of cadaveric head; 3 steps of dissection to show branches to the orbicularis oculi muscle (OOM; A-C) – A – skin incision, B – skin flap raised, C – color at branches to the orbicularis oculi muscle (OOM) after raising covering fat; white box shows the dissected area. (JPG 226 KB)
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Supplemental Digital Content 8. Cadaver preparation. Left side of cadaveric head; skin and fat layer raised posteriorly; posterior rim of the orbicularis oculi muscle OOM (1) reflected anteriorly to demonstrate deep location of nerve branch (arrows) relative to the muscle. (JPG 159 KB)
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Supplemental Digital Content 9. Setting of the high-resolution ultrasonography. 22 MHz linear transducer to detect small branches to the ZMM in transverse view and injection of the color solution with an IP technique. (JPG 190 KB)
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Supplemental Digital Content 10. Cadaver preparation. Left side of cadaveric head; 3 steps of dissection to show branches to the zygomatic major muscle (ZMM; A-C): A – skin incision, B – skin flap raised, C – colored branch detected with ultrasound; white box shows the dissected area. (JPG 249 KB)
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Supplemental Digital Content 11. Cadaver preparation. Left side of cadaveric head; zygomatic major muscle (ZMM; 1) and zygomatic branches of the facial nerve (FN; arrows) coursing deep to the muscle; dye is seen spreading anteriorly along zygomatic branches. (JPG 158 KB)
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Supplemental Digital Content 12. High-resolution ultrasonography. Original image (above) and overlay image to explain the visualized structures (below). 13 MHz ultrasound image of the furcation (dipus in this case of the FN) in transverse view marked with yellow color superficial to the retromandibular vein (1) scanned longitudinal. The retromandibular vein separates superficial (2) from deep lobe (3). (JPG 77 KB)
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Wegscheider, H., Volk, G.F., Guntinas-Lichius, O. et al. High-resolution ultrasonography of the normal extratemporal facial nerve. Eur Arch Otorhinolaryngol 275, 293–299 (2018). https://doi.org/10.1007/s00405-017-4797-z
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DOI: https://doi.org/10.1007/s00405-017-4797-z