Skip to main content

Landmarks of the facial nerve: implications for parotidectomy


Facial nerve paralysis is a daunting potential complication of parotid surgery and is widely reported. Knowledge of the key landmarks of the facial nerve trunk is essential for safe and effective surgical intervention in the region of the parotid gland. In current practice, wide ranges of landmarks are used to identify the facial nerve trunk, however, there is much debate in the literature about the safety and reliability of each of these landmarks. The aim of this study, therefore, was to evaluate the relation of the surrounding anatomical structures and surgical landmarks to the facial nerve trunk. The anatomical relationship of the facial nerve trunk to the surrounding structures was determined after micro-dissection on 40 adult cadavers. The shortest distances between the facial nerve and the “tragal pointer”, attachment of the posterior belly of digastric muscle, tympanomastoid suture, external auditory canal, transverse process of the axis, angle of the mandible and the styloid process were measured. In addition, these distances were compared in the right and left sides, males and females and edentulous and non-edentulous mandibles. The distance of the facial nerve trunk from each of the surrounding landmarks ranged from (mm): tragal pointer, 24.3 to 49.2 (mean 34); posterior belly of digastric, 9.7 to 24.3 (mean 14.6); external auditory canal, 7.3 to 21.9 (mean 13.4); tympanomastoid suture, 4.9 to 18.6 (mean 10.0); styloid process, 4.3 to 18.6 (mean 9.8); transverse process of the axis, 9.7 to 36.8 (mean 16.9); angle of the mandible, 25.3 to 48.69 (mean 38.1). The length of the facial nerve trunk from its point of exit from the stylomastoid foramen to its bifurcation into upper and lower divisions ranged from (mm) 8.6 to 22.8 (mean 14.0). The results demonstrated that the posterior belly of digastric, tragal pointer and transverse process of the axis are consistent landmarks to the facial nerve trunk. However, it should be noted that the tragal pointer is cartilaginous, mobile, asymmetrical and has a blunt, irregular tip. This study advocates the use of the transverse process of the axis as it is easily palpated, does not require a complex dissection and ensures minimum risk of injury to the facial nerve trunk.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    Aslan A, Goktan C, Okumus M, Tarhan S, Unlu H (2001) Morphometric analysis of anatomical relationships of the facial nerve for mastoid surgery. J Laryngol Otol 115:447–449

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Beahrs OH (1977) The surgical anatomy and technique of parotidectomy. Surg Clin North Am 57(3):477–493

    PubMed  CAS  Google Scholar 

  3. 3.

    Bron LP, O’Brien CJ (1997) Facial nerve function after parotidectomy. Arch Otolaryngol Head Neck Surg 123:1091–1096

    PubMed  CAS  Google Scholar 

  4. 4.

    Browne HJ (1988) Exposure of the facial nerve. Br J Surg 75(7):724–725

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Brusati R, Bozzetti A, Chiapasco M (1987) Facial nerve and parotid surgery. J Craniomaxillofac Surg 15:278–280

    PubMed  CAS  Google Scholar 

  6. 6.

    Conley J (1975) Salivary glands and the facial nerve. George Thieme Publishers, Stuttgart

    Google Scholar 

  7. 7.

    Conley J (1975) Prognosis of malignant tumours of the parotid gland with facial paralysis. Arch Otolaryngol 101:39–41

    PubMed  CAS  Google Scholar 

  8. 8.

    Conley J (1978) Search for and identification of the facial nerve. Laryngoscope 88:172–176

    PubMed  CAS  Google Scholar 

  9. 9.

    Conn IG, Wiesenfeld D, Ferguson MM (1983) The anatomy of the facial nerve in relation to CT/sialography of the parotid gland. Br J Radiol 56:901–905

    PubMed  CAS  Article  Google Scholar 

  10. 10.

    De Ru JA, Van Benthem PPG, Bleys RLAW, Lubsen H, Hordijk GJ (2001) Landmarks for parotid surgery. J Laryngol Otol 115:122–125

    PubMed  Google Scholar 

  11. 11.

    De Ru JA, Bleys RLAW, Van Benthem PPG, Hordijk GJ (2001) Preoperative determination of the location of parotid gland tumours by analysis of the position of the facial nerve. J Oral Maxillofac Surg 59:525–528

    PubMed  Article  Google Scholar 

  12. 12.

    Gaughan RK, Olsen KD, Lewis JE (1992) Primary squamous cell carcinoma of the parotid gland. Arch Otolaryngol Head Neck Surg 118:798–801

    PubMed  CAS  Google Scholar 

  13. 13.

    Gooden E, Witterick IJ, Hacker D, Rosen IB, Freeman JL (2002) Parotid gland tumours in 255 consecutive patients: Mount Sinai Hospital’s quality assurance review. J Otolaryngol 31(6):351–354

    PubMed  Article  Google Scholar 

  14. 14.

    Hugo NE, McKinney P, Griffith BH (1973) Management of tumours of the parotid gland. Surg Clin North Am 53(1):105–111

    PubMed  CAS  Google Scholar 

  15. 15.

    Laage-Hellman JE (1965) Facial nerve in parotidectomies. Arch Otolaryngol 81:527–533

    PubMed  CAS  Google Scholar 

  16. 16.

    Langdon JD (1984) Complications of parotid gland surgery. J Maxillofac Surg 12:225–229

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Lin LIK (1989) A concordance correlation coefficient to evaluate reproducibility. Biometrics 45:255–268

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Mehle ME, Kraus DH, Wood BG, Benninger IE, Levine HL, Tucker HM, Lavertu P (1993) Facial nerve morbidity following parotid surgery for benign disease: the Cleveland clinic foundation experience. Laryngoscope 103:386–388

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Nichols RD, Stine PH, Bartschi LR (1979) Facial nerve function in 100 consecutive parotidectomies. Laryngoscope 89:1930–1934

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Nishida M, Matsuura H (1993) A landmark for facial nerve identification during parotid surgery. J Oral Maxillofac Surg 51:451–453

    PubMed  CAS  Article  Google Scholar 

  21. 21.

    Owen ERTC, Banerjee AK, Kissin M, Kark AE (1989) Complications of parotid surgery: the need for selectivity. Br J Surg 76:1034–1035

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Reid AP (1989) Surgical approach to the parotid gland. Ear Nose Throat J 68:151–154

    PubMed  CAS  Google Scholar 

  23. 23.

    State D (1978) Parotidectomy with preservation of the facial nerve in the treatment of tumours of the parotid gland. Surg Gynaecol Obstet 147:94–96

    CAS  Google Scholar 

  24. 24.

    Tabb HG, Scalco AN, Fraser SF (1970) Exposure of the facial nerve in parotid surgery. Laryngoscope 26:559–567

    Google Scholar 

  25. 25.

    Trible WM (1975) Management of the facial nerve. Laryngoscope 62:25–27

    Google Scholar 

  26. 26.

    Watanabe Y, Ishikawa M, Shojaku H, Mizukoshi K (1993) Facial nerve palsy as a complication of parotid gland surgery and its prevention. Acta Otolaryngologica (Stockholm) 504:137–139

    Article  CAS  Google Scholar 

  27. 27.

    Wetmore SJ (1991) Surgical landmarks for the facial nerve. Otolaryngol Clin North Am 24(3):505–530

    PubMed  CAS  Google Scholar 

  28. 28.

    Williams PL, Warwick R, Dyson M, Bannister LH (1989) Gray’s Anatomy. 37th edn. Churchill Livingstone, UK

    Google Scholar 

  29. 29.

    Witt RL (1998) Facial nerve monitoring in parotid surgery: the standard of care. Otolaryngol Head Neck Surg 119(5):468–470

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    Witt RL (1999) Facial nerve function after partial superficial parotidectomy: an 11-year review. Otolaryngol Head Neck Surg 121(3):210–213

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Work WP (1980) Basic concepts in surgery of the parotid gland. J Otolaryngol 9(4):303–308

    PubMed  CAS  Google Scholar 

Download references


The authors will like to acknowledge the late Prof. J.M. Boon (Department of Anatomy, University of Pretoria) and Prof. B. Singh (Department of Surgery, University of Kwa-Zulu Natal) for encouraging this project. This project was conducted in accordance with the Human Tissue Act of the Republic of South Africa.

Author information



Corresponding author

Correspondence to N. Pather.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Pather, N., Osman, M. Landmarks of the facial nerve: implications for parotidectomy. Surg Radiol Anat 28, 170–175 (2006).

Download citation


  • Facial nerve trunk
  • Facial nerve
  • Parotid gland
  • Landmarks
  • Anatomy
  • Parotid surgery