Topognosis (Topographic Diagnosis)

Of Facial Nerve Lesions

OTTO JEPSEN, MD, ARHUS, DENMARK

trophic center for these fibers. It is generally

TOPOGRAPHIC diagnosis of facial nerve agreed that the most frequent pathway from the
lesions may provide valuable information as to geniculate ganglion is the intermedius nerve.
clinical diagnosis, treatment, and prognosis. 4. General visceral afferent fibers, the
A detailed knowledge of the anatomy and trophic center of which is the geniculate gan
physiology of the facial nerve is necessary for glion. These fibers are believed to be concerned
estimating the various problems related to the with deep sensibility from the facial muscles
differential topographic diagnosis of facial and sensory impulses from part of the tympanic
nerve lesions.
membrane, the external auditory meatus, and
the tympanic cavity. The fibers pass through
Survey of the Anatomy and the intermedius nerve to the nucleus of the
Physiology of the Facial Nerve
solitary tract.
Embryologically, the facial nerve belongs to The central nuclei appertaining to the facial
the second branchial (hyoid) arch, from which
nerve are the motor nucleus, the superior
the facial musculature is developed. It is a
and the nucleus of the solitary
mixed nerve, containing four components with salivary nucleus,
tract.
different functions, two efferent and two 1. The motor nucleus of the facial nerve is
afferent divisions.
1. Special visceral efferent fibers, supplying situated in the caudal part of the pons behind
striated musculature (the muscles of expression the superior olivary nucleus and the trapezoid
of the face and neck, the stylohyoid, the poste- body. Several divisions may be distinguished,
rior belly of the digastric and the stapedius). each of which supplies certain facial muscles.
which
2. General visceral efferent fibers, the trophic The superior part of the facial nucleus,
center of which is the superior salivary nucleus. supplies the frontal and orbicularis oculi mus
is bilaterally from
These fibers represent the parasympathetic cles, innervated the cortex,
efferent component of the nerve and proceed to while the inferior part receives unilateral crossed
the lacrimal gland via the greater petrosal nerve, cortical innervation (Fig 1).
while other parasympathetic fibers proceed to In addition to impulses from the pyramidal
the submaxillary and sublingual glands via the tract, the motor nucleus of the facial nerve re
chorda tympani. ceives fibers from the superior colliculus (visual
3. Special visceral afferent fibers, conveying reflex center), from the nucleus of the solitary
taste impulses from the anterior two thirds of tract (taste), from the sensory trigeminal nuclei,
the tongue. The geniculate ganglion is the and from the acoustic nuclei. There is thus a
Submitted for publication Oct 17, 1964. possibility of a large number of reflexes in which
Read before the Symposium on Management of the motor nucleus of the facial nerve may
Facial Palsies, Copenhagen, May 23-26, 1964, under the participate.
auspices of the Danish Otolaryngological Society. In this connection the most important is the
Lecturer of Otolaryngology, University of \l=A%o\rhus.
Reprint requests to \l=O/\reafdelingen,Kommunehos- acoustic stapedius reflex, the presumed course
pitalet, \l=A%o\rhus,Denmark. of which is shown in Fig 2.

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 posterior surface of the petrous temporal bone
to the internal acoustic meatus. The facial nerve
lies immediately above the acoustic nerve, rest
ing in a groove on the superior aspect of the
latter. The approximate length of this course
is 23-24 mm.
B. In the Internal Acoustic Meatus.Here
the facial, intermedius, and acoustic nerves run
transversely in the same mutual relation as in
the posterior cranial fossa. In the floor of the
meatus, the nerves perforate the dura, and now
the facial nerve proceeds through the area nervi
facialis in the bottom of the internal acoustic
VII NUCLEUS/
meatus. The approximate length of its course
through the internal acoustic meatus is 7-8 mm.
C. In the Facial Canal.Here the course of
PONS the facial nerve may be divided into three seg
ments. In the first (labyrinthine) segment,
which is 3-4 mm in length, the nerve runs for
wards and laterally, almost at a right angle to
the longitudinal axis of the petrous temporal
bone, slightly above the cochlea and vestibule.
In a sharp curve, the geniculum, it turns into
the second (tympanic) segment. The geniculate
ganglion lies at the junction of the first and
Fig 1.The upper part of the motor nucleus of the second segments. The second
facial nerve, which supplies the frontal and orbicularis segment runs
oculi muscles, is bilaterally innervated from the cor backwards and laterally, parallel to the longi
tex, while the inferior part receives unilateral crossed tudinal axis of the petrous bone, and slightly
cortical innervation.
downwards in close relation to the medial wall
2. The superior salivary nucleus is situated of the tympanic cavity above the fenestra vesti-
dorsal to the caudal part of the motor nucleus buli and below the lateral semicircular canal.
of the facial nerve. The nucleus conveys para The approximate length of the second segment
sympathetic secretory impulses to the lacrimal, isruns12-13 mm. The third (mastoid) segment
submaxillary, and sublingual glands, while the rior almost vertically downwards in the poste
wall of the tympanic cavity to the
parotid gland receives parasympathetic secretory
stylomastoid foramen. The length of the third
impulses from the inferior salivary nucleus 15-20
segment is mm.
(glossopharyngeal nerve).
3. The nucleus of the solitary tract lies in the D. In the Parotid Gland.Immediately after
its exit from the stylomastoid foramen, the
medulla oblongata just lateral to the dorsal vago-
facial nerve changes its course, passing down
glossopharyngeal nucleus. It is the terminal wards and forwards into the parotid gland. At
nucleus for both the general and special visceral
a distance of 15-20 mm from the stylomastoid
afferent fibers from the facial nerve and for
nerve divides into an upper and
fibers from the vagus and glossopharyngeal foramen the
lower division with several subdivisions, form
nerves.
ing the parotid plexus.
Anatomical Divisions of the
Course of the Facial Nerve Branches From the Facial Nerve
A. In the Posterior Cranial Fossa.From A distinction may be made between branches
its superficial origin at the inferior border of within and outside the temporal bone.
the pons the facial nerve proceeds, together A. Branches Within the Temporal Bone.1.
with the acoustic nerve, forwards, upwards, and The greater petrosal nerve arises from the
laterally across the jugular tubercle up on the geniculate ganglion and ends in the spheno-

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 palatine ganglion in the pterygopalatine fossa.
The nerve conveys parasympathetic secretory
to the lacrimal, palatine, and nasal
impulses
glands.
2. The stapedial branches off in the
nerve
upper part of the third segment of the facial
canal and passes forwards and medially to the
pyramidal eminence, which is a small conical
projection on the posterior wall of the tympanic
cavity. Through a minute bony canal the nerve
passes into the cavity of the pyramidal eminence
and supplies the stapedius muscle.
3. The chorda tympani arises from the facial
nerve in the third segment of the facial canal,
some 5 mm above the stylomastoid foramen,
passing upwards and forwards through the
tympanic cavity to reach the lingual nerve in
the parapharyngeal space. The chorda tympani
may be regarded as an anastomosis between
the facial and lingual nerves, carrying mainly
taste fibers from the anterior two thirds of the
tongue.
B. Branches Outside the Temporal Bone.
Immediately below the stylomastoid foramen
some small branches leave the trunk of the facial
nerve, viz, (1) a sensory twig to the external
acoustic meatus (Ramsay-Hunt's zone) and
(2) motor fibers, which supply the posterior and
superior auricular muscles, the stylohyoid mus
cle, and the posterior belly of the digastric mus
cle. In the parotid gland the facial nerve spreads
out in numerous terminal branches supplying
the musculature of expression of the face and
neck.
Clinical Importance of
Topognosis (Topographic Diagnosis)
A great variety of different affections may
give rise to the well-known clinical picture of
peripheral facial palsy, in which the muscles of
the entire ipsilateral half of the face are in
volved. This picture may be encountered (a) in
pontine lesions, (b) in lesions situated in the
posterior cranial fossa between the pons and
the internal auditory meatus, (c) in lesions
situated in the temporal bone, and (d) in extra-
temporal lesions.
In addition, certain types of facial palsy of
central origin, caused by deep-seated extensive
lesions of the temporal lobe, may give rise to
signs of motor deficiency of the same type as
those seen in peripheral facial palsy ("pseudo-
peripheral" or "temporal" facial palsy).
A. Owing to the close proximity of other
centers and pathways, pontine lesions will
usually, in addition to facial palsy, be associated
with other affections, such as paralysis of the
eye muscles (abducens paralysis or conjugate
ocular paralysis) and pyramidal and lemniscal
involvement. However, isolated lesions of the
motor nucleus of the facial nerve may be en
countered. This is not uncommon, for example,
in poliomyelitis (polioencephalitis), in acute epi
demic encephalitis, and in multiple sclerosis. In
order to be able to differentiate these diseases
from the much more common Bell's palsy a
refined topognosis may be of importance.
B. In lesions situated in the posterior cranial
fossa, facial palsy will generally be associated
with acoustic and vestibular symptoms.

Fig 2.Diagram of
presumed course of acous
tic stapedius reflex arc.
A indicates cochlea; B,
cochlear nerve ; C, pri
mary auditory centers ;
D, superior olivary nu
cleus ; E, facial motor
nucleus ; F, facial nerve ;
G, stapedius muscle and
stapes ; H, chorda tym
pani ; /, stylomastoid
foramen ; /, to temporal
lobe.

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 Fig 3.The acoustic measuring bridge, audiometer for stimulus tone, and tone genera
tor for test done. At right hand bottom corner the right side of the acoustic bridge with
variable impedance standard is shown on enlarged scale. O-B, brass tube in air-tight con
nection with ear ; M, telephone diaphragm ; C and D, side tubes united at A and connected
with ears of the examiner by means of auscultation tubes. Variable acoustic impedance
standard consists of a felt disk (P), which is fixed in end of a tube (W), outside diameter
of which corresponds to inside diameter of main tube; by means of a metal piston (S)
inserted into tube W, length of the air column (s) may be varied.

C. In lesions situated in the temporal bone,
facial palsy will often be the only manifestation.
A refined differential topognosis may in
certain cases of these lesions provide valuable
clinical and theoretical information concerning
factors of etiology, prognosis, and treatment.
It would be of great theoretical and clinical
significance to be able to locate the site of the
facial-nerve lesions, for example, in Bell's palsy,
in Melkersson's syndrome, in Ramsay-Hunt's
syndrome, and in various systemic diseases.
D. In extratemporal lesions associated evi
dence of tumor, injury, leprosy, myasthenia,
etc, is the rule. In extratemporal lesions caused
by tumor and injury, the facial palsy is often
confined to a single muscle-group.
Therapeutic Importance
of theTopognosis
During the last 20-30 years surgical measures
have become more common in the treatment of
lesions of the facial nerve. The more distal the
site of the lesion is in the facial canal, the easier
will surgical intervention be.
Today, however, the facial nerve may be re
paired along its course from its origin from the
brain to the peripheral ramifications. The type
of operation adopted and the difficulty of the
surgical intervention are different in the various
locations of the facial nerve lesions. An opera
tion for a nuclear and a supranuclear facial
lesion would scarcely be successful.
It is therefore of great importance to be able
to decide if the lesion of the facial nerve is
surgically accessible and to choose the most
appropriate surgen.
Methods of Investigation
The first question to be answered in a case
of facial paralysis is : Does the lesion affect the
upper motor neuron (supranuclear lesion) or
the lower motor neuron (nuclear and infra-
nuclear lesion) ?
The upper part of the facial nucleus which
supplies the frontal and orbicularis oculi muscles
is bilaterally innervated from the cortex, while
the inferior part receives unilateral crossed cor
tical innervation (Fig 1). In a supranuclear
lesion the lower third of the face will be para
lyzed, but wrinkling of the forehead and closure
of the eye will be preserved. The emotional in
nervation (as evidenced by the spontaneous
smile) may not be affected. This is now and
then the only reliable sign of a lesion of the
upper motor neuron, since an incomplete re
covery from a peripheral facial palsy, an extra-
cranial injury involving only the inferior
division of the facial nerve, and a nuclear lesion
restricted to the lower portion may give the clin
ical picture of a central facial palsy. The recog
nition of the site of central lesions is dependent
on the study of the whole symptom complex and
will not be discussed here.
Examination of Lacrimation,
Stapeduis Reflex and Taste
Theoretically, with a thorough knowledge of
the anatomy and the physiology of the facial

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 nerve, a of lacrimation, stapedius re
study
flexes, and should give valuable informa
taste
tion in peripheral facial nerve lesions (Erb,3
Tschiassny 23).
In the following discussion each of these
means will be mentioned, and a scheme valuable
for refined topognosis of peripheral facial
nerve lesions will be given.
1. Study of Lacrimation.Disturbances of
lacrimation are often encountered in affections
of the facial nerve. Most frequently, lesions of
the nerve will cause epiphora, but diminution
or loss of lacrimal secretion of the homolateral
eye may also be seen.
Before testing for lacrimation is considered,
it will be necessary to give a brief description of
the secretomotor nerve supply of the lacrimal
gland.
The secretory fibers originate from the supe
rior salivary nucleus, which is situated dorsal to
the caudal part of the motor nucleus of the
facial nerve. From the superior salivary nucleus
secretory fibers proceed via the intermedius
nerve through the geniculate ganglion, the
greater superficial petrosal nerve, and the nerve
of the pterygoid canal to the sphenopalatine
ganglion, from which they continue through the
sphenopalatine nerves to the maxillary and via
the zygomatic to the lacrimal nerve and the
lacrimal gland.
That the secretomotor fibers supplying the
lacrimal gland proceed along this course was
shown by Kster 14 in clinical and experimental
studies and confirmed by Wernoe2e and
Zilstorff-Pedersen.27 Accordingly, a lesion of the
facial nerve proximal to the geniculate ganglion
results in diminution or loss of lacrimation,
whereas an affection of the nerve distal to this
ganglion, ie, after the branching of the greater
superficial petrosal nerve, as a rule does not
cause disturbances of lacrimal secretion.
Even though the lesion of the facial nerve
does not involve the lacrimal secretomotor
fibers, a disturbance of lacrimation may occur,
viz, a tendency to "tearing" of the homolateral
eye.
There may be several causes for this epiph
ora, which is a very frequent symptom in pe
ripheral facial palsy.
1. Paralysis of Horner's muscle (pars lacri-
malis of the orbicularis oculi), the function of
which is, inter alia, to dilate the lacrimal sac.
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Due to the paralysis of Horner's muscle, the
nasolacrimal duct fails to take up the tears.
2. Paralysis of the orbicularis oculi muscle
may cause a slight ectropion resulting in mal
position of the puncta lacrimalia.
3. Absence of winking may cause corneal
irritation with ensuing epiphora.
The nasolacrimal reflex is elicited by stimula
tion of the nasal mucosa with chemical sub
stances (fumes of petrol) or mechanically by
means of a cotton applicator. By this stimula
tion, a vegetative bulbar reflex through the
maxillary nerve, the superior salivary nucleus,
and the lacrimal pathways excites lacrimal se
cretion and conjunctival hyperemia in both eyes,
but most pronounced on the homolateral side.
In a series of patients with confirmed regional
diagnoses the study of lacrimation gave the
following findings (Jepsen5): (1) The absence
of subjective and objective signs of abolished
or diminished lacrimation does not exclude pa
ralysis of lacrimal secretion. Attempts at excita
tion of the nasolacrimal reflex reveal the
disturbance of lacrimation. (2) Facial palsy
due to affections of the cerebellopontine angle
is associated with diminution or loss of lacrima
tion.
A quantitative measurement of the lacrima
tion is made by means of Schirmer's 18 blotting
paper test which is discussed in detail by
Zilstorff-Pedersen in the following paper.
Just to question the patient and look for dry-
ness of the eye is unsatisfactory, because the
Fig 4.Principle of electroacoustic impedance meas
uring bridge : A-B, audiometer and earphone for stimu
lus tone ; C-D, microphone and telephone for test tone ;
E, indicating meter ; F, phase and amplitude control ;
G, tone generator for test tone ; H, pump for variation
of pressure in meatus ; /, manometer.
 Fig 5.Change in the impedance of the tympanic membrane resulting from acoustically
elicited contraction of the stapedius muscle. Upper curve: stimulus tone (in this case 1,000 cps,
100 db). Time marker: 100 msec between the heavy vertical lines. (From Metz, 1951).

information obtained in this manner is unreli
able.
2. Study of Stapedius Reflexes.Detailed
studies on the middle-ear muscles in man have
previously been difficult to undertake. Only with
Metz's 15 investigations on acoustic impedance
did we obtain a reliable method for studying the
middle-ear muscle reflexes in man. In his
monograph "The Acoustic Impedance Meas
ured on Normal and Pathological Ears," which
is particularly concerned with the importance
of impedance measurements in the differential
diagnosis between conductive and perceptive
deafness, he demonstrated that in most indi
viduals a loud acoustic stimulus gives rise to a
distinct change in the impedance due to con
traction of the tympanic muscles. Metz ad
vanced the hypothesis that by this method of
examination it might be possible to throw light
on the function of the tympanic muscles in man.
Following this line, the middle-ear muscle
reflexes in man have been studied by impedance
measurements mainly in Scandinavian clinics
in man arestable phenomena and that the study
of these may be an excellent tool in studies of
the facial nerve and of the auditory system.
Technique: An acoustically elicited contrac
tion of the stapedius muscle will elicit a change
in the acoustic impedance of the ear. The im
pedance of the ear is recorded by a mechanical
acoustic measuring bridge (Fig 3), or by an
electroacoustic measuring device (Fig 4). By
means of these apparatus the unknown imped
ance of the tympanic membrane is balanced and
compared with a variable acoustic impedance
standard. The acoustic stapedius reflex is elicited
by conducting the stimulus tone to the contra-
lateral ear. Fig 5 demonstrates the impedance
change resulting from acoustically elicited
stapedius contraction.
For further particulars on the technique of
stapedius reflex recording the reader is referred
to Terkildsen and Scott Nielsen19 and
Jepsen.56
The threshold of the acoustic stapedius re
flexes was investigated by Jepsen in a control
5

during the last ten years.256'71719,20 series of 91 normal subjects, in whom both ears
These experimental and clinical investigations were examined. In all but one ear distinct
have shown that the middle-ear muscle reflexes stapedius reflexes could be elicited. Fig 6 shows

Fig 6.Thresholds of hearing and

stapedius reflexes, age groups 15-34 years
(88 ears). Heavy line above : average hear
ing threshold ; heavy line below : average
stapedius reflex threshold. Dotted lines
show range of variability.

500 1000 2000 4000 8C00 c,.

Arch OtolaryngVol 81, May, 1965

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Herpes Zoster of
Bell's Melkerson's Geniculate
Palsy Syndrome Ganglion
Nuclear
Suprageniculate
Transgeniculate 3 7
Suprastapedial 47
Infrastapedial 20
Infrachoidal 72
Questionable 7 12
Total 149
the threshold of the stapedius reflexes for a total
of 44 subjects from the control series whose
ages ranges from 15 to 34 years. It appears that
the threshold of acoustic stapedius reflexes de
pends not only on the intensity of the stimulus
tone but also on its frequency. High and low
tones have higher thresholds than those of the
middle-frequency band.
In affections of the facial nerve in which the
lesion is located centrally to the stapedial nerve,
the stapedius reflex on the side concerned can
not be elicited. In case of total facial paralysis,
where the stapedius reflex can be elicited in the
homolateral ear, the site of the lesion can with
certainty be localized peripherally to the branch
ing of the stapedius nerve. If the outcome of
the examination is negative, it must, however,
be borne in mind that conditions other than
facial paralysis may also abolish the reflex. This
applies especially to changes in the middle ear
and the tympanic membrane. Accordingly, the
otoscopie findings must be taken into considera
tion.
From this account it is evident that the study
of the stapedius reflexes in facial-nerve lesions
may be of topognostic value. This applies par-
Fig 7.Krarup's Elgustometer.
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A Series of 316 Patients With Facial Paralysis Classified
Traumatic Cerebello- Chronic
Facial pontine Leptomen- Tumor Eneepha-
Palsy Tumor ingitis of Pons litis
12
14
3
39 16
ticularly if the study of the stapedius reflex is
correlated with tests for taste and lacrimation
(Jepsen,5 Kristensen,13 Krarup11).
The subjective symptom of stapedioparalytic
phonophobia may be a valuable aid in topogno
sis, but, as pointed out by Tschiassny21 and
Jepsen,5 the absence of phonophobia does not
provide evidence of normal stapedius function,
since many patients with facial palsy in whom
the lesion is situated proximal to the stapedial
nerve do not present this symptom.
3. Study of the Sense of Taste.The course
of the fibers carrying taste impulses from the
anterior two thirds of the tongue to the central
nervous system has been the subject of a long
standing discussion. The literature contains
contradictory statements as to the course of the
fibers of taste from the geniculate ganglion to
the solitary nucleus of the medulla oblongata
(Jepsen 5).
This is probably partly due to the fact that
it has been customary to use unnecessarily high
concentrations of testing solutions, so that there
was no certainty that the receptors of common
sensation were not being stimulated. Moreover
it is difficult to prevent the test fluid from
spreading over the tongue and affecting ad
jacent areas.
In patients with confirmed regional diagnoses
of facial palsy the following findings were made
by using a quantitative test employing solutions
of substances representing the four taste qual
ities : sweet, sour, salt, and bitter (Jepsen5):
(1) Facial-nerve lesions in the peripheral por
tion of the third (mastoid) segment of the facial
canal or peripheral to the stylomastoid foramen
were not associated with loss of taste. (2)
Facial-nerve lesions with a more extensive and
proximal localization in the third (mastoid)
segment of the facial canal were associated with
According to Clinical and Regional Diagnoses
Vascular Congenital Leukemia; Peri-
Polio- Multiple Encepha- Polyradic- Poly- Facial Sarcoid- Infectious arteritis Question-
encephalitis Sclerosis lopathy ulitis neuritis Palsy osis Mononucleosis Nodosa able Total

37
70
26
2 92
17 53

316

loss of taste. (3) Facial-nerve lesions of the
portion of the nerve occupying the posterior
cranial fossa and, possibly, the internal acoustic
meatus may or may not be associated with loss
of taste.
Using a quantitative electrogustometric tech
nique in investigations on a series of patients
operated on for an acoustic neurinoma,
Krarup 12 concluded that the taste fibers from
the anterior part of the tongue pass centrally
via the homolateral intermedius nerve.
For clinical work electrogustometry is prob
ably the most suitable technique (Krarup10).
For a detailed account on electrogustometry the
reader is referred to Krarup.10
Here it will suffice to give a brief description
of the principle underlying the method of test
ing the taste by electrical stimulation. It is based
on the phenomenon that a galvanic current ap
plied to the tongue evokes a taste sensation of
an acid, metallic character. Krarup's 10 descrip
tion of his apparatus ("Elgustometer") and
method of investigation is as follows :
The current for the Elgustometer is produced
by a dry battery of 120 adjusted to 100 v.
a Helicalpotentiometer. The current is led
through large resistances to eliminate the great
variability of the electrode resistance at various
current intensities.
The stimulus is recorded in special units
called electric gust units (EGU) assessed as
follows: The measuring scale, from 5.75^amp
to 300juamp, is divided into 37 divisions with
constant percentage variation from unit to unit.
The units are marked out on a big circular scale
where the hand is coupled to the axis of the
potentiometer.
Stainless steel electrodes are used. The tongue
is stimulated with the anode. The different elec
trodes, which have a circular contact area 5 mm
in diameter, are of two typesone has a short
shaft for placing on the anterior part of the
tongue and the other has a long insulated shaft
for posterior placing. The different electrode is
mounted in a holder equipped with a silent and,
to the patient, invisible switch. The electrode
can thus be placed on the
tongue partly with and
partly without current. The indifferent electrode
(cathode) is a disk 4 5
by cm which is placed
on a piece of gauze moistened with saline solu

The stimulus is regulated with the aid of tion and attached to the wrist.

Regional diagnosis Taste Lacrimation Stapedius

reflex

Motor nucleus Nuclear.

Fig 8. Topog-
nostic classification of
Int. audit, meatus. Suprageniculatc.
peripheral facial- Geniculate gangl.
Transgeniculate.
nerve lesions based on the Greater sup. petros. nerve
anatomy and functions of Suprastapedial...
the facial nerve.
Stapedial nerve
Infrastapedial. .

Chorda tympani
Infrachordal. 1
+
Stylomastoid foramen

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 For stimulation of the anterior part of the
tongue, the electrode is placed about 1.5 cm
from the midline, close to the edge, so that the
papillae only are covered by the electrode; for
the posterior part, the anode is placed laterally
at the base at the circumvallate papillae. The
stimulus is applied for 1 to li/a seconds.
A demonstration is first undertaken to enable
the patient to sense impression, partly by the
application of the electrode minus current and
partly with a supraliminal electric stimulus.
With this double stimulation, a threshold de
termination with descending values is carried
out to the point where the patient can no longer
distinguish between the two applications. The
left and right sides of the tongue are taken
alternately. Another threshold determination is
then carried out with the same double stimula
tion but this time with increasing values, com
mencing some EGU below the threshold first
found until a difference can again be registered.
The final threshold is obtained as the average
of the values from further sets of measurements
taken as describedthe number of measure
ments depending on the patient's ability to react
in threshold determination.
Tests should be given in a quiet room, with
only the examiner and patient present. The
tongue should be relaxed and resting on the
lower lip; the mouth should be half open. The
patient must not be allowed to bite his tongue,
and in order to prevent the tongue from drying,
the patient should withdraw the tongue into the
mouth between each test. Before a test, the
electrodes are warmed by friction to feel
pleasantly warm on the back of the hand.
The time taken for this test is approximately
the same as for another type of threshold deter
minationpure tone audiometry.
Scheme for Topognosis
Studies of lacrimation, stapedius reflexes, and
taste in patients with confirmed regional diag
noses were carried out by Jepsen.5 On the basis
of these studies the patients were classified in
the following groups which represent different
segments of the facial nerve: (1) below the
branching of the chorda tympani (infrachordal),
(2) between the chorda tympani and the
stapedial nerve (infrastapedial), (3) between
the stapedial nerve and the geniculate ganglion
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(suprastapedial), and (4) between the genicu
late ganglion and the motor nucleus (supra-
geniculate). In addition, on the basis of
theoretical considerations a transgeniculate and
a nuclear group may be established in which
the interruption of the nerve is located in the
geniculate ganglion or in the motor nucleus,
respectively.
It may be expected that a transgeniculate
affection will result in abolished taste and
lacrimation and paralysis of the stapedius,
while unimpaired taste and lacrimation and pa
ralysis of the stapedius will be found in the
presence of a nuclear affection.
It is impossible on the basis of tests for
lacrimal secretion, stapedius reflexes, and taste
to differentiate between transgeniculate and
suprageniculate lesions. Other diagnostic tests
must be utilized, such as tests for vestibular
function and hearing, roentgen examination,
and
spinal-fluid studies, ophthalmological ex
amination.
A brief survey of the topognostic classifica
tion based on the anatomy and function of the
facial nerve is given in Fig 8. This classification
was originally used by Tschiassny.21
The Table shows a series of 316 patients with
facial paralysis divided into the above-mentioned
groups according to the regional and clinical
diagnoses.
Most of the patients were cured during the
observation period. In parallel with oras often
was the casepreceding the improvement of
the function of the facial muscles, the stapedial
function returned to normal, sometimes pre
ceded by a period with impaired stapedial func
tion, ie, paresis of the stapedius. The same
observation was often made in studies of the
taste function.5'11,13 The examination thus
proved to be of prognostic significance as re
gards the functions of the facial muscles and
at the same time to be of significance for the
therapy especially concerning the problem if
decompression of the facial nerve was indicated
or not.
From the above-mentioned observations it is
seen that the study of the stapedius reflexes
correlated with tests for taste and lacrimation
offers the following three advantages.
A. An increased possibility of differentiating
between infrachordal and nuclear lesions of the
facial nerve. This may be of importance when
it is to be decided if a patient should be sub
jected to decompression.
B. A possibility of subdividing the second
and third segments of the course of the facial
nerve in its bony canal into an infrastapedial
and a suprastapedial portion. Normally, this may
not be of much practical importance, but in
decompression operations of the facial nerve
it may be of significance to know if the lesion
of the facial nerve is situated in the distal or
proximal part of the facial canal.
C. The method used in the study of the
stapedius reflexes incorporates the great advan
tage that it is an objective method, which does
not require cooperation on the part of the pa
tient.
The investigations have shown (1) that it
will scarcely be permissible to draw far-reach
ing conclusions from topognostic studies except advantages.
in the presence of complete facial palsy and (2)
that the tests for lacrimation, stapedius reflexes,
and taste will not always suffice to make a cor
rect regional diagnosis of lesions of the facial
nerve. The past history of the patient and other
diagnostic aids must also be utilized.
This is due to the fact that, just like most infrastapedial and a suprastapedial portion. The
other diagnostic techniques, the three methods test for stapedius reflexes is an objective
of examination are separately only of limited method.
value.
The study of the stapedius reflexes is beset
with the limitation that, as a rule, definite re
sults can be obtained only in the presence of
normal tympanic membranes. The same is often
the case as to taste examination.
The cutaneous stapedius reflex 2 and Klock-
hoff's tensor reflex 7 may be of value when no
acoustic stapedius reflex is recordable.
Summary
Testing for lacrimation, stapedius reflexes,
and taste was carried out in patients with facial
nerve lesions, which had been confirmed by
operation. On the basis of these studies the pa
tients were classified in the following groups,
which represent different segments of the facial
nerve:
1. Below the branching of the chorda tympani
(infrachordal)
2. Between the chorda tympani and the
stapedial nerve (infrastapedial)
3. Between the stapedial nerve and the genic
ulate ganglion (suprastapedial)
4. Between the geniculate ganglion and the
motor nucleus (suprageniculate).
In addition, on the basis of theoretical consider
ations a transgeniculate and a nuclear group
may be established in which the interruption of
the nerve is located in the geniculate ganglion
or in the motor nucleus, respectively.
A series of patients with peripheral facial
paralysis (316 patients) was divided into these
groups according to the regional and clinical
diagnoses. In this way it was demonstrated,
inter alia, that the interruption of the nerve in
Bell's palsy almost invariably is situated
peripheral to the geniculate ganglion in the
facial canal.
The study of the stapedius reflexes correlated
with tests for lacrimation and taste offers certain
1. A possibility of differentiating between
infrachordal and nuclear lesions of the facial
nerve.
2. A possibility of subdividing the course of
the facial nerve in its bony canal into an
However, the studies have shown that the
testsfor lacrimation, stapedius reflexes, and
taste will not always suffice to make a correct
regional diagnosis of lesions of the facial nerve.
The past history and other diagnostic aids must
also be utilized.
A refined topognosis of facial nerve lesions
may provide valuable information as to clinical
diagnosis, treatment, and prognosis.
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NUGGETS OF
LASTING VALUE

The type of prosthesis used after stapedectomy is important in sound transmission. Heavier
prostheses do not improve high frequency transmission. Anderson et al took pictures of the
ossicular chain and prostheses in postmortem humans and showed how violent sounds can dislocate
the prosthesis and cause sudden hearing loss. None of the prostheses tested seemed to consist of
steel wires crimped around the edge of the incus. It is difficult to visualize how such a contact
could be dislocated even by very intensive sounds. With a polyethylene or Teflon prosthesis that is
merely inserted underneath the incus, however, dislocation might readily occur as Anderson has
pointed out.
Anderson, H. C. ; Hanson, C. C. ; and Neergaard, E. B. : Experimental Studies on Sound
Transmission in Human Ear, Acta Otolaryng 57 :231-234, 1964.

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