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Appropriate management of facial nerve disorders requires a thorough knowledge of the pathophysiology of the diseases affecting the facial nerve, experience in the interpretation of findings on radiologic and electrophysiologic tests of the nerve, and expertise in multiple neuro-otologic surgical approaches to the facial nerve.

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The middle fossa craniotomy surgical approach provides access to the canalicular, labyrinthine, geniculate and proximal tympanic segments of the nerve while preserving hearing but is technically challenging. The middle cranial fossa approach can be used for facial nerve decompression in palsy, facial nerve tumor decompression or removal, and facial nerve grafting in the internal auditory canal, and to address facial nerve impingement resulting from longitudinal temporal bone fractures.

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A transmastoid approach can be used to address pathologic processes involving the tympanic and mastoid segments of the facial nerve while preserving inner ear function. Total facial nerve decompression can be achieved using the transmastoid approach in combination with a middle fossa craniotomy.

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The translabyrinthine approach provides access to the entirety of the intratemporal facial nerve for decompression, mobilization, or grafting when no usable hearing remains.

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Retrolabyrinthine and retrosigmoid approaches provide access to the cisternal segment of the facial nerve while preserving hearing and can be used for vascular decompression and combined with other approaches for facial nerve grafting at the brainstem.

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Anterior rerouting of the facial nerve from the geniculate to the extratemporal segment, as in the Fisch type A approach, can be performed with normal facial function possible postoperatively.

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The most important element of successful facial nerve repair is a tension-free anastomosis. An interposition graft, using the great auricular or sural nerve, should be used for nerve repair in all cases in which a tension-free end-to-end anastomosis cannot be achieved.

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In general, facial nerve tumors should be observed in patients with House-Brackmann grade I or II function. Surgical decompression is a management option for patients with facial nerve tumors and House-Brackmann grade II or III function. Tumor resection with facial nerve grafting is recommended for patients with House-Brackmann grade IV function or worse due to a facial nerve tumor.