3. Largest among all
12 cranial nerve
Roots - sensory & motor
3 divisions from
sensory root
- ophthalmic
- maxillary
- mandibular
TRIGEMINAL NERVE
4. Trigeminal Nuclei
The sensory trigeminal nerve nuclei –
largest of the cranial nerve nuclei
extend through whole of the brainstem.
1. The mesencephalic nucleus
- proprioception
2. The chief sensory nucleus (or "pontine
nucleus" or "main sensory nucleus" or
"primary nucleus") – touch
3. The spinal trigeminal nucleus
– pain & temperature.
15. IN PTERYGOPALATINE FOSSA
1. ZYGOMATIC NERVE
enters orbit through
inferior orbital
fissure ,
it gives 2 branches
within inferior orbital
fissure
16. Zygomaticotemporal Nerve
- Runs along lateral orbital wall
- Appears in infratemporal region
- Supplies skin of temporal region after
piercing temporal fascia 2 cm above the
zygoma.
- Gives communicating branch to lacrimal
nerve.
- Supplies parasympethetic Secretomotor
fibres to lacrimal gland.
23. PHARYNGEAL BRANCH
Leaves the posterior part of
pterygopalatine ganglion
pharyngeal canal
Supplies the mucous
membrane of nasopharynx &
posterior part of eustachian tube.
24. 3. POSTERIOR SUPERIOR ALVEOLAR
NERVE (PSA)
generally 2 branches are there
It runs along with internal
maxillary artery.
27. 2. ANTERIOR SUPERIOR ALVEOLAR NERVE
Anterior superior alveolar
nerve
Arises 6-10 mm before
infraorbital groove
Descends in anterior
wall of maxillary sinus.
34. PTERYGOPALATINE GANGLION: connected to maxillary nerve in
infratemporal fossa
sensory to orbital septum, orbicularis and nasal cavity ,
maxillary sinus , palate , nasopharynx.
35.
36.
37. 4. OTIC GANGLION:
between trunk of mandibular nerve and tensor palatini
supplies post ganglionic
Parasympethetic secretomotor
fibres to parotid gland.
38. related to lingual nerve,
rests on hyoglossus muscle
supplies post ganglionic
Parasympethetic
secretomotor fibres to
submandibular and
sublingual gland.
5. SUBMANDIBULAR GANGLION:
39. Applied anatomy
Causes of injury to trigeminal nerve –
1. Maxillofacial surgical procedures
Orthognathic surgeries
third molar odontotomy
salivary gland surgeries
head & neck preprosthetic surgeries
Treatment of bening & malignent lesions
2. Trauma & facial fractures
3. Dental implant placement
4. Endodontic therapy
5. Tratment of pathology (specially periapical)
6. During administration of local anesthesia
40. TRIGEMINAL NEURALGIA –
TIC DOULOUREUX
relatively common
paroxysm of sudden intense,
shocking, stabbing onset of
facial pain
Involves One or more areas of
distribution Of the trigeminal Nerve
maxillary and mandibular
divisions are commonly involved
41. local lesions-
ophthalmic division : acute glaucoma
frontal sinusitis
maxillary division : caries
carcinoma of maxilla
empyema of maxillary sinus
mandibular division : caries
carcinoma or ulcer of tongue
TRIGGER ZONE
42. Surgical procedures for treatment
of trigeminal neuralgia -
Radiofrequency rhizotomy
Microvascular decompression of the nerve at pons
Percutaneous glycerol rhizotomy
Balloon compression rhizotomy
Peripheral Rhizotomy
Microsurgical Rhizotomy
43. Meckel's Cave
The average height
of this oval mouth
was found to be 4.2
mm (range 3-5 mm)
the average width
was 7.6 mm (range
6-8 mm).
located
- 12 mm
Source -
Turkish Neurosurgery
Official journal of neurological society
Anatomy of Meckel's Cave and the Trigeminal Ganglion: Anatomical Landmarks for a Safer Approach
to Them
2012, Volume 22, Number 3, Page(s) 317-323
44. Procedure Description in Short
Through the entry point—2.5 cm lateral to the corner of the mouth, a
specially designed needle with thin stylet was passed into foramen ovale.
45. The balloon catheter was introduced through the needle and navigated
into Meckel’s cave.
46. External Sinus Surgery
Andrew H. Murr, MD
JOURNAL OF AMERICAN RHINOLOGY SOCIETY
Revised 6/2011
care.american-rhinologic.org/external_sinus_surgery
48. ECTOPIC INFRAORBITAL NERVE IN A
MAXILLARY SINUS SEPTUM:
ANOTHER POTENTIALLY DANGEROUS
VARIANT FOR SINUS SURGERY
P. Mailleux1, O. Desgain2, M.I. Ingabire1
Evidence in Health and Social Care
(Online journal)
www.rbrs.org/dbfiles/journalarticle_0814.pdf
World Neurosurg. 2011 Sep-Oct;7 2010,
93: 308-309 ; discussion 266-7
51. Trauma to bones of skull & face
malar fractures-Trauma to infraorbital margin may cause
sensory loss of infraorbital skin.
52. MAXILLARY SINUS
INFECTIONS
Infections of the maxillary sinus may cause
infraorbital pain or
may cause referred pain to other structures
supplied by Vb (e.g. upper teeth).
53. Maxillary teeth abscesses
The roots of the maxillary teeth (especially
the second molars)
are intimately related to the
maxillary sinus. Root abscesses are painful.
54. Hay fever
This is usually allergic,
but the symptoms could be produced by
involvement of parasympathetic “fellow travellers”
with the maxillary nerve.
55. Nerve injury in orthognathic
surgery
Neurosensory impairment in the greater palatine and
infraorbital nerves may be encountered after maxillary
osteotomies.
herkules.oulu.fi/isbn9514269934/html/x486.html
Correction of dentofacial deformities with
orthognathic surgery: Outcome of treatment
with special reference to costs, benefits and risks
Chapter 2. Review of the literature
(De Jongh et al. 1986, Karas et al. 1990, De Mol van Otterloo et al. 1991).
2.5. Complications and adverse effects of orthognathic surgery
Source -
56. Maxillary antrum tumours
Malignant tumours of the mucous lining of the
maxillary antrum
may expand into the orbit,
damaging branches of V(infraorbita)l.
anaesthesia over the facial skin.
The orbital contents may also be displaced causing
proptosis and/or a squint.
57. TUMOR SPREAD ALONG
INFRAORBITAL NERVE
World Neurosurg. 2011 Sep-Oct;76(3-4):335-41;
discussion 266-7 (online journal)
medinfo.ufl.edu/year1/trigem/top_clin.html
A case of BASAL CELL CARCINOMA
58. Histopathology -
A case of BASAL CELL CARCINOMA
typical nuclear palisading at the peripheral layer of the tumor
59. Nasopharyngeal Carcinoma
Source –
Maxillary Nerve Involvement in Nasopharyngeal
carcinoma, American Journal of Roentgenology
AJR:167, November 1996
V.F.H.Chong1 and Y.F. Fan
60. A, Axial unenhanced T1-weighted MR image shows
enlargement of right pterygopalatine fossa (asterisk).
Note
normal fat-filled left pterygopalatine fossa (arrow).
61. B, Axial contrast-enhanced T1-weighted MR image reveals
tumor enhancement in pterygopalatine fossa with
spread into cavernous sinus (arrowheads).
62. C, Coronal unenhanced T1-weighted MR image shows enlargeing
right maxillary nerve of intermediate signal intensity
(black arrow). Note tumor infiltration of right vidian canal (white
arrow).
63. E, Axial unenhanced Ti-weighted MR image inferior to D shows tumor
infiltration in pterygopalatine fossa and
infratemporal wall of right maxillary sinus (arrow) and extension into
infratemporal fossa (asterisk).
64. G, Coronal CT scan (bone window) shows tumor in
pterygopalatine fossa (asterisk). Note enlarged maxillary
nerve groove (thick arrow) and normal left maxillary nerve (thin
arrow).
65. Trigeminal neurinomas extending into multiple
fossae: surgical methods and review of the
literature.
We present a 38-year-old female with a giant dumbbell-shaped
trigeminal neurinoma originating primarily in the middle cranial
fossa,
extending to the infratemporal and posterior fossae through the
foramen ovale and Meckel's cave, respectively.
Because of the large tumour extension into the Infratemporal Fossa, a
combined skull base approach (zygomatic infratemporal -
transmandibular) was utilised for tumour removal, with a subsequent
excellent outcome.
Journals of Neurosurgery 1999 Aug;91(2):202-11.
Source - Trigeminal neurinomas extending into multiple fossae: surgical methods and review of
the literature.2005 Nov;21(11):1008-11. Epub 2005 Mar 16.
Department of Neurology, University Medical Center St Radboud, Nijmegen, The
Netherlands.
66. Trigeminal Neurinoma
Prof. Dr. med. Henry W. S. Schroeder,
Universitätsmedizin Greifswald
A case report by -
Clinic & polyclinic for neurosurgery
Microscopic (A) and endoscopic (B) image of trigeminal neurinoma. In
front of the tumor one can see vestibular nerves (short arrow).
(A) (B)
67. THE MRI IMAGES SHOW THE TUMOUR IN THE
CEREBELLOPONTINE ANGLE
68. The final inspection shows complete tumor
removal.
Removal of tumor
Tumor under endoscopic visual control
Tumor under the operating microscope
visual control
70. Dumbbell trigeminal schwannoma in a child:
complete removal by a one-stage pterional
surgical approach.
PATIENT AND
METHODS:
A 6-year-old girl presented
with tiredness, dysarthric
speech and cerebellar
symptoms.
Imaging studies
Source - Dumbbell trigeminal schwannoma in a child: complete removal by a one-stage pterional
surgical approach. childs Nerv Syst. 2005 Nov;21(11):1008-11. Epub 2005 Mar 16.
Department of Neurology, University Medical Center St Radboud, Nijmegen, The Netherlands.
www.ncbi.nlm.nih.gov/pubmed/15770515
71. One-stage surgery
was performed by
pterional craniotomy.
The tumour was first
debulked in the middle
fossa, then peeled
from the wall of the
cavernous sinus,
followed by extirpation
of the tumour from the
posterior fossa.
Histopathological
72. Trigeminal neuropathy
sensory loss of face or weakness of the jaw muscles
causes- SLE, sjogren syndrome
herpes zoster, leprosy
meningioma, schwanomma
Wallenberg syndrome
vertebral artery occlusion
infarction of lateral medulla
symptoms - ipsilateral facial sensory loss,
ipsilateral horners,
ipsilateral IX,X,XI palsy
ipsilateral cerebellar ataxia ,
contralateral sensory loss
75. Cont….
III, IV, VI th cranial NERVE palsy
Progressive proptosis
Post. Herpetic neuralgias
Treatment
PHN- anlgesic, anti depressants, trigeminal rhizotomy and
stellate ganglion block.
76. STURGE WEBER SYNDROME
encephalotrigeminal angiomatosis
port-wine stain
rare congenital neurological & skin disorder
often associated with port-wine stains of the
face, glaucoma, seizures, mental retardation
77. Neurotrophic keratitis
Occurs due to partial or complete corneal anaesthesia due to loss of sensory
innervation by the trigeminal N.
There is impaired response to corneal microtrauma as a result of impaired
regeneration and healing of corneal epithelium
Causes: infections - HSV, VZV, leprosy
traumatic V N injury
ablation of gasserian ganglion
chemical burns
topical anaesthatic abuse,
betablockrs,
NSIDS
contact lens wear
systemic: DM, stroke, brainstem
haemorrhage, aneurysm
congenital
78. Raeders paratrigeminal syndrome
Oculosympathetic paresis with pain in distribution of
trigeminal Nerve.
Pt. with episodic chronic pain
Pain and headache
Trigeminal hyperasthesia seen in area supplied by
post ganglionic fibers.
79.
80. Raeder’s paratrigeminal syndrome
Pulling pain over the left zygomatic region
which radiated two days later to an area behind
& below the left ear.
Pain presented at mourning & reoccurred at
nigtht .
Wooshing & buzzing sound in left ear.
Numbness over the left side of face.
Blurred vision.
Unable to bite.
Left nostril appeared blocked.
81. Cavernous sinus syndrome
- multiple cranial neuropathies
- exophthalmos, ocular motor
defects, horners syndrome,
sensory loss in V1 and / or V2.
Cavernous sinus syndrome is a
medical emergency, requiring
prompt medical attention,
diagnosis, and treatment
82.
83. Potential causes of cavernous
sinus syndrome include –
1. metastatic tumors,
2. direct extension of nasopharyngeal
tumors,
3. meningioma,
4. pituitary tumors,
5. aneurysms of the intracavernous
carotid artery
6. cavernous-carotid arteriovenous fistula,
7. bacterial infection causing cavernous
sinus thrombosis,
8. aseptic thrombosis,
9. fungal infections.
84. Gradenigo’s syndrome
Petrous bone osteitis due to
suppurative otitis media
Characterized by -
- ipsilateral trigeminal Nerve
palsy (Va, Vb)
- retro orbital pain
- ipsilateral sixth N palsy.
85. Clinical testing
Test skin sensation of lower eyelid, cheek and upper lip.
Three simple clinical tests for trigeminal nerve function:
(1) sensation: apply gentle touch, pinpricks, or warm or cold
objects to areas supplied by the nerve and note responses;
(2) reflex: try the jaw jerk and eye and sneeze reflexes;
(3) motor function: test the patient’s ability to chew and work
against resistance and observe contraction of the massater and
temporal muscles by visual examination and digital palpation.
86. Purpose of test -
1. Is there any loss of senssation ????
2. Where the lesion is present ????
- peripheral branches
- gasserian ganglion
92. Pontine lesion affecting chief sensory nucleus.
causes –
1. Vascular diseases
2. Pontine tumor
3. Brain stem displacement d
due to large tumor
93. Causes –
lesions of descending root due
to
1. syringobulbia
2. foramen magnum tumor
3. bulbar vascular accidents
94. In case of anomalous development or occlusion of
posterior inferior cerebellar artery –
loss of pain & temperature in
- ipsilateral half face
- contralateral opposite half of body
97. RESOURSES
Text book – Malamad’s local anesthesia
Harrison’s principle of internal medicine
Peterson’s principle of oral & maxillofacial surgery
Anesthesia/ dentoalveolar surgery/ office management
-by Frost, Harsh & Levin
Online sources -
Turkish Neurosurgery
Official journal of neurological society, 2012, Volume 22, Number 3, Page(s) 317-323
Anatomy of Meckel's Cave and the Trigeminal Ganglion: Anatomical Landmarks for
a Safer Approach to Them
JOURNAL OF AMERICAN RHINOLOGY SOCIETY, Revised 6/2011
External Sinus Surgery,Andrew H. Murr, MD
98. Evidence in Health and Social Care,
World Neurosurg. 2011 Sep-Oct;7 2010, 93: 308-309 ; discussion 266-7
ECTOPIC INFRAORBITAL NERVE IN A MAXILLARY SINUS SEPTUM:
ANOTHER POTENTIALLY DANGEROUS VARIANT FOR SINUS SURGERY
P. Mailleux1, O. Desgain2, M.I. Ingabire1
(De Jongh et al. 1986, Karas et al. 1990, De Mol van Otterloo et al. 1991).
2.5. Complications and adverse effects of orthognathic surgery
World Neurosurg. 2011 Sep-Oct;76(3-4):335-41; discussion 266-7 (online journal),
TUMOR SPREAD ALONG INFRAORBITAL NERVE
Journals of Neurosurgery 1999 Aug;91(2):202-11.
Trigeminal neurinomas extending into multiple fossae: surgical methods and review of the
literature.2005 Nov;21(11):1008-11. Epub 2005 Mar 16.
Department of Neurology, University Medical Center St Radboud, Nijmegen, The
Netherlands.
99. Dumbbell trigeminal schwannoma in a child: complete removal by a one-stage
pterional surgical approach. childs Nerv Syst. 2005 Nov;21(11):1008-11. Epub 2005 Mar
16.
Department of Neurology, University Medical Center St Radboud, Nijmegen, The
Netherlands.
Maxillary Nerve Involvement in Nasopharyngeal carcinoma,
American Journal of Roentgenology
AJR:167, November 1996
V.F.H.Chong1 and Y.F. Fan
The Ciliary Ganglion (ophthalmic or lenticular ganglion) (Figs. 775, 777).—The ciliary ganglion is a small, sympathetic ganglion, of a reddish-gray color, and about the size of a pin’s head; it is situated at the back part of the orbit, in some loose fat between the optic nerve and the Rectus lateralis muscle, lying generally on the lateral side of the ophthalmic artery.Its roots are three in number, and enter its posterior border. One, the long or sensory root, is derived from the nasociliary nerve, and joins its postero-superior angle. The second, the short or motor root, is a thick nerve (occasionally divided into two parts) derived from the branch of the oculomotor nerve to the Obliquus inferior, and connected with the postero-inferior angle of the ganglion. The motor root is supposed to contain sympathetic efferent fibers (preganglionic fibers) from the nucleus of the third nerve in the mid-brain to the ciliary ganglion where they form synapses with neurons whose fibers (postganglionic) pass to the Ciliary muscle and to Sphincter muscle of the pupil. The third, the sympathetic root, is a slender filament from the cavernous plexus of the sympathetic; it is frequently blended with the long root. According to Tiedemann, the ciliary ganglion receives a twig of communication from the sphenopalatine ganglion.Its branches are the short ciliary nerves. These are delicate filaments, from six to ten in number, which arise from the forepart of the ganglion in two bundles connected with its superior and inferior angles; the lower bundle is the larger. They run forward with the ciliary arteries in a wavy course, one set above and the other below the optic nerve, and are accompanied by the long ciliary nerves from the nasociliary. They pierce the sclera at the back part of the bulb of the eye, pass forward in delicate grooves on the inner surface of the sclera, and are distributed to the Ciliaris muscle, iris, and cornea. Tiedemann has described a small branch as penetrating the optic nerve with the arteriacentralisretinæ.
During administration of local anesthesia – prilocaine & atricaine causes long term paresthesia.
Detailed and sound knowledge of the microsurgical anatomy of Meckel's cave, which borders on surgically important structures, such as the internal carotid artery and cavernous sinus, is essential to performing precise microneurosurgery in this region. This study describes the complex anatomy of Meckel's cave and surrounding structures to provide the knowledge needed to devise a more complete surgical strategy and establish accurate orientation during the surgical procedure.
For PBC Mullanpercutaneous trigeminal ganglion microcompression set (Cook Vascular Inc., US) was used. Patient was positioned supine on the operating table. Procedures were done in general anesthesia with a short-acting anesthetic agent. X-ray control of pyramid and foramen ovale was performed. A specially designed 14-gauge needle with thin stylet was passed 6 cm into the depth towards foramen ovale through entry point located 2.5 cm lateral to the corner of the mouth (Figure 1). Foramen ovale was entered with dull tip of stylet. X-ray control of needle position was made and the balloon catheter was introduced through the needle and navigated into Meckel’s cave. The position of tip was confirmed by using a C-arm fluoroscopic image intensifier in both anteroposterior and lateral views. About 1 mL of water-soluble contrast (iohexol) was injected to inflate the balloon, until ideal pear shape of the balloon was acquired (Figure 2). The duration of inflation depended upon the duration of the disease (longer course of disease, longer time of inflation). After one to five minutes the balloon was deflated and the needle and catheter were removed simultaneously. Firm pressure was applied to the cheek for some minutes. The patients were discharged after an overnight stay.
Creation of large antrostomies, however, is now a somewhat controversial topic amongst rhinologists. A competing technology to the creation of large surgical drainage openings was popularized by Ruben Setliff and is referred to as “small hole” or “small fenestra” surgery. Also, the development of balloon technologies to expand natural sinus drainage tracts has been recently refined which have a theoretical advantage of requiring less sinus surgical disruption to achieve improvement of chronic sinusitis symptoms. One of the new balloon technologies actually uses a Caldwell-Luc approach to place the balloon through a small incision in the gum under the upper lip much as described in the original operation. The advantage of the Caldwell-Luc approach in this setting is that it allows a more direct approach to the natural ostium of the maxillary sinus for balloon placement using endoscopic instrumentation and causes less disruption of the ethmoid sinus anatomy.
Axial CT scan slices, from top to bottom. A. Upper part of the maxillarysinus.B,C, slightly below A: the septum (straight arrow ) starts from the lateral sinuswall. Within it the infraorbital nerve (curved arrow) .D: lower portion of the sinus , withoutseptum. CT parameters in both cases were the following: 64 slices MDCT , 0625 mmthin slices, 100 kV, 50 mA resulting in patient 1 in a CTD/vol of 2,74 mGy, DLP 37,5 mGycmand 1,5 mSev
The incidence of prolonged sensitivity disturbances has been reported to be less than 4%, and they do not seem to bother the patients.
revealed a unilateral dumbbell-shaped tumor, extending into both the middle and posterior fossa, centred over Meckel's cave.
SymptomsSturge–Weber syndrome is manifested at birth by seizures accompanied by a large port-wine stain birthmark on the forehead and upper eyelid of one side of the face. The birthmark can vary in color from light pink to deep purple and is caused by an overabundance of capillaries around the ophthalmic branch of the trigeminal nerve, just under the surface of the face. There is also malformation of blood vessels in the pia mater overlying the brain on the same side of the head as the birthmark. This causes calcification of tissue and loss of nerve cells in the cerebral cortex. Neurological symptoms include seizures that begin in infancy and may worsen with age. Convulsions usually happen on the side of the body opposite the birthmark and vary in severity. There may be muscle weakness on the same side.[clarification needed] Some children will have developmental delays and mental retardation; about 50% will have glaucoma (optic neuropathy often associated with increased intraocular pressure), which can be present at birth or develop later. Increased pressure within the eye can cause the eyeball to enlarge and bulge out of its socket (buphthalmos). Sturge–Weber syndrome rarely affects other body organs.
Potential causes of cavernous sinus syndrome include metastatic tumors, direct extension of nasopharyngeal tumors, meningioma, pituitary tumors or pituitary apoplexy, aneurysms of the intracavernous carotid artery, cavernous-carotid arteriovenous fistula, bacterial infection causing cavernous sinus thrombosis, aseptic thrombosis, idiopathic granulomatous disease (Tolosa-Hunt syndrome), and fungal infections. Cavernous sinus syndrome is a medical emergency, requiring prompt medical attention, diagnosis, and treatment
Syringobulbia is a medical condition when syrinxes, or fluid filled cavities, affect the brainstem. This defect normally results from congenital abnormality, trauma or tumor growth.Syringomyelia ( /sɪˌrɪŋɡɵmaɪˈiːliə/) is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord. The damage may result in pain, paralysis, weakness,[1] and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. The disorder generally leads to a cape-like loss of pain and temperature sensation along the back and arms. Each patient experiences a different combination of symptoms. These symptoms typically vary depending on the extent and, often more critically, to the location of the syrinx within the spinal cord.
