Trigeminal nerve (CN V)

The trigeminal nerve (CN V) transmits both sensory information about facial sensation
and motor information to the muscles of mastication.

 Ophthalmic (V1): carries sensory information from the scalp and forehead, nose,
upper eyelid as well as the conjunctiva and cornea of the eye.
 Maxillary (V2): carries sensory information from the lower eyelid, cheek, nares,
upper lip, upper teeth and gums.
 Mandibular (V3): carries sensory information from the chin, jaw, lower lip,
mouth, lower teeth and gums. Also carries motor information to the muscles of
mastication (masseter, temporal muscle and the medial/lateral pterygoids) as
well as the tensor tympani, tensor veli palatini, mylohyoid and digastric muscles.

Sensory assessment

First, explain the modalities of sensation you are going to assess (e.g. light
touch/pinprick) to the patient by demonstrating on their sternum.

Ask the patient to close their eyes and say ‘yes’ each time they feel you touch their face.

Assess the sensory component of V1, V2 and V3 by testing light touch and pinprick

 Forehead (lateral aspect): ophthalmic (V1)

 Cheek: maxillary (V2)
 Lower jaw (avoid the angle of the mandible as it is supplied by C2/C3):
mandibular branch (V3)

You should compare each region on both sides of the face to allow the patient to
identify subtle differences in sensation.

Motor assessment

Use the muscles of mastication to assess the motor component of V3:

 Inspect the temporalis and masseter muscles for evidence of wasting. This is
typically most noticeable in the temporalis muscles, where a hollowing effect in
the temple region is observed.

 Palpate the masseter & temporalis muscles bilaterally whilst asking the patient to
clench their teeth to allow you to assess and compare muscle bulk.

 Ask the patient to open their mouth whilst you apply resistance underneath the
jaw to assess the lateral pterygoid muscles. An inability to open the jaw against
resistance or deviation of the jaw (typically to the side of the lesion) may occur in
trigeminal nerve palsy.
Reflexes

Jaw jerk reflex

The jaw jerk reflex is a stretch reflex that involves the slight jerking of the jaw upwards
in response to a downward tap. This response is exaggerated in patients with an UML.
Both afferent and efferent pathways of the jaw jerk reflex involve the trigeminal nerve.

To assess the jaw jerk reflex:

 Clearly explain what the procedure Ask the patient to open their mouth.
 Place your finger horizontally across the patient’s chin.
 Tap your finger gently with the tendon hammer.
 In healthy individuals, this should trigger a slight closure of the mouth. In pt with
UML, the jaw may briskly move upwards causing the mouth to close completely.

Corneal reflex
The corneal reflex involves involuntary blinking of both eyelids in response to unilateral
corneal stimulation (direct and consensual blinking). The afferent branch of the corneal
reflex involves V1 of the trigeminal nerve whereas the efferent branch is mediated by
the temporal and zygomatic branches of the facial nerve.

To assess the corneal reflex:

 Clearly explain what the procedure will involve to the patient and gain consent to
proceed.
 Gently touch the edge of the cornea using a wisp of cotton wool.
 In healthy individuals, you should observe both direct and consensual blinking.
The absence of a blinking response suggests pathology involving either the
trigeminal or facial nerve.

Trigeminal nerve abnormalities

 Wasting of the masseter and temporalis muscles (especially in the LMNL or after a
long time of UMNL)
 Jaw deviation to the affected side (when the patient opens her/his mouth)
 Exaggerated jaw jerk→UMNL
 Absent jaw jerk→ LMNL