Cranial Nerves

part 1

Moderators:
Dr. Chaitnya Kothari

Presented by:
Dr. Shahid Khan
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 Trigeminal Nerve
• largest cranial nerve.
• 2 functional components:
General somatic afferent (GSA,
somatosensory) - sensation
from face, eye, nasal and oral
cavities.
Special visceral efferent (SVE,
motor) - muscles of
mastication
• The trigeminal n. also innervates
most of the dura mater.
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2 Roots:
Larger Sensory Root
Smaller Motor Root

3 primary divisions:
Ophthalmic ( V1) - sensory
- innervates the upper portion
of the face
Maxillary (V2)- sensory –
innervates the mid face region
Mandibular (V3)
-sensory+motor – innervates
the lower facial region

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 Nuclei

Spinal trigeminal
nucleus
•In the medulla and
pons (C1-C3).
•Pain and temperature
input
•To Ventro Posterior
Medial nucleus of
thalamus
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 Nuclei

Main sensory nucleus

•In the pontine tegmentum

•Tactile input from the face
•to VPM of thalamus

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 Nuclei

Mesencephalic nucleus
•Accompany the motor
branches to the muscles of
mastication and extra
ocular muscles.
•End on muscle spindle
and proprioceptive
receptors.

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 Nuclei
Motor nucleus
•In pontine tegmentum
•Innervates muscles:
•mastication
•tensor tympani
•tensor veli
palatini
•Mylohyoid
•Ant. Belly of
digastric 7
 GANGLIONS
SEMILUNAR GANGLION (GASSERIAN)
• Occupies a cavity (cavum Meckelii) in the Dura
mater covering trigeminal impression near - apex
of the petrous temporal bone.

• Crescentic in shape.

• Motor root runs - front and medial to the sensory

root & passes beneath the ganglion.

• Leaves the skull - foramen ovale - immediately

below this foramen - joins the mandibular nerve.
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• Give off minute branches - tentorium cerebelli and
to dura mater in the middle cranial fossa.
• From its convex border three large nerves arises
Ophthalmic
Maxillary and
Mandibular.
• Ophthalmic and Maxillary - exclusively of sensory
fibers.
• Mandibular is joined outside the cranium by the
motor root.

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CILIARY GANGLION (Lenticular ganglion)

• Situated - back part of the orbit - on the lateral side of the

ophthalmic artery.
• Its roots are 3 in number and enter its posterior border.

Long or Sensory Root

-Derived from the nasociliary nerve.

Short or Motor Root

- Derived from the branch of the oculomotor nerve

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SPHENOPALATINE GANGLION (ganglion of
Meckel)

• Triangular or heart-shaped, of a reddish-gray

color.

• Situated just below the maxillary nerve as it

crosses the fossa.

• It receives a sensory, a motor, and a sympathetic

root.

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OTIC GANGLION:

• Small, oval shaped,reddish-gray color ganglion

- situated immediately below the foramen ovale.
• Lies - medial surface of the mandibular nerve.

DISTRIBUTION:
• A filament to the
Tensor tympani.
Tensor veli palatini.

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SUBMAXILLARY GANGLION:

• Small size & fusiform in shape.

• Situated above the deep portion of the submaxillary
gland.

DISTRIBUTION:
• Arise - from the lower part of the ganglion.
• Supply - mucous membrane of the mouth and the duct
of the submaxillary gland.

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OPHTHALMIC BRANCH OF TN
• First division of the trigeminal.
• Is a sensory nerve. supplies skin over forehead
and scalp back to about the level of line
connecting the two external acoustic meatus.
• Smallest of the three divisions of the trigeminal.
• Arises - upper part of the semi lunar ganglion as a
short, flattened band, about 2.5 cm. long ,passes
forward along the lateral wall of the cavernous
sinus,below the oculomotor and trochlear nerves.
• Before entering the orbit through superior orbital
fissure, it divides into three branches,
Lacrimal,
Frontal and
Nasociliary. 17
 Nasocilliary
Travel along medial border of the orbital roof
Give branches to nasal cavity
Ant. ethmoidal post.ethmoidal long cilliary infra trochlear
Mucous memb. Ethmoidal &
Of nasal septum, sphenoidal sinuses Iris skin of
cornea lacrimal
sac,
lacrimal
caruncle

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 Frontal nerve
Supra orbital Supra trochlear
Upper eyelid,scalp conjuctiva,skin of
medial aspect of
upper eyelid,skin
over forehead

Lacrimal nerve
Lateral part of upper eyelid,adjacent skin

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MAXILLARY BRANCH OF TN
• Second division of the trigeminal nerve.

• Is a sensory nerve.

• It begins - middle of semilunar ganglion as a

flattened plexiform band, passing horizontally
forward - leaves the skull , foramen rotundum.

• Then crosses - pterygopalatine fossa - enters the

orbit through the inferior orbital fissure - it
traverses the infraorbital groove and canal in the
floor of the orbit and appears on the face -
infraorbital foramen
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 Branches of
Maxillary Nerve
In the cranium Middle Meningeal Nerve
In the Pterygopalatine Zygomatic
fossa Sphenopalatine
Posterior Superior
Alveolar
In the Infraorbital Canal Anterior Superior
Alveolar
Middle Superior Alveolar
On the Face Inferior Palpebral
External Nasal
Superior Labial 23
 Maxillary divison(v2)
From middle of the gaserion ganglion it travels
anteriorly & downwords

Branche Within cranium –Middle minengial nerve

Run along with middle minengial

artery, sensory innervation to dura
matter.

Exit cranium from foramen rotundum 24

Within pterigopalatine fossa
Zygomatic pterygopalatine nerve
inferior.orbital fissure pterygopalatine ganglion
Zygomatico temporal zygomatico facial
Skin of forehead to skin of cheek

Orbital nasal/nasopalatine palatine pharyngeal

Periosteum roof of nasal cavity, greater palatine nerve pharyngial canal
of orbit mucous memb.&ant. Part g.p.foramen supplies to nasal
of nasal septum, runs muco periosteum & part of pharynx
incisive canal hard palate
incisive foramen supplies soft tissues ant. to
rt.&lt. nasopalatine nerve 1st PM
supplies hard palate -1 to 3 Lesser palatine nerve
lesser palatine foramen &supplies
mucous memb. Of soft palate &
tonsillar region.
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 Post. Superior alveolar nerve
1st trunk 2nd trunk
External to bone inters into maxilla
Buccal gingiva sensory innervation to
In maxillary molars sinus, alveolus,pdl of
maxillary
molars(exception -mesio
buccal root of 1st molars)

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In infra orbital canal
MSA nerve ASA nerve

1st & 2nd PM region supplies antarior wall of

Mesiobuccal root of 1st M maxillray sinus &

supplies 1 to 3.
PDL, buccal soft tissue, bone
(in 30% cases, it is absent then
Psa & Asa
Provides its supplies).
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In the face

Inferior pulpaberal external nasal sup. Labial

Skin of lower eyelid skin of lateral skin,mucous
aspect of nose
memb.,upper
lip.

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MAXILLARY NERVE BRANCHES
A. Zygoticaticotemporal
B. Zygomaticofacial
C. Post. Sup. Alveolar
D. Nasopalatine
E. Greater Palatine
F. Lesser Palatine
G. Mid. & Ant. Alveolar
H. Infraorbital

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Mandibullar division v3
Origin motor root sensory root
motor nucleus of pons gasserion ganglion
& medulla oblongata
Foramen ovale
Branches from undivided nerve:
Nervus spinosum medial pterygoid
enters along middle minengial medial pterygoid
artery through foramen muscle
spinosum small branches to tensor
to supply dura matter,mastoid air cells. velli palatini, tensor r
tympani.

Runs under the lateral pterygoid muscles

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Branches From antarior division:
Buccal/long buccal n. masseteric deep temporal lateral pterygoid

Sensory supply to mucous

Memb. Of cheek &buccal
part of mand. Molars.
Passes between the two
heads of lateral pterygoid motor supply to related muscles
At the level of occlusal plane
Between 2nd &3rd molar it
crosses ant.
Border of the ramus &
enters into cheek
through buccinator muscles.

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Branches from posterior division:
Auriculo temporal lingual nerve inferior alveolar nerve
Sensory supply to medial to IAN& lateral medial to lingual nerve &
parotid gland, pterygoid muscle. lateral pterygoid,runs on
external auditory medial surface of ramus
meatus,TMJ, in pterygomandibular space. Along with inf. alveolar

Temporal region. sensory supply to ant. 2/3rd artery & vein.

of the tongue, mucous memb. Supplies mandi. molars of floor of
the mouth,lingual before entering mental
aspect of the gingiva foramen it divides into
mylohyoid nerve.
in mental foramen

incisive nerve mental nerve

mandi. Incisors & PM’s chin & lower lips.

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 MANDIBULAR NERVE
BRANCHES (posterior division)

A. Auriculotemporal
B. Lingual
C. Inferior Alveolar
D. N. to the
Mylohyoid
E. Mental
F. Buccal

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 TRIGEMINAL NERVE REFLEXES
• Pains referred - various branches of the trigeminal
nerve are of very frequent occurrence - should always
lead to a careful examination in order to discover a
local cause.
• General rule - diffusion of pain - various branches of
the nerve is at first confined to the main divisions -
search for the causative lesion – commence -
thorough examination of all those parts which are
supplied by that division.
• Severe cases pain may radiate over the branches of
the other main divisions.

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• Commonest example - neuralgia which is so often
associated with dental caries.

• Examples of trigeminal reflexes

Dealing with the ophthalmic nerve - severe
supraorbital pain - commonly associated with
acute glaucoma or with disease of the frontal
or ethmoidal air cells.

Malignant growths or empyema of the

maxillary antrum or unhealthy conditions about
the inferior conchæ or the septum of the nose are
often found giving rise to “second division”
neuralgia - should be always looked for in the
absence of dental disease in the maxilla.

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• On the mandibular nerve
With patients who c/o pain in the ear, in whom
there is no sign of any disease and the cause is
usually to be found in a carious tooth in the
mandible.

With an ulcer or cancer of the tongue - often the

first pain to be experienced is one which
radiates to the ear and temporal fossa - over the
distribution of the auriculotemporal nerve.

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TRIGEMINAL NEURALGIA

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 TRIGEMINAL NEURALGIA
INTRODUCTION:
• Causes facial pain. 
• TN develops in mid to late life.
• The condition is the most frequently
occurring of all the nerve pain
disorders.
• The pain which comes and goes -
feels like bursts of sharp, stabbing,
electric-shocks.
• This pain can last from a few
seconds to a few minutes.

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• People with TN become plagued by intermittent
severe pain that interferes with common daily
activities such as eating and sleep.

• They live in fear of unpredictable painful attacks,

which leads to sleep deprivation and under-eating.

• The condition can lead to

Irritability
Severe anticipatory anxiety and
Depression
Life-threatening malnutrition.
Suicidal depression is not uncommon.

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• Pain of TN occurs - exclusively in the maxillary and mandibular divisions.

• Most commonly - feel pain in the maxillary nerve, which runs along
cheekbone, most of nose, upper lip, and upper teeth.

• Next most commonly affected is the mandibular nerve affecting - lower

cheek, lower lip, and jaw.

• Almost all cases (97%), pain will be restricted to one side of your face.

• TN - frequently affects women older than 50 years.

• The disease occurs rarely in those younger than 30 years.

• Such cases are usually linked to damage from diseases of central nervous
system for example - multiple sclerosis.

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CAUSES OF TRIGEMINAL NEURALGIA?

• In the vast majority of cases of TN the exact cause

is unknown. Injury to the face or oral surgery.

• Autoimmune disorders - immune system attacks

the person's own body. These include SLE
(Lupus), Multiple Sclerosis and Scleroderma.
• Herpes Zoster - extremely painful viral infection
affecting the nerves.
• An abnormality in the arteries or blood vessels
which can result in compression of the nerve.

• Malignant or non-malignant tumors which may

also compress the nerve.
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DIAGNOSIS OF TRIGEMINAL NEURALGIA:
• There are no specific tests to diagnose trigeminal
neuralgia.

• However, there is a very specific type of pain

associated with this condition which will enable you
to make a proper diagnosis.

• Some tests may be carried out in order to rule out

other possible causes of facial pain such as diseases
of the jaw, gums, teeth or sinuses.

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TYPES OF TRIGEMINAL NEURALGIA:
TYPICAL TN:
• The superior cerebellar artery - most often
responsible for neurovascular compression upon
the trigeminal nerve root.

• All typical TN are caused - blood vessels

compressing the trigeminal nerve root as it enters
the brain stem.

• Pulsation of vessels upon the TN root do not

visibly damage the nerve.

• Irritation from repeated pulsations - changes of

nerve function and delivery of abnormal signals to
the trigeminal nerve nucleus. 43
ATYPICAL TN:

• Vascular compression is cause of many cases of

atypical TN.

• Atypical TN is due to vascular compression upon

a specific part of the trigeminal nerve.

• Atypical TN pain can be at least partially relieved

with medications used for typical TN such as
carbamazepine.

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TREATMENT:

• Medications - first line of treatment for TN and

include carbamazepine , phenytoin, gabapentin
and baclophen.

• As the disease progresses and pain becomes more

frequent and severe, increased doses of
medications are required - lead to intolerable side
effects or inadequate pain control.

• The surgical procedures then considered are

either microvascular decompression surgery or
some form of nerve injury procedure.
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SURGICAL MICROVASCULAR DECOMPRESSION:
• Walter Dandy pioneered the posterior fossa
approach for treatment of TN.

This is done to rule out other causes of compression of

the TN, such as- Mass lesions
Large catatic vessels
Other vascular malformations

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OPERATIVE TECHNIQUE:
• Incision – 2.5 to 6 cm in length is made 2 cm
posterior to mastoid process.

• After reflecting the muscle, fascia & pericranium

from the calvarium – craniectomy is performed.

• Usually 2.5 to 3 cm in size, high & laterally in the

posterior fossa – exposing the caudal edge of
lateral sinus & its junction with sigmoid sinus.

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• An incision made in dura mater under lateral
sinus & extends caudally.

• By using binacular microscope superior vein

identified & coagulated.

• Arachnoid is opened exposing TN

• After sharp & blunt dissection of arachnoid, it is

possible to identify vessels related to root entry
zone.

• Vessel loops gently teased out b/w TN & pons in

horizontal position.
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• An implant made of one or multiple pieces of
Teflon ,placed b/w vessel & nerve.

• After implant placement, dura is closed.

• A methylmethacrylate cranioplasty can be

performed.

• Incision placed in layers & small dry dressing is

applied.

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ASSESSMENT:
• CN V tested by assessing facial sensation to light
touch & pain on the
forehead (V1)
cheeks (V2)
chin (V3)
• Performed with use of cotton wisp & safety pin.
• Temperature – applying hot or cold objects.
• Muscular innervation – palpating temporal &
masseter muscles & having pt clench teeth while
observing for deviation of jaw or asymmetry in muscle
contraction.
• Corneal reflex – ask the pt to look away from
examiner while cotton wisp is used to touch cornea. If
reflex is intact – both eyes will blink. 50
• Trauma which results in skull #, tumors & facial
surgery – all result in disturbances of peripheral
branches of sensory component of CN V.
• Presents as decrease in sensation to the area
served by peripheral nerve.
• Trigeminal neuralgia – pain in lips, gums, cheek
or chin without sensory loss.
• Trigeminal neuropathy – caused by tumors
,schwannomas of CN V or lesions in cavernous
sinus.
• Lead to asymmetry of jaw on opening or weakness
with mastication.

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 References
1. Gray’s anatomy, 38th ed. 1995
2. Human anatomy, Regional and Applied –
by B.D. Chaurasia’s, vol 3.1996
3. Hollenshead.WH.Anatomy for
surgeons.The Head and Neck,1968
4. Local anesthesia,stanley F. Malamaid

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THANK YOU…

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