Trigeminal Nerve (CN V)

Trigeminal Nerve
(CN V)
The trigeminal nerve is a
mixed nerve. It possesses
a larger component
(portio major) consisting
of sensory fibers for the
face, and a smaller
component (portio
minor) consisting of
motor fibers for the
muscles of mastication.
Trigeminal ganglion
and brainstem nuclei.
The sensory trigeminal nerve nucleus is the
largest of the cranial nerve nuclei, and
extends through the whole of the brainstem
, midbrain to medulla.
The nucleus is divided into three parts,
from rostral to caudal (top to bottom in
humans):
The mesencephalic nucleus The peripheral
processes of neurons in this nucleus receive
impulses from peripheral receptors in the
muscle spindles in the muscles of
mastication, and from other receptors that
respond to pressure.
The chief sensory nucleus (or "pontine
nucleus") for touch and discrimination.
The spinal trigeminal nucleus for pain and
temperature
There is also a distinct 
trigeminal motor nucleus that is medial to
the chief sensory nucleus.
 The trigeminal ganglion is located
at the base of the skull over the apex
of the petrous bone, just lateral to the
posterolateral portion of the
cavernous sinus. It gives off the three
branches of the trigeminal nerve to
the different areas of the face, i.e., the
ophthalmic nerve (V1), which exits
from the skull through the superior
orbital fissure;
The maxillary nerve (V2), which
exits through the foramen rotundum
The mandibular nerve (V3),
which exits through the
foramen ovale.
Ophthalmic Nerve
Ophthalmic nerve gives rise to 3 terminal
branches: frontal, lacrimal and nasociliary, which
innervate the skin and mucous membrane of
derivatives of the frontonasal prominence
derivatives: Forehead and scalp,Frontal and
ethmoidal sinus, Upper eyelid and its
conjunctiva,Cornea,Dorsum of the nose.
Parasympathetic Supply: 
parasympathetic innervation to the lacrimal gland.
Maxillary nerve gives rise to 14 terminal branches,
which innervate the skin, mucous membranes and
sinuses of derivatives of the maxillary
prominence of the 1st pharyngeal arch: Lower
eyelid and its conjunctiva, Cheeks and maxillary
sinus, Nasal cavity and lateral nose, Upper lip,
Upper molar, incisor and canine teeth and the
associated gingiva Superior palate
Parasympathetic Supply:
Lacrimal gland: parasympathetic innervation to
the lacrimal gland.
Nasal glands: Parasympathetic fibres are also
carried to the mucous glands of the nasal mucosa.
Mandibular nerve gives rise to four terminal
branches in the infra-temporal
fossa: buccal nerve, inferior alveolar nerve,
 auriculotemporal nerve and lingual nerve. These
branches innervate the skin, mucous membrane and
striated muscle derivatives of the mandibular
prominence of the 1st pharyngeal arch.
Sensory supply:
Mucous membranes and floor of the oral cavity
External ear ,Lower lip, Chin, Anterior 2/3 of the
tongue (only general sensation; special taste
sensation supplied by the chorda tympani, a branch
of the facial nerve). Lower molar, incisor and
canine teeth and the associated gingiva
Motor Supply:
Muscles of mastication; medial pterygoid, lateral
pterygoid, masseter, temporalis. Anterior belly of
the digastric muscle and the mylohyoid muscle.
Tensor veli palatini, Tensor tympani
Parasympathetic Supply:
Submandibular and Sublingual glands: Post-
ganglionic fibres from the submandibular ganglion
travel with the lingual nerve to innervate these
glands.
The second neurons that emerge from the spinal
nucleus of the trigeminal nerve traverse the pons and
midbrain, toward the thalamus, where they terminate
in the ventral posteromedial nucleus The axons of the
thalamic (third) neurons in the trigeminal pathway
then ascend in the posterior limb of the internal capsule
to the caudal portion of the postcentral gyrus.
Motor trigeminal fibers. The motor nucleus from which
the motor fibers located in the pontine tegmentum, just
medial to the principal sensory nucleus of the trigeminal
nerve. The portio minor exits the skull through the
foramen ovale together with the mandibular nerve and
innervates the masseter, temporalis, and medial and
lateral pterygoid muscles, as well as the tensor veli
palatini, the tensor tympani, the mylohyoid muscle, and
the anterior belly of the digastric muscle
The motor nuclei (and, through them, the muscles of
mastication) are under the influence of cortical centers
that project to them by way of the corticonuclear tract.
This supranuclear pathway is mostly crossed, but there is
also a substantial ipsilateral projection. This accounts for
the fact that a unilateral in- terruption of the
supranuclear trigeminal pathway does not produce any
noticeable weakness of the muscles of mastication.
The supranuclear pathway originates in neurons of the
caudal portion of the precentral gyrus.
 Lesions of the motor trigeminal fibers
A nuclear or peripheral lesion of the
motor trigeminal pathway produces
flaccid weakness of the muscles of
mastication.
This type of weakness, if unilateral, can
be detected by palpation of the masseter
and temporalis muscles while the
patient clamps his or her jaw: the
normally palpable muscle contraction is
absent on the side of the lesion. When
the patient then opens his or her mouth
and protrudes the lower jaw, the jaw
deviates to the side of the lesion,
because the force of the contralateral
pterygoid muscle predominates. In such
cases, the masseteric or jaw-jerk reflex is
absent
the TrigeminalDisorders Affecting Nerve

Trigeminal neuralgia. The classic variety of

trigeminal neuralgia is characterized by
paroxysms of intense, lightning or “lancilike
pain in the distribution of one or more
branches of the trigeminal nerve. The pain can
be evoked by touching the face in one or more
particularly sensitive areas (“trigger zones”).
Typical types of stimuli that trigger pain
include washing, shaving, and tooth-brushing.
in particular, there is no sensory deficit on the
face.
The pain can be significantly diminished, or
even eliminated, in 80­% of cases by medical
treatment alone, either with carbamazepine or
with gabapentin, which has recently come into
use for this purpose. Neurosurgical intervention
is indicated only if the pain becomes refractory
to medication. The options for neurosurgical
treatment include, among others,
microvascular decompression (mentioned
above) and selective percutaneous
thermocoaguation of the nociceptive fibers of
the trigeminal nerve.
 The most common cause of symptomatic
trigeminal neuralgia is multiple sclero- sis:
2.4 % of all MS patients develop
trigeminal neuralgia; among these
patients, 14 % have it bilaterally.
Other, rarer causes of symptomatic pain
in the distribution of the trigeminal nerve
include dental lesions, sinusitis, bony
fractures, and tumors of the
cerebellopontine angle, the nose, or the
mouth. Pain in the eye or forehead should
also arouse suspicion of glaucoma or iritis.
The pain of acute glaucoma can mimic that
  of classic trigeminal neuralgia.
Gradenigo syndrome consists of pain in
the distribution of the ophthalmic nerve
accompanied by ipsilateral abducens palsy.
It is caused by infection in the air cells of
the petrous apex.
 Differential Diagnosis: Disorders with Facial Pain in the Absence of a
•  
Trigeminal Lesion
Charlin neuralgia consists of pain at the inner canthus of the eye and root of the nose
accompanied by increased lacrimation. It is thought to be due to irritation of the ciliary
ganglion.
Cluster headache is also known as Bing­Horton syndrome, erythroprosopalgia, and
histamine headache. It is characterized by brief attacks of pain occurring mainly at night,
including during sleep (in distinction to trigeminal neuralgia). These attacks are
accompanied by facial erythema, lacrimation, watery nasal secretion, and often Horner
syndrome as well. Typical provocative factors include high altitude, alcohol consumption,
and the taking of nitroglycerin (glyceryl trinitrate). The attacks occur repeatedly in periods
(clusters) characteristically lasting a week or more, separated by headache-free intervals of
at least two weeks’ duration. There is as yet no consensus on the pathophysiology of this
disorder. Its treatment is empirical, with oxygen, triptanes, or other medications.