NERVE SUPPLY OF HEAD AND NECK

Contents :

Introduction to cranial nerves Trigeminal nerve in detail Clinical implications of trigeminal nerve Recent trends in approach to nerve disorders of maxillofacial region References
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Introduction to cranial nerves

Cranial nervesarenervesthat emerge directly from thebrain, in contrast tospinal nerves which emerge from segments of thespinal cord. In humans, there are traditionally 12 pairs of cranial nerves. Only the first and the second pair emerge from thecerebrum; the remaining 10 pairs emerge from thebrainstem.
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THE TRIGEMINAL NERVE

Contents:

Introduction Origin and course Nuclei Introduction video Connections Gasserian ganglion Branches
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Introduction to trigeminal nerve

largest and most complex of the 12 cranial nerves (CNs). supplies sensations to the face, mucous membranes, and other structures of the head. motor nerve for the muscles of mastication and contains proprioceptive fibers.

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It exits the brain by a smaller motor root and a large sensory root coming out of the side of the pons near its upper border at its junction with the middle cerebral peduncle, the former being situated in front of and medial to the latter. The motor root unites with the sensory root of the mandibular division to form a single nerve trunk. 5/25/12

Nuclei of the trigeminal nerve Acranial nerve nucleusis a collection

ofneurons(gray matter) in thebrain stemthat is associated with one or morecranial nerves. Axonscarrying information to and from the cranial nerves form asynapsefirst at thesenuclei. Lesions occurring at these nuclei can lead to effects resembling those seen by the severing of nerve(s) they are associated with. All the nuclei excepting that of the IV http://en.wikipedia.org/wiki/Cranial_nerve_nucleus nerve for later supply nerves of the same side of the body. 1. Chief
study on cranial nerve nucleus and its organisation

sensory
2. 3.

Motor Mesencephal ic

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Sensory nucleus

located in the pons quite extensive receives ordinary sensations from the main 3 branches of thetrigeminal nerve :ophthalmic division is in the lower part of the nucleus, and the mandibular branch is in the upper part. The large rostral head is the main sensory nucleus. The caudal tapered part is the spinal tract, which is continuous with substantia gelatinosa of Rolando in the spinal cord.

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The spinal tract

the sensory nucleus, primarily for pain afterLuigi and temperature. It is named Rolando.) The main sensory nucleus serves mostly for discrimination sense1,2,3,4,5
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(The apex of theposterior hornof the gray matter of thespinal cordis capped by a V-shaped or crescentic mass of translucent, gelatinous neuroglia (Glial cells), termed thesubstantia gelatinosa of Rolando(orSGR) (orgelatinous substance of posterior horn of spinal cord), which contains bothneurogliacells, and smallnerve cells. The gelatinous appearance is due to a very low concentration of is myelinated fibers.

Motor nucleus:

lies ventral-medial to the sensory nucleus, near the lateral angle of the fourth ventricle in the rostral part of the Pons ventricular system lateral ventricle supply the muscles of mastication (masseter, temporalis and lateral and medial pterygoid muscles), as well as the tensor tympani, tensor veli palatini, anterior belly of digastric and the mylohyoid muscles. Lesions involving motor V or the motor fibers in the trigeminal nerve result in ATROPHY of the muscles listed above ipsilateral to the lesion. Since the pterygoids OPEN 5/25/12 the jaw in concert with a downward and opposing inward

Clinical aspect:

Mesencephalic nucleus:

located beneath the lateral edge of the floor of the fourth ventricle in the pons and in the lateral region of the periaqueductal grey matter in the midbrain. Most of the peripheral processes of mesencephalic V neurons occupy the motor root of the trigeminal nerve and are distributed to muscle spindles in the muscles of mastication. The central processes of mesencephalic V neurons terminate within motor nucleus V. This connection establishes the stretch reflex originating in the muscle spindles of the masticatory muscles, together with a reflex for the control of the force of the bite. Function : unconscious proprioception from muscle 5/25/12 spindles-

Points to remember

a) Pain and temperature

Spinal tract nucleus V Chief sensory nucleus V

b) 2-pt. discrimination, vibration, conscious proprioception

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Mesencephalic nucleus V

Introduction video :

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The main sensory nucleus receives its afferents (as the sensory root) from the semilunar ganglion through the lateral part of the pons ventral surface. Its axons cross to the other side, ascending to the thalamic nuclei to relay in the postcentral cerebral cortex. The descending sensory fibers from the semilunar ganglion 5/25/12 course through the pons

Connections of trigeminal nerve

The lateral spinothalamic tract: pathway for transmission of pain and temperature

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The proprioceptive fibers of CN V arise from the muscles of mastication and the extraocular muscles. They terminate in the mesencephalic nucleus. This nucleus has connections to the motor nucleus of CN V.

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The motor nucleus of CN V receives cortical fibers for voluntary control of the muscles of mastication. These fibers are mostly crossed. It also receives input from the mesencephalic and sensory nuclei. The axons emerge anterior to the sensory root from the lateral surface of the pons. This motor root joins the semilunar ganglion together with the sensory root. 5/25/12

The Gasserian ganglion

The semilunar (gasserian or trigeminal) ganglion is the great sensory ganglion of CN V. It contains the sensory cell bodies of the 3 branches of the trigeminal nerve 5/25/12 (the ophthalmic,

The gasserian ganglion lies in a depression on the petrous apex, within a dural fold called the Meckel cave. The sensory roots of the 3 branches of CN V are received anteriorly. They then pass from the posterior aspect of the ganglion to the pons. The motor root passes under the ganglion to join the sensory division of the mandibular nerve and exits the skull through foramen ovale. The carotid plexus contributes sympathetic fibers to the gasserian ganglion.
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Branches of trigeminal nerve The

ophthalmic, maxillary, and mandibular
branches of the trigeminal nerve leave the skull through 3 separate foramina: the superior orbital
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The Opthalmic Nerve(V1)

First branch of the trigeminal nerve. Exclusively sensory Smallest of the three divisions
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Nerve

trunk

Arises from the convex surface of the gasserian ganglion, in the dura of the lateral wall of the cavernous venous sinus under CN IV and above the 5/25/12 maxillary nerve

Coverage area information from the scalp and forehead. Sensory

The eyeball, upper eyelid, the conjunctiva, cornea of the eye and the lacrimal glands. The nose [including the tip of the nose(external nasal nerve), except alae nasi], the nasal mucosa. The frontal sinuses, and parts of the meninges (the dura and blood vessels). Click to edit Master subtitle paralaysed, the ocular conjunctiva Note: when the opthalmic nerve is style becomes insensitive to touch.

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Receives sympathetic filaments from the cavernous sinus and communicating branches from CN III and IV. Just before it exits the skull through the superior orbital fissure, it gives off a dural branch, and then divides into 3 branches: the frontal, lacrimal, and nasociliary

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Frontal nerve

-the largest branch of the ophthalmic nerve -passes in the lateral part of the superior orbital fissure, below the lacrimal nerve and above CN IV,5/25/12 between the

The supraorbital nerve exits the skull through the supraorbital notch (or foramen). It The supplies the supratrochlear upper lid and nerve exits then turns the medial superiorly orbit and under the gives frontalis 5/25/12

Lacrimal nerve

Arises in the narrow, lateral part of the superior orbital fissure and courses between the lateral rectus and the periorbita. Supplies the lacrimal gland, conjunctiva, and upper lid. In the orbit, it receives a communication from the zygomatic branch of the maxillary nerve. This represents postganglionic parasympathetic secretory fibers from the sphenopalatine ganglion to the lacrimal gland. The preganglionic fibers reach the ganglion via the greater petrosal and vidian nerves from CN VII.
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Nasociliary nerve The nasociliary nerve

travels along the medial border of the orbital roof, giving off branches to the nasal cavity and ending in the skin at the roof of the nose.

It then branches into the anterior ethmoidal and external nasal nerves. The internal nasal 5/25/12

 There are 2 or 3 long

ciliary nerves supplying the iris and cornea. nerve supplies the skin of the lacrimal sac and the lacrimal caruncule. ethmoidal nerve 5/25/12 supplies the ethmoidal

The infratrochlear

The posterior

Visual explanation of the opthalmic nerve

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The Maxillary Nerve

Arises from the middle of the trigeminal ganglion

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Origin and course

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Branches of the maxillary nerve

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The zygomatic nerve

Travels anteriorly, enters the orbit through the inferior orbital fissure where it divides into

1.Zygomaticotemporal nerve: supplies sensory innervation to the skin on the side of the forehead 2.Zygomaticofacial nerve: supplies the prominence of the cheek
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Zygomatico temporal nerve:

The zygomaticotemporal nerve is a terminal branch of the zygomatic nerve. It traverses a canal in the zygomatic bone to emerge into the anterior part of the temporal fossa, ascends between the bone and temporalis and finally pierces the temporal fascia 2 cm above the zygomatic arch to supply the skin of the temple. It communicates with the facialDate Added: 22 May 2006 and auriculotemporal nerves. As UPDATE Abstract: Surgical anatomy of the zygomaticotemporal it pierces the deep layer of the nerve in the orbit and 5/25/12 temporal area http://www.ncbi.nlm.nih.gov/pubmed/15167230?dopt=Abstract temporal fascia it sends a slender twig

Zygomaticofacial nerve

The zygomaticofacial nerve is a terminal branch of the zygomatic nerve. It traverses the inferolateral angle of the orbit, and emerges on the face through a foramen in the zygomatic bone. It next perforates orbicularis oculi to supply the skin on the prominence of the cheek. It forms a plexus with zygomatic branches of the facial nerve and palpebral branches of the maxillary nerve.

Pterygopalatine nerves

The pterygopala tine nerves are the two trunks that unite in the pterygopala tine ganglion and then redistribute d5/25/12 into

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3. The palatine braches: include greater/anterior palatine and the lesser(middle and posterior) palatine nerves. Greater palatine supplies sensory innervation to the palatal soft tissues and bone as far as first premolar where it communicates with terminal fibers of nasopalatine nerve. Middle palatine nerve emerges from the lesser palatine foramen along with the 5/25/12 posterior palatine nerve, together

4. Pharyngeal branch is a small nerve that leaves the posterior part of the ptergopalatine ganglion, passes through the pharyngeal canal and is distributed to the mucous membrane of nasal part of the pharynx, posterior to the auditory.

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Posterior superior alveolar nerve

Descends from the main trunk of the maxillary division in the pterygopalatine fossa just before the maxillary division enters the infraorbital canal Commonly there are two PSA branches but on occasion a single trunk arises Passing down through the pterygopalatine fossa, they reach the inferior temporal(posterior) surface of maxilla Together, the posterior superior alveolar nerve supplies buccal gingiva in maxillary molar region, adjacent facial mucosal surfaces, mucous membrane of maxillary sinus Continuing downwards, the second branch of PSA 5/25/12 provides sensory innervation to the alveoli, PDLs, and

Branches in the infraorbital canal

Gives 2 significant branches within the infra orbital canal: middle superior alveolar and anterior superior alveolar

While in infraorbital groove and canal, the maxillary division is known as infraorbital nerve.

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Middle superior alveolar

Branches off the main trunk within the IO canal to form a part of the superior dental plexus(reference.malamedpage 179), composed of posterior, middle and anterior superior alveolar nerves. Provides sensory innervation to the two maxillary premolars plus its periodontal tissues and buccal soft tissues, and perhaps to the mesio 5/25/12

Anterior superior alveolar

Given off the infra orbital nerve approximately 6 to 10 mm before the latters exit from the infra orbital foramen. Descending within the anterior wall of maxillary sinus, provides pulpal inervation to the central and lateral incisors and the canine and sensory innervation to the periodontal tissues, buccal bone, mucous
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Organization of dental nerve supply

Actual innervation of individual roots of all teeth, bone, and periodontal structures in max and md derives from the terminal branches of larger nerves in the region, these nerve networks are known as the DENTAL PLEXUS.

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Superior dental plexus: composed of smaller nerve fibres from the three superior alveolar nerves (and in the mandible, from the inferior alveolar nerve) Three types of nerves emerge from these plexuses:

Dental nerve(enters a tooth through the apical foramen), Interdental branches(also c/a perforating branches- travel through entire height of interradicular septum 5/25/12 and provide sensory innervation to the

Branches on the face

Terminal branches given by infraorbital nerve once it emerges through the IO foramen onto the face to divide into terminal branches: Inferior palpebral: skin of lower eyelid External nasal: skin and lateral aspect of the nose

Superior labial branches: skin and 5/25/12 mucous membrane of the upper lip

Visual explanation of the maxillary nerve

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The Mandibular Nerve

Largest division of the trigeminal nerve Mixed nerve with two roots: a larger sensory root 5/25/12 and a smaller

Origin and course

Sensory root originates at the inferior angle of the trigeminal ganglion Motor root arises In the motor cells located in the pons and medulla oblongata

The two roots emerge from the cranium separately through the foramen ovale, motor root lying medial to the sensory

Unite outside the skull and form the main trunk of 3rd division
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Areas innervated by V3

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Branches of the Mandibular Nerve

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Branches from the undivided nerve

On leaving the foramen ovale, main trunk gives two branches during 2-3 mm course before division: Nervus spinosus (meningeal branch of mandibular nerve): re-enters cranium through foramen spinosum along the middle meningeal artery to supply the dura mater and the mastoid air cells Nerve to medial pterygoid : a motor nerve to the medial/internal pterygoid muscle, gives off small branches that are 5/25/12

Branches from the anterior division

Provide motor innervation to the muscles of mastication and sensory innervation to the cheek and buccal mucous membrane of the mandibular molars Significantly smaller than the Runs forward under the posterior lateral/external pterygoid muscle for a short distance and then reaches the external surface of the muscle by passing between its two heads, or 5/25/12 less frequently, winding over its

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Although under the lateral pterygoid muscle, the buccal nerve gives off several branches:

1. The deep temporal nerves ( to temporalis mucsle), 2. The masseteric nerve ( to the masseter muscle), and 3. The lateral pterygoid nerve (to the lateral pterygoid muscles)

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The buccal nerve

Also k/a the buccinator nerve or the long buccal nerve Usually passes between the two heads of the lateral pterygoid to reach the external surface of that muscle Then follows the inferior part of the temporal muscle and emerges under the anterior border of masseter, continuing in anterolateral direction At the level of occlusal plane of the mandibular third or second molar, it 5/25/12

Branches from the posterior division

The posterior division of V3 is primarily sensory with a small motor component Descends for a short distance downward and medially to the lateral pterygoid muscle, at which point it branches into: Auriculotemporal nerve Lingual nerve
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Inferior alveolar nerve

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The auriculotemporal nerve: Traverses the upper part of the parotid gland and then crosses the posterior portion of the zygomatic arch Gives off a number of branches of which all are sensory: -gives sensory, secretory and vasomotor fibers to the parotid gland -anterior auricular branches supply the skin over helix and tragus of ear -branches to external auditory meatus 5/25/12

The lingual nerve: 2nd branch of the posterior division of V3 Passes downward medial to the lateral pterygoid muscle and, as it descends, lies between the ramus and the medial pterygoid muscle in the pterygomandibular space. Runs anteriorly and medial to the inferior alveolar nerve whose path it parallels.
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Then proceeds anteriorly across the muscles of the tongue, looping downward and medial to the whartons duct to the deep surface of the sublingual gland, where it breaks up into its terminal branches. Nature /function:

Sensory to the anterior two thirds of the tongue, providing both general and taste sensation (gustation) for this region Also provides sensory innervation to the 5/25/12 mucous membranes of the floor of mouth

The inferior alveolar nerve: Largest branch division. of the mandibular

Descends medial to the lateral pterygoid muscle and lateroposterior to the lingual nerve, to the region between the sphenomandibular ligament and the medial surface of ramus of mandible, where it enters the mandibular canal at the level of the mandibular foramen. Through out its path, is accompanied by the inferior alveolar artery(branch of 5/25/12 max. artery) and the inferior alveolar

Note: bifid inferior alveolar nerves and mandibular canals have been observed radiographically (0.95%) Brings difficulty in achieving adequate anesthesia with conventional techniques IAN divides into two terminal branches : the incisive nerve and the mental nerve:

The incisive nerve remains within the mandibular canal and forms a nerve plexus that supplies pulpal tissues of mandibular first premolar, canine, and 5/25/12

The mylohyoid nerve: Branches from the inferior alveolar nerve before the latters entry into the mandibular canal. Runs downward and forward in the mylohyoid groove on the medial surface of ramus and along the body of mandible to reach mylohyoid muscle Is a mixed nerve: motor to the mylohyoid muscle and the anterior belly of digastric, 5/25/12 thought to contain sensory fibers to supply

Microscopic anatomy

Sensory nerve endings that respond to stimuli and convert them to nervous energy toward the central nervous system are called receptors or central transducers. Sensory receptors are classified into the following 3 main groups: exteroreceptors, interoreceptors, and proprioceptors.[6, 7, 8]
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Exterorecep tors

These are stimulated by the external environment. Examples of these types of receptors include the following: Merkel corpuscles - Located in submucosa of the tongue and oral cavity Meissner corpuscles - Tactile receptors in the skin Ruffini corpuscles - Pressure and 5/25/12

Interorecep tors

These are located in and transmit sensations from body cavities. Most of the sensations for these structures deal with body functions and are below the conscious level. Examples include the following: Pacinian corpuscles - Detect pressure sense Free nerve endings - Perceive visceral or other sensations
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Propriocep tors

The sensations associated with proprioceptors are also below conscious level; examples include the following: Muscle spindles - Respond to passive stretch of the muscle Golgi tendon organs - Located in tendons and respond to muscle tension (contraction and stretching)
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Natural Variants of Trigeminal Nerve

-Different

anatomic variations have been described regarding the trigeminal nerve, its branches, and its subdivisions. -Examples include the very rare occurrence of unilateral trigeminal nerve hypoplasia, in which no corneal sensitivity exists on the affected side and facial sensitivity is reduced in all branches of the trigeminal nerve. -Anomalies may coexist also in association with craniofacial anomalies, such as hypoplasia of the trigeminal nerve in Goldenhar syndrome (oculo-auriculo-vertebral dysplasia). -A few other examples affecting the different divisions are described below.[9, 10, 11, 12, 13, 14]
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Frontal nerve

A variation has been reported in which the frontal nerve divides at a variable point before leaving the orbit to form the supratrochlear and supraorbital branches. In such cases, the supraorbital branch passes through the supraorbital foramen, through which the undivided nerve ordinarily passes. When the foramen is absent, it may have a special groove, the frontal notch (Henle notch).
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Ethmoidal nerve This nerve may be limited to the nasal cavity. It may also traverse the posterior ethmoidal foramen to gain entrance to the cranial cavity. This nerve may appear to be derived from the trochlear nerve. However, the probable source in such cases is the ophthalmic nerve, through its communicating branch to the trochlear nerve (CN IV) in the cavernous sinus. Lacrimal nerve The lacrimal nerve may be small at its
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Nasociliary (nasal) nerve

Several variations in the branches of this nerve have been reported. The nasociliary nerve may send branches to the superior rectus, medial rectus, and levator palpebral superioris muscles. Branches emanating from a small ganglion connected to the nasal nerve have been followed to the oculomotor (CN III) and abducens (CN VI) nerves. The infratrochlear branch of the nasal (nasociliary) nerve may be missing, in which case the areas normally supplied by this branch (skin of the upper eyelid, root of nose, conjunctiva, lacrimal sac) receive their supply from the supratrochlear branch of the frontal nerve. Branches of the nasal nerve have been described passing to the frontal, ethmoid, and sphenoid sinuses. The branches to the frontal and anterior ethmoid sinuses arise in the anterior ethmoid foramen; branches to the sphenoid and posterior ethmoid sinuses arise in the posterior ethmoid foramen. The branches to the sphenoid sinuses are known as sphenoid branches, whereas the branches to the posterior ethmoid sinuses are known as sphenoethmoid or posterior ethmoid branches. An anastomosis between the nasal and lacrimal nerves has been reported.
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Maxillary division (V2) The maxillary nerve may split into 2 trunks, each entering the skull through a separate foramen Zygomatic nerve The following variations have been reported in this nerve or its 2 branches (the temporal or facial or malar). The nerve may pass through the zygomatic bone before it divides into 2 branches, or the 2 branches may pass separately through foramina in the zygomatic bone instead of passing through a common foramen (sphenozygomatic foramen). The temporal branch in some cases passes through the sphenomaxillary fissure into the temporal fossa. Either branch of the zygomatic may be absent or smaller than normal, in which case the other branch compensates by carrying the additional nerve fibers. The area usually supplied by the zygomatic branch (skin of the zygomatic region) may be supplied instead by the infraorbital nerve. The area usually supplied by the temporal branch (skin of the anterior temporal region) may be supplied solely or additionally by the lacrimal nerve.
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Posterior superior alveolar nerve In the absence of the buccal nerve, the posterior superior alveolar nerve distributes branches to the areas normally supplied by this nerve (mucous membrane and skin of the cheek). Inferior alveolar nerve The inferior alveolar nerve may form a single trunk with the lingual nerve, extending as far as the mandibular foramen. The inferior alveolar nerve is sometimes perforated by the internal (medial) maxillary artery. It may have accessory roots from other divisions of the mandibular nerve. In some cases, the mylohyoid branch of the inferior alveolar gives rise to a branch that pierces the mylohyoid muscle and joins the lingual nerve. Branches have been described arising from the mylohyoid branch and supplying the depressor anguli oris muscle and parts of the platysma (that are usually supplied by the facial nerve), the skin below the chin, and the submandibular (submaxillary) gland (which is usually supplied by the facial nerve). The inferior alveolar may form connections with the auriculotemporal nerve. In one case, the roots of the third lower molar tooth were found to be surrounding the inferior alveolar nerve.
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Auriculotemporal nerve
This nerve carries the otic ganglion, which is derived from glossopharyngeal neurons. The nerve usually arises by 2 roots from the posterior division of the mandibular nerve. The 2 roots usually surround the middle meningeal nerve before joining to form a single trunk. A variation in this relationship has been described in which the middle meningeal artery pierces the anterior root instead of passing between the 2 roots. According to Baumel et al, the auriculotemporal nerve is commonly misrepresented in illustrations and textbooks.[11]Their 85 dissections of the nerve demonstrated that the roots of the "typical" auriculotemporal nerve do not form a tight buttonhole around the middle meningeal artery. Instead, the roots outline an elongated, Vshaped interval, with the roots widely separated from one another. At their junction, the roots form a short trunk that immediately breaks up in line with the posterior border of the mandible into a spray of branches. The superficial temporal ramus of the auriculotemporal nerve should not be considered as the main continuation of the nerve but merely as its largest branch. A substantial portion of the nerve makes up its 2 communicating rami with the facial nerve; these are the strongest and 5/25/12 most consistent of the many peripheral communications between trigeminal and facial nerves. Common variations in configuration,

Lingual nerve A minute sublingual ganglion has been described arising from the lingual nerve or submandibular ganglion (a ganglion of the facial nerve carried by the lingual nerve), supplying the sublingual gland. This nerve may pierce the lateral pterygoid muscle rather than pass between the 2 pterygoid muscles. It occasionally provides motor branches to the medial and lateral pterygoids and to the palatoglossus muscle.

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Pathophyscial variants

http://emedicine.medscape.com/article/1 (To be discussed in section of trigeminal nerve disorders)

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Parasympathetic Ganglia
Four small parasympathetic (accessory) ganglia are associated anatomically (but not functionally) with the branches of the trigeminal nerve.[2, 4]They are as follows:

Ciliary ganglion Sphenopalatine (or pterygopalatine) ganglion Otic ganglion Submandibular ganglion
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The ciliary ganglion

The ciliary ganglion is associated with the ophthalmic nerve. It is the size of a pinhead and has the following 3 roots:

The parasympathetic root from the nerve to inferior oblique (CN III) from Edinger Westphal nucleus and caudal central nucleus to supply the sphincter papillae and ciliary muscles Sympathetic root from the nasociliary nerve to dilator papillae muscle of the eye 5/25/12

Spheno-palatine ganglion

The sphenopalatine ganglion is associated with the maxillary nerve. It receives its parasympathetic fibers from CN VII (as seen in the image below). The otic and submandibular ganglia are associated with the mandibular nerve. They receive parasympathetic fibers from CNs IX and VII, respectively.
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Clinical implications of trigeminal nerve

Damage to the complete nerve leads to the following features on affected side

Unilateral anesthesia of the face Unilateral anesthesia on the anterior aspect of the scalp Unilateral anesthesia on the auricle Unilateral anesthesia of the mucous membrane of mouth

Unilateral anesthesia of the mucous membrane of nose 5/25/12

Recent trends in approach to nerve disorders of maxillofacial region

1.The fine branches of the human trige

Uryvaev MY,Sudarikova TV, Trufanov IN,Gorskaya TV,Tsybul'kin AG. Source Department of Human Anatomy, Moscow State Medical-Stomatological 5/25/12 University, Russia.

2.Imaging the trigeminal nerve.

Borges A,Casselman J. Source Radiology Department, Instituto Portugus de Oncologia Francisco Gentil, Centro de Lisboa, Rua Prof. Lima Basto, 1093, Lisboa, Portugal. borgalexandra@gmail.com Abstract Of all cranial nerves, the trigeminal nerve is the largest and the most widely distributed in the supra-hyoid neck. It provides sensory input from the face and motor innervation to the muscles of mastication. In order to adequately image the full course of the trigeminal nerve and its main branches a detailed knowledge of neuroanatomy and imaging technique is required. Although the main trunk of the trigeminal nerve is consistently seen on conventional brain studies, high-resolution tailored imaging is mandatory to depict smaller nerve branches and subtle pathologic processes. Increasing developments in imaging technique made possible isotropic sub-milimetric images and curved reconstructions of cranial nerves and their branches and led to an increasing recognition of symptomatic trigeminal neuropathies. Whereas MRI has a higher diagnostic yield in patients with trigeminal neuropathy, CT is still required to demonstrate the bony anatomy of the skull base and is the modality of choice in the context of traumatic injury to the nerve. Imaging of the trigeminal nerve is particularly cumbersome as its long course from the brainstem nuclei to the peripheral branches and its rich anastomotic network impede, in most cases, a topographic approach. Therefore, except in cases of classic trigeminal neuralgia, in which imaging studies can be tailored to the root entry zone, the full course of the trigeminal nerve has to be imaged. This article provides an update in the most recent advances on MR imaging technique and a segmental imaging approach to the most common pathologic processes 5/25/12 affecting the trigeminal nerve.

Referenc es

1.Agur AMR, Dalley AE. The Cranial Nerves. In:Grant's Atlas of Anatomy. Baltimore: Williams & Wilkins; 2004. 2.Sooy CD, Boles R. Neuroanatomy for the Otolaryngologist Head and Neck Surgeon. In: Paparella MM, and Shumrich DA.Otolaryngology: Basic Sciences and Related Principles. Philadelphia: WB Saunders; 1991. 3.Moore KL, Dalley AL.Clinically Oriented Anatomy. 4th. Philadelphia: 5/25/12

9.Wilson-Pauwels, L, Akesson EJ, Stewart PA.Cranial Nerves: Anatomy and Clinical Comments. BC Decker Inc; 1998. 10.Tewfik TL, Teebi, AS, Der Kaloustian VM. Selected Syndromes and Conditions. In: Tewfik TL, Der Kaloustian VM (eds).Congenital Anomalies of the Ear, Nose, and Throat. New York: Oxford University Press; 1997. 11.Baumel JJ, Vanderheiden JP, McElenney JE. The auriculotemporal nerve of man.Am J Anat. Apr 1971;130(4):431-40.[Medline]. 12.Bergman RA. Anatomy Atlases. Available at http://anatomyatlases.org. 13.Ries MW, Tetz MR, Egelhof T, Volcker HE. [Unilateral trigeminal nerve hypoplasia].Klin Monbl Augenheilkd. Jul 1997;211(1):60-4. [Medline].
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Bibliograph y
1. 2.

Grays Anatomy, 39th edition Handbook of Local Anesthesia, 5th edition, Stanley F. Malamed B.D. Chaurasias Human Anatomy, vol.3, 5th edition

3.

4. 5.

http://emedicine.medscape.com/article/18

http://www.neuroanatomy.wisc.edu/virtual

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