TRIGEMINAL NERVE

Anatomy

Largest & one of most complex cranial nerves Mixed nerve Large sensory part (portio major) & much smaller motor part (portio minor) Sensory component has 3 divisions : ophthalmic, maxillary, mandibular. Motor & prinicipal sensory nuclei midpons Spinal tract & nucleus (pain, temp) pons to upper cervical cord

Mesencephalic root receives proprioceptive fibres. Trigeminal nuclear structures extend from rostral midbrain to rostral spinal cord

Motor Portion
Motor nucleus midpontine level medial to main sensory nucleus of Vth nerve , near the floor of fourth ventricle. Supranuclear control - corticobulbar fibres from precentral gyrus. Motor root : exits from motor nucleus , passes thr substance of pons and emerges from anterolateral aspect of pons anterior and medial to the large sensory root.

Motor root

Passes forward in posterior fossa Pierces the duramater beneath attachment of tentorium to tip of petrous part of temporal bone. Enters the meckels cave leaves skull via Foramen Ovale. It joins the mandibular div of Vth N to form mandibular nerve supplies masticatory muscles .

Masseter : close the jaw , protrude it slightly Temporalis : close the jaw , retract it slightly Medial pterygoids : close the jaw & protrude it Lateral pterygoids : open the jaw & protrude it When pterygoids contract on one side- pull the mandible contralaterally -- Unilateral pterygoid weakness jaw deviates towards side of weak muscle

Also supplies

Mylohyoid Ant.belly of digastric Tensor veli palatini Tensor tympani

Sensory portion
Trigeminal / gasserian / semilunar ganglion Situated just beside pons in a shallow depression in petrous apex meckels cave Sensory root enters the pons course dorsomedially & terminate within brainstem: Nucleus of spinal tract of Vth N Main/Principal sensory nucleus Mesencephalic nucleus

Nucleus of spinal tract of Vth .N

Pars Oralis mid pons to inferior olive Pars Interpolaris rostal third of inferior olive to obex of fourth ventricle Pars Caudalis extends to & is continous with dorsal horn grey matter of cervical spinal cord

Fibres pain & temp enter spinal tract of trigeminal & descend to various levels depending on their somatotropic origin, then synapse in adjacent nucleus of spinal tract. The axons of second order neurons cross midline, aggregate as trigeminothalamic tract & ascend to VPM From VPM , fibres project through thalamic radiations to sensory cortex in post central gyrus

Onion skin somatotopic organization Described by Dejerine Face is represented as concentric rings from perioral to preauricular region. Fibers from foreface synapse most rostrally in nucleus of spinal tract. Fibers from hindface synapse more caudally, adjacent to sensory input from C2- C3 Because of this organization occasional sparing , less freq selective inv of perioral compared to posterior face -- BALACAVA HELMET Distribution

Main sensory nucleus

Lateral pons Posterolateral to motor nucleus Tactile & proprioceptive sensation Afferent fibers light touch , pressure enter this nucleus synapse second order neurons which cross midline en route to VPM Thalamic nucleus.

Mesencephalic nucleus

Extends cephalad from main sensory nucleus to sup.colliculus of mesencephalon. Receives proprioceptive impulses from masticatory muscles, extraocular & muscles of facial expression.

Gasserian ganglion lies lateral to int.carotid.a & posterior part of cavernous sinus Gives rise to 3 trunks : ophthalmic, maxillary & mandibular divisions

Ophthalmic div

Skull foramen : superior orbital fissure Terminal br: : frontal , lacrimal, nasociliary, meningeal Cutaneous innervation : bridge & side of nose, upper eyelid, forehead, scalp back to vertex, eyeball, lacrimal gland, nasal septum, lat wall of nasal cavity, ethmoid sinus, tentorium cerebelli

Maxillary div

Skull foramen : foramen rotundum Terminal br : infraorbital, zygomatic, sup.alveolar, pterygopalatine, meningeal Cutaneous innervation : cheek, lat.forehead, side of nose, upper lip, upper teeth & gums, palate, nasopharynx, post.nasal cavity, meninges of ant & middle cranial fossae

Mandibular div

Skull foramen : foramen ovale Terminal br : buccal, lingual, inf.alveolar, auriculotemporal, meningeal Cutaneous innervation : Inner cheek, temple, lateral scalp, ext.aud.meatus, tympanic membrane, TMJ, mandible, lower teeth & gums, ant.2/3 tongue, lower lip, meninges of ant & middle cranial fossae

Clinical examination motor functions

Bulk & power of masseters & pterygoids palpating as pt clinches the jaw Ask pt to protrude & retract the jaw Pt bite on tongue depressors with molar teeth U/L Trigeminal motor weakness deviation of jaw towards the weak side on opening pt will be unable to move the jaw contralaterally. Lesion inv brainstem, gasserian ganglion, motor root

Clinical examination motor functions

B/L Weakness of muscles of mastication with inability to close the mouth ( dangling jaw ) motor neuron ds, neuromuscular transmission disorder, myopathy

Trismus: acute dystonic reactions, polymyositis tetanus trauma to muscles of mastication inf pterygomandibular space Flaccidity of floor of mouth : mylohyoid, digastric paralysis Difficulty in hearing high notes : paralysis of tensor tymapani

Clinical examination sensory functions

Pain, touch, heat, cold tested on face & mucous membranes Each of the 3 divisions of Vth.N is tested individually and compared with the opposite side.

Clinical examination sensory functions

Determine whether sensory loss is organic/nonorganic Determine which modalities are involved Define the distribution of sensory loss

Sensory evaluation lesions

Individual divisions (distal to gasserian ganglion) : sensory loss confined to cut.supply of that division. At / proximal to gasserian ganglion : sensory loss that affects whole ipsilateral face. Within brainstem / upper cervical cord : onion skin distribution of sensory loss Dissociation of sensation on face ( pain,temp Vs touch sensation ) : differentiating b/w lesions affecting spinal tract, nucleus of trigeminal.n from lesions affecting main sensory nucleus.

Clinical examination reflexes

Jaw / Masseter / Mandibular Reflex : Afferent arc : Ia motor fibers in mandibular div of Vth.N Efferent arc : mandibular fibers that originate in motor nucleus of Vth.N Reflex centre : pons Normally it is minimally active / absent Exaggerated : lesions of corticobulbar pathway above the motor nucleus esp if b/l : pseudobulbar palsy, ALS

Corneal Reflex

Afferent arc : ophthalmic div ( upper cornea ) & maxillary div ( lower cornea ) of trigeminal.n Efferent arc : facial nerve

Stimulate
Complete Involved eye VthN lesion Opposite eye Complete VIIthN lesion Involved eye

Direct corneal Consensual reflex corneal reflex Absent Absent

Normal Absent Normal Normal

Opposite eye

Normal

Absent

Sternutatory ( Nasal,Sneeze ) Reflex

Afferent limb : Ophthalmic div of Vth nerve Efferent limb : CNs V, VII, IX, X & motor nerves of cervical & thoracic spinal cord. Reflex center : brain stem & upper spinal cord

Trigeminal mediated reflexes

Head retraction : b/l corticospinal lesions rostral to cervical spine ALS Zygomatic reflex : supranuclear lesions Corneomandibular reflex : supranuclear interupption of ipsilat corticotrigeminal tract. Only eye sign in ALS Blink / glabellar / orbicularis oculi reflex

Localization of lesions affecting VthCN

Supranuclear lesions

Lesions affecting corticobular pathway Contralateral trigeminal motor paresis (deviation of jaw away from the lesion) B/L UMN lesions ( pseudobulbar palsy ) trigeminal motor paresis , exaggerated jaw jerk.Mastication markedly impaired. Thalamic lesions anaesthesia of c/l face Parietal lesions depression of c/l corneal reflex

Nuclear lesions
Motor , sensory nuclei primary/met . tumours AV malformations demyelinating ds infarction/hage syringobulbia that affect pons, medulla and upper cervical cord.

Nuclear lesions
Motor nucleus lesions of dorsal midpons Cong anomalies of motor component rare , asso with CN VII /XII --- I/P paresis, atrophy, fasiculations of muscles of mastication.

Nuclear lesions
Pontine lesions with masticatory paresis C/L hemiplegia ( basis pontis ) I/P hemianaesthesia of face (main sensory nuc) C/L hemisensory loss of limbs & trunk (spinothalamic tract) I/P tremor Dorsal pontine lesions ( tumours ) : u/l spasm & contracture of masseter Impairing pt to open jaw Forcing to speak through ones teeth

Nuclear lesions
Hemimasticatory spasm : electrophysiologic studies ectopic excitation of trigeminal motor root / its nucleus . Nucleus of spinal tract of VthCN : Lesions affecting caudal pons, lat.medulla, upper cervical cord I/P facial analgesia, hypesthesia, thermoanaesthesia

Nuclear lesions

Rostral spinal trigeminal nuclei caudal pontine lesions --- decreased intraoral sensation but spared facial sensation Rostral medullary spinal nuclear lesions entire trigeminal cut distribution involvement Lower medullary / upper cervical lesions sensory disturbance forehead, cheek, jaw (onion skin pattern of sensory loss)

Nuclear lesions
Spinal nucleus of VthCN lateral medullary syn sec to brainstem infarction d/t IC vertebral artery occlusion Typical syn pain, temp sensation lost over entire side of face Ventral syn V1,V2 Dorsolateral syn V2,V3 Superficial syn all portions of i/p face inv initially , but symptoms mild & improve rapidly

Nuclear lesions

Lesions affecting mesencephalic nucleus no apparent neurological signs, symptoms except depression of i/p jaw jerk

Lesions affecting preganglionic trigeminal nerve roots

Tumour ( meningioma, schwannoma, metastasis, nasopharyngeal ca ) Infection ( granulomatous, infectious , carcinomatous meningitis ) Trauma Aneurysm Char i/p facial pain, parasthesias, numbness, sensory loss, corneal reflex depressed, trigeminal motor paresis.

Trigeminal neuralgia

Tic douloureux / fothergills neuralgia Paroxysms of fleeting ,excruciating u/l facial pain, usually lasting less than a minute. Usually V2/V3 , rarely V1 MC adv age, women , rt side Stimulation of trigger zone pain Pain by activities like talking, chewing, brushing teeth, exposure to cold, by wind on face

Trigeminal neuralgia

MC cause compression of sensory root by ectatic arterial loop . MC CP angle tumour to cause TN- like symptoms is acoustic neuroma B/L TN Multiple Sclerosis

Herpes zoster

Lesions affecting Gasserian ganglion

Lesions of middle cranial fossa ( tumour, herpes zoster, sarcoidosis, syphilis, tuberculosis, arachnoiditis, trauma, abscess ) Pain severe & paroxysmal Hemifacial / selective div of Vth CN ( esp V2,V3 ) Parasthesias , numbness may also occur Sensory loss depends on div involved u/l pterygoid & masseter paresis may occur.

Raeders paratrigeminal syndrome

u/l oculosympathetic paresis miosis , ptosis (without facial anhydrosis) Evidence of trigeminal involvement on same side. d/t lesions in middle cranial fossa ( b/w trigeminal ganglion & int.carotid.a, near petrous apex) Lesions of gasserain ganglion tumour, aneurysm, trauma, infection

Gradinego syndrome - lesions at apex of temporal bone- metastasis, osteitis, leptomeningitis d/t otitis media Cavernous sinus syndrome lesions within sinus tumour, carotid aneurysm, trauma, carotid cavernous fistula, infection. Superior orbital fissure syndrome tumour, trauma, aneurysm, infection complete ophthalmoplegia with pain, parasthesias, sensory loss in V1 cut. distribution

Lesions affecting peripheral branches of VthCN

Ophthalmic div : in middle cranial fossa , at temporal bone apex, lat wall of cavernous sinus, sup.orbital fissure, distally in face Maxillary div : lower lateral wall of cavernous sinus, at foramen rotundum, in pterygopalatine fossa, in floor of orbit, at infraorbital foramen, in face

Numbness & discomfort in maxillary distribution initial presentation of nasopharyngeal ca Lesions in infraorbital foramen Numb cheek syndrome Injury to ant.sup.alveolar nerve in trumpet players upper lip numbness & pain trumpet players neuropathy

Mandibular div : in foramen ovale, zygomatic fossa, in face The syndrome of numb chin / rogers sign : syn of isolated mental neuropathy pain, swelling, numbness in jaw ( lower lip, chin, mucous mem on inside of lip ) Seen in systemic cancer lymphoreticular ca , ca breast, ca lung .

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