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TRIGEMINAL, GLOSSOPHARYNGEAL AND HYPOGLOSSAL NERVES
PRESENTED BYMANTHRU NAIK1ST YEAR PG
GUIDED BYDr. K. SUREKHA MDSPROF. & HEAD
Dr. G. SUDHAKAR MDSASST. PROF.
NERVE IN ORDER
Cranial Nerve I - OlfactoryCranial Nerve II - OpticCranial Nerve III - OcculomotorCranial Nerve IV - TrochlearCranial Nerve V - TrigeminalCranial Nerve VI - AbducensCranial Nerve VII - FacialCranial Nerve VIII- VestibulocochlearCranial Nerve IX - GlossopharyngealCranial Nerve X - VagusCranial Nerve XI - Spinal Accessory Cranial Nerve XII - Hypoglossal
CLASSIFICATION OF CRANIAL NERVESSensory cranial nerves(special sensory fibers ): I, II, VIIIMotor cranial nerves(somatic efferent nerves ): III, IV, VI, XI, XIIMixed nerves (branchiomeric nerves ): V, VII, IX, X
FUNCTIONAL COMPONENTS OF NERVES
1) General Somatic Afferent (GSA) 2) General Visceral Afferent (GVA)3) General Visceral Efferent (GVE)4) General Somatic Efferent (GSE) 5) Special Somatic Afferents (SSA) 6) Special Visceral Afferents (SVA) 7) Special Visceral Efferents (SVE)
INTRODUCTION
ELEMENTARY STRUCTURE OF A TYPICAL NEURON
TYPES OF NEURON
1-UNIPOLAR 2-BIPOLAR3-MULTIPOLAR4-PSEUDOUNIPOLAR
TRIGEMINAL NERVE
EMBRYOLOGY OF TRIGEMINAL NERVE
Trigeminal nerve is derived from 1st pharyngeal arch
NUCLEI OF TRIGEMINAL NERVE
1) Mesencephalic nuclei2) Main sensory nuclei3) Spinal nuclei 4) Motor nuclei
sensory
FUNCTIONAL PATHWAYS OF TRIGEMINAL NERVE
TOUCH PATHWAY FROM THE HEAD
PAIN & TEMPERATURE PATHWAY
ATTACHMENT OF TRIGEMINAL NERVE TO BRAIN
TRIGEMINAL GANGLION
RELATIONS OF TRIGEMINAL GANGLION
Foramen lacerum
Medial relations
TRIGEMINAL NERVE
THE OPHTHALMIC DIVISIONCOURSE
BRANCHES
GANGLIA ASSOCIATED WITH THE TRIGEMINAL NERVE
CILIARY GANGLION
a- occulomotor nerveb- internal carotid plexusc- nasociliary nerven- inferior oblique muscle
OPHTHALMIC NERVE NUT SHELL
SUPRAORBITAL
SUPRATROCHLEAR
LACRIMAL
REGION OF NASOCILLIARY
AREA OF DISTRIBUTION
COURSEMAXILLARY DIVISION
CRANIUM
PTERYGOPALATINE FOSSA
INFRAORBITAL CANAL
FACE
BRANCHES
SUPERIOR ALVEOLAR NERVES
PTERYGOPALATINE GANGLION
ROOTS
BRANCHES
NASOPALTINE AND GREATER PALATINE NERVES
2) Nasopalatine nerve 4) Greater palatine nerve
5) Lesser palatine nerve
ZYGOMATIC REGION
SUPERIOR ALVELOLAR
REGION
INFRAORBITAL REGION
AREA OF DISTRIBUTION
MAXILLARY NERVE NUT SHELL
COURSEMANDIBULAR DIVISION
BRANCHES OF MAIN TRUNK
(2)
BRANCHES OF ANTERIOR DIVISION
BRANCHES OF POSTERIOR DIVISION
(2 )
LINGUAL NERVE
INFERIOR ALVEOLAR NERVE
INFERIOR ALVEOLAR NERVE LINGUAL NERVE
INFERIOR ALVEOLAR ARTERY
SPHENOMANDIBULAR LIGAMENT
BRANCHES
Mylohyoid nerve
OTIC GANGLION
Preganglionic parasympathetic fibers
Inferior salivatory nucleus in medulla
glossopharyngeal N.jugular foramen
Glossopharyngeal n. tympanic branch of IX
tympanic plexus
lesser petrosal nerveotic ganglion
postganglionic parasympathetic fibers otic ganglion
auriculotemporal branch (CN V)parotid gland
SUBMANDIBULAR GANGLION
SECRETOMOTOR PATHWAY TO SUBMANDIBULAR AND SUBLINGUAL GLAND
AREA OF DISTRIBUTION
AURICULO-TEMPORAL
BRANCHES OF BUCCAL
INFERIOR ALVEOLAR AND MENTAL
MOTOR ROOT OF TRIGEMINAL NERVE
MANDIBULAR NERVE NUT SHELL
OVERALL DISTRIBUTION OF TRIGEMINAL NERVE
EXAMINATION OF TRIGEMINAL NERVESENSORY FUNCTION
MOTOR FUNCTION
V1V2 V3
BULK OF MASSETER STRENGTH OF JAW OPENING
TRIGEMINAL REFLEXES
CORNEAL REFLEX JAW JERK REFLEX
CLINICAL APPLICATIONS OF TRIGEMINAL NERVE
TRIGEMINAL GANGLION
Trigeminal neuralgia (tic douloureux)
The paratrigeminal syndrome
Wallenberg syndrome
TRIGEMINAL NEURALGIA
PAINsudden ,usually ,unilateral ,severe ,brief ,stabbing , lancinating , stereotyped and recurring pain
SYMPTOMS
TRIGGER POINTS
TYPES OF TRIGEMINAL NEURALGIA CLASSI TN SYMPTOMATIC TN
AETIOLOGY
Usually idiopathic
Other etiological factors include
COMMON PATTERNS OF VASCULAR COMPRESSION OF TRIGEMINAL NERVE (JANNETA, 1967)
Intra cranial tumors - cerebellopontine angle tumors
Postherpetic neuralgia Multiple sclerosis (MS) Infections
PATHOGENESIS
Demyelination
Hyperactivity or abnormal discharge of impluses(ignition hypothesis - Devor et al )
Ephaptic cross- talk between fibres
Ephaptic cross- talk between fibres
Touching trigger points causes pain
DIAGNOSIS
Sweet diagnostic criteria
1. Pain is paroxysmal2. The pain may be provoked by light touch to the face
(trigger zones)3. The pain is confined to the trigeminal distribution4. The pain is unilateral5. The clinical sensory examination is normal
DIAGNOSTIC MRI SCANNING
DIFFERENTIAL DIAGNOSIS
Differentiation from atypical facial pain
TREATMENTMedical treatment
Surgical treatment Peripheral injections(anaesthetic agent or 95% absolute alcohol)
Peripheral neurectomy
Cryotherapy
Peripheral radiofrequency
Neurolysis(thermocoagulation)
Gasserian ganglion procedures
TREATMENT ALGORITHAM
MEDICAL TREATMENT
HOW A DRUG FOR SEIZURES IS USEFUL IN THE TREATMENT OF NEUROPATHIC PAIN ?
MICROVASCULAR DECOMPRESSIONCraniotomy Vascular compression
Teflon sponge placed Fixation of Ti plate
SURGICAL TREATMENT
RHIZOTOMY PROCEDURES
Percutaneous glycerol rhizotomy Balloon compression rhizotomy
Stereotactic Radiosurgery (Gamma Knife)
Attachment of a frame Beams of cobalt radiation are precisely focused
Percutaneous stereotactic radiofrequency rhizotomy (PSR)
Preparation of the patient Insertion of electrode
Identification of site of pain Application of heat
Peripheral Rhizotomies Microsurgical Rhizotomy
Wallenberg syndrome
OPHTHALMIC DIVISIONEthmoid tumoursNasal fracturesSupraorbital injuriesBilateral cleft lip and palateHerpes zoster ophthalmicus
MAXILLARY DIVISIONInfraorbital injuries (malar fractures)Maxillary antrum tumoursMaxillary sinus infectionsMaxillary teeth abscessesAnaesthetic nerve blocksSphenopalatine ganglioneuralgia( brain freeze)
Dendritic fluoresceine uptake from HZO
MANDIBULAR DIVISIONLingual nerve
Inferior alveolar nerve
Mental nerve neuralgia
Mumps
Submandibular duct
Superficial temporal artery biopsy
THE AURICULOTEMPRAL NERVESYNDROME(FREY SYNDROME)
Mechanism of frey’s syndrome
Sweating and flushing in area supplied by auriculotemporal nerve
GLOSSOPHARYNGEAL NERVE
Glossopharyngeal nerve nuclei
FUNCTIONAL MODALITIES: SVE, GVE, GVA, SVA, GSA
Am - Nucleus ambiguus I s - Inferior salivary nucleus
Sol - Nucleus tractus salitarius spT - Spinal tract of V nerve
COURSE
BRANCHES
TYMPANIC BRANCH
OUTLINE OF GLOSSOPHARYNGEAL NERVE
Effects of Damage and Clinical Test Gag reflex Ask the patient to swallow or cough Test the posterior one-third of the tongue with
bitter and sour substances.
CLINICAL IMPLICATIONS GLOSSOPHARYNGEAL NEURALGIA
DRUGSTEGRETOL
NEURONTIN(GABAPENTIN)DILANTIN
LIORESAL(BACLOFEN)
Diagnostic test
HYPOGLOSSAL NERVE
HYPOGLOSSAL NUCLEUS
Segments of the hypoglossal nerve
Hypoglossal nerve
Vertebral arteries
COURSE
Hypoglossal nucleus, medullary & cisternal segments
Suprahyoid carotid space segment
Sublingual segment
BRANCHES OF HYPOGLOSSAL NERVE
Hypoglossal nerve nut shell
EXAMINING THE HYPOGLOSSAL NERVE
HYPOGLOSSAL PALSY Unilateral palsy is merely troublesome, resulting
in difficulty with speech, tongue biting during mastication of food, and difficulties in swallowing for as long as four months postoperatively
Bilateral palsy can pose a life-threatening situation by producing upper airway obstruction
Hypoglossal palsy can be due to iatrogenic injuries to hypoglossal nerve or due to lesions affecting it.
IATROGENIC INJURIES OF HYPOGLOSSAL NERVE
During Dissection of floor of submandibular triangle Blind application of hemostats and monopolar
coagulation to ranine veins Dissection in level I and II during RND carotid endarterectomy High exposure of internal carotid artery
The use of transverse neck incisions has probably served to increase the number of injuries to the hypoglossal nerve and the marginal mandibular nerve.
The incision is close to, and parallels, the course of both nerves.
DISSECTION IN SUBMANDIBULAR TRIANGLE
First Surgical Plane: The Roof of the Submandibular Triangle
•Composed of skin, superficial fascia enclosing the platysma muscle and fat, and the underlying mandibular and cervical branches of the facial nerve (VII)
The Roof of the Submandibular Triangle
Second Surgical Plane: The Contents of the Submandibular Triangle Structures of the second surgical plane, from superficial to deep,
are
facial (anterior facial) vein
retromandibular (posterior facial) vein
part of the facial (external maxillary) artery
submental branch of the facial artery
superficial layer of submaxillary fascia (deep cervical fascia)
lymph nodes
deep layer of submaxillary fascia (deep cervical fascia)
hypoglossal nerve (XII)
Contents of submandibular triangle
Third Surgical Plane: The Floor of the Submandibular Triangle
Structures of the third surgical plane, from superficial to deep
mylohyoid muscle with its nerve
hyoglossus muscle
middle constrictor muscle covering the lower part of the superior
constrictor muscle
part of the styloglossus muscle
Fourth Surgical Plane: The Basement of the Submandibular Triangle
Deep portion of the submandibular gland Submandibular (Wharton's) duct Lingual nerve Sublingual vein Sublingual gland Hypoglossal nerve (XII) Submandibular ganglion
The Basement of the Submandibular Triangle
RANINE VEIN Ranine vein is vena comitans of hypoglossal nerve which
begins below the tip of the tongue. Inadvertent clamping while controlling bleeding from
plexus posterior and inferior to the posterior belly of digastric muscle can result in hypoglossal nerve injury
HIGH EXPOSURE OF INTERNAL CAROTID ARTERY DURING CAROTID ENDARTERECTOMY
The hypoglossal nerve, because of its intimate relationship to the internal carotid artery, may limit exposure since it crosses the internal carotid artery at various levels in different individuals, from just above the carotid bifurcation to as high as the level of the anterior belly of the digastric muscle. It usually crosses the ICA and ECA approximately 2 to 4 cm above the carotid bifurcation
Frequently, in order to visualize the uppermost extent of carotid bifurcation plaques, to deal with internal carotid kinks or internal carotid aneurysms the hypoglossal nerve may be retracted, resulting in temporary paralysis of one-half of the tongue
Never attempt to separate the hypoglossal and vagus nerves if they fuse together
STRUCTURES TETHERING HYPOGLOSSAL NERVE
Sternocleidomastoid artery and veinOccipital arteryDescends hypoglossiDigastric muscleStylohyoid muscle
METHODS OF ATRAUMATIC MOBILISATION OF HYPOGLOSSAL NERVE
By dividing sternocleidomastoid artery
By dividing occipital artery, descendens hypoglossi, digastric muscle
By mandibular subluxation
A – orotracheal intubationB - nasotracheal intubationC – mandibular subluxation
CONDITIONS AFFECTING HYPOGLOSSAL NERVE
REFERENCES GRAY’S ANATOMY- 39TH EDITION
NETTER’S- COLOUR ATLAS OF ANATOMY
B.D.CHAURASIA’S HUMAN ANATOMY- VOL 3 CRANIAL NERVES – FUNCTIONAL ANATOMY, STANLEY
MONKHOUSE Handbook of LOCAL ANESTHESIA- Stanley F. Malamed
Trigeminal neuralgia- Pathology & pathophysiology Seth Love & Hugh b. Coakham
Trigeminal nerve- Sashank prasad and Steven Galetta
INTERNET SOURCES Vascular reconstructions : anatomy, exposures, and techniques amal J
Hoballah