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