GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
Oral & Maxillofacial Surgery

SEMINAR ON
Neurological disorders
Of
Maxillofacial region
Presented By:
Dr. Satyajit Sau
II MDS
TRIGEMINAL NERVE ANATOM!" LESIONS AND TREATMENT
INTRODUCTION
NEURO ANATOMY
NEURONS
Functional Anatomy
Physiology of Ne!e Con"uction
T#E TRI$EMINA% NER&E 'COURSE(
INTRODUCTION
INTRACRANIA% COURSE
E)TRACRANIA% COURSE
O*thalmic Ne!e
Ma+illay Ne!e
Man"i,ula Ne!e
PAIN PAT#-AYS
NER&E IN.URIES
Ty*es of Ne!e in/uies
#isto*athology of Ne!e In/uies
Re*ai of Ne!e In/uies
Sutuing Techni0ues
Ne!e Tans*lantation
POST TRAUMATIC PAIN SYNDROMES
Anesthesia Doloosa
Causalgia
Phantom Facial Pain
%ESIONS OF T#E TRI$EMINA% NER&E
Cental
Oei*heal
TRI$EMINA% NEURA%$IA
Into"uction
Diagnosis
Clinical Featues
Diffeental Diagnosis
Pathogenesis
Teatment
Me"ical
Sugical
POST #ERPETIC NEURA%$IA
#EADAC#E
MI$RAINE
MI$RANEOUS NEURA%$IA
A TYPICA% FACIA% NEURA%$IA
MYOFASCIA% PAIN DYSFUNCTION
CONNECTI&E TISSUE NEUROPAT#IES
TO)IC AND NUTRITIONA% NEUROPAT#IES
TUMORS OF NER&E TISSUE ORI$IN
1ENI$N TUMOR
Taumatic Neuoma
Neuo Fi,oma
Neuilemmoma
MA%I$NANT TUMORS
Neuo Fi,o Sacoma
TRI$EMINA% NER&E
ANATOMY
INTRODUCTION
NEURO ANATOMY
Di!isions of the Ne!ous System
a( Cental Ne!ous System2 ma"e u* of the ,ain an" s*inal co"3
,( The Pei*heal Ne!ous system2 consisting of the Pei*heal ne!es an"
the
ganglia associate" 4ith them
The 1ain consists of 'i( Cee,um 5 Com*ising t4o lage
cee,al
hemis*hees3
'ii( The Cee,ellum
'iii( The Mi",ain
'i!( The Pons
'!( The me"ulla o,longata3
The mi",ain2 *ons an" me"ulla fom the ,ain stem3 The me"ulla is
continuous ,elo42 4ith the s*inal co"3 Pei*heal ne!es attache" to the
,ain ae calle" canial ne!es3 An" those attache" to the s*inal co" ae
calle" s*inal ne!es3 The ne!es su**lying the !is!e2 along 4ith
the *ats of the ,ain an" s*inal co" elate" to them2 contitute the
autonomic ne!es system3 The autonomic ne!e systems is su,"i!i"e" in to
t4o ma/o *ats 5 The Sym*athetic Ne!ous System3
5 The Paa Sym*athetic Ne!ous
System3
TISSUES CONSTITUTIN$ T#E NER&OUS SYSTEM
The ne!ous systems is ma"e u* *e"ominantly of tissue that has the
s*ecial *o*ety of ,eing a,le to con"uct im*ulses a*i"ly fom one *at of
the ,o"y to anothe3 The s*eciali6e" cells that consitute the functional units
of the ne!ous system ae calle" Neuons3 Neuon Tissue2 com*ose" of
neuons an" Neuoglia2 is ichly su**lie" 4ith ,loo"3
Neuons75 'The Stuctual an" functional unit of ne!ous system(
Neuons ae e+cita,le cells2 S*eciali6e" fo the ece*tion2 integation2
tansfomation an" tansmission of co"e" infomation3
It has got a cell ,o"y 'the ne!e cell( a mass of s*eciali6es Cyto*lasm
4ith a "i*loi" nuleus an" an e+cita,le mem,ance2 fom 4hich *o/ect one
o moe neuites3 These ae ,anching2 cyto*lasmic *ocesses2 enclose" ,y
e+cita,le *lasma mem,ane3 Neuans ae classifie" us uni*ola2 ,i*ola o
mutli*ola acco"ing to the num,e of e+tension3 Most neuites con"uct
to4a"s the num,e of e+tension3 Most neuites2 con"uct to4a"s o
"iectly influence the ne!e cell as "en"ites2 only one con"ucts a4ay fom
it2 the a+on3
Neuons 'Definition(
Neuons is the stuctual an" functional unit of the ne!ous system an"
consists of a ne!e cell ,o"y an" its *ocesses3
Functional Anatomy
A neuon contains '8( a ne!e cell ,o"y
'ii( The *ocesses 5 t4o 9in"s
'a( Den"ite ',( A+on3
All neuons contain one an" only one a+on3 1ut "entite may ,e
a,sent2 one o many3
A+on caies im*luses a4ay fom ne!e cell ,o"y an" Den"ite ,ings
im*ulse fom a "istance3
Ne!e cell ,o"y contains 'i( Nucleus
'ii( Nissl ,o"ies
'iii( Mitochon"ia
'i!( $olgi a*o*aatus
'!( Neuofi,ils
The *ocesses of Neuons
'I: Den"ites ';( A+on
A ne!e fi,e may ,e myelinate" o non myelinate"3
Myelinate" Ne!e Fi,e75
The a+on2 sho4n at egula inte!als an a**aently consticte" ae
calle" the no"es of an!ie3 At the no"e of Ram!ie2 thee is no myelin
Sheath2 an" the neuilemma is in "iect contact 4ith a+is cylin"e3 The
*otion in ,et4een the t4o successi!e no"es an" inteno"es2 gi!es the
a**eaance 'of myelinate" ne!e fi,e( of a ,am,oo stic93
The myelin Sheath is ma"e u* of li*i" mateials2 $eat ma/oity of
ne!e fi,es in ou ,o"y ae myelinate" ne!es3 Each inteno"e contains one
nuclius of sch4ann2 4hich lies ,et4een the neuilemma2 an" myelin sheath3
Non Myelinate" Ne!es75
Thee is no myelin sheath2 the "iamete of these ne!es ae !ey small2
an" thee is no no"e of an!ie3
Im*otance of Myelin Sheath
Po*agation of Action Potential is !ey fast in myelinate" n e!e fi,e
an" slo4 in non myelinate" one3 This is ,ecause of the Saltatoy con"uction
4hich is *ossi,le only in a myelinate" ne!e fi,e3
Physiology of Ne!e Con"uction 75
The t4o ,asic *o*eties of ne!e fi,e ae
'i( E+cita,ility an" 'ii( Con"uct!ity
E+cita,ility
-hen a ne!e fi,e is stimulate" a"e0uately the fi,e is e+cite"
Theshol" intensity of stimulus is the minimum stength of stimulus 4hich
can cause e+citation3
Action Potential
-hen a theshol" stimulus is a**lie" to a ne!e fi,e2 the fi,e "e!elo*s
an AP 4hich *o*agates on4a"s 4ithout any e"uction in the am*litu"e
until it eaches the en" of the fi,e3
'i ( The AP sho4s2 all o none *henomenon3
That is2 once the ne!e fi,e eci!es theshol" stength stimulus2 it
"e!elo*s2 an AP3 If the stength of stimulus is incease"2 thee is no
augumentation of the a*litu"e of AP3
'ii( -hen the AP *o*ogates2 thee is no "imnution of the
am*litu"e of it
'iii( Stimulation75 A single theshol" stimulus fails to *o"uce
AP2 ,ut if a secon" stimulus is a**lie" sufficiently 0uic9ly afte the fist one2
the t4o stimuli ae summate" an" an e+citation esults3
Refactoy Peio"75
-hen a ne!e fi,e is *o"ucing an AP2 the fi,e ,ecomes efactoy to
a secon" stimulus3 The fist *hase of this efacto *eio" is calle"2 a,solute
efactoy *eio"3 'Duing a late *hase2 only a !ey stong stimulus can
*o"uce a es*onse2 this *hase is calle" elati!e efactoy *eio"(3
Con"ucti!ity75
Po*agation of AP75
In non mylinate" 5 a s*ot of the ne!e fi,e "e*olai6e" fist3 1ecause
of the fact that the ne!e mem,ane is ,oth e+cita,le an" esistant2 *otential
"o* acoss the mem,ane "e!elo*s in neigh,ouing *oint3
Saltatoy Con"uction75 In myelinate" ne!e3
#ee enty of Na< o e+it of =< can occu only at the no"es of Ran!ie
an" not in any othe *oints2 As a esult2 sha* "o* of mem,ane *otential
can occu only at the no"es of Ran!ie2 conse0uently the im*luse a**eas
to /um* fom no"e to no"e3 This ma9es the !elocity of the con"iction in the
myelinate" fi,es much highe than thei non5myelinate" counte *ats3
T#E TRI$EMINA% NER&E
Int"uction75 This is the lagest canial ne!e2 an" is the sesoy su**ly to
the face2 the geate *at of the scal*2 the teeth2 the oal an" nasal ca!ities2
an" moto su**ly to the masticatoy an" some othe muscles3 It also
contains *o*ioce*ti!e ne!e fi,es fom the masticatoy an" *o,a,ly the
e+ta5ocula muscles3
It has thee "i!isions
'i( O*hthalmic
'ii( Ma+illay
'iii( Man"i,ula3
The tigeminal ne!e emeges fom the !ental suface of *ons2 nea its
u**e ,o"e2 as a lage sensoy an" a small motooot2 the latte lying
anteome"ial to the fome3
Fi,e in the sensoy oot ae mainly a+ons of cells in the tigeminal
ganglion 'Semiluna( 4hich occu*ies a ecese in the "ua mate co!eing
the tigeminal im*ession nea the a*e+ of the *etous tem*oal ,one3 The
ganglion liess at a "e*th of >3?5?Cm3 fom the lateal suface of the hea" of
the *osteio en" of @ygomatic ach3 Me"ial to it ae the intenal caoti"
atey an" the *ost3 *at of the ca!enous sinus2 infeio ae the moto5oot
of the ne!e2 the geate *etosal ne!e2 the a*e+ of the *etous tem*oal
,one an" the foamen laceum3 It ecei!es filaments fom the intenal
caoti" sym*athetic *le+us an" su**lies t4igs to the tentoium cee,elli3
The neuites of uni*ola cells in the tigeminal ganglion "i!i"e into
*e*heal an" cental ,anches2 the fome ,eing gou*e" to fom the
o*hthalmic an" ma+illay ne!e an" the sensoy *at of the man"i,ula3
The cental ,anches constitute the fi,es of the sensoy oot2 lea!ing the
ganglionAs canca!e magin to un *osteome"ially un"e the su*eio
*etosal sinus an" tentoium cee,ell to ente the *ons3 Some fi,es fom
*o*ioce*to en"ings in the masticatoy muscles ta!ese the ganglion
uninteu*te"ly to *ass to the mesence*halic nucleus of the tigeminal3
On enteing the *ons2 the fi,es of the sensoy oot un "osome"ially
to4a"s the Pinci*al sensoy nucleus situate" at this le!el3 1efoe eaching
the nucleus a,out ?:B of the fi,es "ei!i"e into ascen"ing an" "escen"ing
,anches2 the othes ascen"ing o "escen"ing 4ithout "i!ision3 The
"escen"ing fi,es2 *e"omintly myelinate" o non myelinate"2 fom the
s*inal tact of the tigeminal ne!e 4hich eaches the u**e ce!ical s*inal
co"s2 as it "escen"s2 teminals an" collateals ae gi!en off to syna*se 4ith
neuons in the s*inal tigeminal nucleus3 -hich contain small an"
inteme"iate neuons an" is continuous 4ith the su,stantia gelationsa of the
s*inal co"3 The tact em,aces the nucleus "oso lateally2 in the lo4e
me"ulla o,longata it is su*eficial an" lies un"e the tu, eculum Cineum3
The fi,es 4hich syna*se in the nucleus ae concene" mostly 4ith *ain an"
themal sensi,ility3
The s*inal tigeminal nucleus "i!i"e" into thee le!els the nucleus
oalis 'most ostal2 a"/oining the *inci*al sensoy nucleus(3 The Nucleus
inte*olais2 The nucleus Cau"alis3
They "iffe in stuctue an" to some e+tent in thei connection3 All
le!els ecei!e affeents fom the 4hole tigeminal sensoy fiel"3
Some ascen"ing tigeminal fi,es2 hea!ily myelinate"2 syna*se aoun"
the small neuons in the *inci*al sensoy nucleus2 4hich lies lateal to the
moto nucleus an" me"ial to the cee,ella *e"uncle2 It is continuous
infeioly 4ith the s*inal nucleus an" is concene" 4ith tactile stimulus3
Othe ascen"ing fi,es ente the mesence*halic nucleus2 a column of
uni*ola cells2 4hose *e*heal ,anches con!ey *o*ioce*ti!e im*ulses
fom the masticatoy muscles3 It is also state" that simila im*ulses each it
fom the teeth an" fom the facial an" occula muscles3
CONNECTIONS
Most fi,es aising in the tigeminal sensoy nuclei coss the mi"line to
ascen" in the tigeminal leminscus to the thalamic nuclius centalis *osteio
me"ialis elaying to the cotical *ost centalgyus3 Some2 ho4e!e2 ascen"
to the nucleus of the i*silateal thalamus3 Collateal ,anches of *imay
an" secon"ay affeent tigeminal neuons each may othe cental egion2
such as the canial ne!e nuclei2 the eticula fomation2 cee,ellum2 tectum2
su,thalamus2 hy*othalamus etc3
The moto nucleus of tigeminal ne!e is a!oi"2 4ith lage multi*ola
cells intes*ese" 4ith smalle multi*ola cells3 It lies in the u**e *ons
me"ial to the *inci*al sensoy nucleus2 se*aate" fom it ,y fi,es of the
tigeminal ne!e3
E+ta Canial Couse7
T#E OP#T#A%MIC NER&E
The o*thalmic ne!e the su*eio an" the smallest tigeminal "i!ision2
is 4holly sensoy3 It su**lies the eye,all2 lacimal glan" an" con/uncti!a2
*at of the nasal mucosa an" the s9in of the nose2 eyeli"s2 foehea" an" *at
of the scal*3 It aises fom the anteo me"ial en" of the tigeminal ganglion
on a flat ,an"2 a,out ;3?cm3 long2 *assing fo4a"s in the ca!enous sinus in
its lateal 4all2 ,elo4 the occulomoto an" tochlea ne!es2 /ust ,efoe
enteing the o,it ,y the su*eio o,ital fissue it "i!i"es into the lacimal2
fontal an" nasociliay ,anches3
The o*hthalmic ne!e is /oine" ,y filaments fom the intenal caoti"
sym*athetic *le+us an" communicates 4ith the occulomoto tochliea an"
a,"ucent ne!es2 thus foming outes ,y 4hich *o*ioce*ti!e fi,es in these
ne!es may *ossi,ly ente the tigeminal3 It has a ecuent meningeal
,anch 'Tentoial ne!e(2 4hich aises ,elo4 an" a"hees to the tochlea
ne!e an ais "isti,ute" in the tentoium cee,elli3
T#E %ACRIMA% NER&E
he smallest of the main o*hthalmic ,anches2 sometimes ecei!esu*
filament fom the tochlea ne!e3 The lacimal ne!e entes the o,it
though the lateal *at of the su*eio o,ital fissue an" uns along the
u**e ,o"e of the ectus latealis 4ith the lacimal atey2 ecie!ing a t4ig
fom the 6ygomatico tem*oal ,anch of the ma+illay ne!e3 -hich contain
lacimal secoto moto fi,es2 enteing the lacimal glan"2 it su**lies the
a"/oining con/uncti!a3 It then *ieces the o,ital se*tum an" en"s in the
u**e eyeli"2 /oining filaments of the facial ne!e3
The Fontal Ne!e
The lagest ,anch of the o*hthalmic "i!ision2 entes the o,it ,y the
su*eio o,ital fissue2 an" *ocee"s ,et4een the le!ato *al*etae su*eio
is an" the *eiosteum2 "i!i"ing a,out mi"4ay ,et4een the a*e+ an" ,ase of
the o,it into a small su*atochlea an" a lage su*ao,ital ,anch3
The su*atochlea uns anteo me"ially2 *assing ,o!e the tochlea2 an"
su**lies a "escen"ing filament to the infatochlea ,anch of the nasociliay
ne!e3 It then emeges ,et4een the tochlea an" the su*ao,ital foaman2
cu!ing u*on the foehea" close to the ,one 4ith the su*atochlea atey
an" su**lying the con/uncti!a an" the s9in of the u**e eyeli"3 It then
ascen"s ,eneath the cougato an" fontal ,elly of occi*ito fontalis
"i!i"ing into ,anches 4hich *iece these muscles to su**ly the s9in of the
lo4e foehea" nea the mi"line3
The Su*ao,ital ne!e *ocee"s ,et4een the le!ato *al*e,ae
su*eions an" the o,ital oof an" ta!ese the su*ao,ital notch o foamen2
su**lying *al*e,al fiaments to the u**e eyeli" an" con/uncti!a3 It ascen"s
on the foehea" 4ith the su*ao,ital atey2 "i!i"ing into smalle me"ial an"
a lateal ,anch2 4hich su**ly the s9in of the scal* as fa u*to the lam,"oi"
sutue3 These ,anches ae at fist "ee* to the fontal ,elly of occi*ito
fontalis2 the me"ial ,anch *efeates it2 4hile lateal *ieces the e*icamial
a*oneuosis3 The main ne!e an" ,oth ,anches su**ly small ami to the
mucosa of the fontal sinus an" to the *eiCcanium3 Some ente the sinus
,y foamina in the floo of the su*ao,ital notch3
The Nasociliay Ne!e
Inteme"iate in si6e ,et4een fontal an" lacimal2 "ee*ly *lace" in the
o,it2 entes ,et4een the t4o ami of the occulomoto ne!e3 It cosses the
o*tic ne!e 4ith the o*hthalmic atey an" uns o,li0uely ,elo4 the ectus
su*eio an" o,li0us su*eio to the me"ial o,ital 4all3 #ee as the anteio
ethmoi"al ne!e2 it ta!es the anteio ethmoi"al fomen an" canal2 entes
the canial ca!ity an" uns fo4a"s in a goo!e on the u**e suface of the
ci,ifom *late ,eneath the "ua mate3 It "escen"s though aslit lateal to
the cista galli into the nasal ca!ity2 4hee it occu*ies a goo!e on the
suface of the nasal ,one3 It su**lies t4o intenal nasal ,anches2 a me"ial
to the anteio se*tal mucosa an" a lateal to the anteio *at of the lateal
nasal 4all3 It emeges2 as the e+tenal nasal ne!e2 at the lo4e ,o"e of the
nasal ,one2 "escen"ing un"e the tans!ese *at of the nasal is to su**ly the
s9in of the nasal ala2 a*e+ an" !esti,ule3
The nasociliay ne!e connects 4ith the ciliay ganglion an" has long
ciliay2 infatochlea an" *osteio ethmoi"al ,anches3
T4o o thee long ciliay ne!es ,anch fom the nasociliay as it
cosses the o*tic ne!e3 They accom*any the shot ciliay ne!es to *iece
the sclea nea the attachment of the o*tic ne!e3 Running fo4a"s ,et4een
sclea an" chooi"2 they su**ly the ciliay ,o"y2 iis an" conea an" usually
contain the sym*athetic fi,es of the "ilato *u*illae2 these ,eing
*ostganglionic fi,es fom neuons in the su*eio ce!ical ganglion3
The infatochlea ne!e ,anches fom the nasociliay nea the anteio
ethmo"ial foamen2 unning fo4a"s along the me"ial o,ital 4all a,o!e the
ectus me"ialis it is /oine"2 nea the tochlea2 su**lying the s9in of the
eyeli"s an" the si"e of the nose a,o!e the me"ial canthus2 the con/uncti!a2
lacimal sac an" lacimal cauncle3 The *osteio ethmoi"al ne!e lea!es the
o,it ,y the *osteio ethmoi"al foamen an" su**lies the ethmoi"al an"
s*henoi"al sinuses3
T#E MA)I%%ARY NER&E
The ma+illay ne!e the inteme"iate "i!ision of the tigeminal2 is
4holly sensoy2 it lea!es the tigeminal ganglion ,et4een the o*hthalmic
an" man"i,ula "i!isions as a flat *le+ifom ,an" 4hich *asses hoi6ontally
fo4a"s2 lo4 in the lateal 4all of the ca!enous sinus2 to ta!ese the
foamen otun"um2 4hee it ,ecomes moe cylin"ical an" com*act3
Cossing the u**e *at of the *teygo*alatine fossa2 it incline intally on the
*osteio suface of the o,ital *ocess of the *alatine ,one an" on the u**e
*at of the *osteio suface of the ma+illa an" entes the o,it thought the
infa,ital fissue2 as the infao,ital ne!e3 Ta!esing the infao,ital
goo!e an" canal inn he o,ital in the o,ital floo2 it a**eas on the face
though the infao,ital foamen2 un"e the co!e of the le!ato la,ii su*ei
cs2 an" "i!i"es2 in to ,anche c4hich "isti,ute to the nasal ala an" lo4e
eyeli" an" to the s9in an" mucous mem,ane of theuDhee9 an" u**e li*2
these amiFaommunicates 4ith the facial ne!e3
Since the mouth is ega"e" as ha!ing e!ol!e" fom a *ai of fuse"
!isceal clefts2 the ma+illay ne!e can ,e "esci,e" as *etematic an"
man"i,ula ne!e as the *ost tematic ,anch of the tigeminal ne!e3 The
,anches of the ma+illay ne!e can ,e "e!i"e" into fou gou*s
coes*on"ing to thei oigine3
In the canial Ca!ity 5 Meningeal
In the *teygo*alatine fossa 5 $anglionic2 @ygomatic2
Posteio
su*eio al!eola2
In the infao,ital canal 5 Mi""le su*eio2 al!eola2
anteio
su*eio al!eola3
On the face 5 Pal*e,al2 Nasal 2 su*eio
la,ial3
The Meningeal Ne!e75
%ea!es the ma+illay ne!e nea t he foaman otun"um2 it ecei!es a
ami fom the intenal caoti" sym*athetic *le+us an" accom*anies the
fontal ,anch of the mi""le meningeal atey to su**ly the "ua mate in
the mi""le canial fosa3 Its anteio t4igs /ust each the anteio fossa3
T4o $anglionic 1anches75 Connect the ma+illay ne!e to the
*teygo*alatine 's*heno*alatine( ganglion situate" /ust ,elo4 it in the
*teygo*alatine fosa3 They contain lacimal sceto moto fi,es an"
sensoy fi,es fom the o,ital *eiosteum an" mucosa of the nose2 *alate
an" *hayn+3
The @ygomatic Ne!e75 Stats in the *teygo*alatine fossa2 entes
the o,it thouight the infeio o,ital fissue2 uns along its lateal 4all an"
"i!i"es into t4o ,anches2 @ygomatico Tem*oal an" @ygomatic Facial3
The @ygomatico facial ta!ese the infeolateal angle of the o,it2
emeging in the face though foamen2 in the @gomatic ,one2 *efoating
the o,iculais oculi2 it su**ly the s9in on the *ominence of the chee93 It
foms a *le+us 4ith 6ygomatic ,anches of the facial ne!e an" *al*e,al
,anches of the ma+illay nel e3
The Su*eio3 Al!eola ne!es75 Aises fom the ma+illay ne!e in the
*teygo*alatine fossa o in the infao,itao,*oo!e 'canal(E They ae the
*osteio2 mi""le an" anteio su*eio al!eola ne!e3
The Posteio su*eio al!eola ne!e lea!es the ma+illay in the
*teygo*alatine fossa an" uns anteo5infeioly to *iece the infatem*oal
suface of the ma+illa2 "escen"ing un"e the mucosa of the ma+illay sinus
afte su**lying the sinus the ne!e "i!i"es into small ,anches 4hich lin9 u*
" the mola *at of the su*eio "ental *le+us su**lying t4igs to th mola
teeth3 It also su**lies a ,anch to the u**egum an8F8Fthe a"/oining *at of
the chee93
The Mi""le Su*eio Al!eola Ne!e75 It aises fom the infao,ital
ne!e as it uns in the info,ital goo!e an" un "o4n an" fo4a"s in the
lateal 4all of the ma+illay sinus3 %i9e the *osteio2 it en"s in small
,anches 4hich lin9 u* 4ith the su*eio "ental *le+us2 su**lying small ami
to the u**e *emola teeth3
The Anteio Su*eio Al!eola Ne!e75 %ea!es the latee l si"e of the
infao,ital ne!e nea the mi" *oint of its canal an" ta!eses the canalis
sinuosus in the anteio 4all of thy ma+illay sinus3 Cu!ing fist un"e the
infao, ital foamen2 it *asses me"ially to4a"s the nose2 tuns "o4n4a"s2
an" "i!i"es into ,anches su**lying the inciso an" canine teeth3 It assists in
the fomation of su*eio "ental *le+us an" gi!es off a nasal ,anch2 4hich
*asses though a minute canal in the lateal 4all of the infeio meatus to
su**ly the mucuous mem,ane of the anteio aea of the lateal 4all an" the
floo of the nassal ca!ity2 communicating 4ith the nasal ,anches of the
*teygo*alatine ganglion3 Fin ally it emeges nea the oot of the anteio
nasal s*ine to su**ly the a"/oining *at of the nasal se*tum3
The Pal*e,al 1anches75 Ascen" "ee* to the o,iculaies oculi2 *iecing the
muscle to su**ly the s9in in the lo4e eyeli" an" /oins 4ith the facial an"
6ygomatics facial ne!es nea the lateal canthus3
Nasal 1anches75 Su**ly the s9in of the si"e of the nose an" of the
mo!a,le *at of the nasal se*tum2 /oining the e+tenal nasal ,anches of the
anteio ethmo"ial ne!e3
Su*eio %a,ial ,anches75 Descen" ,ehin" the le!ato la,ii su*eiois2
to su**ly the s9in of the anteio *at of the chee92 u**e li*2 oal mucosa
an" la,ial glan"s2 an" ae /oine" ,y ,anches fom the facial ne!e to fom
the infao,ital *le+us3
T#E PTERY$O PA%ATINE $AN$%ION
The lagest of the *ei*heal *aasym*athetic ganglia2 is *lace" "ee*ly
in the *teygo *alatine fossa2 nea the s*heno*alatine foamen an" anteio
of the *teygoi" canal2 an" lies /ust ,elo4 the ma+illay ne!es as it cosses
the fossa3 Though connecte" functionally 4ith the facial ne!e2 it is closely
elate" to the ma+illay ne!e in *osition3
Its moto o *aasym*athetic oot is the ne!e of the *teygoi" canal3
Enteing the ganglion *oseioly2 its fi,es aise fom a s*ecial lacimatoy
nucleus in the lo4e *ons2 emeging in the sensoy oot of the facial ne!e to
un in its geate *etosal ,anch unites 4ith the "ee* *etosal ne!es to fom
the ne!e of the *teygoi" canal3 These *eganglionic fi,es elay in the
*teygo*alatine ganglion2 the *ostganglionic fi,es follo4ing a com*licate"
couse to thei "estimation2 lea!ing the ganglion in one of its ,anches2 they
/oin the ma+illay ne!e an" *ass into its 6ygomatic ,anch an" then into the
6ygomatico tem*oal ne!e2 lea!ing it in its communicating amus to each
the lacimal ne!e3 Thus they su**ly secetomoto fi,es to the glan"3
Secetomoto fi, es fo the *alatine2 *hayngeal an" nasal glan"s ae also
,elie!e" to follo4 a simila oute to the ganglion2 4hee they ae elaye"2 the
*ostganglionic fi,es unning in the *alatine an" nasal ,anches3
The ,anches 4hich a**ea to aise fom the *teygo*alatine ganglion
ae lagely "ei!e" fom the ma+illay ne!e an" though intimately elate" to
the ganglion2 "o note syna*se in it3 They inclu"e the o,ital2 nasal an" the
*hayngeal ,anches3
The o,ital ,anches ae t4o o thee fine ami 4hich ente the o,it ,y
the infeio o,ital fissue an" ae "isti,ute" to the *eiosteum an" o,italis
muscle3 Some fi,es ta!ese the *osteio ethmoi"al foamen to su**ly the
s*henoi"al an" ethmoi"al sinuses3 The fi,es su**lying the o,italis ae
fom the sym*athetic oot3
The *alatine ne!es ae "isti,ute" to the oof of the mouth2 the
soft*alate2 tonsil an" nasal mucosa3 The geate *alatine ne!es "escen"s
though the geate *alatine foamen2 uns fo4a"s in a goo!e on the
infeio suface of the ,ony *alate almost to the inciso teeth an" su**lies
the gums an" the mucosa an" glan"s of the osseous *alate3 It also
communicates 4ith the teminal filaments of the naso*alatine ne!es3 In the
geate *alatine canal it su**lies the *osteio infeio nasal ,anches2 4hich
emeges though the *e*en"icula *late of the *alatine ,one an" amify
o!e the infeio nasal concha an" the 4Falls of the mi""le an" infeio
meatuses2 as its e+it fom the canal the *alatine ,anches ae "isti,ute" to
,oth sufaces of the soft *alate3 The lesse *alatine ne!es "escen" though
the geate *alatine canal2 enege though the lesso *alatine foamen an"
gi!e ,anches to the u!ula2 tonsil an" soft *alate3 Fi,es con!eying taste
im*ulses fom the *alate *o,a,ly *ass !ia the *alatine ne!es to the
*teygo*alatine ganglion an" though it to the ne!e of the *teygoi" canal
an" geate *etosal ne!e to the facial ganglion3
Nasal ,anches ente the nasal ca!ities though the s*heno*alatine
foamen2 foming the lateal an" me"ial gou*s3
'8( A,out si+ lateal *osteio su*eio nasal ne!es inne!ates the mucosa
of the *osteio *at of the su*eio an" mi""le nasal conchae an" the lining
of the *osteio ethmoi"al sinuss3
';( T4o o thee me"ial *osteio su*eio nasal ne!es coss the nasal oof
,elo4 the o*ening of the s*henoi"al sinus to su**ly the mucosa of the
*osteio *at of the oof an" of the nasal se*tum3
The lagest of these ne!es is the naso*alatine ne!e2 4hich uns anteo5
infeioly on the nasal se*tum in a goo!e on the !ome3 It "escen"s to the
oof of the mouth though the incisi!e fossa in the anteio ha" *alate3
The naso*alatine ne!es su**ly a fe4 filaments to the nasal se*tum an"
en" ,y su**lying the mucosa of the anteio *at of the ha" *alate2 thee
communicating 4ith the anteio *alatine ne!es3
T#E MANDI1U%AR NER&E
The man"i,ula ne!e su**lies the teeth an" gums of the man"i,le2 the
s9in in the tem*oal egion2 *at of the auicle2 the lo4e li*2 the lo4e *at
of the face an" muscles of mastication2 it also su**lis the mucosa of the
anteio2 *esulcal *at of the tongue an" the oal floo32 The lagest
tigeminal "i!ision2 it has a lage2 sensoy oot 4hich *ocee"s fom the
lateal *at of the tigeminal ganglion to emege almost at once fom the
foamen o!ale an" a small moto oot 4hich *asses un"e the ganglion to
unite 4ith sensoy oot /ust ,eyon" the foamen o!ale2 4hee the ne!e
*asses ,et4een the tenso !eli *alatini 'me"ial( an" the lateal *teygoi"3
.ust ,eyon" this /unction a meningeal ,anch an" the ne!e to the me"ial
*teygoi" lea!e the ne!eAs me"ial si"e3 It then "i!i"es into small anteio
an" *osteio tun93 As it "escen"s fom the foamen o!ale2 the ne!e is
a,out >cm fom th suface an" a little anteio to the nec9 of the man"i,le3
The Meningeal 1anches 'ne!us 5 S*inosus(75 Re entes the canium
though the foamen s*inosum 4ith the mi""le meningeal atey2 "i!i"ing
the anteio an" *osteio ,anches 4hich accom*any the main "i!ision of
the atey an" su**ly the "ua mate in the mi""le canial fossa an" to a
lesse e+tent in the anteio fossa an" cal!aium the *osteio also su**lies
the mucous lining of the mastoi" ai cells 4hile the anteio communicates
4ith the meningeal ,anch of the ma+illay ne!e3 The ne!es s*inosus also
contain sym*athetic *ostganglionic fi,es fom the mi""le meningeal
*le+us3
The ne!e to the me"ial *teygoi"75 is a slen"e amus enteing the "ee*
as*ect of its muscle2 su**lying one o t4o filaments 4hich *ass though the
otic ganglion 4ithout inteu*ting to su**ly the tenso tym*ani an" tenso
!eli *alatini3
The Anteio Tun975 It gi!es ise to '8( the sensoy ,uccal ne!e an"
';( moto ,anches2 Masseteice2 "ee* tem*oal an" lateal *teygoi" ne!es3
The 1uccal Ne!e 75 Pocee"s ,et4een the t4o *ats of the lateal
*teygoi"2 "escen"ing ,eneath o though the lo4e *at of the tem*oalis
an" "ee* to the man"i,le an" massete2 it emeges fom un"e the co!e of
the man"i,ula amus an" massete anteioly an" unites 4ith the ,uccal
,anches of the facial ne!e3 It su**lies the lateal *teygoi" 4hile *assing
though it an" may gi!e of the anteio "ee* tem*oal ne!es3 It su**lies
the s9in o!e the anteio *at of the ,uccinato an" the mucous mem,aine
lining its inne suface togethe 4ith the *osteio *at of the ,uccal gingi!al
suface3
The Masseteic Ne!e75 Passes lateally2 a,o!e the lateal *teygoi"
anteio to the TM. an" *osteio to the ten"on of the tem*oalis2 it coss the
*osteio *at of the man"i,ula incisi!e 4ith the masseteic atey2 amifies
on an" entes the masseteAs "ee* suface an" also su**lies the /oint3
The "ee* tem*oal ne!es75 Usually an anteio an" *osteio2 *ass
a,o!e the lateal *teygoi" to ente the "ee* suface of the tem*oalis3 The
small *osteio ne!e is *osteio in the tem*oal fossa2 sometimes aising in
common 4ith the masseteic ne!e2 it ascen"s o!e the u**e hea" of the
lateal *teygoi"3
The ne!e to the lateal *teygoi"75 entes the "ee* suface of the muscle3
It may aise se*eately fom the anteio "i!ision of the man"i,ula2 o 4ith
the ,ucal ne!e3
The Posteio Tun975 The *osteio an" lage2 man"i,ula tun9 is
mainly sensoy ,ut eci!es a fe4 filaments fom the moto oot3 It "i!i"es
into auiculo tem*oal2 lingual an" infeio al!eola ne!es3
The Auiculo Tem*oal Ne!es75 Usually has t4o oots2 encicling the
mi""le meningeal atey3 It uns ,ac9 un"e the lateal *teygoi" on the
suface of the tenso !eli *alatini to *ass ,et4een the s*henoman"i,ula
ligament an" the nec9 of the man"i,le an" then lateally ,ehin" the TM.
inelation 4ith the u**em *at of the *aoti" glan"3 Emeging fom ,ehin"
the /oint2 it ascen"s *osteio to the su*eficial tem*oal !essels2 o!e the
*osteio oot of the 6ygoma2 an" "i!i"es into su*eficial tem*oal
,anches3
It communicate 4ith the facial ne!e an" otic ganglion3 The ami of the
facial ne!e2 usually t4o2 *ass anteo lateally ,ehin" the nec9 of the
man"i,le to /oin the facial ne!e at the *osteio ,o"e of the massete3
Filaments fom the oicganglion /oin the oots of the auiculo tem*oal ne!e
close" to thei oigin3
The ,anches of auiculo tem*oal ne!e ae the anteio auicula2
,anches to the e+tenal acoustic meatus2 aticula2 *aoti" an" su*eficial
tem*oal3 Usually t4o anteio auicula ,anches su**ly the s9in of the
tagus an" sometimes a small *at of the a"/oining heli+3 The t4o ,anches
of the e+tenal acoustic meatus *ass ,et4een the osseous an" catilaginous
*ats of the meatus to su**ly the s9in of the meatus2 the u**e sents a t4ig to
the tym*anic mem,aine3 The aticul ,anches ae one o t4o filaments
4hich ente the *osteio *at of the TM.3 The *aoti" ,anches con!ey
secetomoto fi,es to the glan"2 *eganglionic fi,es come fom the
glosso*hayngeal ne!e ,y its sym*anic ,anch2 ta!elling !ia the lesso
*etosal ne!e to the otic ganglion2 4hee *ostganglionic fi,es *ass to the
auiculotem*oal ne!e to each the glan"3 &asoomoto fi,es to the ,loo"
!essels of the *aoti" glan" ae fom the sym*athetic oot of the otic
ganglion3 The su*eficial tem*oal ,anches accom*any the su*eficial
tem*oal atey an" its teminal ,anches su**lying the s9in in the tem*oal
egion an" connecting 4ith the facial an" 6ygomatico tem*oal ne!es3
The lingual ne!e75Is sensoy to the mucousa of the *esulcal *at of the
tongue2 the floo of the mouth an" the man"i,ula gingi!ae3 It aises fom
the *osteio tun9 of the man"i,ula ne!e an" at fist uns ,et4een the
tenso &eli *alatini an" the lateal *teygoi"2 4hee it is /oine" ,y cho"a
tym*ani ,anch of the facial ne!e an" often ,y the ,anch of the infeio
al!eola ne!e3 Emeging fom the co!e of the lateal *teygoi" it *ocee"s
"o4n an" fo4a"s ,et4een the man"i,ula amus an" the me"ial
*teygoi"2 lying anteio an" slightly "ee* to the infeio al!eola ne!e3 It
them *asses ,elo4 the man"i,ula attachment of the su*eio *hayngeal
consticto an" lies against the me"ial suface of the man"i,le nea the oots
of the thi" mola tooth2 4hee it is co!ee" only the gingi!al mucosa2 hee it
can ,e *asse" against the ,one ,y a finge *lace" insi"e the mouth2 It lea!es
the gingi!a an" *asses into the si"e of the tongue2 4hee it cosses the
styloglossus an" uns on the lateal suface of the hyoglossus an" "ee* to the
mylohoi"2 a,o!e the "ee* *at of the su,man"i,ula glan" an" its "uct3 It
*ocee"s fo4a"s on the si"e of the tongue2 lateal to the hyoglossus an"
gemioglossus2 an" "i!i"s into teminal ,anches 4hich lie "iectly un"e the
lingual mucosa3 In the latte *at of its couse the ne!e is nea the
su,man"i,ula "uct2 it *asses "o4n4a"s an" fo4a"s lateal to the "uct2
4in"s ,eol4 it an" then ascen"s fo4a"s me"ial to it3
In a""ition to ecei!ing the cho"a tym*ani an" a ,anch fom the
infeio al!eola ne!e2 the lingual ne!e is connecte" to the su,man"i,ula
ganglion ,y t4o o thee ,anches an"2 at the anteio magine of the
hyoglossus it foms connecting loo*s 4ith t4igs of the hy*oglossal ne!e3
1anches of the lingual ne!e su**ly the mucosa of the oal floo2
lingual as*ects of the gingi!ae an" the mucosa of the *esulcal *at of the
tongue2 ,eing o!ela**e" slightly ,y the lingual fi,es of the
glosso*hayngeal ne!e2 teminal filaments /oin t the lingual a*e+ 4ith t4igs
of the hy*oglossal ne!e3 It also caies *ostganglionic fi,es fom the
su,man"i,ula ganglion to the su,lingual an" anteio lingual glan"s3
The Infeio Al!eola Ne!e75
It "escen"s me"ial to the lateal *teygoi" an" then2 at its lo4e ,o"e2
*asses ,et4een the s*heno man"i,ula ligament an" the man"i,ula amus
to ente though the man"i,ula foamen into the man"i,ula canal2 in this2 it
uns ,elo4 the teeth2 to the mental foamen2 4hee it emeges to "i!i"e into
incisi!e an" mental ,anches3 1elo4 the lateal *teygoi" it is accom*nie"
,y the infeio al!eola atey3
Dissection an" a"ioga*hy sho4 that 4ith in most man"i,les the
infeio "ental ne!e is *le+ifom an" "oes not occu*y a single canal3 It is
/oine" "iectly2 o though *le+ifom ,anches2 ,y ami enteing the ,one as
*ats of neuo !ascula ,un"les "ei!e" fom attache" muscles such as the
massete3 Such accessoy "ental ne!es amify in a *lane lateal to the
mola tooth2 thee common occuence accounts fo incom*lete anaesthesia
,y infeio "ental ne!e ,loc93
The mylohyoi" ne!e lea!es /ust ,efoe the infeio al!eola ne!e
entes the man"i,ula foamen3 It *ieces the s*heno man"i,ula ligament2
"escen"s in a goo!e as the me"ial suface of the amus of the man"i,le an"2
*assing ,elo4 the mylohyoi" line2 eaches the infeio suface of the
mylohyoi"2 su**lyng it an" the anteio ,elly of "igastic3
1anches to the mola an" *emola teeth su**ly the a"/oining gingi!a
also3 1efoe they ente the "ental oots they communicate an" fom an
infeio "ental *le+us3 The incisi!e ne!e is often "esci,e" as continuing
on inthe ,one to su**ly the canine an" inciso teeth3 The canine teeth may
,e su**lie" fom the inciso *le+us o fom the *le+us inne!ating the
*emolaas3
The mental ne!e2 emeging fom its foamen2 "i!i"es ,eneath the
"e*esso anguli ois into thee3 A ,anch "escen"ing to the s9in of the chin
an" t4o ascen"ing to the s9in an" mucosa of the lo4e li*2 these
communicates feely 4ith the facial ne!e 'Man"i,ula ,anch(
PAIN PAT#-AYS
The tigeminal ne!e2 is the *inci*al sensoy ne!e of the hea" egion3
Any stimulus in the aea of the tigeminal ne!e is fist ecei!e" ,y ,oth
myelinate" an" non myelinate" fi,es an" con"ucte" as an im*ulse along the
affeent fi,es of the o*hthalmic2 ma+illay an" man"i,ula ,anches into
the semiluna o gasseion ganglion3 Fom the ganglion the im*ulse is
me"iate" ,y the sensoy oot of the ne!e into the *ons3 #ee the sensoy
oot eithe en"s "iectly in the main sensoy nucleus o ,ifucates into
scen"ing an" "escen"ing fi,es3 The ascen"ing fi,es con!eys geneal
tactile sensi,ility2 4heeas the "escen"ing fi,es con!eys *ain an"
tem*eatue3 Thus the *ain im*ulse "escen"s fom the *ons ,y the s*inal
tact fi,es of the tigeminal ne!e2 though the me"ulla2 "o4n to a,out the
le!el of the secon" ce!ical segment2 4hee the tact teminates3 The
man"i,ula2 ma+illay an" o*hthalmic ,anches teminate in the nucleus in
that o"e3
A+ons of the secon"ay neuons emege fom the s*inal nucleus2 coss
the mi"line2 an" ascen" to /oin 4ith fi,es of mesence*halic nucleus fom
the tigeminal lemniscus2 o s*inothalmic tacts2 of the tigeminal ne!e3
These tacts continue u*4a"s an" teminate in the *osteo!ental nucleus of
the thalamus3 Some fi,es of the lateal s*inothalamic tact caus a geneal
stimulation of the eticula fomation that inceases the *atients a4aeness of
an" eaction to *ain3
The *ain im*ulse2 on eaching the *osteo!ental nucleus of the
thalamus2 is me"iate" ,y secon"ay connecting neuon that *o/ect fom the
*osteo!ental thalamus to the *osteocental con!olutions of the cee,al
cote+3
Although the fifth cainal ne!e is the main sensoy ne!e of the hea"2
the se!enth2 ninth an" tenth cainal ne!es an" the secon" an" thi" ce!ical
ne!es *lay a mino *at in the me"iation of *ain fom this aea3
NER&E IN.URIES
In in/uies of the facial s9eleton an" facial soft tissues2 !aious canial
ne!es ae in!ol!e"3 Tigeminal ne!e is most fe0uently in!ol!e"3
Inci"ence75
G:B inci"ence of inf3 al!eola ne!e in/uy foun" 4ith factues of the
man"i,ula ,o"y an" 8::B inci"ence of infao,ital ne!e in/uy 4ith
6ygomatico ma+illay com*le+ factues3 Electi!e man"i,ula thi" mola
sugey accounts fo most common in/uies to inf3 al!eola ne!e an" lingual
ne!e3 %ong ,uccal ne!e in/uy can occu 4hile aising the ,uccal fla* fo
thi" mola e+*osue2 man"i,ula osteotomy an" !esti,ulo *lasty3 Remo!al
o e+*osue of im*acte" cus*i"s an" su*enumeay teeth fom the *alate
can lea" to naso *alatine neuo*athy3
Infeio al!eola neuo*athy follo4ing sagittal man"i,ula osteotomy
an" follo4ing osteotomy fo man"i,ula augumentation has got ?:B to G:B
inci"ence3 Mental ne!e *aaesthesia is usual 4ith s9in gaft !esti,ulo
*lasty3 The sensoy neuo*athies associate" 4ith econstucti!e an"
*e*osthetic sugeies ae moe se!ee as they ae *efome" in ol"e age
*o*ulations an" ha!e less fa!oua,le egeneati!e es*onse3
Ne!e in/uies ae classifie" acco"ing to the "egee of ne!e in/uy as
neua*a+ia2 A+onotmesis2 Neuotmesis3
Neua*a+ia75 Neua*a+ia2 usually the esult of com*ession2 is the
sim*lest fom of ne!e "amage3 Only the nao4 sheath is locally "mage"
in a limite" egion3 Afte an e"ematous *hase2 thee can ,e "isintegation
an" eso*tion of the myelin sheath2 ,ut 4ithout "ee*e "amage in!ol!ing
the a+ons3 Thee foe2 the esult is only a tem*oay inteu*tion of
con"uction2 4ith the continuity of the a+ial cylin"e emaining com*letely
intact3 As soon as the cause of the "amage is emo!e"2 function is estoe"3
The egeneation *hase "e*en"s on the time e0uie" fo egeneation of the
myelin sheaths3 If the "amage continues2 ho4e!e2 com*lete "isintegation
of the myelin sheath sults2 an" the a+ons themsel!es may ,ecome in!ol!e"2
sometimes2 ,ecause of an ischemic "istu,ances of the ,loo" su**ly3 Since
neua*a+ia *ocee"s 4ithout significant mo*hologic "amage2 of couse it
"oes not e0uie sugical inte!ention2 fun ction etuns s*ontaneously3
A+onotmesis75 A+onotmesis is chaactei6e" ,y "estuctions of a+ons an"
myelin sheaths2 4hile connecti!e tissue stuctues emain intact3 The chief
cause of a+onotmesis is *olinge" com*ession of the ne!e o locali6e"
ischemic "amage3 As the continuity of the ne!e is not inteu*te" in
a+onotmesis2 "egeneati!e an" egeneati!e *ocesses can *ocee" in an
i"eal fashion afte inteu*tion of the ne!e fi,es3
Fist2 the a+ons an" maoo4 sheath in the "istal segment fall !ictim to
4alleian "egeneation2 they "isintegate2 an" thei fagments ae
"ecom*ose" ,y the Sch4ann cells an" ,y enteing maco*hages3 At the
same time2 the sch4nn cells *olifeate 4ithin the ,asal mem,ane2 they
multi*ly an" ae ogani6e" into ,an" li9e chains2 the #an9e51ungne ,an"s3
The "egeneation in the Cental ne!e segment *ocee"s2 as a ule2 only as
fa as the ne+t2 *o+imally locate" Ran!ies no"e3 It may go e!en futhe if
e+tensi!e tauma is *esent3 Regeneation of the ne!e fi,es can *ocee"
only fom the cente3 That is fom the *o+imal stum*3 Usually2 se!eal
a+ones e+ce*t fom the en"s of the a+ial cylin"e2 they use the #an9e5
1ungne ,an"s *e*ae" ,y the Sch4ann cells as a *ath an" follo4 them to
the en" ogan3 The Sch4ann cells cause a ne4 myelin sheath to fom
aoun" the a+one2 4hose sheath segments2 ho4e!e2 ae shote than those of
the intact ne!e3 The ne!e fi,es egeneate ,y :3;? to Fmm *e "ay2 thei
egeneati!e ca*acity emains intact o!e a *eio" of yeas3
Neuotmesis75 #ee2 the ne!e 4ith its ne!e fi,es is com*letely se!ee"3
The 4allaian "egeneation *ocee"s in the "istal segment in the same 4ay
as in a+ono tmesis3 #ee2 also the esult is com*lete "egeneation of the
a+ial cylin"es an" myelin sheath3 Nutition to the emaining slements of
the "istal ne!e is *ese!e"2 afte inteu*tion of the longitu"inal !essels2
,y 4ay of collateal !essels in the !icinity2 so that the connecti!e tissue
co!eing su!i!es3 #ee2 also einne!ation *ocee"s ,y 4ay of the a+ons
aising fom the *o+imal stum*s2 the a+ons2 ho4e!e2 must fist fin" thei
4ay though the in/uy site into the "istal ne!e3 1ut this is *ossi,le only in
the i"eal case in 4hich the fascicles ae a**o+imate" *ecisely an" the
ne4ly fome" a+one "o not ha!e to o!ecome any o,stacle ,efoe
*enetating the *ei*heal ne!e segment3 This is the eason fo the cental
*o,lem in econstucti!e sugey of ne!e in/uies3 The sugical *oce"ues
must ensue that the egeneating a+ons can *enetate into the *ei*heal
ne!e stum* 4ithout hin"ance an" must emo!e all factos that intefee
4ith this *ocess3
#isto*athology of Ne!e In/uy75
Degeneation an" egeneation of Neuons75
-hen the a+on of a neuon is cut acoss a seies of "egeneati!e
changes ae seen in the a+on "istal to the in/uy2 in the a+on *o+imal to the
in/uy an" in the cell ,o"y3
The changes in the *at of the a+on "istal to the i/uy ae efee" to as
anteoga"e "egeneation o 4alleian "egeneation3 They ta9e *lace in the
entie length of this *at of the a+on3 A fe4 hous afte in/uy the a+on
,ecomes s4ollen an" iegula in sha*e2 an" in a fe4 "ays it ,ea9s u* into
small fagments3 It also uun"egoes chemical changes3 The sch4ann cells
incease in si6e an" muti*ly in num,e3 They act as maco*hages an"
emo!e emnants of the a+on an" of myelin3 At the same time sch4ann cells
*o"uce a lage seies of mem,anes that hel* to fom numeous tu,es %ate
these tu,es *lay a !ital ole in egeneation of ne!e fi,es3
Degeneati!e changes in the neuon *o+imal to the in/uy ae efee"
to as etoga"e "egeneation3 These changes ta9e *lace in the cell ,o"y an"
in the a+on *o+imal to the in/uy3
The cell ,o"y of the in/ue" neuon un"egoes seies of changes that
constitute the *henomenon of chomatolysis3 The cell ,o"y enlages to
,ecome s*heical2 the nucleus mo!es fom the cente to the *ei*hey2 the
nissl sustances "issol!es a4ay3 The eactions is moe se!ee 4hen the
in/uy to the a+on is nea the cell ,o"y3
Some times the changes esulting fom a+onal in/uy ae not confine"
to the in/ue" neuons2 ,ut e+ten" to othe neuons 4ith 4hich the in/ue"
neuon2 syna*ses3 This *henomenon is efee" as tans neuonal
"egeneation3
Changes in the *o+imal *at of the a+on ae confine" to a shot
segment nea the site of in/uy3 If the in/uy is ha* an" clean the effects
e+ten" only u*to one o t4o no"es of Ran!ie *o+imal to the in/uy3 If the
in/uy is se!ee enough longe segment of a+on may ,e affecte"3 The
changes in the affecte" *at a e+actly the same s fo the "istal *at of the
a+on3 They ae soon follo4e" ,y acti!e go4th at the ti* of the su!i!ing
*at of the a+on3 This causes the teminal *at of the a+on to s4ell u*3 If
then gi!es off a num,e of ,anches3 These ,anches go4 into the
connecti!e tissue at the site of in/uy2 in an effot to each the "istal cut en"
of the ne!e3 The sch4ann cells of the "istal *at of the ne!e *olifeate to
fom a seies of tu,es3 -hen one of the egeneating a+onal ,anches
succe"s in eaching such a tu,e2 it entes it an" then go4s a*i"ly 4ithin it3
The tu,e se!es as a gui"e to the go4ing fi,e3 A+onal ,anches that fail to
each one of the tu,es "egeneate3 The a+on teminal go4ing though the
sch4ann cell tu,e ultimately eaches an" esta,lishes3 contact 4ith an
a**o*iate *ei*heal en" agan3
REPAIR OF NER&E IN.URIES
Pinci*les of Ne!e Anastomosis75
Sutue Techni0ue75Diect Sutue Anastomosis of ne!es is in"icate" 4hen
neuomesis ty*e in/uy is 9no4n to ha!e occue"3 Imme"iate e*ai of total
ne!es an" sheath in/uies is most effecti!e if the fiel" is fee of foeign
mateial an" thee is no infection an" 4hen the ne!e en"ings can ,e
a**o+imate" *assi!ely 4ithout significant tension3 Tension of geate than
;?gms is e+cessi!e an" stetching of moe than HB of the ne!e length 4ill
e"uce the intinic !enule flo43
Delaye" ne!e anastomosis can also ,e successful ,ut "elay fo moe
than ; months 4ill *emit the ingo4th of significant fi,ous tissue2 neuoma
fomation an" e"uction of ?:B off nomal e*ineual sheath "iamete3
In the stan"a" techni0ue fo ne!e anastomosis the meso neuium is
elease"2 an" the ne!e is fee" fo atleast ?mm3 on eithe si"e of the in/uy
site in o"e to o,se!e fo secon"ay in/uies an" "e,is an" to ai" in
tension fee e*ai3 1lee"ing shoul" ,e contolle" 4ith ,i*ola
micocoagulato2 taumatic suctioning o etaction of neuo !ascula tun9s
shoul" ,e a!oi"e"3 The anatomic featues of the cut ne!e en"s ae
i"entifie" to ena,le a *o*e ealignment2 of fascicles3 Any e+cess
fascicula *oto*lasum o iegula e*ineuium ae timme"3
Fo monofasciula ne!es such as the infeio al!eola ne!e an"
lingual2 e*inual *ai is sim*lest an" effecti!e3 Fo ne!es 4ith moe than
one fascicle such as the infao,ital an" mental2 *eineual sutuing is
necessay to match u* coect *o+imal an" "istal ,anches3
The actual sutuing is accom*lishe" 4ith G5: o 8:5: nylon mateial3 It
sutues ha!e ,een o!etightene"2 thee 4ill ,e a lateal ,ulging of fascicula
contents2 e0uiing eithe timming o esutue3
The Cause of Failue of macosco*ic sutuing o e*inual sutuing75
I( E!en 4ith a fesh cut2 the cut sufce of a ne!e emains smooth"ue to
the en"s neul *essue an" the etaction of the *eineuiam2 the e+an ten"
to ,ulg out fom the *einual tu,es of in"i!i"ual fascicles3
II( It is "ifficult to achie!e e+act a"a*tation of coes*o"ing fasciles ,y
means of e*ineual sutues2 e!en slightest t4isting of the ne!e stum*s lea"s
to incom*lete a*o+imation of i"entical fasciles o to thei gli"ing *ast one
anothe
Peineual Sutuing75
The use of sugical micosco*e ma9es *ossi,le ataumatic han"ling of
the ne!e stum*s2 e+act e!aluation of the cut sufaces of the ne!e2 an"
a"a*tation of the smalle unit of the ne!e stum*s 'the fascicles(3
Afte emo!al of the e*ineuium2 single lage fascicles can ,e isolate"
an" it is *ossi,le to esect the ne!e su,stance ,ulging fom the *eineual
tu,es 4ithout shotening the *eineuium an" thus to a!oi" e*eate" ,ulging
out of a"itional a+on masses3 The fascicles stum*s 4hich ae smooth no42
ae /oine" ,y one o t4o inteu*te" sutues3 This *oce"ue thee foe
efee" to as *eineual inte fascicula ne!e sutue3 'Millesi 5 etal 8GI;2
Sammi an" -ille,an" 8GI:(3
Polifeation of Connecti!e tissue at the sutue site75
This is the geatest "ange in ne!e anastomosis as it *e!ents the
go4th of the a+on into the "istal ne!e stum* an" 4hich can lea" to
fomation of sca3
Factos lea"ing to sca fomation ae
i( Tissue tauma
ii( Ty*e an" amount of sutue mateial an"
iii( Inte *osition of ,loo" ,et4een the ne!e stum*s '"ue to
,lee"ing
fom the !essels of the ne!e en"ings(
Pe!ention75 I( To *e!ent tissue tauma 5 9ee* the sutues fee of tension3
If it is not *ossi,le2 in a ne!e in/uy2 to achie!e a tension fee a**o+imation
,y mo,ili6ation of the ne!e en"ings2 *o+imally an" "istally2 then only the
inte *osition of a ne!e tans*lant can lea" to tension fee ,i"ing of the
"efect3
Ataumatic "issection shloul" ,e "one2 o*eating un"e sugical
micosco*e ma9es this *ossi,le3 The ty*es of sutue mateial can also affect
connecti!e tissue *olifeation2 simila to a foeign ,o"y eaction3 Thee fo
the anastomosis shoul" ,e *efome" 4ith sutue mateial of goo" tissue
com*ati,ility3 Monofilament nylon I:C: o IIC: is *aticulaly suita,le3
To a!oi" such foeign ,o"y eaction to the sutue mateial2 synthetic
a"hesi!es ae tie" 'Using fi,in clot(3
Inte *osition of coagulate" ,loo" ,et4een the ne!e stum*s can lea" to
se!ee connecti!e tissue *olifeation at the sutue site3 Using 1i*ola
coagulation caeful coagulation of small !essels can ,e "one 4ithout tauma
to the fascicles3
NER&E TRANSP%ANTATION 'NER&E $RAFTIN$(
Ne!e gafting is in"icate" in cases of acute neuo5tmesis 4hee I(
eanastomosis can not ,e accom*lishe" 4ithout tension3
;( Neuotmesis an" a+onotmesis ha!e esulte" in *ain an" *oo etun of
sensiti!ity3
F( Thee is e!i"ence of sym*tomatic neuoma3
T4o *imay gaft "ono ne!es ae suita,le
8( Sual ne!e ,anch of the *eoneal ne!e
;( $eat Auicula ne!e3
The sual ne!e is com*ati,le 4ith the infeio al!eola ne!e an"
segments of geat auicula ne!e can ,e a"a*te" to infaiJo,ital an" mental
ne!e ,anches an" less sensoy "eficit can ,e *o"uce" ,y emo!ing only a
*otion of the geat auicula3
A clean !etical sectioning is then ma"e *o+imal an" "istal to the
"isease" ne!e egion3 E+cess e+o*lasm that e+u"es fom the cut fascicles
shoul" ,e timme" flush 4ith the e*ineual o *eineual sheath in
*e*aation fo the gaft3
The gaft is ,ought to *lace 4ith a single G5: o 8:5: taction sutue
*lace" fist though the o+imal ne!e stum*2 then though the gaft3 A
secon" sutue is then gi!en ,y otating the ne!e 8;: to 8H:
o
3 The fist
taction sutue of the "istal e*ai shoul" ,e *lace" fist though the "istal
ne!e stum* athe than though the gaft2 to a!oi" e+cessi!e *ull on the
*o+imal e*ai3 O!etightening of sutues a!oi"e" othe4ise lateal
,ulging an" neuoma fomation 4ill occu3
POST TRAUMATIC PAIN SYNDROMES
Anesthesia Doloosa75
It is a constant2 ,oing2 *enetating *ain e+*eience" in the cente of a
"isti,ution of num,ness3 Seen mainly in *atients 4ho un"e4ent ne!e oot
hi6otomies3 The site of *athology *ossi,ily in the highe thalamic an"
cotical le!els3
CAUSA%$IA75 It is a "ee* aching o ,uning that s*each out fom the
in/ue 6one an" ,eyon" natual ,oun"aies3 These *ain neithe *ao+ysmal
o no tiggee"2 although attac9s ae ,ought on ,y mil" *ain o touch
stimulation of the egion2 ,y "ying of tissue o ,y en!ionmental stimuli
such as lou" noises3 The affecte" tisues s4eat e+cessi!ely ,come 4am o
col" an" 4ill sho4 "egeneati!e to*hic changes3 All the sym*toms ae
intensifie" ,y emotional stess3 The s*ecific mechanisum of causaligia may
,e the atificial syna*sing of effeent sym*athetic fi,es 4ith somatic
sensoy fi,es 4ithin neuomas that ha!e fome" at the site of oiginal ne!e
in/uy3 Usually cue" ,y i"entifying an" e+cising neuomas3
Phantom facial *ain75
Patients 4ho ha!e un"egone e+cision of a ,o"y *at often e+*eience a
sense of a4aness of the missing *at calle" the *hantom *enomenon3
Pao+ysms of 8: minutes "uation felt as sta,,ing2 4ith e+teme itching o
"ee* ,uning an" *essue of the missing *at3 May get tiggee" ,y tactile
stimulation3
Com*laints can ,e antici*ate" fom *atients 4ho ha!e un"egone
glossectomy an" man"i,ulectomy o*eation fo cance contol3 Com*laints
of toothache an" of *hantom teeth in "ental e+taction sites2 es*ecially 4hen
the teeth ha!e ,een chonically sym*tamatic ,efoe emo!al ae not unusual3
Afte am*utation of a ,o"y *at2 a,out half the associate" neuons "ie2
an" the egeneate" fi,es of the stum* ae small2 *ooly myelinate" an"
slo4 con"ucting3 Stimulation of these stum*s may ha!e the effect of
acti!ating an im,alance" gate contol machanisum in the ,ain stem an"
ina**o*iate sensoy *henomena such as *hantom *ain3
Ca,ama6a*ine thea*y is successful sometimes3 Su**oti!e cae an"
eassuance is often a"0uate ,ecause *hantom *ain "iminish 4ith time3
%ESIONS OF T#E TRI$EMINA% NER&E
Pei*heal %esions75
The ne!e may ,e in!ol!e" ,et4een the *ons an" the tigeminal
ganglion in ganulomatous meningitis o it may ,e com*esse" ,y a tumou
o an aneuysm3
In the tigeminal ganglion it may ,e com*esse" ,y a tumou of the
ganglion itself2 o ,y a meningiona o acoustic neuoma aising in its
neigh,ouhoo" o "amage" ,y a ,asal s9ull factue in!ol!ing the mi""le
fossa3 Inflammation of the ganglion occus in tigeminal he*es 6oste3
Its u**e t4o "i!isions may ,e "amage" ,y lesions in the ca!enous
sinus o its fist "i!ision ,ylesion in the su*eio o,ital fissue2 moe
*ei*heally still its "i!ision an" ma/o ,anches may ,e as a esult of
factue of the facial ,ones3
-hen the ne!e is in!ol!e" ,et4een the *ons an" the ganglion2 all the
thee "i!isions ae li9ely to ,e affecte"3 %esions of the moto oot cause
4ea9ness an" 4asting of muscles of mastication on the affecte" si"e3
-asting of tem*ealis an" massete lea"s to hollo4ing a,o!e an" ,elo4 the
6ygoma2 an" 4hen *atient clenches his teeth2 *al*ation e!eals that
contaction of these muscles is less !igous that on the nomal si"e3 -hen
the mouth is o*en"2 the /a4 "e!iates to the *aalyse" si"e" as a esult of the
unantagoni6e" action of the o**osite lateal *teygoi"3
Cental %esions75
The cental connection of tigeminal ne!e may ,e in!ol!e" in lesions2
es*ecially tumos2 syingo,ul,ia2 an" !ascula lesions3 Affcting *ons2
me"ulla an" the u**e ce!ical co"3 A *la0ue of "emyelination may occu
at the *oint of enty of the sensoy oot into the ,ainstem in multi*le
scleosis lea"ing to tigeminal neualgia o unilateal facial sensoy loss3
The moto nucleus can ,e affecte" ,y a lesion in the lateal *ontine
tegmentum3
Neuo*athic =eatitis75
It is change in the conia 4hich may follo4 any lesion of the fifth
ne!e if conial analgesia esults3 It 4as often seen in the *ast afte alcoholic
in/ection of the tigeminal ganglion3 It is "ue to the ecuent tauma to the
insensiti!e conea3 The coneal suface ,ecomes ha6ya2 If unchec9e"2 loss
of suface e*ithelium2 ulceation2 an" secon"fay infection may "e!elo*3
TRI$EMINA% NEURA%$IA AND RE%ATED DISORDERS
Into"uction75
Tigeminal neualgia is *o,a,ly the most e+cuciating of all of the
"iso"es of facial *ain3 As the *ainful *eo+ysms of tigeminal neualgia
ae often tiggee" ,y che4ing an" s4allo4ing2 *atients a e often una,le to
eat an" may ,ecome se!ealy cachetic as a esult3 Not only ae the attac9s
of tigeminal eualgia agoni6ingly *ainful2 they ae also efactoy to all
con!entional analgesic "ugs3 E!en o*iates ae effecto!e only 4hen gi!en
in high "oses3 Fotunately2 4e no4 ha!e a num,e of effecti!e me"ical an"
sugical thea*ies fo this "iso"e2 all of 4hich ae faily s*ecific fo
tigeminal neualgia3 Conse0uently2 successful teatmnt of this mala"y
"e*en"s on accuate "iagnosis3
Diagnosis75 Su,/ecti!e sym*toms ae the outstan"ing featues of tigeminal
Neualgia3 G:B of neualigic "iagnosis "e*en"s on the *atients histoy3
This is cetainly tue fo oofacial *ain in geneal an" tigeminal eualgia in
*aticula3
#igh essential to o,tain as accuate an" "etaile" infomation as
*ossi,le ega"ing the fe0uency2 "uation2 site2 a"iation n" 0uality of *ain
an" 4hethe thee is any *eci*itating o agga!ating facto is thee3
The "iagnostic e!aluation of *atients 4ith oofacial *ain is com*lete"
,y *efoming a com*lete neuologic an" "ental e+amination an" o,taining
magnetic esonance imaging 'MRI( of hea"2 as 4ell as s*ecific la,oatoy
tests in"icate" ,y the histoy an" *hysical e+amination an" E3M3$3
Clinical Chaacteistic o Tigeminal Neualgia75
Sym*toms75 Tigeminal neualgia is chaactei6e" ,y ecuing *ao+ysms
of sha*2 sta,,ing2 ,uning o electic+ shoc9 li9e *ain in the "isti,ution of
one o moe ,anches of the tigeminal ne!e3 The secon" an" thi"
"i!isions ae affecte" much moe fe0uently than the fist "i!ision an" the
ight si"e of face is moe li9ely to ,e in!ol!e" than the left si"e3 The attac9s
only last a fe4 secon"s to a fe4 minutes2 an" *atients ae *ain fee in
,et4een attac9s3
A chaacteistic featue of tigeminal neualgia is the *esence of
tigge *oints on the face o in the mouth3 These ae li9ely to set off an
attac9 if touche"3 Most tigge *oints ae in the cente *at of the face2
aoun" the nose an" li*s3 %ight touch an" !i,ation ae the most effecti!e
tiggeing stimuli3 Thus2 4ashing the face2 sha!ing o a light ,ee6e hitting
the face commonly *eci*itates the *ainful *eo+ysms of tigeminal
neualgia3 Some *atients e!en ,ecome "angeously emaciate" an"
"ehy"ate" ,ecause an attac9 ensues esch time they ty to eat o "in93
Natual #istoy75
Age75 Tigeminal neualgia usually stats in mi""le o late life ,ut may
occu at any age3
Se+75 -omen ae affecte" some4hat moe than men3
Thee is an association ,et4een multi*le scleosis an" tigeminal
neualgia2 4ith a 8 to H *ecent inci"ence of multi*le scleosis in *atients
suffeing fom tigeminal neualgia3
Thee is an occasional familial inci"ence3 Most *atients 4ith
tigeminal neualgia 4ill ha!e e+ace,ation an" emissions 4ith an o!eall
*ogessi!e incease in se!eity as time goes ,y3 E!entually thee 4ill ,e
fe0uent attac9s occuing e!ey "ay3
Diagnosis of tigeminal neualgia is ma"e on the ,asis of its
chaacteistic sym*toms in a *atient 4hose neuological e+amination is
essential nomal an" 4ho has a negatice MRI stu"y3
Diffeential Diagnosis75
Tigeminal neualgia must ,e "iffeentiate" fom othe ty*es of face
*ain such as aty*ical o"ontalgia2 *osthe*etic neualgia2 glosso*hayngeal
neualgia tem*oal ateitis2 cluse hea"ache2 TM. "ysfunction2 myofascial
*ain2 aty*ical facial neualgia2 costents syn"ome2 migaine2 efee" *ain2 o
sim*le toothache3
Aty*ical o"ontalgia is chaactei6e" ,y "ull2 aching2 tho,,ing o
,uning *ain 4hich is moe o less continuous an" is tiggee" ,y
mechanical stimulation of one of the teeth3 It is elie!e" ,y sym*athetic
,loc9s3
Post he*etic nualgia usually affects the fist "i!ision of the tigeminal
ne!e an" is *ec"e" ,y a !esicula eu*tion3 The *ain is "esci,e" as a
chonic ,uing feeling3
Cluste hea"aches cause a ,uning2 ,oing2 *iecing o teaing *ain
lasting minutes to hous an" ae often tiggee" ,y the ingestion of alcohol3
Tem*oal ateits causes chonic aching o!e the affecte" atey2 an"
thee is ma9e" ten"eness on *al*ation of this atey3
TM. "ysfunction is an o!e"iagnose" entity ,ut "oes occu in some
*atients3 This in"i!i"uals com*lains of aching *ain that is tiggee" an"
e+ace,ate" ,y /a4 mo!ement an" that lasts fo "ays2 4ee9s o months3
Myofascial *ain simulaly *esents as an aching *ain lasting fe4 "ays2
4ee9s2 o months ,ut is tiggee" ,y *al*ation of tige *oints in the effecte"
muscle3
ConstenAs syn"ome may easom,le tigeminal neualgia3 In constenAs
Syn"ome *ain a"iating into the lo4e /a4 an" tem*le on che4ing is
*esent3 1ut is *o!o9e" ,y che4ing only an" no othe tigge it is usually
"ue to TM. athosis an" "ental malocclusion an" may ,e elie!e" ,y
,uil"ing u* the ,ite3
Refee" Pain may ,e seen in fontal an" ma+illay sinusitis2 malignant
"iseases2 glaucoma of the eye2 Dental caies2 Pei a*ical a,scess2 uneu*te"
4is"om teeth2 an" in Angina of effet3
PAT#O$ENESIS OR TRI$EMINA% NEURA%$IA
Aetiology75
&aious *ostulations ae *ut fo4a" as etiology
5 Com*ssion of the Sensoy oot ,y an atey
5 In Patients 4ith i*silateal o contalateal tumos in the *osteio foss
taction on the sensoy oot is *ostulate" '#am,y 8G>I(
5 Tactions u*on the sensoy oot of the ne!e2 not only "ue to tumou
,ut also "ue to hy"oce*halus 'Tu9e2 fleming2 Taylo an" Schut6 8GIH( o
to ,asila anueuysm o com*ession of the ne!e tun9 in *osteio fossa ,y
a !ete,o,asila ateial system 'Puhinelli an" Rotten,eg 8GII(
Non s*ecific inflammation of the ganglion an" "ental malocclusion
'Caney 8GKI( an" ischemia ha!e all ,een *ostulate" as the cause3 1ut this
is often a "isease 4ithout a s*ecific *athology3
5 E*i"emological is9 factos 'age2 ce2 smo9ing an" "in9ing ha,its(
ha!e ,een *ostulate" as ,eing of significance in elation to 4hethe the
u**e o lo4e face is in!ol!e" 'Rothman an" 1ec9 man 8GI>(3
T4o ma/o Schools of thought ega"ing the etiology an" *athogenesis
of tigeminal neualgia3
i( A Pei*heal cause of this "iso"e
ii( A Cental Mechanism3
The sugical teatment of tigeminal neualgia has ,een mainly ,ase"
on the notion of a *ei*heal cause2 such as com*ession of the tigeminal
ne!e o oots ,y !ascula2 neo*lastic o inflammatoy lesions3
On the othe han"2 effecti!e me"ical thea*hy has "e!elo*e" as a
conse0uence of TousseauAs Suggestion that the attac9s of *ain ae "ue to
*ao+ysmal acti!ity in the tigeminal nuclei in the ,ain stem3
Clinical Data75
Thee ha!e ,een many e*ots that com*ession o stetching of the
tigeminal oots ,y a,eant ateies2 !ascula malfomation of slo45go4ing
tumos causes tigeminal neualgia3
Inflamatoy changes in the tigeminal ne!es ha!e also ,een *o*ose"
as the etiologic agent in the tigeminal neualgia '#ais(33
The notion that a cental mechanism is in!ol!e" in the *ainful
*ao+ysm of tigeminal neualgia is su**ote" ,y a num,e of th clinical
featues of this "iso"e3 Thee is measua,le latent *eio" ,et4een the
onset of the stimulus to the tigge *oint an" the onset of attac9 of tigeminal
neualgia3 The attac9s ae moe ea"ily e!o9e" ,y stimulating lo45
theshol" mechano ece*ti!e affeants3 Finally2 the *ain of tigeminal
neualgia a"iates outsi"e the stimulate" aea an" may ,e felt in entiely
"iffeent "i!ision of tigeminal ne!e than the location of the tigge *oint3
E+*eimental Data75
5 Focal "emyelination of tigeminal oots in e+*eimental animals lea"s
to the geneation of a,nomal im*ulses in the "emyelinate" aeas3
5 The a**lication of e*ile*togenic agents to the s*inal tigeminal nucleus
cause" o!e eaction to tactile stimulation of the I*silateal face3
E+*eimental stu"ies inte*ete" that tigeminal "ysfunction elicite"
"e*en"s on the "egee of "amage inflicte"3 Mil" in/uies cause" only
tansient inceases in euonal acti!ity2 4hee as se!ee in/uies lea" to
continuous high fe0uency neuon fiing2 esulting "ysesthesias3 %esions
some 4hee in ,et4een these t4o e+temes esult in intemittent *ao+ysmal
neuonal "ischages that ae *ecei!e" on the agoni6ing attac9s of
tigeminal neualgia3
The fact that the "ugs effecti!e2 in the teatment of tigeminal
neualgia all facilitate segmental inha,ition of the tigeminal com*le+3 Also
suggest that a failue of this inhi,ity mechanism may ,e in!ol!e" in these
*athogenisis of tigeminal neualgia3
D3$eha"3#3Fomm suggeste" that ,oth cental an" *ei*heal
mechanism *lays a ole3
#e suggeste" the most li9ely e+*lanation that chonic iitation of
tigeminal affeent fi,es esults in a continuing im*aiment of segmental
inhi,ition in the tigeminal com*le+ as 4ell as incease" acti!ity in the
*imay affeent fi,es "ue to ecto*ic action *otentials3 As a conse0uence
of such a com,ination of incease" affeent in*ut an" im*aie" segmental
inhi,ition2 tactile stimulation of the face lea"s to hy*eacti!ity an"
e!entually *ao+ysmal "ischages of flo45theshol" mechano ece*ti!e an"
4i"e "ynamic ange neuons in the tigeminal nuclei3 The tansmission of
such *ao+ysmal acti!ity ,y tigeminolthalamic 4i"e5"ynamic ange
neuons esult in the *ece*tion of the flashes of *ain that chaactei6e the
attac9s of tigeminal neualgia3
It a**eas2 theefoe2 that ,oth schools of thought ega"ing the cause of
tigeminal neualgia ne!e *atly coect an" that tigeminal neualgia can ,e
consi"ee" to ha!e a *ei*heal etiology ,ut a cental *athogenesis3
C#RONIC IRRITATION OF TRI$EMINA% NER&E
ECTOPIC ACTION FAI%URE OF
POTENTIA% SE$MENTA%
IN#A1ITATION
PARO)YSMA% DISC#AR$E OF
INTERNEURONS IN TRI$EMINA% NUC%EUS
FIRIN$ OF NOCICEPTI&E
TRI$EMINO T#A%AMIC NEURONS
ATTAC= OF TIC= DOU%OURE)
INCREASED AFFERENT ACTI&ITY < INCREASED SE$MENTA%
IN#I1ITION
PARAO)YSMA% DISC#AR$ES IN T#E
TRI$EMINA% NUC%EUS
'Fom 5 Fomm $3#32 Teence CF2 Maoon .C
Tigeminal neualgia 5 Cuent conce*ts ega"ing etiology an"
*athogenesis 8GH> (
TREATMENT OF TRI$EMINA% NEURA%$IA
&aious teatment mo"alites ha!e ,een tie" in the *ast
8( 1osoo9 etal '8GFG( I3&3 In/ection thiamine hy"ochloi"e su**lement
,y oal
inta9e of !it3 13 ' 8: to 8:: mgm3(
;( Tichloethylene inhalation 's*ecific action on sensoy ne!e en"ing of
T3N(
%oomis '8GFI(
F( Alcohal o *henol in/ection to gasseion ganglion 'hami 8GFI(
>( Di!ision of the s*inal tact of the ne!e in the me"ulla S/o0!ist 8GFI3
?( Retogasseian hi6otomy 5 tem*oal a**oach a,o!e the 6ygoma 5
ecommen"e" ,y Fa6ie '8G;?(3
K( Ra"io fe0uency themo coagulation 'Sengu*ta an" Stun"en 8GII(3
Teatment75 'Recent(
Me"ical
Sugical
MEDICA% TREATMENT
The Me"ical teatment shoul" ,e the *imay a**oach an" that
sugical inte!ention shoul" ,e ese!e" fo those *atients 4ho ,ecome
efactoy to2 o can not toleate2 the cuently a!aila,le me"ication3
1efoe 8G>82 the me"ical teatment of tigeminal neualgia consist only
of a 4i"e !aiety of nostum3 Tuly effecti!e me"ical thea*y eally state"
4ith the "isco!ey of the a,ility of ca,ama6ae*ine to *e!ent the attac9s of
tigeminal neualgia3 The moe ecent "isco!ey that ,aclofen is also
effecti!e2 an" has a stong synegistic action 4ith ca,ama6e*ine an"
*heytoin2 has geatly e+*an"e" the thea*eutic aamamentaium3
Phenytoin75
Main use as an a"/uncti!e "ug to ,aclofen an" 4ho can not toleate
ca,ama6e*ine3
Dose 5 F:: to >:: mgC"ay in t4o "i!i"e" "oses3
Si"e Effects 5 Do4iseness2 "i6iness2 "i*lo*ia an" ata+ia3
ca,ama6e*ine75
The effecti!eness of ca,ama6e*ine in the teatment of tigeminal
neualgin ha!e ,een cnfime" ,y a num,e of contolle" tials3 '1lomAs
stu"y(3 It has le" to the sugestion that ca,ama6e*ine can ,e em*loye" as a
"iagnostic test2 fo tigeminal neualgia3
The stating "ose of Ca,ama6e*ine fo the teatment of tigeminal
neualgia is 8:: to ;:: mgm t4ice a "ay3 This "oes is incease" ,y ;::
mgm3 e!ey othe "ay until the *atient fee o si"e effect occus3 The usual
maintenanace "ose is K:: to 8;:: mgC"ay3 The half life of ca,ama6a*ine is
F: to ?: hous 4hen *atients fist stat on this "ug3 ,ut "o*s to H to 8;
hous afte a fe4 4ee9s3 Many *atients theefoe e0uie F times a "ay
egimen fo ,est esults an" some may e!en nee" to ta9e in fou "i!i"e"
"oses3
Si"e Effects75 Most commonly "o4siness2 "i66iness2 unstea"iness
nausea an" anoe+ia3
Raely causes o*lastic anemia2 leu9o*enia an" thom,ocyto*enia an"
has also in"uce" congesti!e heat failue aely3
1aclofen75
1aclofen esem,les ca,ama6e*ine an" *henytoin in facilitating
segmental inhi,ition an" "e*essing e+citatoy tansmission in the s*inal
tigeminal nucleus2 suggesting that this "ug shoul" also ,e use" in the
teatment of tigeminal neualgias3 O*en tials ha!e futhe su,stantiate" the
effecti!eness of 1aclofen in tigeminal neualgia3
The stating "ose of ,aclofen is ? to 8: Mgm thee times a "ay3 This
"ose is incease" ,y 8: mg e!ey othe "ay until the *atient is *ain fee o
si"e effects occu3 The usual maintenanace "ose is ?: to K: mgm *e "ay3
Si"e Effects75 not h!e ca,ama6a*ineAs *otential fo life theatening
si"e effects3 1ut it can cause "o4siness2 "i66iness an" $3I3T3 "istess3
The most im*otant *ecaution to o,se!e in teating *atients 4ith
,aclofen is ne!e to sto* this me"ication a,u*tly afte long tem
a"ministation2 as halucinations o sei6ues can occu3 A ne4 "ug
chlo*henein ca,amate is also use"3
RECOMMENDED TREATMENT FOR TRI$EMINA% NEURA%$IA
In !ie4 of its geate safely2 teatment of tigeminal neualgia shoul"
stat 4ith ,aclofen2 e!en though it may not ,e 0uite as effecti!e as
ca,ama6e*ine3
Ca,ama6a*ine is the ne+t choice if ,aclofen is ineffecti!e o causes
unacce*ta,le si"e effects3 One shoul" al4ays ta*e the me"ication
ga"ually afte the *atient has ,een fee of attac9s3
O4ing to the *ogessi!e incease in the se!eity of tigeminal
neualgia2 e!entually neithe ,aclofen no ca,ama6a*ine may ,e a,le to
contol the *ainful attac9s3 The com,ination of ,aclofen an "
ca,ama6e*ine is much moe effecti!e than eithe "ug alone2 So shoul" ,e
tie" in those *atients 4ho "o not es*on" to monothea*y3
The com,ination of ,aclofen an" *henytoia is also use" 4hee *atients
can not toleate ca,ama6e*ine3
Those *atients 4ho ,ecome efactoy to all these me"ication 4ill
e0uie neuosugical inte!ention3
SUR$ICA% MANA$EMENT
Mico !ascula "ecom*ession an" a"io fe0uency o glyceol
gangliolysis an" hi6otomy ae cuently the *oce"ues of choice3 Mico
!ascula "ecom*ession offes the a"!antages of attac9ing the *esume"
etiology of tigeminal neualgia2 *ese!ing the tigeminal ne!e an"
*o"uing longe lasting elief in most *atients3 Ra"io fe0uency o glyceol
gangliolysis an" hi6otomy a!oi" the is9s of caniectomy2 entail minimal
mo,i"ity an" essentially no motality2 ae much less em*ensi!e an" can ,e
e*eate" easily3
In younge healthy *atients the chances of long tem elief of *ain 4ith
mico!ascula "ecom*ession 4oul" ,e an im*otant consi"eation2 4heeas
the mino o*eati!e *oce"ues 4oul" ,e *efea,le in ol"e *atients 4ith
significant me"ical *o,lems3 It shoul" ,e 9e*t in min" that no sugical
*oce"ue has yet ,een "e!elo*e" that is 8:: *ecent successful an" that
e!en mico!ascula "ecom*ession "oes not LCueL tigeminal neualgia3
Patients 4ill often es*on" to anothe tial of me"ical thea*y 4hen
thei tigeminal neualgia ecus afte sugical inte!ention3 1aclofen2
Ca,oma6e*ine an" *henytoin shoul" thee foe ,e tie" once moe at that
*oint3
I( Pei*heal Dene!ation75
The s*ecific o,/ecti!e of *ei*heal neuectomy ae to eliminate as
much as *ossi,le of the affecte" ne!e ,anch an" also to attem*t to ,loc9 its
egeneation3 Theefoe2 afte the ne!e has ,een e+*ose" an" ,efoe it is
cut2 "issection shoul" ,e caie" "istally into the teminal tissues as fa as
*ossi,le3 Po+imally the ma+imum amount of ne!e tissue shoul" ,e
a!ule" ,y olling the ne!e aoun" a hemostat3 Finally the ne!e foamen
shoul" ,e o,liteate" 4ith steile 4oo"en *egs2 amalgam o ,one *lugs to
,loc9 futhe ne!e egeneation3
In the thi" tigeminal "i!ision2 infeio al!eola ne!e an" lingual
ne!es ae commonly esecte"3 The lingual ne!e can most easily ,e
e+*ose" at the inne suface of man"i,le in the thi" mola egion ,y
ma9ing a !etical incision along the intenal o,li0ue i"ge3 This same
incision can ,e use" to a**oach an" cut the infeio al!eola ne!e at the
man"i,ula foamen3
E+taoal a**oach to infeio al!eola ne!e esection is sim*le an"
has the a"!antage of a!oi"ing "amage to the lingual ne!e an" *emitting
"iect o,liteation of the man"i,ula canal3 In this *oce"ue2 a 8cm3
incision is ma"e at the infeio ,o"e of the man"i,le in the antegonial
notch egion3 Dissection is caie" "iectly to the ,one2 an"2 ,y use of a
nasal s*eculum to etact the massete2 the outline of the man"i,ula canal
can ,e seen 4ith the ai" of intaoal tansillumination3 The lateal ,ony
*late of the canal is emo!e"2 the ne!e is a!ulse" an" the canal is finally
o,liteate"3 -hen this *oce"ue has ,een com,ine" 4ith mental ne!e
esection2 the entie inta man"i,ula length of the infeio al!eola ne!e
can ,e emo!e" intact3
Fo infao,ital neuectomy intaoal a**oach is use"3 1oth the
su*eio la,ial an" lateal nasal ,anches of the ne!e "issecte" fee2 an"
then the infao,ital foamen can ,e clealy !isuali6e"3 Afte a!ulsion2
canal o,liteation "one3
1anches of the fist tigeminal "i!ision2 inclu"ing the su*ao,ital2
fontal an" su*atochlea ne!es2 may ,e e+*ose" though an incision in the
mi"*otion of the eye,o43 Cae shoul" ,e ta9en to a!oi" "amaging the
lacimal glan" in the lateal oof of the o,it3
Pei*heal neuectomies ae mino o*eation that may ,e *efome"
comfeta,ly 4ith local anaesthesia3
Ra"io Fe0uency Themogangliolysis75
Done at the le!el of tigeminal ganglion an" sensoy oot2 4hen a**lie"
to *ei*heal ne!es2 ha!e the effect of selecti!ely "estoying small ne!e
fi,es at the same time etaining the lage ne!e fi,es3 So *ese!es the
nomal tactile sensation of the *atient3
In the Ra"io Fe0uency themogangliolysis techni0ue a ;;5gauge
nee"le2 insulate" e+ce*t at its ti*2 is insete" though the s9in of the chee92
*asse" me"ial to the man"i,ula amus an" though the foamen o!ale to
come to est at the !ental as*ect of the tigeminal ganglion in Mec9elAs
ca!ity3 One o t4o themal lesions of K:
o
to I:
o
ae ma"e fo F: secon"s
each3 Results of these lesions ha!e ,een !ey goo"3 -ith a high ate of *ain
contol2 minimal com*lications3
Ra"io Fe0uency Themo Neuolysis75
In these techni0ues the same ,asic a**oach is use" as "isci,e"
*e!iously e+ce*t that the lesions can ,e ma"e in the out*atient setting2 $3A3
is not e0uie"2 thee ae no is9s of "angeing !ital intatanial stuctues2
an" lesions can ,e e*eate" moe ealy if necessay3
Cyosugey75
Contolle" fee6ing of *ei*heal sensoy ne!e has ,een use"
successfully to su**ess neualgia fom *ain3 Cyosugical lesions ae ma"e
at tem*eatue lo4e than ?:oC ,y "iectly e+*osing the e*ineeuim fo 8?
to K: secon"s an" e*eating F to > times3 Pain elief can ,e e+*ecte" to last
; 4ee9s to a yea2 "e*en"ing on the cause of the *ain an" on the e+tent of
the fee6e3
Cyoneuolysis "e*en"s on an ice cystali6ation of intacellula flui"s
an" "issolution of the a+on *lasm mem,ane3 This *o"uces a+on
"egeneation ,ut *ese!e the connecti!e tissue sheaths 4hen "one *o*aly3
If the lesion is not contolle"2 occlusion of *eineuial !essels 4ill *o"uce
local ischemia an" esult in *aesthesias3
Osseous Cuettage 'Rathe *oce"ue(
Sugical ,ony "ecotication 4ith a""e" to*ical an" systemic anti,iotic
has ,een a"!ocate" fo the management of Tigeminal Neualgia an"
aty*ical neualgia3
Retogasseian Rhi6otomy75
In this oeation the tigeminal sensoy oot fi,es ae sectione" ,et4een
the ganglion an" the *oint of oot enty into the *ons3 A com*lete
*emanent "egeneation of the ne!e cell ,o"ies esults fom this lesion3
Incom*lete lesioning o the action of a,eant sensoy fi,es in the moto
tigeminal oot may lea" to ecuence3 The esulting *ofoun" num,ness
occassionally lea"s to anesthesia "oloosa as 4ell as ecuent he*es 6oste2
coneal ulceation an" othe toi*hic tissue changes3 Fo these easons this
*oce"ue no4 aely "one to contol tigeminal neualgia an" ha!e ,een
e*lace" ,y the Ra"io Fe0uency themal lesions an" an e!en moe
*omising o*eation2 Micosugical oot "ecom*ession3
Mico &ascula Ne!e Root Decom*ession75
Dan"y 4as the fist to suggest that !ascula com*ession of th &th
ne!e nea the *ons might ,e an etiologic cause fo tigeminal Neualgia an"
late .anetta consi"ee" Tigeminal Neualgia "ue to !ascula com*ession of
Tigeminal Ne!eoot enty 6one in the *ons an" "e!elo*e" Mico!ascula
"ecum*ession o*eation3 .anetta has a"!ocate" a *osteio fossa a**oach
to "ecom*ess the neuo!ascula anomalies ,y *lacing allo*lastic mateials
,et4een the !assels an" oots3 H?B success ate has ,een seen3 Motality
less than ?B 3 This o*eation ese!e" fo healthio *atients 4ith long life
e+*ectancies3
Com*lication75
5 #ematoma 'Intacee,al(
5 Infaction of ,ainstem
5 Status e*ile*ticus
5 Posto*eati!e #eaing lose
5 Fusion of the mi""le ea3
1alloon Com*ession Rhi6olysis75
1alloon insete" to Mec9elAs ca!e an" inflate" an" thus "ecom*ession
*o"uce"3
Tactotomy75 The *imay "esen"ing tacts of tigeminal2 as 4ell
as eighth2 ninth an" tenth ne!e sensoy fi,es may ,e inteu*te" ,y lesions
*lace" >mm3 ,elo4 the o,e+ in the me"ulla3
It is es*ecially in"icate" 4hen *ain is ,ilateal o 4hen many canial
ne!es ae in!ol!e"3 Me"uallay tactotomy has a highe motality ate than
hi6otomy an" ecuence ate is high3
Tactotomy also "one at the le!el of the *ons o mi",ain to contol
ma+illofacial *ains such as *ost he*etic neualgia3
Thalamotomy an" Cotical %eu9otomy Poce"ues75
Selecti!e lesions in the thalamus an" cote+ ae the only 9no4n
sugical teatment fo most !aities of cental *ain such as *hantom *ain2
thalamic syn"om2 *ost he*etic neualgia3 %esions of the *osteio me"ial
thalamus ae ma"e ,y a"io fe0uency electo"es that ae left im*lante" fo a
*eio" of time3
Cotical leu9otomy consists of 4hite matte lesions of the fontal lo,es
n" has the inteesting esult of "eceasing the suffeing o emotional
com*onent of *ain 4ithout causing any significant change in the *ece*tion
thes hol"es3
An im*otant "ange 4ith leu9otomy *oce"ues is the *otential to
in"uce significant *esonality "efects an" loss of LSocial SensesL3 So "one
only as a last eso3
Misallaneous Thea*ies75
Use of electical stimulation of the gasseian ganglion 4as *o*ose" ,y
Meyesin in 8GH: an" consists of chonic im*lantation of an electo"e in the
gasseion ganglion3
POST #ERPETIC NEURA%$IA
Post he*etic neualgia 'P#N( is a common caus of se!ee neuo*athic
*ain2 es*ecially in the el"ely3
Oigin75 P#N is a conse0uence of he*es 6oste '#@(2 4hich is cause"
,y eacti!ation of the !aicella @oste !ius2 usually contacte" in
chil"hoo"3 On intial e+*osue2 !aicella 6oste causes !aicella2 in 4hich
the !ius "isseminates hematogenously fom the neaso*hayn+ to the s9in
an" mucous mem,anes3 %ate in the cause of the illness2 the !ius
*esuma,ly entes sensoy ne!e fi,es an" its tans*ote" to tigeminal2
geniculate an" "osal oot gan glia2 4hee it comes to ,e "omant fo many
yeas3 The "eclining immus su!eillance accom*anying a"!ancing age o an
immuno com*omise" state causes the !ius to e5eu*t in the sensoy
ganglion3 This esults in a segmental hemohagic inflammatoy eaction in
the s9in2 mucous mem,ain etc3 This "iso"e is often !ey *ainful an"
constitutes he*es 6oste3 Usually *ain su,si"es2 ,ut if *esists o ecus
4ith healing2 efee" to as P#N3
5 Females ae moe *one to P#N
5 Ol"e age gou* moe affecte"
Teatment75
Post he*ectc *ain *esists fo 8 month o longe "uation an" in most
"iminishes 4ith time3
Fo *e!ention of P#N systemic Steio"s usually K: Mg3 of
*e"misone ta*ee" o!e 8: to 8> "ays3
5 Amanta"ine is use" in *atients fo 4hom steio"s ae conta in"icate"
'8::mgm t4ice "aily fo a month(
Fo esta,lishe" P#N 5 Amiti*tyline can ,e gi!en in lo4 "oses '8:mgm3(
Sugical Teatment75 Tigeminal tactotomy has e*ote" success
'#itchcoc9 an" Sch!a6(3
#EADAC#E
Migaine75
Tue migaine hea"aches ae "e,ilitating *ains that tho, an" ache
unilateally in the tem*oal egion3 -omen ae affecte" t4ice than men3
Familial ten"ency is thee3 Occus ,efoe the age of 8K Yeas3
The attac9 lasts mnutes2 hous o fo fe4"ays3 Migaine may ,e cause"
,y e+cess !aso"ilation of the e+ta canial !essels3
Teatment is entiely me"ical3
In mil"e cases as*iin is enough3 In se!ee foms egotamine tataate
is use"3
Peio"ic miganious neualgia75
Also 9no4n as cluste hea"ache3
Its clinical featues ae inteme"iate ,et4een tigeminal neualgia an"
migaine hea"ache3 The *ain is ,uning o aching ,egins "ee* 4ithin the
mi"face an" then migates unilateally to the foehea"2 tem*le an" then to
the lo4e face3
#ee"itay factos an" emotional factos seems to *lay a ole in this
"iso"e3 Thee is no 9no4n tigge *oints2 althoug alcohol inta9e
*eci*itate attac9s3
This "iso"e is a esult of an ateial "ilation as in migaine hea"ache2
,ut in *eio"ic miganious neualgia the *oint of neuo*athology is some
4hee along the couse of the geate *etosal ne!e3
Diganosis an" *ain elief can ,e ai"e" ,y local anaesthetic ,loc9 of the
s*heno *alatine ganglion though the geate *alatine foamen3
Egotamine usually gi!es goo" elief to *atients 4ith this "iso"e3
Aty*ical Facial Neualgia75
In 8G;I2 Tem*le Fay "esci,e" aty*ical facial neualgia as a !ascula
syn"ome of "ull aching2 tho,,ing2 situate" "ee* in the eye an" mala
egions3
Aty*ical facial neualgia is chaactei6e" ,y ,uning2 ,oing2 tho,,ing
*ain a**eaing in attac9s of ;: to G: minutes "uation3 Thee is no
e+*losi!e 0uality o tactile tiggeing chaacteistic of classic neualgias3
Egotamine 8?:mgm3 F times a "ay is effecti!e in managing many
cases3 Moe ecently2 *o*anolol K: to 8;: mgm "aily has *o!en to ,e
effecti!e an" sfe *o*hylactic thea*y fo many *atients3
Moe ecently this sy"ome has ,een effecti!ely manage" 4ith
ela+ation thea*ies an" ,iofee",ac9 techni0ues3
Myofacial Pain Dysfunction75
Cause" ,y muscle s*asm in the masticatoy a**aatus3 In thei acute
fom2 these s*asms *o"uces tismus2 "e!iation of the man"i,le to the
affecte" si"e2 ina,ility to occlu"e the teeth2 an" sha* *ain ,ought on ,y
clenching3 The *ain felt o!e TM. o a,o!e the gonial angle an" some times
o!e the 6ygoma2 tem*oal2 su,man"i,ula o occi*ital egion3
The acute syn"ome often follo4s tauma such as su,lu+ation o
"islocation of man"i,le an" a"ical changes in the che4ing *attens2 ,ut the
most im*otant facto is emotional stess3
.oine clic9ing an" /e9y man"i,ula mo!ements ae common3 The
myofacial *ain syn"ome must ,e "iffeenciate" fom tue osteoathitis2
miganious neualgia2 ma+illay sinusitis an" efee" *ain3
Teatment of the acute *hase of myofacial *ain ,y 'I( Su**oti!e
thea*y 4ith analgesics2 tan0uili6es an" muscle ela+ants an"
*hysiothea*y such as local moist heat3 'II( Disengagement of the
masticatoy a**aatus ,y consciously a!oi"ing stessful clenching an" ,y
using tem*oay occlusal s*lints3 The nee" fo est an" *sychological
counselling shoul" ,e stesse"3
Connecti!e tissue neuo*athies75
Tigeminal neuo*athies ,een lin9e" 4ith ma/o collagen "iso"es2
inclu"ing SIE2 S/ogenAs syn"ome2 heumatoi" athitis2 Scleo"ma2
Polyateitis no"osa an" "ia,etes mellitus3
Pathogenesis in these "iso"es ae ,elie!e" to ,e "ue to &asculitis
occus in the nutient !essels of *ei*heal ne!es2 causing ischemia an"
micoinfacts to the ne!e segments3
The "isease state most commonly associate" 4ith neuo*athies of all
ty*es is "ia,etic mellitus3
To+ic an"n Nutitional Neuo*athies75
In con"itions of nutitional "e*i!ation2 the ne!e cell meta,olism may
,e "iste,e" that it no longe maintain its *e*heal *ocesses2 an" 4alleian
"egeneation esults an" ae chaactei6e" ,y num,ness an" *aesthesias in
the moe "istal *otion of ne!e3
Deficiencies of &itamin 18 'Thiamin( cause ,ei,ei an" esult in ne!e
"eafness an" a *atchy tigeminal *aesthesia3 In *ellaga '&it3 1; "ef3( also
tigeminal sensoy neuo*athy seen3
In *enicious anemia neuo*athy is cause" ,y incom*lete a,so*tion of
&it3 18; ,y the small intestine3
#ea!y metal into+ication *o"uces necosis in the tigeminl sensoy
ganglia3 The metals most fe0uently associate" 4ith ma+illofacial
neuo*athies ha!e ,een mecuy2 lea"2 ca"mium2 ,issmuth an" asenic3
Finally2 tigeminal sensoy neuo*athies ha!e lin9e" 4ith a num,e of
4ell 9no4n thea*eutic "ugs2 inclu"ing *enicillins2 cotisone2 isonia6i" an"
mitofuantoin3
TUMORS OF NER&E TISSUE ORI$IN
1ENI$N TUMORS7
Taumatic Neuoma 'Am*utation Neuoma(75
Not a tue neo*lasm2 ,ut an e+u,eant ttem*t at e*ai of a "amage"
ne!e tun93 A hy*e *lasia of ne!e fi,es an" thei su**oting tissues3
Occus "ue to acci"ental o *u*oseful sectioning of a ne!e o may ,e
inci"entl to "ifficult e+taction3
Re*ai of a "amage" ne!e ,egins 4ith *olifeation of the a+is
cylin"es2 the cells of the neuilemmal sheaths an" the en"oneuium3
Regeneation is facilitate" ,y the *esistence of the neuilemmal tu,es2
since ne4 fi,es *olifeate though them an" sch4ann cells multi*ly aoun"
them3
Reinne!ation occus un"e the ,*olifeating *o+imal en"s meet some
o,stuctions such as sca tissue2 in 4hich case the ne!e continues to
*olifeate into an unogani6e" ,ul,ous o no"ula mass of ne!e fi,es an"
sch4ann cells in !aying *o*otions3 This constitute a taumatic neuoma3
Teate" ,y sugical a+cision of the no"ule along 4ith a small *o+imal
*otion of the in!ol!e" ne!e3
Neuo Fi,oma75
The Neuo Fi,oma is a tume of the ne!e tissue oigin3 It is most
fe0uently in!ol!es the s9in o oal mucosa an" "oes not "iffe fom the
"isseminate" o multi*le fom of the "isease2 9no4n as neuo fi,omatosis
o &on Rec9linghausenAs "isease3
They ae uncommon in the mouth an" *esent as soft *e"unculte"
s4ellings of the chee92 tongue o *alate2 o as sessile masses on the gingi!a3
Dee*a lesions *o"uce a fusifom s4elling often soft an" lo,ulate" in the
su,stance of chee92 tongue o *alate an" may ,e mista9en fo a li*oma3
1o4n *atches ' Cafe 5 au 5 lait( 4ill ,e *esent on the s9in in !on5ec9ling
hausenAs "isease3 %esions aising fom the Infeio al!eola ne!e 4ill
enlage the ,ony canal o e!en ceate a significant inta5osseous
a"iolucency3
Ple+ifom neuofi,omatosis affect the hea" an" nec9 egion3 #ee the
4hole *le+us of ne!es is thic9ne" *o"ucing a ma9e" "efomity "ue to the
soft e"un"ant mass3 #istologically thee is *olifeation of sch4ann cells3
Teatment75 E+cision3 Incom*lete emo!al lea" to ecuence3
Sacomatoms tansfomation can occu lea"ing to a *oo *ognosis3
Neuilemmoma 'Sch4annoma(
Is a common tumo "ei!e" fom sch4ann cells3 CCF 5 is a slo4
go4ing lesion3 They ae usually *ainless unless they ae causing *essue
on a"/acent ne!es3 The *eseting sym*tom of the ma/oity of *atients is
only the *eence of a tumo mass3 In all instances the tumo is enca*sulate"3
Teatment is ,y sugical e+cision3 The neuolemmoma "oes not un"ego
malignant tansfomation3
Malignant Tumos75
Neuo fi,o Sacoma 'Malignant Sch4annoma(
&ey ae
Sacomatous tansfomation in neuo fi,omatosis occus moe in the
"ee* seate" lesions athe than in the su*eificial ones3
CCF 5 Foun" to occu in the F" to Kth "eca"es2 no se+*e"ilection3 The
li*s2 gingi!a2 *alate an" ,uccal mucosa ha!e ,een the site of in!ol!ement3
In the cental tumos2 the man"i,le o man"i,ula ne!e affecte" than
the ma+illa3
Teatment75 Teate" ,y Sugoy an" a"iation3 #igh ecuence ate "ue to
the ten"ancy of the tumo to go4 along the in!ol!e" ne!e2 ma9ing total
e+cision "ifficult3
CONC%USION
In summay2 the e+*ience of *ain is the most common *o,lem in
ma+illofacial neuo *athology an" shoul" ,e !ie4e" s moe than a
*e"icta,le s*ecific sensation o a 4aning sign of a "isease3 The "iagnosis
of ma+illofacial neuological *o,lems "e*en"s on an o"ely *ocess of
i( Inte*eting the sym*toms an" signs of altee"
neuo*hysiology ii( "etemining the anatomical locali6ation of the "isease
*ocess iii( un"estan"ing the ,asic *athological *ocesses that e+ist an"
i!( i"entifying the etiological o *eci*itating factos3
Teatment of these *o,lem is a challange to *actiones fom many
"isci*line an" effecti!e action "e*en" on a team a**oach3 #o4e!e2 the
oal an" ma+illo facial sugeon is in a *osition to ma9e a stong conti,ution
in this fiel" ,ecause of his e+tensi!e 9no4le"ge of ma+illo facial
sym*tomatology anatom y2 *hysiology an" *athology3
REFERENCES
83 $RAYAS ANATOMY
;3 MANUA% OF ANATOMY 5 CUNNI$#AM
F3 #UMAN NEUROANATOMY 5 INDER 1IR SIN$#
>3 ANATOMY AND P#ISIO%O$Y 5 MI%%ER
?3 #UMAN P#YSIO%O$Y 5 SARADA SU1RAMNIAM
K3 TE)T 1OO= OF MEDICA% P#YSIO%O$Y 5 $UYTON
I3 CONCISE MEDICA% P#YSIO%O$Y 5 SU.IT 3=3 C#AUD#ARI
H3 TE)T 1OO=S OF SUR$ERY 5 1AI%ERY AND %O&E
G3 TE)T 1OO= OF SUR$ERY 5 SA1ISTON
8:3 ORA% AND MA)I%%OFACIA% TRUMATO%O$Y 5 SC#I%%I AND
=RU$ER
883 DISEASES OF T#E NER&OUS SYSTEM 5 1RAINAS SIR .O#N
-A%TON
8:3 CURRENT AD&ANCES IN ORA% AND MA)I%%OFACIA%
SUR$ERY -I%%IAM2 13 IR1Y3 DA&ID -3 S#E%TON
8F3 ORA% AND MA)I%%OFACIA% SUR$ERY 5 $USTA& 3O3
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8>3 AN AT%AS OF #EAD AND NEC= SUR$ERY 5 %OR
8?3 TE)T 1OO= OF NEUROSUR$ERY 5 RO$ER3N 3 ROSEN1ER$
8K3 ORA% PAT#O%O$Y 5 SC#AFER
8I3 ORA% PAT#O%O$Y 5 T#OMA AND $O%DMAN
8H3 TE)T 1OO= OF P#ARMACO%O$Y 5 SATOS=AR
8G3 TE)T 1OO= OF MEDICINE 5 DA&IDSON
;:3 MINOR ORA% SUR$ERY 5 =I%%EY AND =AY
;83 %OCA% ANAEST#ESIA 5 MON#EIMAS
;;3 NEURO%O$Y C%INICS 5 MAY 8GHG
;F3 NEURO%O$Y C%INICS 5 FE13GG:
;>3 AMERICA% .OURNA% OF ORA% AND MA)I%%OFACIA%
SUR$ERY OCT
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;?3 AMERICA% .OURNA% OF ORA% AND MA)I%%OFACIA%
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