This lecture is about the anatomy, examination and clinical points about C5 & C7.

1. Lecture Title:
Trigeminal & Facial Nerve Clinically
Ismail Fadhil Abbas
M.B.Ch.B / Kirkuk Medicine College
Certified International Medical Education Trainer (TMET)
Certified International Trainer (TNT)
Certified Local Human Rights Trainer (TNHRT)

2. Ismail Fadhil Abbas, MD M.B.Ch.B
Contents of the lecture:
1. Introductionto Trigeminalnerve.
2. Anatomyof Trigeminalnerve.
3. Examinationof Trigeminalnerve.
4. Trigeminalnerve Clinically.
5. Anatomyof Facial nerve.
6. Examinationof Facial nerve.
7. Facial nerve Clinically.
Contents

3. Ismail Fadhil Abbas, MD M.B.Ch.B
Introduction to Trigeminal nerve :‫ي‬‫ثالث‬ ‫عصب‬‫التؤائم‬
The term "trigeminal"comes from the Latin "trigeminus" meaning "threefold," referring to
the three divisions (ophthalmic‫,العيني‬ maxillary‫العلوي‬ ‫الفك‬ and mandibular‫السفلي‬ ‫الفك‬ ) of
this nerve.
Introduction to Trigeminal Nerve :‫ي‬‫الثالث‬ ‫العصب‬‫التؤائم‬

4. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
It provides sensationto the face, mouth and part of the dura, and motor supply to the
muscles of mastication.There are three major branches of the nerve:
• Ophthalmic(V1): conveyssensory informationfrom the scalp, forehead, upper parts of
the sinuses, upper eyelid, cornea of the eye & bridge of the nose.
• Maxillary(V2): transmits sensory informationfrom the lower eyelid,middle part of the
sinuses, nasal cavity and middle part of the nose, cheeks, upper lip & roof of the mouth.
• Mandibular(V3): communicates sensory information from the outer part of the ear, lower
part of the mouth, front and middle parts of the tongue, lower lip & chin. It also stimulates
movement of the muscles in the jaw (masticationmuscles) and some of the muscles within
the inner ear.
Anatomy

5. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerveAnatomy

6. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
Remember:
1. Always do the examination Bilaterally.
2. Always ask patientto compare.
3. C5 examinationcontainsSensory, motor and two reflexes.
Examination

7. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
A- Ask the patient to close his eyes and say ‘yes’ each time he feels you lightly touch them
using a cotton wool tip.
1- Sensory Examination

8. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
B- Repeat using a fresh neurologicalpin,e.g. Neurotip,to test superficial pain.
1- Sensory Examination

9. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
C- Nasaltickle test: use a wisp of cotton wool to ‘tickle’ the inside of each nostril.
1- Sensory Examination

10. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
A- Inspect for wasting of the muscles of mastication(most apparentin temporalis).
2- Motor Examination

11. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
B- Ask the patient to clench his teeth; feel the masseters & temporalis.
2- Motor Examination

12. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
C- Place your hand under the jaw to provide resistance; ask the patientto open his jaw.
2- Motor Examination

13. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
A- Corneal reflex
•Explainto the patient what you are going to do, and ask him to remove contact lenses, if
relevant.
•Gently depress the lower eyelid while the patientlooks upwards.
•Lightly touch the lateraledge of the cornea with a wisp of damp cotton wool
•Look for both direct and consensual blinking.
3- Reflexes

14. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
B- Jaw jerk
•Ask the patientto let his mouth hang loosely open.
•Place your forefinger in the midline between lower lip and chin.
•Percuss your finger gently with the tendon hammer in a downwards direction noting any
reflex closing of the jaw. An absent, or just present, reflex is normal.
3- Reflexes

15. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerveMacleod’s Clinical Examination

16. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
1- Unilateralloss of sensation:may result from direct injury in associationwith facial
fractures (particularly V2) or localinvasionby cancer.
2- Loss of the corneal reflex: Lesions in the cavernous sinus
3- Facial numbness and pain: could be due to
A- Trigeminalneuralgiacauses severe, lancinating(‫)طعنة‬ pain typicallyin distributionof V2
or V3, and is often due to neurovascularcompression.
B- Reactivation ofherpes varicellazoster virus (chickenpox) and it affects typicallyV1.
4- Weakness of the muscles of mastication:myastheniagravis (skeletal muscle weakness,
neuromuscular disease).
5- Brisk jaw jerk (hyper-reflexia) occurs in pseudobulbarpalsy(upper motor neuron lesion)
in cases of stroke, etc.
Clinical Points

17. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
1- Unilateralloss of sensation:may result from direct injury in associationwith facial
fractures (particularly V2) or localinvasionby cancer.
Clinical Points

18. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
2- Loss of the corneal reflex: Lesions in the cavernous sinus
Clinical Points

19. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
3- Facial numbness and pain: could be due to
A- Trigeminalneuralgiacauses severe, lancinating(‫)طعنة‬ pain typicallyin distributionof V2
or V3, and is often due to neurovascularcompression.
Clinical Points

20. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
3- Facial numbness and pain: could be due to
B- Reactivation ofherpes varicellazoster virus (chickenpox) and it affects typicallyV1.
Clinical Points

21. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
4- Weakness of the muscles of mastication:myastheniagravis (skeletal muscle weakness,
neuromuscular disease).
Clinical Points

22. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
5- Brisk jaw jerk (hyper-reflexia) occurs in pseudobulbarpalsy(upper motor neuron lesion)
in cases of stroke, etc.
Clinical Points

23. Ismail Fadhil Abbas, MD M.B.Ch.B
Introduction to Trigeminal nerve :‫ي‬‫ثالث‬ ‫عصب‬‫التؤائم‬

24. Ismail Fadhil Abbas, MD M.B.Ch.B
Introduction to Trigeminal nerve :‫ي‬‫ثالث‬ ‫عصب‬‫التؤائم‬
The facialnerve supplies the muscles of facial expression, and carries parasympathetic
secretomotor fibres to the lacrimal, submandibularand sublingualsalivaryglands (via
nervus intermedius). It receives taste sensation from the anterior two-thirds of the tongue
(via the chorda tympani branch), and also provides the efferent supply to several reflexes.
Anatomy of Facial Nerve :‫ي‬‫الوجه‬ ‫العصب‬

25. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
Remember:
1. Always do the examination Bilaterally.
2. Always compare.
3. C7 Examinationis usuallyconfined to motor function; taste is rarely tested.
Motor Examination

26. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
A- Inspect the face for asymmetry or differences in blinkingor eye closure on one side.
Note that minor facialasymmetry is common and rarely pathological.
B- Watch for spontaneousor involuntarymovement.
Motor Examination

27. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
C- Ask the patient to raise the eyebrows and observe for symmetrical wrinkling of the
forehead
Motor Examination

28. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
D- Demonstratebaring your teeth and ask the patientto mimic you. Look for asymmetry
Motor Examination

29. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
E- Test power by saying:‘Screw your eyes tightly shut and stop me from opening them
Motor Examination

30. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
F- Test power by saying: ‘Blow out your cheeks with your mouth closed’
Motor Examination

31. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerveMacleod’s Clinical Examination

32. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
1. Weakness of both upper and lower facialmuscles: unilaterallower motor neurone VII
nerve lesion (bell’s palsy, Ramsay Hunt syndrome, cerebellopontineangle tumours, e.g.
acoustic neuroma, trauma and parotidtumours.)
2. Weakness in the lower facial muscles only with relativesparing of the upper face:
unilateral VIInerve upper motor neurone lesions (because there is bilateralcortical
innervationof the upper facial muscles and unilateralcorticalinnervationof the lower
facial muscles).
3. Weakness Bilaterally:less common and occur in cases of Guillain–Barrésyndrome,
sarcoidosis, Lyme disease and HIV infection.
Clinical Points

33. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
1- Weakness of both upper and lower facialmuscles: unilaterallower motor neurone VII
nerve lesion (bell’s palsy) in which there is the patientis unable
to close his eye. As he tries, the eyeballrolls upwards, exposing the conjunctivabelow the
cornea.
Clinical Points

34. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
2- Weakness in the lower facial muscles only with relativesparing of the upper face:
unilateral VIInerve upper motor neurone lesions (because there is bilateralcortical
innervationof the upper facial muscles and unilateralcorticalinnervationof the lower
facial muscles).
Clinical Points

35. Ismail Fadhil Abbas, MD M.B.Ch.B
Anatomy of Trigeminal nerve
3- Weakness Bilaterally:less common and occur in cases of Guillain–Barrésyndrome,
sarcoidosis, Lyme disease and HIV infection.
Clinical Points

36. Ismail Fadhil Abbas, MD M.B.Ch.B
Introduction to Trigeminal nerve :‫ي‬‫ثالث‬ ‫عصب‬‫التؤائم‬

37. Ismail Fadhil Abbas, MD M.B.Ch.B
Introduction to Trigeminal nerve :‫ي‬‫ثالث‬ ‫عصب‬‫التؤائم‬

38. References:
1. Macleod's Clinical Examination, 13rd Edition.
2. KenHub.
3. Pictures from Macleod & Google.

39. For more questions contact me:
Mail: ismailfadhil1996@yahoo.com
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