The Ciliary Ganglion (ophthalmic or lenticular ganglion) (Figs. 775, 777).—The ciliary ganglion is a small, sympathetic ganglion, of a reddish-gray color, and about the size of a pin’s head; it is situated at the back part of the orbit, in some loose fat between the optic nerve and the Rectus lateralis muscle, lying generally on the lateral side of the ophthalmic artery.Its roots are three in number, and enter its posterior border. One, the long or sensory root, is derived from the nasociliary nerve, and joins its postero-superior angle. The second, the short or motor root, is a thick nerve (occasionally divided into two parts) derived from the branch of the oculomotor nerve to the Obliquus inferior, and connected with the postero-inferior angle of the ganglion. The motor root is supposed to contain sympathetic efferent fibers (preganglionic fibers) from the nucleus of the third nerve in the mid-brain to the ciliary ganglion where they form synapses with neurons whose fibers (postganglionic) pass to the Ciliary muscle and to Sphincter muscle of the pupil. The third, the sympathetic root, is a slender filament from the cavernous plexus of the sympathetic; it is frequently blended with the long root. According to Tiedemann, the ciliary ganglion receives a twig of communication from the sphenopalatine ganglion.Its branches are the short ciliary nerves. These are delicate filaments, from six to ten in number, which arise from the forepart of the ganglion in two bundles connected with its superior and inferior angles; the lower bundle is the larger. They run forward with the ciliary arteries in a wavy course, one set above and the other below the optic nerve, and are accompanied by the long ciliary nerves from the nasociliary. They pierce the sclera at the back part of the bulb of the eye, pass forward in delicate grooves on the inner surface of the sclera, and are distributed to the Ciliaris muscle, iris, and cornea. Tiedemann has described a small branch as penetrating the optic nerve with the arteriacentralisretinæ.
During administration of local anesthesia – prilocaine & atricaine causes long term paresthesia.
Detailed and sound knowledge of the microsurgical anatomy of Meckel's cave, which borders on surgically important structures, such as the internal carotid artery and cavernous sinus, is essential to performing precise microneurosurgery in this region. This study describes the complex anatomy of Meckel's cave and surrounding structures to provide the knowledge needed to devise a more complete surgical strategy and establish accurate orientation during the surgical procedure.
For PBC Mullanpercutaneous trigeminal ganglion microcompression set (Cook Vascular Inc., US) was used. Patient was positioned supine on the operating table. Procedures were done in general anesthesia with a short-acting anesthetic agent. X-ray control of pyramid and foramen ovale was performed. A specially designed 14-gauge needle with thin stylet was passed 6 cm into the depth towards foramen ovale through entry point located 2.5 cm lateral to the corner of the mouth (Figure 1). Foramen ovale was entered with dull tip of stylet. X-ray control of needle position was made and the balloon catheter was introduced through the needle and navigated into Meckel’s cave. The position of tip was confirmed by using a C-arm fluoroscopic image intensifier in both anteroposterior and lateral views. About 1 mL of water-soluble contrast (iohexol) was injected to inflate the balloon, until ideal pear shape of the balloon was acquired (Figure 2). The duration of inflation depended upon the duration of the disease (longer course of disease, longer time of inflation). After one to five minutes the balloon was deflated and the needle and catheter were removed simultaneously. Firm pressure was applied to the cheek for some minutes. The patients were discharged after an overnight stay.
Creation of large antrostomies, however, is now a somewhat controversial topic amongst rhinologists. A competing technology to the creation of large surgical drainage openings was popularized by Ruben Setliff and is referred to as “small hole” or “small fenestra” surgery. Also, the development of balloon technologies to expand natural sinus drainage tracts has been recently refined which have a theoretical advantage of requiring less sinus surgical disruption to achieve improvement of chronic sinusitis symptoms. One of the new balloon technologies actually uses a Caldwell-Luc approach to place the balloon through a small incision in the gum under the upper lip much as described in the original operation. The advantage of the Caldwell-Luc approach in this setting is that it allows a more direct approach to the natural ostium of the maxillary sinus for balloon placement using endoscopic instrumentation and causes less disruption of the ethmoid sinus anatomy.
Axial CT scan slices, from top to bottom. A. Upper part of the maxillarysinus.B,C, slightly below A: the septum (straight arrow ) starts from the lateral sinuswall. Within it the infraorbital nerve (curved arrow) .D: lower portion of the sinus , withoutseptum. CT parameters in both cases were the following: 64 slices MDCT , 0625 mmthin slices, 100 kV, 50 mA resulting in patient 1 in a CTD/vol of 2,74 mGy, DLP 37,5 mGycmand 1,5 mSev
The incidence of prolonged sensitivity disturbances has been reported to be less than 4%, and they do not seem to bother the patients.
revealed a unilateral dumbbell-shaped tumor, extending into both the middle and posterior fossa, centred over Meckel's cave.
SymptomsSturge–Weber syndrome is manifested at birth by seizures accompanied by a large port-wine stain birthmark on the forehead and upper eyelid of one side of the face. The birthmark can vary in color from light pink to deep purple and is caused by an overabundance of capillaries around the ophthalmic branch of the trigeminal nerve, just under the surface of the face. There is also malformation of blood vessels in the pia mater overlying the brain on the same side of the head as the birthmark. This causes calcification of tissue and loss of nerve cells in the cerebral cortex. Neurological symptoms include seizures that begin in infancy and may worsen with age. Convulsions usually happen on the side of the body opposite the birthmark and vary in severity. There may be muscle weakness on the same side.[clarification needed] Some children will have developmental delays and mental retardation; about 50% will have glaucoma (optic neuropathy often associated with increased intraocular pressure), which can be present at birth or develop later. Increased pressure within the eye can cause the eyeball to enlarge and bulge out of its socket (buphthalmos). Sturge–Weber syndrome rarely affects other body organs.
Potential causes of cavernous sinus syndrome include metastatic tumors, direct extension of nasopharyngeal tumors, meningioma, pituitary tumors or pituitary apoplexy, aneurysms of the intracavernous carotid artery, cavernous-carotid arteriovenous fistula, bacterial infection causing cavernous sinus thrombosis, aseptic thrombosis, idiopathic granulomatous disease (Tolosa-Hunt syndrome), and fungal infections. Cavernous sinus syndrome is a medical emergency, requiring prompt medical attention, diagnosis, and treatment
Syringobulbia is a medical condition when syrinxes, or fluid filled cavities, affect the brainstem. This defect normally results from congenital abnormality, trauma or tumor growth.Syringomyelia ( /sɪˌrɪŋɡɵmaɪˈiːliə/) is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord. The damage may result in pain, paralysis, weakness, and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. The disorder generally leads to a cape-like loss of pain and temperature sensation along the back and arms. Each patient experiences a different combination of symptoms. These symptoms typically vary depending on the extent and, often more critically, to the location of the syrinx within the spinal cord.
PRESENTED BY –DR. SHEETAL KAPSE1st YEAR, P.G. STUDENT
Largest among all12 cranial nerve Roots - sensory & motor 3 divisions fromsensory root- ophthalmic- maxillary- mandibularTRIGEMINAL NERVE
Trigeminal Nuclei The sensory trigeminal nerve nuclei –largest of the cranial nerve nucleiextend through whole of the brainstem.1. The mesencephalic nucleus- proprioception2. The chief sensory nucleus (or "pontinenucleus" or "main sensory nucleus" or"primary nucleus") – touch3. The spinal trigeminal nucleus– pain & temperature.
MAXILLARY NERVE Middle or 2nd branch fromgasserian or trigeminal ganglion. Purely sensory.
Zygomaticotemporal Nerve- Runs along lateral orbital wall- Appears in infratemporal region- Supplies skin of temporal region afterpiercing temporal fascia 2 cm above thezygoma.- Gives communicating branch to lacrimalnerve.- Supplies parasympethetic Secretomotorfibres to lacrimal gland.
Zygomaticofacial nerve Appears on face through foramen in the zygomatic bone Supplies the skin over prominence of cheek.
2. PTERYGOPALATINE NERVEThese are communications between pterygopalatineganglion & maxillary nerve
PTERYGOPALATINE GANGLION: connected to maxillary nerve ininfratemporal fossasensory to orbital septum, orbicularis and nasal cavity ,maxillary sinus , palate , nasopharynx.
4. OTIC GANGLION:between trunk of mandibular nerve and tensor palatinisupplies post ganglionicParasympethetic secretomotorfibres to parotid gland.
related to lingual nerve, rests on hyoglossus musclesupplies post ganglionicParasympetheticsecretomotor fibres tosubmandibular andsublingual gland.5. SUBMANDIBULAR GANGLION:
Applied anatomyCauses of injury to trigeminal nerve –1. Maxillofacial surgical proceduresOrthognathic surgeriesthird molar odontotomysalivary gland surgerieshead & neck preprosthetic surgeriesTreatment of bening & malignent lesions2. Trauma & facial fractures3. Dental implant placement4. Endodontic therapy5. Tratment of pathology (specially periapical)6. During administration of local anesthesia
TRIGEMINAL NEURALGIA –TIC DOULOUREUX relatively common paroxysm of sudden intense,shocking, stabbing onset offacial pain Involves One or more areas ofdistribution Of the trigeminal Nerve maxillary and mandibulardivisions are commonly involved
local lesions-ophthalmic division : acute glaucomafrontal sinusitismaxillary division : cariescarcinoma of maxillaempyema of maxillary sinusmandibular division : cariescarcinoma or ulcer of tongueTRIGGER ZONE
Surgical procedures for treatmentof trigeminal neuralgia -Radiofrequency rhizotomyMicrovascular decompression of the nerve at ponsPercutaneous glycerol rhizotomyBalloon compression rhizotomyPeripheral RhizotomyMicrosurgical Rhizotomy
Meckels Cave The average heightof this oval mouthwas found to be 4.2mm (range 3-5 mm) the average widthwas 7.6 mm (range6-8 mm). located- 12 mmSource -Turkish NeurosurgeryOfficial journal of neurological societyAnatomy of Meckels Cave and the Trigeminal Ganglion: Anatomical Landmarks for a Safer Approachto Them2012, Volume 22, Number 3, Page(s) 317-323
Procedure Description in ShortThrough the entry point—2.5 cm lateral to the corner of the mouth, aspecially designed needle with thin stylet was passed into foramen ovale.
The balloon catheter was introduced through the needle and navigatedinto Meckel’s cave.
External Sinus SurgeryAndrew H. Murr, MDJOURNAL OF AMERICAN RHINOLOGY SOCIETYRevised 6/2011care.american-rhinologic.org/external_sinus_surgery
ECTOPIC INFRAORBITAL NERVE IN AMAXILLARY SINUS SEPTUM:ANOTHER POTENTIALLY DANGEROUSVARIANT FOR SINUS SURGERYP. Mailleux1, O. Desgain2, M.I. Ingabire1Evidence in Health and Social Care(Online journal)www.rbrs.org/dbfiles/journalarticle_0814.pdfWorld Neurosurg. 2011 Sep-Oct;7 2010,93: 308-309 ; discussion 266-7
Trauma to bones of skull & facemalar fractures-Trauma to infraorbital margin may causesensory loss of infraorbital skin.
MAXILLARY SINUSINFECTIONS Infections of the maxillary sinus may causeinfraorbital pain or may cause referred pain to other structuressupplied by Vb (e.g. upper teeth).
Maxillary teeth abscesses The roots of the maxillary teeth (especiallythe second molars)are intimately related to themaxillary sinus. Root abscesses are painful.
Hay fever This is usually allergic, but the symptoms could be produced byinvolvement of parasympathetic “fellow travellers”with the maxillary nerve.
Nerve injury in orthognathicsurgery Neurosensory impairment in the greater palatine andinfraorbital nerves may be encountered after maxillaryosteotomies.herkules.oulu.fi/isbn9514269934/html/x486.htmlCorrection of dentofacial deformities withorthognathic surgery: Outcome of treatmentwith special reference to costs, benefits and risksChapter 2. Review of the literature(De Jongh et al. 1986, Karas et al. 1990, De Mol van Otterloo et al. 1991).2.5. Complications and adverse effects of orthognathic surgerySource -
Maxillary antrum tumours Malignant tumours of the mucous lining of themaxillary antrummay expand into the orbit,damaging branches of V(infraorbita)l.anaesthesia over the facial skin. The orbital contents may also be displaced causingproptosis and/or a squint.
TUMOR SPREAD ALONGINFRAORBITAL NERVEWorld Neurosurg. 2011 Sep-Oct;76(3-4):335-41;discussion 266-7 (online journal)medinfo.ufl.edu/year1/trigem/top_clin.htmlA case of BASAL CELL CARCINOMA
Histopathology -A case of BASAL CELL CARCINOMAtypical nuclear palisading at the peripheral layer of the tumor
Nasopharyngeal CarcinomaSource –Maxillary Nerve Involvement in Nasopharyngealcarcinoma, American Journal of RoentgenologyAJR:167, November 1996V.F.H.Chong1 and Y.F. Fan
A, Axial unenhanced T1-weighted MR image showsenlargement of right pterygopalatine fossa (asterisk).Notenormal fat-filled left pterygopalatine fossa (arrow).
B, Axial contrast-enhanced T1-weighted MR image revealstumor enhancement in pterygopalatine fossa withspread into cavernous sinus (arrowheads).
C, Coronal unenhanced T1-weighted MR image shows enlargeingright maxillary nerve of intermediate signal intensity(black arrow). Note tumor infiltration of right vidian canal (whitearrow).
E, Axial unenhanced Ti-weighted MR image inferior to D shows tumorinfiltration in pterygopalatine fossa andinfratemporal wall of right maxillary sinus (arrow) and extension intoinfratemporal fossa (asterisk).
G, Coronal CT scan (bone window) shows tumor inpterygopalatine fossa (asterisk). Note enlarged maxillarynerve groove (thick arrow) and normal left maxillary nerve (thinarrow).
Trigeminal neurinomas extending into multiplefossae: surgical methods and review of theliterature. We present a 38-year-old female with a giant dumbbell-shapedtrigeminal neurinoma originating primarily in the middle cranialfossa, extending to the infratemporal and posterior fossae through theforamen ovale and Meckels cave, respectively. Because of the large tumour extension into the Infratemporal Fossa, acombined skull base approach (zygomatic infratemporal -transmandibular) was utilised for tumour removal, with a subsequentexcellent outcome.Journals of Neurosurgery 1999 Aug;91(2):202-11.Source - Trigeminal neurinomas extending into multiple fossae: surgical methods and review ofthe literature.2005 Nov;21(11):1008-11. Epub 2005 Mar 16.Department of Neurology, University Medical Center St Radboud, Nijmegen, TheNetherlands.
Trigeminal NeurinomaProf. Dr. med. Henry W. S. Schroeder,Universitätsmedizin GreifswaldA case report by -Clinic & polyclinic for neurosurgeryMicroscopic (A) and endoscopic (B) image of trigeminal neurinoma. Infront of the tumor one can see vestibular nerves (short arrow).(A) (B)
THE MRI IMAGES SHOW THE TUMOUR IN THECEREBELLOPONTINE ANGLE
The final inspection shows complete tumorremoval.Removal of tumorTumor under endoscopic visual controlTumor under the operating microscopevisual control
Dumbbell trigeminal schwannoma in a child:complete removal by a one-stage pterionalsurgical approach.PATIENT ANDMETHODS: A 6-year-old girl presentedwith tiredness, dysarthricspeech and cerebellarsymptoms. Imaging studiesSource - Dumbbell trigeminal schwannoma in a child: complete removal by a one-stage pterionalsurgical approach. childs Nerv Syst. 2005 Nov;21(11):1008-11. Epub 2005 Mar 16.Department of Neurology, University Medical Center St Radboud, Nijmegen, The Netherlands.www.ncbi.nlm.nih.gov/pubmed/15770515
One-stage surgerywas performed bypterional craniotomy.The tumour was firstdebulked in the middlefossa, then peeledfrom the wall of thecavernous sinus,followed by extirpationof the tumour from theposterior fossa. Histopathological
Trigeminal neuropathysensory loss of face or weakness of the jaw musclescauses- SLE, sjogren syndromeherpes zoster, leprosymeningioma, schwanommaWallenberg syndrome vertebral artery occlusion infarction of lateral medullasymptoms - ipsilateral facial sensory loss,ipsilateral horners,ipsilateral IX,X,XI palsyipsilateral cerebellar ataxia ,contralateral sensory loss
Neurotrophic keratitis Occurs due to partial or complete corneal anaesthesia due to loss of sensoryinnervation by the trigeminal N. There is impaired response to corneal microtrauma as a result of impairedregeneration and healing of corneal epithelium Causes: infections - HSV, VZV, leprosytraumatic V N injuryablation of gasserian ganglionchemical burnstopical anaesthatic abuse,betablockrs,NSIDScontact lens wearsystemic: DM, stroke, brainstemhaemorrhage, aneurysmcongenital
Raeders paratrigeminal syndrome Oculosympathetic paresis with pain in distribution oftrigeminal Nerve.Pt. with episodic chronic painPain and headache Trigeminal hyperasthesia seen in area supplied bypost ganglionic fibers.
Raeder’s paratrigeminal syndromePulling pain over the left zygomatic regionwhich radiated two days later to an area behind& below the left ear.Pain presented at mourning & reoccurred atnigtht .Wooshing & buzzing sound in left ear.Numbness over the left side of face.Blurred vision.Unable to bite.Left nostril appeared blocked.
Cavernous sinus syndrome- multiple cranial neuropathies- exophthalmos, ocular motordefects, horners syndrome,sensory loss in V1 and / or V2.Cavernous sinus syndrome is amedical emergency, requiringprompt medical attention,diagnosis, and treatment
Potential causes of cavernoussinus syndrome include –1. metastatic tumors,2. direct extension of nasopharyngealtumors,3. meningioma,4. pituitary tumors,5. aneurysms of the intracavernouscarotid artery6. cavernous-carotid arteriovenous fistula,7. bacterial infection causing cavernoussinus thrombosis,8. aseptic thrombosis,9. fungal infections.
Gradenigo’s syndrome Petrous bone osteitis due tosuppurative otitis media Characterized by -- ipsilateral trigeminal Nervepalsy (Va, Vb)- retro orbital pain- ipsilateral sixth N palsy.
Clinical testing Test skin sensation of lower eyelid, cheek and upper lip. Three simple clinical tests for trigeminal nerve function:(1) sensation: apply gentle touch, pinpricks, or warm or coldobjects to areas supplied by the nerve and note responses;(2) reflex: try the jaw jerk and eye and sneeze reflexes;(3) motor function: test the patient’s ability to chew and workagainst resistance and observe contraction of the massater andtemporal muscles by visual examination and digital palpation.
Purpose of test -1. Is there any loss of senssation ????2. Where the lesion is present ????- peripheral branches- gasserian ganglion
RESOURSES Text book – Malamad’s local anesthesiaHarrison’s principle of internal medicinePeterson’s principle of oral & maxillofacial surgeryAnesthesia/ dentoalveolar surgery/ office management-by Frost, Harsh & Levin Online sources -Turkish NeurosurgeryOfficial journal of neurological society, 2012, Volume 22, Number 3, Page(s) 317-323Anatomy of Meckels Cave and the Trigeminal Ganglion: Anatomical Landmarks fora Safer Approach to ThemJOURNAL OF AMERICAN RHINOLOGY SOCIETY, Revised 6/2011External Sinus Surgery,Andrew H. Murr, MD
Evidence in Health and Social Care,World Neurosurg. 2011 Sep-Oct;7 2010, 93: 308-309 ; discussion 266-7ECTOPIC INFRAORBITAL NERVE IN A MAXILLARY SINUS SEPTUM:ANOTHER POTENTIALLY DANGEROUS VARIANT FOR SINUS SURGERYP. Mailleux1, O. Desgain2, M.I. Ingabire1(De Jongh et al. 1986, Karas et al. 1990, De Mol van Otterloo et al. 1991).2.5. Complications and adverse effects of orthognathic surgeryWorld Neurosurg. 2011 Sep-Oct;76(3-4):335-41; discussion 266-7 (online journal),TUMOR SPREAD ALONG INFRAORBITAL NERVEJournals of Neurosurgery 1999 Aug;91(2):202-11.Trigeminal neurinomas extending into multiple fossae: surgical methods and review of theliterature.2005 Nov;21(11):1008-11. Epub 2005 Mar 16.Department of Neurology, University Medical Center St Radboud, Nijmegen, TheNetherlands.
Dumbbell trigeminal schwannoma in a child: complete removal by a one-stagepterional surgical approach. childs Nerv Syst. 2005 Nov;21(11):1008-11. Epub 2005 Mar16.Department of Neurology, University Medical Center St Radboud, Nijmegen, TheNetherlands.Maxillary Nerve Involvement in Nasopharyngeal carcinoma,American Journal of RoentgenologyAJR:167, November 1996V.F.H.Chong1 and Y.F. Fan
Online other sourceshttp://smj.sma.org.sg/0902/0902smj10.pdfhttp://www.rbrs.org/dbfiles/journalarticle_0814.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/21986433http://www.medizin.unigreifswald.de/neurohttp://www.medizin.uni-greifswaldwww.tsdocs.org/downloads/CranialNerves.pdf