Nerve injuries can occur from trauma, surgery, or other causes. They are classified based on the severity and type of injury. Minor injuries may heal on their own while more severe injuries require surgical repair. The goal of treatment is to promote regeneration of injured nerves. This involves classifying the injury, evaluating it clinically, and managing it through observation, surgery such as neurorrhaphy, or non-surgical means like physical therapy. Proper classification, management, and repair techniques can help improve outcomes from nerve injuries.

2. Nerve Injuries

3. CONTENTS
• Introduction
• Anatomy of the nerve
• Etiology of nerve injuries
• Classification of nerve injuries
• Clinical evaluation of nerve injuries
• Factors influencing the timing and results of
nerve repair
• Management of nerve injuries

4. INTRODUCTION…
PNS
Cranial nerves Spinal nerves
Somatic nerves Visceral nerves
Sensory Motor

5. • Injured by oral & maxillofacial surgical &
general dental procedures, trauma or 2º to
pathologic destruction
• Capable of regeneration
• Goal – to develop methodology that enhances
1 or more of processes that allow a peripheral
nerve to regrow & function again

6. HISTORY…
• Hippocrates- 460- 370 BC-1st written description of PNS
• Wlliam of Saliceto- 1210- 1277- 1st record of nerve suture
• Van Leeuwenhoek- 1632- 1723- microscopic structure of
nerve
• Haller- 1850- understanding of nerve injuries- IX & XII
nerve injuries in frog- degenerative changes distal to the
level of injury & orderly progression of regenerating
axons down the nerve fiber

7. History…
• Seddon- 1943- pioneered nerve grafting
techniques
• Contemporary milestones are being reached
with the research of Sunderland, Miller, Terzis
and Dykes regarding the management of
peripheral nerve injuries and the technical
consideration of their repair

8. ANATOMY OF NERVE…

9. Anatomy Of Nerve…

13. • AXON
– A-alpha fibers- largest myelinated fibers, range in dia
from 7-16 m, conduction velocity – 70-120 m/sec.
– A-beta fibers- next largest myelinated axons, Diameter 
6-8 m,Conduction velocity  30-70 m/sec. Sensibility of
touch is attributed to these axons
– A- delta fibers- smallest of myelinated fibers, Diameter 
2-4m, Conduction velocity  0.5-2m/sec. Transmit
stimuli encoded for slow pain, temperature & efferent
sympathetic fibers

14. Terminology…
• Allodynia
• Analgesia
• Anesthesia
• Anesthesia dolorosa
• Causalgia
• Paresthesia
• Dysesthesia
• Hyperesthesia
• Hypoesthesia
• Hyperalgesia
• Hypoalgesia

15. Etiology …
• Third molar removal
• Injections
• Infections
• Foreign bodies
• Endodontic therapy
• Maxillofacial trauma
• Orthognathic surgery
• Temporomandibular joint arthroscopy
• Miscellaneous causes

16. EFFECT OF NERVE INJURY…
• Depends on the type of nerve  pure
motor, pure sensory or mixed
• Motor effect
• Sensory effects
• Pseudomotor effects
• Vasomotor effect
• Loss of reflexes

17. Nerve Injury…
• NERVE INJURY- CHANGES DISTAL TO INJURY, SITE OF
INJURY, PROXIMAL TO INJURY & WITHIN THE CNS
• NEURON
– Hypertrophic changes- 3rd or 4th day following injury to
the axon & peak b/w 10th & 20th day
– Total RNA content ↑ as the cell ↑ in size RNA migrates to
outer edges of the cell & break up in to smaller particles
– Anabolic proteosynthetic state is maintained as long as
there are regenerative efforts – up to many years

18. – Chromatolytic hypertrophic changes are more pronounced in more
proximal injuries. sometimes the neuron cannot meet these metabolic
demands and cell death occurs.
– After regeneration is complete and conduction maturation has occurred,
the neuron return to normal size and electrical activity
• PROXIMAL NERVE TRUNK
– 1 hr after laceration of a nerve there is marked swelling proximally as far
as 1cm
– 7th day there is vigorous sprouting of axons
– It is not until the 28th day that axons cross the point of injury and at 42nd
day before a sizable no. of axons occupy the distal segment .

19. • SITE OF INJURY
–Within hrs of injury there is proliferation of
macrophages, perineurial fibroblasts,
schwann cells and epineurial fibroblasts
–7th day the schwann cell is clearly the most
active cell and assumes a phagocytic
function of debridement

20. • DISTAL NERVE TRUNK
–Wallerian degeneration in preparation for
the arrival of sprouting axons
–7th post injury day the majority of neural
elements break down, facilitated by
digestive enzymes present in the axons
–Majority of cellular debris has been
phagocytosed by schwann cells by 21st day
–At 42 days debridement is complete and
parts of the fascicular anatomy persist

21. CLASSIFICATION…
SEDDON
Neuropraxia
Axonotmesis
Neurotmesis

22. SEDDON’S CLASSIFICATION

23. SUNDERLAND
First degree
Second degree
Third degree
Fourth degree
Fifth degree
Sixth degree
Type I
Type II
Type III

25. Classification…
PHYSIOLOGIC CONDUCTION
BLOCK
TYPE “A” TYPE “B”
Intraneural circulatory arrest
or metabolic (ionic) block with
no nerve fiber pathology
Intraneural edema resulting
in increased endoneural fluid
Pressure or metabolic block

26. CLASSIFICATION…
SYMPTOMATIC
CLASSIFICATION
ANESTHESIA
DYESETHESIA
PARESTHESIA

27. CLASSIFICATION…
ANATOMIC
CLASSIFICATION
INTRAOSSEOUS
NERVE INJURY
SOFT TISSUE
NERVE INJURY

28. CLASSIFICATION…
HISTOPATHOLOGIC
CLASSIFICATION
NEUROMA FIBROSIS
Amputation Eccentric
Central

29. • Amputation or stump neuroma- Is a knobby, disorganized
mass of axons and collagen associated with proximal nerve
stump and completely separated from distal nerve stump-
5th degree injury
• Central neuroma or neuroma in continuity- fusiform
expansion or fibrotic narrowing of nerve with variable
degrees of fascicular disruption & disorganization- No
breach in epineurium- 4th degree & 5th degree injuries
• Lateral entrapment neuroma- Neurofibrous union between
the epineurium & lingual periosteum of mandible usually in
3rd molar region
• Lateral exophytic neuroma- Breach in epineurium

30. Classification…
Classification of damage by location of
the reactive fibrosis
Designation Location Prognosis
A* Epifascicular epineurium Generally good
B* Interfascicular epineurium Depends on original
damage
C* Endoneurium Poor
N In a Sunderland class IV injury, the
epineural connective tissue that
maintains continuity can be
infiltrated by a neuroma (IVN)
Poor
S Continuity in class IV injury
maintained only by scar tissue
Poor

31. PATHOPHYSIOLOGIC
CLASSIFICATION
Compression
Compartment Syndrome
Transection,
Laceration & Avulsion
Stretch Injury
Chemical injuries
Nerve Injection
Injury

32. CLINICAL EVALUATION OF NERVE INJURIES…
• History
– Chief complaint
– Visual analogue scale
– McGill pain questionnaire
– Onset of sensory disturbance

33. CLINICAL NEUROSENSORY EXAMINATION
Static light
touch
Brush directional
discrimination
Two-point
discrimination
Pin pressure
Nociceptive
discrimination
Thermal
discrimination
Weinstein- Semmes

34. FACTORS INFLUENCING TIMING & RESULTS OF
NERVE REPAIR…
FACTORS
1º Vs 2º
repair
Tech of
nerve repair
Age
Type of
trauma
Level of
nerve injury

35. PROGNOSIS…
• Spontaneous recovery depends on- condition of nerve, severity
of nerve injury & site of injury
– Intraosseous nerve Vs extraosseous nerve
• Conditions limiting regeneration- chronic compression or
stretch, divided nerves in which nerve ends are not
approximated, excessive scarring of either nerve/ tissue bed-
– Infected or contaminated wounds
– Poorly vascularized wounds
– Wound closure or neurorhaphy under tension

36. MANAGEMENT
• Observed Vs unobserved
• Timing of nerve repair- primary, delayed primary or
secondary
• Primary nerve repair- within hours of the injury,
• Delayed primary repair 14-21 days following injury &
• Secondary repair > 3 weeks following surgery

37. • Microsurgical operations for repair
–External decompession
–Transposition
–Internal neurolysis
–Neuroma excision
–Neurorrhaphy
–Reconstruction with autogenous
nerve, vein or muscle grafts or
alloplastic nerve guides
• Ablative nerve procedures using
thermal, chemical, capping – nerve
repair is not possible or practical.
• Non surgical treatments

38. • OBSERVED NERVE INJURY
Clean / sharp laceration
Immediate repair
Fibrin sealant Suture Collagen tube

39. Sensation improving
Sensation
deteriorating
> weekly for 1 mth
> monthly for 3 mth
Unacceptable
sensation
Acceptable
sensation
Stretch
Serial diagnostic evaluation
Surgical exploration
1. Neurolysis
2. Excision
3. Cooptation
4. Nerve graft
5. Nerve sharing
Compression
OR
Alleviate stretch ,decompression as needed

40. Sensation improving
Sensation
deteriorating
> weekly for 1 mo
> monthly for 3 mo
Unacceptable
sensation
Acceptable
sensation
UNOBSERVED NERVE INJURY
Compression
Serial diagnostic evaluation
Surgical exploration
1. Neurolysis
2. Excision
3. Cooptation
4. Nerve graft
5. Nerve sharing
Stretch
Transection
OR
OR

41. Sensation improving
Sensation
deteriorating
> weekly for 1 mth
> monthly for 3 mth
Unacceptable
sensation
Acceptable
sensation
Serial diagnostic evaluation
Surgical exploration
1. Neurolysis
2. Excision
3. Cooptation
4. Nerve graft
5. Nerve sharing
Chemical injury
Immediate decompression

42. SURGICAL M/M OF LINGUAL NERVE INJURIES
• Causes
• Technique

44. SURGICAL M/M OF INFERIOR ALVEOLAR NERVE INJURIES…
• 3 approaches
– Through the socket
– Sagittal split
– Extraoral

45. SURGICAL M/M OF INFRAORBITAL NERVE
INJURIES…
• Etiology and Incidence
• Incisions
• Soft tissue dissection
• Removal of bone
• Visualization
• Management

46. • Direct nerve repair
– Adequate preparation
of nerve ends by
resecting contused
tissue or excess
epineurium
– Careful alignment,
epineural suture
– Microsurgical technique
10-0 nylon sutures
– Avoid tension at suture
line
NEURORRHAPHY…

47. MICROSURGICAL
SUTURING
Interfascicular
Epineurium
Perineurium

48. NERVE HARVESTING PROCEDURES :
First reported by Hausamen et al in 1974
DONOR NERVE SELECTION FACTORS
1) Size of donor nerve Vs reciprocal nerve
2) Length of donor nerve available for grafting
3) Proximity to recipient area
4) Patients or surgeons preference
Nerve Diameter
(mm)
Number of
fascicles
Number
of Axons
Pattern
Inferior alveolar 2.4 18-21 16200 Polyfascicular without
grouping
Lingual 3.2 15-18 14200 Polyfascicular without
grouping
Facial 2.5 1-5 Oligofascicular
Sural 2.1 11-12 7600 Oligofascicular
Great auricular 1.5 8-9 9500 Polyfascicular with
grouping

49. SURAL NERVE

50. GREATER AURICULAR NERVE

51. CABLE GRAFT

52. ENTUBULATION NERVE REPAIR

53. • NON SURGICAL TREATMENT
• Indications
– Metabolic neuropathy
– Centrally mediated pain
– Atypical pain that does not conform to anatomic distribution of
peripheral nerves
– Chronic injuries – atrophy in distal nerve
– Pain unrelieved by LA block of suspected peripheral nerves
– Poor physical status
• Types
– Behavioral – counseling, meditation, yoga, psychotherapy
– Physiologic – physical therapy, acupuncture
– Pharmacologic – analgesics, anticonvulsants, antidepressants

55. NEURALGIAS

56. CONTENTS…
• Introduction
• Trigeminal Neuralgia
• Paratrigeminal neuralgia
• Sphenopalatine neuralgia
• Glossopharyngeal Neuralgia

57. TRIGEMINAL NEURALGIA…
• Definition
• John Locke-1677- 1st full description with its
T/t
• Nicholaus Andre- 1756- ‘Tic Doloureux’ means
painful jerking
• John Fothergill- 1773-
‘Fothergill’s disease’

58. Definition
• Sudden, usually unilateral, severe, brief, stabbing, recurrent pains in the
distribution of one or more branches of the fifth cranial nerve
(INTERNATIONALASSOCIATION FOR THE STUDY OF PAIN)
• Painful unilateral affliction of the face, characterized by brief electric shock like
pain limited to the distribution of one or more divisions of the trigeminal nerve.
Pain is commonly evoked by trivial stimuli including washing, shaving, smoking,
talking, and brushing the teeth, but may also occur spontaneously. The pain is
abrupt in onset and termination and may remit for varying periods
(INTERNATIONAL HEADACHE SOCIETY)

59. • ETIOLOGY
– Idiopathic
– Vascular factors- transient ischemia & auto- immune
hypersensitivity responses- demyelination of nerve
– Mechanical factors- pressure of
aneurysms of intrapetrous
portion of internal carotid
artery- erode the floor of
intracranial fossa to exert a
pulsatile irritation on the ventral
side of the trigeminal ganglion

60. – Anomaly of superior cerebellar a- lies in contact with
sensory root of trigeminal nerve- demyelination. Surgical
elevation of the artery or decompression of the sensory
root has been highly successful

61. • OTHER ETIOLOGIC FACTORS
– Multiple sclerosis- Olfson (1966)
– Petrous ridge (Basilar) Compression- Lee (1937)
– Post-traumatic neuralgia
– Intracranial tumours
– Intracranial vascular
abnormalities
– Viral etiology

62. • General Characteristics
– Incidence
– Age
– Sex prediliction
– Affliction for side
• Clinical Characteristics
– No abnormal neurologic deficit
– Sudden, u/l, intermittent paroxysmal, sharp,
shooting, lancinating, shock like pain- ‘trigger
points’

63. – Pain is- confined to one division- V2 or V3- rarely
crosses midline, Short duration
– Pt grimaces with pain, clutches his hands over
affected side of face, stopping all activities &
holds or rubs his face, reddening & watering of
eyes
– Refractory period
– Oral hygiene- poor

64. –Paroxysms occur in cycles, each cycle
lasting for weeks or months & with time-
cycle appears closer
–With each attack- pain seems to become
more intense and unbearable

65. • Attacks do not occur during sleep
• Poor quality of life
• Pts may undergo indiscriminate extractions
• Diagnosis
– Well-taken history
– Classic clinical pattern

66. – Symptoms in <35 yrs - possible intracranial space
occupying lesion or intracranial av anomalies
– MRI/ CT scan
– Response to T/t with carbamazepine
– Diagnostic injections of a LA into trigger zone

67. Special features Aggravating
factors
Relieving
factors
TRIGEMINAL
NEURALGIA
Unilateral isolated
attacks
Hot/cold fluids in
mouth,
blowing nose,Chewing,
carbamazepine
Phenytoin
surgical
MIGRANOUS
FACIAL
PAIN
Sporadic attacks,
often nocturnal or
early morning
Alcohol Ergotamine,
Sumatriptan
ATYPICAL
FACIAL PAIN
Bilateral,
Continuous
Interferes with sleep
None Antidepressants
,
tranquilizers
COSTEN’S
SYNDROME
Pain over TMJ when
eating
Chewing,Yawning
Talking
Bite correction
POST
HERPETIC
NEURALGIA
Tender areas between
white scars of herpes
eruption
Touching affected area
Cold wind
Phenytoin,
Anti
depressants
Differential Diagnosis:

68. • PROTOCOL FOR DIAGNOSTIC NERVE BLOCKS
– Armamentarium
– Begin injections at surface site of pain & then move
proximally
– Inject 0.5 cc of normal saline
– If pain persists- inject 0.5 ml of 2 % plain lignocaine at
surface site- wait for 5 min- If pain is relieved- direct therapy
at small nociceptor fibres

69. – If pain persists — inject little deeper & wait for 5
min- If pain is relieved- musculo skeletal origin
of pain
– If pain is not relieved- inject at more proximal
portion of nerve- If pain is relieved- direct
therapy at site
– Thus selective inferior alveolar, lingual, buccal,
infra orbital, posterior superior alveolar blocks
can be given to know involvement of branch of
trigeminal Nerve.

70. TREATMENT
Surgical
Medical
– Blom (1962)-anticonvulsants Carbamazepine-
highly specific
– Carbamazapine 100 mg 3times/ day is introduced
& titrated over 1- 5 wks until either remission is
achieved or side effects or toxicity are unacceptable
– Side effects-Visual blurring, dizziness, skin rashes,
ataxia & in rare cases hepatic dysfunction,
leukopenia, thrombocytopenia- aplastic anaemia

71. – Carbamazepine- ineffective- phenytoin or baclofen, sodium
valproate
– When carbamazepine is Contra Indicated Clonazepam 1.5
mg/day
• Side effects- Drowsiness, fatigue, lethargy.
– Tab. Phenytoin: Dose- 100 mg 3 times/ day
• Side effects- slurred speech, abnormal movements, swelling of
lymph glands, gingival hypertrophy, hirsutism, folate def
– Tab. Oxcarbazepine- 1200 mg/day
• Side effects- Hyponatremia, double vision
– Valproic acid- 600 mg/day.
• Side effects- irritability, tremors, confusion, hepatotoxicity, wt
gain

72. –Mephenesin Carbamate (Tolceram)- 5 to 15
ml/5 times a day
• Side effects—fatigue, vomiting
–Other less toxic agents
• Baclofen (Lioresal)
• Gabapantin (Neurontin)
• Lamotrigine
• Felbamate
• Topiramate
• Vigabtrin

73. Surgical M/m
Intracranial
procedures
Peripheral
procedures
Peripheral
Injections
Microvascular
decompression
Peripheral
Neurectomy
Trigeminal root
section
Gasserian Ganglion
Procedures
Cryotherapy
LA
Glycerol
Thermo
coag
Balloon
Alcohol

74. • Peripheral Injections
– Long-acting anesthetic agents
– Alcohol
• Peripheral Neurectomy (Nerve Avulsion)
– lnfraorbital neurectomy
• Conventional intraoral approach
• Braun’s transantral approach- 1977
– Complications, inadvertent section of vessels in
pterygopalatine fossa, inadvertent sectioning
branches of sphenopalatine ganglion or vidian
nerve
– Inferior alveolar neurectomy
• Extraoral approach
• Intraoral approach

75. – Lingual neurectomy
• CRYOTHERAPY OR CRYONEUROLYSIS
– Direct application of cryotherapy probe- temp < - 60°C-
Wallerian degeneration without destroying nerve sheath
– Frozen with a cryoprobe (Nitrous oxide probe) for a
period of 1-2 minutes followed by 3 minutes thaw,
repeated 3 times
• PERIPHERAL RADIOFREQUENCY NEUROLYSIS
(THERMOCOAGULATION)
– Gregg and Small- 1986- radiofrequency electrode- use of
radiofrequency (RF) lesioning of trigeminal nerve has
been used sparingly, but with success. RF neurolysis has
been shown to induce pain remission in 80 % of cases
with a 20 % recurrence rate

76. – PROCEDURE
• Topical anaesthesia
• Patient is grounded in an electronic circuit & the 22 gauge
lesion probe is positioned adjacent to nerve
• Tissue temp is measured with probe tip through probe
thermocouple
• Lesioning carried out at 65- 75°C for 1- 2 min
– Advantages- Low morbidity in high risk- elderly
patients.
– Disadvantages- Needs specific electronic
armamentarium & reasonable pt cooperation, In case
of inaccessibility of some pain triggering nerve trunks,
the technique will fail to achieve pain relief

77. • GASSERIAN GANGLION PROCEDURES
– Around 1900- 1st open surgery- gasserian ganglion for
TN- hazardous procedures
– 1910- Harris, Tapatas & Hartel separately introduced
percutaneous approaches to the ganglion via foramen
ovale - absolute alcohol or phenolglycerol mixture…
– 1931- Kirschner introduced percutaneous electro
coagulation of gasserian ganglion
– 3 percutaneous gasserian ganglion procedures
• Glycerol injection
• Thermocoagulation
• Balloon compression

78. • Technique
– Anaesthesia + Injection methahexitone- iv- 1.5 to 2
mg/kg body wt in increments
– Pt- lie on a table with neck well-extended-foramen
ovale is best visualized with the X-ray tube placed
for a submentovertex position
– 3 points of Hartel are marked
– on side of face
• 1ST
• 2ND
• 3RD

79. – During this phase- needle/electrode lies below orbit,
medial to ramus of mandible & lat to maxilla.
Engagement of the needle/electrode in foramen ovale
is best confirmed by biplanar radiology or image
intensifier
– Final position of needle/electrode is then pushed for
another half a centimeter
• Glycerol injection- 16 gauge spinal needle
• CONTROLLED RADIOFREQUENCY
THERMOCOAGULATION
– 1st by Kirschner- 1931 & later modified by Sweet-1970

80. – Advantages
• Avoidance of denervation of cornea
• Comparative lower rate of recurrence
• Procedure can be repeated in case of recurrence
• Zero mortality
• Well-tolerated by elderly & medically compromised
pt
• Can be performed on outpatient basis
• Preserves motor function of trigeminal nerve
• Simple, accurate, ↓ time-consuming & ↓ expensive
• Comfortable
– Indications
• Toxicity of drugs
• Failure of response to other modalities
• Dependence on drug for lifetime
• Recurrence cases

81. – PROCEDURE
• Probe is placed correctly in foramen ovale & advanced
into trigeminal ganglion, CSF should emerge on
removal of the stylet. Electrode is inserted then just
beyond the tip of the probe and low amplitude current
is applied using a lesion generator.
• Pt at this stage should be awake & cooperative- asked
whether on face the stimulation is felt. Stimulation is
initiated at 50 cycles/ sec slowly raising voltage until
full areas of pain covered

82. • A radiofrequency current- alternating current of
high frequency is passed through electrode- Heat-
ionic friction- coagulation of tissues. A facial blush
usually appears at this point & helps to localize
region of nerve root undergoing thermal destruction
• End of procedure- pt is asked to perform those
maneuvers that trigger TN
• Once pt & operator is satisfied with desired RF lesion
production, electrode is removed

83. NEURO-OPTHALMIC COMPLICATIONS

86. • BALLOON COMPRESSION
– Under general anaesthesia
– Mechanical technique to destroy root fibres partially
by advancing 4FG Fogarty catheter 1 to 2 cm within
Meckel’s cave & inflating balloon at ventral aspect of
ganglion root
– 12 gauge spinal needle is passed 1st into foramen
ovale & balloon catheter is passed through it
– Once it is in position balloon is inflated with X-ray
contrast medium upto 0.75 ml- 1min

87. • 1967-1976 - Jannetta
• Open craniotomy approach- gain access to trigeminal root
• Root is examined under microscope. A compressing br of superior
cerebellar a. will be seen medial to nerve
• Artery is carefully separated from nerve & interpositioned by
using sponge or Teflon wool
• Pt usually retains good facial sensation
• 75 - 80 % pts are pain free for years
• Mortality rate- 2 %- infrequent hearing loss, vertigo, CN VII
weakness
• Contraindicated in elderly patients& medically compromised pts
INTRACRANIAL
PROCEDURES
Trigeminal
root section
Microvascular
decompression

88. Trigeminal
root section
Extradural sensory
Root section
Frazier’s approach (1901)
Intradural root section
Wilkins (1966)
Trigeminal tractotomy
(Medullary Tractotomy)

89. PARATRIGEMINAL NEURALGIA
• Char by severe headache or pain in the area of
the trigeminal distribution with signs of ocular
sympathetic paralysis
• Sympathetic symptoms & homolateral pain in
head or eye occur without vasomotor or trophic
disturbances
• Signs and symptoms appear suddenly
• Most common in males- middle age

90. • It presents some of the signs of Homer’s
syndrome, but can be differentiated from it by
the presence of pain & little/ no change in
sweating activity on affected side of face
• Cause of the disease is unknown, but in a case
reported by Lucchesi & Topazian, dramatic
improvement occurred after elimination of
dental infection

91. SPHENOPALATINE NEURALGIA
• Pain syndrome originally described by Sluder as a symptom
complex referable to the nasal ganglion
• Subsequently Vial described a similar syndrome, but believed
that it involved vidian nerve & concluded that condition
reported by Sluder should be termed ‘vidian neuralgia’
• In recent years, the term ‘periodic migrainous neuralgia’
• an idiopathic syndrome consisting of recurrent brief attacks of
sudden severe, unilateral periorbital pain

92. • Etiology
– Not understood entirely
– Attributed to hypothalamic hormonal influences
– Pain is thought to be generated at the level of
pericarotid/cavernous sinus complex
• Clinical Features
– U/l paroxysms of intense pain in region of eyes,
maxilla, ear & mastoid, base of nose, & beneath
zygoma
– Pain- rapid onset, persist for 15 minutes- several
hours, & then disappear as rapidly as they began
– No ‘trigger zone’

93. –‘Alarm clock’ headache
–Apart from pain sensation- sneezing,
swelling of nasal mucosa & nasal discharge,
epiphora
–Paresthetic sensations of skin over lower
half of face also are reported
–Precipitated by either emotional stress or
injudicious intake of alcohol
–Men > women (5 : 1)
–Before the age of 40 years

94. • TREATMENT
– Alcohol injection
– Resection of the ganglion
– Ergotamine often produce immediate & complete
relief of symptoms- not totally effective: +
methylsergide antiserotonin agent- synergistic action
– Invasive nerve blocks and ablative neurosurgical
procedures - refractory cases

95. GLOSSOPHARYNGEAL NEURALGIA
• Pain similar to TN
• Not common
• Pain may be as severe & extruciating
• Clinical features
– Predilection in middle-aged or older persons
– Sharp, shooting pain in ear, pharynx, nasopharynx,
tonsil or the posterior part of tongue
– U/l & paroxysmal, rapidly subsiding type of pain
– trigger zone- post oropharynx or tonsillar fossa
– ↑ swallowing talking, yawning or coughing

96. • Etiology- unknown- ischemia is suggested (without
conclusive evidence)
• Treatment- resection of extracranial portion of nerve or
intracranial section. injection of alcohol into the
glossopharyngeal nerve
has not been as widely
accepted

97. RECENT ADVANCES IN MANAGEMENT OF
TRIGEMINAL NEURALGIA:

98. REFERENCES
• ORAL AND MAXILLOFACOAL TRAUMA – RAYMOND J
FONSECA & ROBERT V WALKER
• MAXILLOFACIAL SURGERY – P. WARDBOOTH
• MANAGEMENT OF BELL’S PALSY – JOMS, 1993.
• TEXT BOOK OF ORAL PATHOLOGY – SHAFERS.
• BELLS OROFACIAL PAINS—FIFTH EDITION. BY JEFFRY
P. OKESON
• TEMPEROMANDIBULAR DISODERS AND ORO-FACIAL
PAIN- RICHARD A. PERTES & SHELDON G. GROSS