TRIGEMINAL NERVE AND ITS CLINICAL IMPORTANCE The IASP defines TRIGEMINAL NEURALGIA as an often unilateral orofacial pain disorder that presents as brief and recurrent episodes of an electric shock-like pain and is limited in distribution to one or more divisions of the trigeminal nerve. Fothergill’s disease/tic douloureux

1. TRIGEMINAL NERVE AND ITS
CLINICAL IMPORTANCE
Dr Prem Shankar Chauhan

2. CONTENTS
• INTRODUCTION
• EMBRYOLOGY
• NUCLEI OF TRIGEMINAL NERVE
• TRIGEMINAL GANGLION
• DIVISIONS OF TRIGEMINAL NERVE
• GANGLIA ASSOCIATED WITH TRIGEMINAL NERVE
• TRIGEMINAL REFLEXES
• REVIEW ARTICLES
• CLINICAL IMPORTANCE
• REFERENCES

3. INTRODUCTION
• A neuron also known as a neurone
or nerve cell is an electrically
excitable cell that processes and
transmits information through
electrical and chemical signals.
• A typical neuron consists of a cell
body (soma), dendrites, and an
axon.

4. • The nervous system has two major components:
 Central nervous system (CNS)
 Peripheral nervous system (PNS)
• The central nervous system - primary control centre for the body and is
composed of the Brain and Spinal cord.
• The peripheral nervous system - a network of nerves that connects the rest of the
body to the CNS.

5. CRANIAL NERVES
• The cranial nerves are composed of 12 PAIRS of nerves that emanate from the
nervous tissue of the brain.
• They exit/enter the cranium through openings in the skull.
• Hence, their name is derived from their association with the cranium.

6. CLASSIFICATION OF NERVES:
1) SENSORY NERVES(afferent nerves)
Olfactory
Optic
Vestibulocochlear
2 ) M OTOR NERVES(efferentnerves)
Occulomotor
Trochlear
Accessory
Abducent
Hypoglossal
3) MIXED NERVES
Trigeminal
Facial
Glossopharyngeal
Vagus

7. CRANIAL NERVES

8. EMBRYOLOGY
Pharyngeal arches usually appear with in fourth or fifthweek of IU life.

9. TRIGEMINAL NERVE
• 5th cranial nerve, Largest nerve
• First described by Fallopius and later by Friedrich meckel in 1748
• Term trigeminal nerve was proposed by Jacob beningus winslow
• NERVES TRIGEMINUS,TRIFACIAL NERVE
• It is a paired nerve, and each nerve supply ipsilateral half of the head and face.
• Mixed consists of large sensory and small motor root
• Sensory root contain 1,70,000 fibres where as motor root 70,000 fibres.

11. NUCLEI OF TRIGEMINAL NERVE
• The trigeminal nerve has 4 nuclei in the
brainstem: the mesencephalic nucleus,
the principal sensory nucleus, the spinal
trigeminal nucleus, and the motor
nucleus. The three sensory nuclei
(mesencephalic, principal sensory and
spinal trigeminal) form a long column
in the brain stem that extends from the
upper portion of the midbrain to the
upper cervical spinal cord, while the
motor nucleus in the mid-pons provides
special visceral efferent fibers (Haines,
2006).

13. NUCLEI OF TRIGEMINAL NERVE

14. TRIGEMINAL GANGLION
• It is a sensory ganglion of the trigeminal nerve.
• It is the largest sensory ganglion of the body and the only sensory ganglion that lies
inside the cranial cavity.
• It corresponds to the dorsal root ganglion (sensory) of a spinal nerve.
• Antonius Hirsh in 1965, first described this ganglion with the terminology Gasserian
ganglion in honor of his teacher Johann Lorenz Gasser, an Austrian anatomist.

15. • The ganglion is an expansion of sensory root from the pons.
• It is a crescent shaped structure with convex anterior margin, and so also known as
Semilunar Ganglion.
• It lies in the floor of the middle cranial fossa in a small impression near the apex of
petrous part of temporal bone.
• It invaginates a dural fold known as Trigeminal or Meckel’s Cave (Cavum
Trigeminale) that is formed by folding of meningeal layer of dura-mater around the
ganglion.

17. DIVISION OF TRIGEMINAL NERVE
TRIGEMINAL NERVE
OPHTHALMIC MAXILLARY MANDIBULAR

19. OPHTHALMIC DIVISION (V1):
• Ophthalmic Nerve is a pure sensory nerve which originates from the anterolateral aspect
of trigeminal ganglion.
• It is the smallest of the three divisions of trigeminal nerve.
• It lies in the lateral wall of the cavernous sinus and branches into the frontal, lacrimal and
nasociliary nerves.
• All the three branches pass through the superior orbital fissure into the orbit.
• Within the cavernous sinus it also gives a meningeal branch and fine twigs to
oculomotor, trochlear and abducens nerves that carry sensory fibers (proprioception) to
extraocular muscles supplied by these nerves.

23. MAXILLARY DIVISION (V2):
• It is the second division of the Trigeminal nerve, is intermediate in size compared to the
other two divisions and is purely sensory in function.
• It arises from the middle portion of Gasserian ganglion, passes anteriorly, low in the
lateral wall of the cavernous sinus, to the foramen rotundum of the sphenoid bone.
• After exiting the cranium through the foramen rotundum, the maxillary nerve passes
through the superior portion of the pterygopalatine fossa within the infratemporal fossa,
giving off several branches.
• It enters the orbit through the inferior orbital fissure, traverses the infraorbital groove and
canal in the floor of the orbit and reaches the face at the infraorbital foramen. It terminates
by dividing into several branches which supply the midfacial region.

27. MANDIBULAR DIVISION(V3):
• It is the largest of the three divisions of the Trigeminal Nerve.
• It has two roots: a large, sensory root arising from the inferior angle of the Gasserian
ganglion, and a small motor root which passes beneath the ganglion, and unites with the
sensory root, just after its exit through the foramen ovale.
• Immediately beneath the skull base, the nerve gives off a recurrent branch (nervus
spinosus) and four branches in the infra temporal fossa : the middle meningeal nerve, the
tensor tympani nerve, the tensor veli palatini nerve, and the medial pterygoid nerve
(Fillmore, Seifert 2015) and then divides into two trunks-anterior and posterior.

28. BRANCHES OF MANDIBULAR NERVE:
M andibular
nerve
Undivided divided
anterior posterior

32. GANGLIA ASSOCIATED WITH
TRIGEMINAL NERVE
1. Ciliary Ganglion (Ophthalmic or Lenticular Ganglion)
2. Sphenopalatine Ganglion( Pterygopalatine or Ganglion of Meckel)
3. Submandibular Ganglion
4. Otic Ganglion

38. TRIGEMINAL REFLEXES
1. Corneal (Blink) Reflex
• It involves involuntary closing of the eyelids resulting from stimulation of the sensory
nerves of the cornea (short and long ciliary nerves), which are branches of the
ophthalmic division (V1). Stimulation results in both direct and indirect (consensual)
blinking. The motor component of this reflex involves the branches of the facial nerve
to the Orbicularis oculi muscle, which closes the eyelids.
2. Glabellar Reflex (“Glabellar Tap Sign”)
• It is produced by repetitive tapping on the forehead between the eyes and above the
nose. Patients blink in response to the first several taps and then stop blinking. The
afferent sensory signals are transmitted by the Supraorbital/Supratrochlear branches of
V1 and the efferent signals reach the Orbicularis oculi muscle via the facial nerve.

39. 3. Oculocardiac Reflex (Aschner or Aschner-Dagnini Reflex)
• It is a reduction in pulse rate that occurs with compression of the eyeball. The
reflex involves presumed neural connections between the ophthalmic and vagus
nerves.
4. Jaw-Jerk Reflex (Masseter Reflex)
• It occurs when the mandible is tapped at a downward angle at the chin while the
mouth is kept slightly open. In response, both Masseter muscles will contract and
moves the mandible upward (Joel A Vilensky et al. 2015).

40. • Purpose: Knowledge of lingual nerve anatomy is of paramount importance
to dental practitioners and maxillofacial surgeons. The purpose of this article
is to review lingual nerve anatomy from the cranial base to its insertion in the
tongue and provide a more detailed explanation of its course to prevent
procedural nerve injuries.

41. • Materials and Methods: Fifteen human cadavers from the University of
Alabama at Birmingham School of Medicine’s Anatomical Donor Program
were reviewed. The anatomic structures and landmarks were identified and
confirmed by anatomists. Lingual nerve dissection was carried out and
reviewed on 15 halved human cadaver skulls (total specimens, 28).

42. • Results: Cadaveric dissection
provides a detailed examination of the
lingual nerve from the cranial base to
tongue insertion. The lingual nerve
receives the chorda tympani nerve
approximately 1 cm below the
bifurcation of the lingual and inferior
alveolar nerves. The pathway of the
lingual nerve is in contact with the
periosteum of the mandible just behind
the internal oblique ridge. The lingual
nerve crosses the submandibular duct
at the interproximal space between the
mandibular first and second molars.
The sub-mandibular ganglion is
suspended from the lingual nerve at
the distal area of the second
mandibular molar.

43. • Conclusion:
A zoning classification is another
way to more accurately describe the
lingual nerve based on close
anatomic landmarks as seen in
human cadaveric specimens. This
system could identify particular
areas of interest that might be at
greater procedural risk.
Zone 1 is the lingual nerve pathway from the skull base to the lingula.
Zone 2 is the lingual nerve pathway from the lingula to the junction of the internal oblique ridge and
mylohyoid line.
Zone 3 is the lingual nerve pathway from the junction of the internal oblique ridge and mylohyoid line to the
peripheral nerve end supplying the tongue.

44. • The mandibular canal is a conduit that allows the inferior alveolar neurovascular bundle to
transverse the mandible to supply the dentition, jawbone and soft tissue around the gingiva and the
lower lip.
• It is not a single canal but an anatomical structure with multiple branches and variations.
• The branches are termed accessory, bifid or trifid canals depending on their number and
configuration.
• A bifid mandibular canal is an anatomical variation reported more commonly than the trifid
variant.
• Because of these variations, it is of the utmost importance to determine the exact location of the
mandibular canal and to identify any branches arising from it prior to performing surgery in the
mandible.

45. Accessory mandibular canal
• Accessory canals can be attributed to the incomplete fusion of any of the three nerve
branches supplying the incisors, deciduous molars (and their permanent successors) and
permanent molars (Chavez-Lomeli, Mansilla Lory, Pompa, & Kjaer, 1996). Normally, a
single main trunk is formed, which is later corticalized via intramembranous
ossification.
• However, because of this embryological failure, accessory canals have been observed in
panoramic radiographs of children as young as 9 years old (Auluck, A, & Pai KM,
2005).
• The present report reviews the current literature on the bifid mandibular canal (BMC)
and its variant, the trifid mandibular canal (TMC). Their clinical significance for
dentistry is highlighted.

46. Bifid Mandibular Canal
• The bifid variant of the mandibular canal was first described in anatomical dissection in
1971, where the inferior alveolar nerve was classified into three types. The third type was
reported by Carter and Keen (1971) as the one showing nerve branching. Their
classification was:
Type I: The inferior alveolar nerve is a single large structure lying
in a bony canal.
Type II: The inferior alveolar nerve is situated substantially lower
in the mandible.
Type III: The inferior alveolar nerve is separated posteriorly into
two large branches, which together could be regarded as equivalent
to an alveolar branch.

47. Classification of bifid mandibular canal
Type I: Unilateral or bilateral bifid canals that
extend to the mandibular third molar area or the
immediately surrounding area.
Type II: Unilateral or bilateral bifid canals that
rejoin within the ramus or extend to the body of
the mandible.
Langlais et al. (1985) proposed a more detailed classification system based on the anatomical location and
configuration of the BMC. The four main patterns of duplication reported were:

48. Type III: A combination of types I and II.
Type IV: Two canals arising from two separate
foramina and joining to form one larger canal.

49. Trifid Mandibular Canal
• The trifid mandibular canal (TMC) is an anatomical variant that has been less studied
than the bifid canal. The first case of a TMC was reported in 2005.
• Rashsuren et al. (2014) have proposed a classification of TMCs. Their five subtypes
are:
A. Two accessory canals of the retromolar type;
B. Two accessory canals, one retromolar and one dental;
C. Two accessory canals of the dental type;
D. Two accessory canals, one dental and one forward;
E. Two accessory retromolar canals with two mandibular foramina.

50. THE CLINICAL SIGNIFICANCE OF
ACCESSORY MANDIBULAR CANALS
1. Failure of local anesthesia
2. Mandibular third molar surgery
3. Implant surgery
4. Orthognathic surgery
5. Endodontic surgery
6. Neurosensory disturbance
7. Diagnosis
8. Nerve prediction

51. CONCLUSION
• There is a wide range of reported prevalences of accessory mandibular
canals, depending on the method of study and classification system adopted.
• More BMCs and TMCs have been observed using CT/CBCT than
panoramic radiographs.
• Their prevalence seems to differ among patients of different ethnic origins
and even within the same ethnic stock.
• There are also wide differences in the types and configurations of BMC
within each ethnic group.
• There is also wide variation in the diameters and lengths of these accessory
canals.

52. Introduction:
• The Mandibular Foramen (MF) is a landmark for administering local anaesthetic solution
for Inferior Alveolar Nerve Block (IANB).
• The position of MF shows considerable variation among different ethnicity, ages and on
either sides even within the same individual.
• Failure to achieve IANB leading to repeated injection of the local anaesthetic solution
will not only pose a behaviour problem in children but can also lead to systemic toxic
level of anaesthetic solution being administered.

53. Aim:
• To determine the relative position of the mandibular foramen in 7 to 12-year-old
children in relation to the mandibular occlusal plane and the deepest point on
coronoid notch.
Materials and Methods:
• Ninety orthopantamograph of 7 to 12-year-old children were selected from the
database and were divided into three groups: Group 1 (G1): seven to eight-year-old,
Group 2 (G2): 9 to 10-year-old and Group 3 (G3): 11 to 12-year-old.
• The radiographs were traced on acetate paper, anatomical landmarks were marked
and linear measurements were noted from the Mandibular Lingula (ML) to the
occlusal plane, and to the deepest point on coronoid notch.
• The data obtained was tabulated and subjected to statistical analysis. One way
ANOVA test followed by Bonferroni post hoc analysis and Student’s paired t-test
were used.

55. Results:
• Mandibular foramen is approximately, 2-3 mm above the occlusal plane and 11.6-
13.0 mm from deepest point of coronoid notch for seven to eight-year-old
children.
• 3-4 mm above the occlusal plane and 13.0-13.9 mm from deepest point of
coronoid notch for 9-10 year age group.
• and 5.5-6.5 mm above the occlusal plane and 11.9-12.2 mm from deepest point of
coronoid notch for children of the ages 11-12 years.
• The linear distance from the deepest point of coronoid notch to the mandibular
lingula showed statistical significance in G2 vs G3 on right side G1 vs G2 and G2
vs G3 on the left side.
• The variance of this distance for either side showed statistical significance for G1
and G2.

56. Conclusion:
• The distance from the mandibular lingula to the occlusal plane showed gradual
increase in all the three groups, which was statistically significant.
• The position of the mandibular foramen is not bilaterally symmetrically for any of
the considered age groups.

57. CLINICALIMPORTANCE
1) Maxillary and mandibular anesthesia techniques
2) Trigeminal neuralgia
3) Herpes zoster ophthalmicus
4) Wallenburg syndrome

58. EXAMINATION OF TRIGEMINAL NERVE
• Sensory examination
Test touch , pain, pressure ,
temperature sensation over the skin
and mucous membrane of face by
all three branches of trigeminal
nerve .
• Motor examination
Check temporalis muscle
Check masseter muscle
Check pterygoid muscle
Check tensor tympani

59. Sensory system examination
• Tactile sensibility
Fine touch
Crude touch
Tactile localization
Two point discrimination
Stereognosis
Barognosis
Graphesthesia
• Joint senses
Sense of position
Appreciation of movement
• Vibration
• Pain
Superficial pain
Pressure pain
• Temperature

60. Motor examination
• Check temporalis and masseter
muscle
Tell subject to clench his mouth ,
normally there is equal prominence on
each side and it should be confirmed
by palpation.
No prominence on paralyzed side
• Pterygoid muscle
Tell subject to open his mouth , see
the position of jaw whether it is placed
in center or deviate on either side .
Jaw will deviate towards paralyzed
side.
• Tensor tympani muscle
Ask subject whether any loss of
hearing or not

61. Trigeminal reflexes
Reflex Level of spinal cord How to elicit Response
Conjunctival reflex Afferent – 5th CN
Efferent – 7th CN
Touch conjunctiva with
cotton wool swab
Contraction of orbicularis
oculi muscle – rapid
closure of eye lid
Corneal reflex Afferent – 5th CN
Efferent – 7th CN
Touch cornea with cotton
wool swab at its
conjunctival margin
Contraction of orbicularis
oculi muscle – rapid
closure of eye lid
Jaw jerk Nuclei of 5th CN • Slightly open mouth
• Place one finger over
chin and tap it
Closure of the jaw due to
contraction of masseter
muscle

62. NEUROSENSORY EXAMINATION OF TN
• Interview
 A history
 The patients’ self assessment of neurosensory function in
terms of reduced function (hypesthesia, anesthesia), and
neurogenic discomfort (paresthesia, dysesthesia, allodynia,
dysgeusia, ageusia, etc.)
• Examinations took place in a quiet room
 0 = no perception of touch
 1 = perception of touch with no ability to differentiate
(pointed/blunt, warm/cold, localization of touch, direction of
moving touch)
 2 = perception with ability to differentiate less clear than
normal
 3 = normal perception.
Simple kit of instruments for clinical
neurosensory examination of oral
branches of the trigeminal nerve

63. 1. Feather light touch
2. Pin prick
3. Pointed/dull discrimination
4. Warm
5. Cold
6. Localization of touch
7. Brush stroke direction
8. Two point discrimination thresholds
9. Pain protective reaction
• Patients with injury to the lingual nerve were
examined for the presence of a traumatic
neuroma.
• Injury to the inferior alveolar nerve -“B 1000
Pulp pen”

64. Techniques of Maxillary Anesthesia
1. LOCAL INFILTRATION
• The area of treatment is flooded with local
anesthetic. An incision is made into the same
area
2. FIELD BLOCK
• Local anesthetic is deposited near the larger
terminal nerve endings An incision is made away
from the site of injection.
3. NERVE BLOCK
• Local anesthetic is deposited close to the main
nerve trunk, located at a distance from the site of
incision

65. Supraperiosteal Injection
The syringe should be held parallel to the long
axis of the tooth and inserted at the height of the
mucobuccal fold over the tooth.
Large terminal branches of the dental
plexus.

66. Posterior Superior Alveolar (PSA) Nerve Block
Advance the needle upward, inward, and backward.

67. Middle Superior Alveolar Nerve Block
Position of needle between maxillary premolars for a
middle superior alveolar (MSA) nerve block.

68. Anterior Superior Alveolar Nerve Block
(Infraorbital Nerve Block)
Advance the needle parallel to the long axis of
the tooth to preclude prematurely contacting bone.

69. Greater Palatine Nerve Block

70. Nasopalatine Nerve Block

71. Anterior Middle Superior Alveolar Nerve Block

72. Maxillary Nerve Block

75. Techniques of Mandibular Anesthesia
Inferior Alveolar Nerve Block

76. Buccal Nerve Block

77. Mandibular Nerve Block: The Gow-Gates Technique

78. Vazirani-Akinosi Closed-Mouth Mandibular Block
Barrel of syringe is held parallel to maxillary occlusal
plane with the needle at the level of the mucogingival
junction of the second or third maxillary molar.

79. Mental Nerve Block

80. Incisive Nerve Block

82. TRIGEMINAL NEURALGIA
(Fothergill’s disease/tic douloureux)
• The IASP defines TN as an often unilateral orofacial pain disorder that presents as brief and
recurrent episodes of an electric shock-like pain and is limited in distribution to one or more
divisions of the trigeminal nerve.
• Incidence: seen in about 4 in 100000 persons
• Age of occurrence: 5th to 6th decade
• Sex predilection: female predisposition
• Side involved more frequently: right side
• Division of trigeminal nerve involved; most commonly : maxillary> mandibular> ophthalmic
• Trigeminal neuralgia (TGN) is a form of facial pain which is uncommon in children.

83. • Superficial trigger points which radiates across the distribution of
one or more branches of the trigeminal nerve.
• Pain rarely crosses the midline pain is of short duration and last for
few seconds to minutes.
• In extreme cases patient has a motionless face called the frozen or
mask like face
83

84.  It is provocated by obvious stimuli like:
 Touching face at particular site
 Chewing
 Speaking
 Brushing
 Shaving
 Washing the face
 The characteristic of disorder is that the
attacks do not occur during sleep.
84

87. PATHOLOGY
• Compression of the trigeminal nerve root
• Primary demyelinating disorders
• Infiltrative disorders
• Changes secondary to the lesioning of the nerve root or gasserian ganglion

88. DIAGNOSTIC CRITERIA

89. DIAGNOSTIC CRITERIA

90. DIFFERENTIAL DIAGNOSIS
• Migraine
• Trigeminal Post Herpetic Neuralgia
• Cluster head ache
• Cluster Tic
• Burning Mouth Syndrome
• Glossopharyngeal Neuralgia
• Trigeminal Autonomic Cephalgias
• Cracked Tooth
• Dentinal Caries Or Pulpitis
• Temporomandibular Disorders
• Disorders Of Salivary Glands
• Maxillary Sinusitis
• Vascular Causes
• Nervus Intermedius Neuralgia
• Tic Convulsif And Hemifacial Spasm
• Tolosa- Hunt Syndrome
• Multiple Sclerosis
• Temporal arteritis

91. MANAGEMENT OF TRIGEMINAL
NEURALGIA
• Medical treatment Carbamazapine and phenytoin are the
traditional anticonvulsants given primarily
91

93. • Objective: To Evaluate the efficacy of Carbamazepine and Gabapentin in the
management of Trigeminal Neuralgia.
• Materials and Methods: A total of 42 patients with a mean age of 52.78
years included in the study were randomly divided into two groups A and B
and were given the tablets of carbamazepine in the dose range of 400mg to
1200 mg and gabapentin in the dose range of 600mg to 1800mg and recalled
after 3rd day, 15th day, 1 month and 3 month period to evaluate the response
to the drugs. The collected data was subjected to statistical analysis.

94. • Results: The therapeutic effectiveness of carbamazepine recorded as good
response in 52.38% of patients of group A after 72 hours of recall while
28.57% patients had an average response and 19% patients had not relieved
off pain attacks at the dose of 400mg of carbamazepine. The therapeutic
effectiveness of gabapentin recorded as good response in 52.38% of group B
patients after 72 hours of recall while 42.8% patients had an average
response at the dose of 600mg of gabapentin.
• Conclusion: The study suggests that gabapentin can be effective as first or
second line treatment of trigeminal neuralgia, even in cases resistant to
traditional treatment modalities.

95. SURGICAL MANAGEMENT
• Peripheral Injections
• Peripheral Neurectomy
• Cryotherapy
• Peripheral Radiofrequency
• Microvascular Decompression
• Gasserian Ganglion Nerve Block
• Percutaneous Glycerol rhizotomy
• Percutaneous radiofrequency thermal
rhizotomy
• Percutaneous Balloon Compression
• Stereotactic Radiosurgery/Gamma Knife
Radiosurgery

96. NERVE BLOCKS
• Supraorbital Nerve Block
• Supratrochlear Nerve Block
• Infraorbital Nerve Block
• Auriculotemporal and Zygomaticotemporal Nerve Block
• Mandibular Nerve Block
• Maxillary Nerve Block
• Mental Nerve Block

97. BOTULINUM TOXIN IN THE TREATMENT OF TN

98. Peripheralneurectomy
Thermocoagulation :(KRISCHNER(1931),SWEET(1970)

99. Microvascular decompression:
JANNETTA -1976

100. Gasserian ganglion procedures:
o Glycerol injections
o Thermocoagulation
o Balloon compression

101. GAMMA KNIFE RADIOSURGERY:
 LARS LEKSELL-1951

102. • Objective. To assess the therapeutic efficacy and safety of botulinum toxin type A
(BTX-A) for treating idiopathic trigeminal neuralgia (ITN) in patients ≥80 years
old.
• Methods. Selected patients (n =43) with ITN, recruited from the neurology clinic
and inpatient department of the Second Affiliated Hospital of Soochow University
between August 2008 and February 2014, were grouped by age, one subset (n= 14)
≥80 years old and another (n= 29) <60 years old. Each group scored similarly in
degrees of pain registered by the visual analogue scale (VAS). Dosing, efficacy, and
safety of BTX-A injections were compared by group.

103. • Results. Mean dosages of BTX-A were 91.3 ± 25.6 U and 71.8 ± 33.1 U in
older and younger patients, respectively (t =1.930, p = 0.061). The median of
the VAS score in older patients at baseline (8.5) declined significantly at 1
month after treatment (4.5) (p = 0.007), as did that of younger patients (8.0
and 5.0, resp.) (p=0.001). The median of the D values of the VAS scores did
not differ significantly by group (older, 2.5; younger, 0; Z =−1.073, p =
0.283). Two patients in each group developed minor transient side effects (p
= 0.825). Adverse reactions in both groups were mild, resolving
spontaneously within 3 weeks.
• Conclusions. BTX-A is effective and safe in treating patients of advanced
age (≥80 years old) with ITN, at dosages comparable to those used in much
younger counterparts (<60 years old).

104. HERPES ZOSTER INFECTION
 Caused by Varicella zoster
 Predilection for nasociliary branch of
ophthalmic division of the trigeminal nerve
CLINICAL FEATURES:-
Cutaneous lesions:-
•Rash
•Vesicle
•Pustule
•crust
•permanent scar
104

105. • OCULAR LESIONS
Eyelid:- Perorbital pain
Oedema
Hyperasthesia
Conjunctivitis
Scleritis
Corneal scarring
Glaucoma
• TREATMENT:
 Acyclovir 800mg 5 times /day
within 4 days of onset of rash
 Analgesics
 Antibiotic ointments
 Systemic steroids 60mg/day
 Corneal grafting
105

106. WALLENBERG SYNDROME:
 A stroke which cause loss of pain and
temperature sensation from one side of
face and other side of body.
 CHECKERBOARD PATTERN

107. REFERENCES
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Springer Nature Singapore Pte Ltd. 2019
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