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TRIGEMINAL NERVE

Introduction:

 Largest of all cranial nerves

 Mixed nerve with large sensory & small motor root
 Principal regulator of sensory modalities of head 0

Functional components/ Nuclei:

 Nuclei related to trigeminal are 1 motor nucleus located in pons & 3

sensory nuclei present all along brain stem

 Motor nucleus:
 Special visceral efferent (SVE) are branchiomotor fibers are motor
fibers which supply the muscles developed from first
branchial/pharyngeal arch
 The muscles of mastication, tensor tympani, tensor veli palatini,
anterior belly of digastric and mylohyoid.

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 Sensory nuclei:
 General somatic afferent:
 Carry general exteroceptive sensations
 Pain
 Touch
 Temperature carried by sensory nerves
 Skin of face
 Scalp
 Teeth
 Mucosa of nasal & oral cavities along with paranasal air sinuses
 Orbits (cornea & conjunctiva)
 Duramater
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 Cell bodies of these neurons are located in trigeminal ganglion.

 Principal/chief sensory nucleus of trigeminal nerve which is located in

pons lateral to motor nucleus and the nucleus of spinal tract of trigeminal
nerve begins in the principal nucleus and continuous in the spinal cord as
substantia gelatinosa up to second cervical segment.
 Proprioceptive sensations from muscles of mastication, facial muscles and
extraocular muscles are conveyed by the sensory nerves which traverse
trigeminal ganglion without interruption and their cell bodies are present in
mesencephalic nucleus of trigeminal nerve.
 Mesencephalic nucleus is located in midbrain and continuous inferiorly as
principal/chief nucleus of trigeminal nerve. It is equivalent to sensory
ganglion as it contains pseudounipolar neurons.

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 Emergence of trigeminal nerve:

 Sensory & motor roots emerge from ventral aspect of pons at its
junction with middle cerebellar peduncle

Trigeminal ganglion /Gasserian ganglion/Semilunar ganglion:

 Contains pseudounipolar 1st order neurons carrying various exteroceptive

sensations
 Pain
 Touch
 Pressure
 Stereognosis
 From various parts of face including orbits, nasal cavities, oral cavity

 Location:
 Located in the middle cranial fossa near apex of petrous part of temporal
bone within the dural sac termed as trigeminal cave or Meckel’s cave.
This dural pouch is formed by the evagination of tentorium cerebelli.

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 Divisions:
o Sensory root emerges from pons enter this pouch & forms sensory
ganglion thin, slender motor root lies along with ganglion.

 Anterolaterally the ganglion divides into its three divisions- ophthalmic,

maxillary, mandibular. The motor root accompanies the sensory division of
mandibular.
 Ophthalmic division (CN V1 or Va),
 Maxillary division (CN V2 or Vb),

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 Mandibular division (CN V3 or Vc).

 Ophthalmic division:
 This is purely sensory nerve. After its origin from the trigeminal ganglion
it runs anteriorly into lateral wall of cavernous sinus, where it lies below
trochlear nerve. Here it gives a recurrent tentorial branch (meningeal
branch) to supply tentorium cerebelli. Further it divides into three
branches before entering orbit namely lacrimal, frontal and nasociliary.

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 Maxillary nerve:
 This is purely sensory nerve. After its origin from the trigeminal ganglion
it runs anteriorly into lateral wall of cavernous sinus inferior to all other
nerves. It gives a meningeal branch to duramater of middle cranial fossa
and enters the pterygopalatine fossa through foramen rotundum
 Mandibular nerve:
 It is the largest of three divisions. It is a mixed nerve having sensory and
motor fibers. The sensory fibers are from trigeminal ganglion and motor
is from motor nucleus of trigeminal present in pons. Both the roots
enter exit the cranium through foramen ovale to enter infratemporal
fossa.

Clinical insight:

 Shingles/acute herpes zoster is the viral infection of trigeminal neurons

which is characterised by painful blisters of skin along the one or more
distribution of main divisions of trigeminal nerve.
 Trigeminal neuralgia is characterized by acute unilateral out bursting pain
in sensory area supplied by one of the divisions of trigeminal nerve. The
treatment given to reduce the pain is to inject medicine into trigeminal
ganglion via foramen ovale.
 Numb chin syndrome (NCS)
 Numb chin syndrome (NCS) involves reduced or absent sensation in an
area over the chin and lower lip within the distribution of the mental or
inferior alveolar nerves. Sensory loss may be associated with
paresthesia, dysesthesia, or pain.
 NCS and other types of trigeminal neuropathy can be due to a variety of
neoplastic, traumatic, dental, inflammatory, and infectious causes
 In the absence of a known dental or iatrogenic etiology, patients with
unexplained new-onset numbness in the area of the mental or inferior
alveolar nerve require careful evaluation with imaging to exclude
malignancy and other serious conditions. For patients with acute onset
of NCS and no obvious cause, we suggest contrast-enhanced MRI with
special attention to the length of the trigeminal nerve and branches
extending through the face and mandible. For patients with no clear
history of trauma to the nerve and negative or indeterminate imaging,
we suggest a broader evaluation for metabolic, infectious, and

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inflammatory causes, including cerebrospinal fluid analysis, blood, and

serologic studies as discussed above.
 The treatment and prognosis of NCS depend upon the underlying cause.

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