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Before the syndromes we should re-learn some facts…

Syndromes of CN V Kassaundra Johnston, OD, FAAO Spring 2016

S

CN V Trigeminal

Anatomy of CN V Trigeminal Nerve

The largest and most complex of the 12 cranial nerves

S  Mixed nerve S  Sensory S  Face sensations S  Motor S  Muscles for mastication S  Massester S  Temporalis S  Pterygoids S  Both IPSILATERAL

innervation

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Let’s break this down… S  CN V nuclei is a little complicated… S  Principal sensory nucleus S  Mesencephalic nucleus S  Spinal nucleus S  Motor nucleus

Anatomy of CN V S  Mesencephalic nucleus S  Located in midbrain S  Proprioception & deep sensation S  From tendons & muscles for

chewing

S  Spinal nucleus S  From upper pons to upper cervical

cord

S  Pain & temperature S  Dermatomes concentric around

Anatomy of CN V: Nucleus S  Main sensory nucleus S  Located in pons S  Detects light touch S  3 branches S  Sensory portion S  From midbrain to

upper cervical cord

Spinal nucleus S  Central organization

of the trigeminal nerve S  Concentric rings around the mouth S  Corresponding to dermatomes

mouth

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Anatomy of CN V S  Motor nucleus S  Ventromedial to the

sensory nucleus. S  Near the lateral angle of

the fourth ventricle in the rostral part of the pons. S  Axons travel with V3 division

Function

Central connection

Cell Bodies

Peripheral Distribution

Afferent general somatic

General senses

Sensory nucleus CN V

Gasserian ganglion

Sensory branches of V1, V2 & V3

Efferent special visceral

Mastication

Motor nucleus CN V

Motor nucleus CN V

Branches muscles of mastication

Afferent proprioceptive

Muscular senses

Mesencephalic nucleus CN V

Mesencephalic nucleus CN V

Sensory endings in muscles of mastication

Trigeminal Nerve

Components

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CN VTrigeminal Nerve Supplies sensation to the IPSIATERAL side of the face via 3 branches (Hint: TRI-geminal) V1: Ophthalmic division V2: Maxillary division V3: Mandibular division

Ophthalmic division (V1)

Before the divisions… •  It has an area called the

Trigeminal (or Gasserian or semilunar) ganglion •  Located in petrous apex •  Within a fold called Meckel cave

Ophthalmic division (V1) S  Frontal nerve S  Supraorbital nerve S  Upper lid, frontalis muscle,

scalp

S  Supratrochlear nerve S  Conjunctiva, upper lid,

forehead

S  Lacrimal nerve S  Branch from zygomatic nerve of

maxillary S  Lacrimal gland, conjunctiva, upper lid

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Ophthalmic division (V1)

Ophthalmic division (V1)

S  Nasociliary nerve S  Anterior ethmoid nerve

S  Long ciliary nerves

S  Frontal, anterior and

S  Posterior ethmoid sphenoid

ethmoid sinuses S  Branches to ciliary ganglion

sinuses S  Sympathetic fibers of eye

S  Anterior septum, nasal wall

S  CB, iris, CORNEA

S  Posterior ethmoid nerve S  Cornea, iris, ciliary body

Corneal Reflex (blink reflex) Controlled by the CN V If facial paraesthesia is present •  Corneal tearing reflex can be affected •  Ex. Bell’s palsy CN VII •  BUT corneal sensation still exists! •  Nasociliary V1 •  • 

Maxillary division (V2) S  Zygomatic nerve S  Lacrimal gland S  Forehead, Cheek S  Pterygopalatine nerve

S  Middle meningeal nerve S  Dura S  Posterior superior alveolar nerve S  Gums

S  Nasal cavity, pharynx, palate

S  Posterior cheek

S  Soft and hard palate S  Superior, middle turbinate,

S  Teeth S  Nasal floor

septum

S  Nasopharynx

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Mandibular Nerve (V3)

Last reminder…

Cavernous sinus

Annulus of Zinn

S  Motor S  Pterygoid S  Masseter S  Temporalis S  Sensory S  Mandible S  Lower lip S  Tongue S  External ear S  Tympanum

Oculofacial hypesthesia Decreased sensation or numbness

LOCATION…LOCATION…LOCATION

Now for some numbness & pain…

S  Distribution can determine

S

central or peripheral pathway origin S  Central (nuclear) S  Concentric numbness S  Peripheral S  Band of numbness S  Typically a lesion of middle cranial fossa or orbit

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Notes about Trigeminal Neuropathy S  Manifested ipsilateral facial pain,

paresthesias, numbness and sensory loss.

S  Similar causes as other CN

damage S  Tumor S  Infection S  Trauma: penetrating or blunt S  Aneurysm

S  Locations along pathway: S  Apex of temporal bone

Trigeminal Neuralgia

S  Gradenigo syndrome

(tic douloureux)

S  Cavernous sinus S  Orbit S  Also goes through SOF

Trigeminal neuralgia

S

Trigeminal neuralgia

S  Pain distributed in 1 or more

division of CN V S  V3>V2>V1 S  Recurring, “lightening”/

“shock-like” hemifacial pain S  20-30 seconds S  Triggers

S  Patients with MS have

increased frequency of bilateral neuralgia

S  Incidence is 1 in every

15,000-20,000

S  More common in females

S  Chewing, speaking, or touch S  No other neurologic deficits S  Normal corneal blink reflex

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Trigeminal neuralgia- Causes

Trigeminal neuralgia- Treatment

S  Typically idiopathic S  Middle aged or elderly

populations S  Compression of trigeminal

nerve root by SCA or adjacent venous structures S  Can be associated to more

serious findings S  New onset should be imaged

S  Medications S  Ex: carbamazepine, gabapentin, or baclophen S  Acupuncture S  Gamma knife radiosurgery S  Microvascular decompression S  Some may spontaneously remit

Trigger points L

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Raeder’s Paratrigeminal Neuralgia

Raeder’s Paratrigeminal Neuralgia

S  CN V distribution pain with

ipsilateral Horner’s syndrome

S  Exclusive to middle-aged or elder

male patients S  FINALLY!

S

Raeder’s vs. Carotid dissection S  Carotid dissection: S  A separation of the layers of the vessel

wall, usually between the internal elastic lamina and the media S  Typically from trauma

S  Pain: ipsilateral fronto-temporal, orbital

and facial

S  Associated Horner’s syndrome S  Postganglionic

S  Causes: S  Migrainous dilation of ICA S  If persistentS  Tumor, aneurysm, trauma

or infection

Raeder’s vs. Carotid dissection S  Bad stuff it can cause: S  Stroke in 50% S  Amaurosis in 25% S  Within 2 days! S  Treatment S  Anticoagulants S  Antiplatelet meds S  Surgery

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Herpes Zoster- VZV Presentation S  Severe, burning and aching

Herpetic Neuralgia Herpes Zoster

S  Dermatome V1 S  Pain PRECEDES rash by 4-7 days S  “crawling,” “tingling,” or

“prickly” sensations

S

S  Regresses within 1-2 weeks S  Incidence increases with age

Hutchinson’s sign

Side note: Neurotrophic cornea •  CN V & cornea: •  Blink reflex •  Reflex tearing •  Maintaining the

cornea function & integrity

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Isolated Trigeminal Neuropathy Isolated Trigeminal Neuropathy

S  Benign, self-limiting CN V

neuropathy S  Any division of CN V S  Typically seen 1-3 weeks after a

S

nonspecific viral infection or upper respiratory infection S  Diagnostics are negative

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Isolated Trigeminal Neuropathy

Isolated Trigeminal Neuropathy S  Important part… S  Can be seen in association with

S  Difficult to localize to nuclear or

peripheral S  Although some think Gasserian ganglion

S  Sjögren syndrome S  Systemic sclerosis S  Systemic lupus erythematous S  Demyelinating disease- (MS- consider when younger) S  Connective tissue disease S  Neoplasms S  TB, syphilis or Lyme disease

Cerebellopontine Angle Tumor S  Signs/Symptoms S  Facial pain S  Corneal hypoesthesia S  CN VI palsy S  V2 hypoesthesia S  Decreased tearing

Cerebellopontine Angle Tumor S  SUSPECT S  Nasopharyngeal tumor/

carcinoma in the subarachnoid space S  Future aberrant regeneration S  Crocodile tears

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Here is the problem…

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