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Nerve Supply of Head and Neck & Its Applied anatomy

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DrSusmita Shah

This document provides an overview of the nervous system and cranial nerves. It begins with an introduction to the nervous system and its main components - the central nervous system and peripheral nervous system. It then discusses the cranial nerves in detail, covering their names, functions, and applied anatomy. For each cranial nerve, it describes the nuclei, ganglia, functional components and exits from the skull. Clinical testing methods and common conditions are also reviewed. The document uses multiple anatomy references and includes diagrams to illustrate key concepts.

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1/13/2019 1
Presented By: DR. SUSMITA SHAH MDS Part- I Department of Paediatrics & Preventive Dentistry K.M.S.D.C.H 1/13/2019 2
CONTENT: • Introduction • Basic Neuroanatomy • Origin Of Nervous System • Division Of Nervous system • Cranial Nerves • Applied Anatomy • References 1/13/2019 3
Introduction: • Nervous system is an organ system containing a network of specialized cells called Neurons that transmit signals between different parts of the body & co-ordinate the actions. • Consists of - 1.Central Nervous System 2.Peripheral Nervous System 1/13/2019 4• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Terminologies • NUCLEUS: Applies to an aggregate of nerve cell bodies located within the CNS • GANGLION: is a group of nerve cell bodies situated outside the brain and spinal cord. • TRACT: defined as a group of nerve cell processes within the CNS. • NERVE: is a bundle of neuronal processes outside the CNS. • PLEXUS: site of intermingling and regrouping of peripheral nerve fibers deriving from diverse origins 1/13/2019 5• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
FUNCTIONAL COMPONENTS: • Functions performed by each type of fiber contained within a given nerve, as a class the several specialized fiber types referred by the generic term Functional Components A)1.General: refers to stimuli conducted throughout the entire body, common to both cranial & spinal nerves 2.SPECIAL: Afferent information is encoded by highly specialized sense organs and transmitted to the brain in certain cranial nerves (I, II, VII, VIII, IX) B)1.SOMATIC: Refers to skin and muscles of body wall 2.VISCERAL: Organs within the body cavities 1/13/2019 6 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
C) 1.AFFERENT: or sensory means the direction of conduction is towards the CNS 2.EFFERENT: or motor means the direction of conduction is away from CNS ( Brain to effector ) D) 1.GENERAL AFFERENT: fibers carry sensations of pain, temperature, touch and pressure from widely distributed receptors to brain. 2.GENERAL EFFERENT: Includes all motor fibers to skeletal muscles, smooth muscles, cardiac muscle or glands. 1/13/2019 7• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Various combinations of terms to describe 4 General Functional Component Types: 3 Special Functional Component Types V SSA SVA SVE GSA GSE GVA GVE 1/13/2019 8• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Origin Of Nervous System 1/13/2019 9 • Frank H. Netter Atlas Of Human Anatomy-7th Edition • Inderbir Singh – Human Embryology – 10th Edition
1/13/2019 10
CENTRAL NERVOUS SYSTEM Brain- control center of nervous system receives sensory input from spinal cord as well its own nerves. ex: olfactory, optic Spinal cord- conducts sensory information from PNS to brain. • Conducts motor information from brain to our various effectors • Serves as minor reflex center 1/13/2019 11
Peripheral Nervous System • Cranial nerves: means by which receives information from and controls activities of head and neck and to a lesser extent the thoracic and abdominal viscera. • Spinal nerves: means by which CNS receives information from and controls activities of trunk and limbs. 1/13/2019 12
Autonomic Nervous System • Division of PNS. • Automatically controls involuntary functions. • Consists motor neurons arising from brainstem and spinal cord that carry nerve impulses to smooth muscle in glands, blood vessels, cardiac muscle and other organs. 1/13/2019 13
Divisions of ANS SYMPATHETIC NERVOUS SYSTEM: Typically excitatory, prepares body for stress. Ex: increase in heart rate, slowing the movement of intestines. PARA SYMPATHETIC NERVOUS SYSTEM: Restores /maintains energy. Ex: slowing heart rate, speeding up movement of intestines. 1/13/2019 14
Names of Cranial Nerves I. Olfactory nerve II. Optic nerve III. Oculomotor nerve IV. Trochlear nerve V. Trigeminal nerve VI. Abducent nerve VII. Facial nerve VIII.Vestibulocochlear nerve IX. Glossopharyngeal nerve X. Vagus nerve XI. Accessory nerve XII. Hypoglossal nerve XIII. Terminal Nerve 1/13/2019 15• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
1. OLFACTORY NERVE Function: smell Cells of origin: olfactory mucosa in the nasal cavity Component: SA Exit from skull: cribriform plate of ethmoid bone It carries SA fibers, its sensory neurons have Peripheral processes receptors in the nasal mucosa Central processes- return information to brain 1/13/2019 16• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Applied Anatomy of Olfactory Nerve  Anosmia: loss of olfaction unilateral/bilateral  Hyperosmia: Hysterias Unilateral- frontal lobe tumors Bilateral- Common colds,other forms of rhinitis,severe anterior cranial fossa injury • Clinical Testing- Each nostril tested separately using common test odours. 1/13/2019 17• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
2. OPTIC NERVE • Nerve of sight Functional component: SA Exit from skull: optic canal • Structure: - each optic nerve contains 1.2 million myelinated fibers - 4 cm long - enclosed in 3 meningeal sheaths 1/13/2019 18• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Applied Anatomy of Optic Nerve • Lesions involving the retina or optic nerve on one side result in unilateral symptoms. Optic Nerve Hypoplasia – underdevelopment Optic Neuritis – Inflammation of Optic Nerve Unilateral blindness - complete destruction  Scotoma -partial alteration in vision Optic atrophy - primary/secondary Injury to the Optic Nerve- congenital or hereditary problems, trauma ,toxicity, inflammation or aneurysms 1/13/2019 19• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
3. OCCULOMOTOR NERVE Supplies muscles of eye, superior ,inferior, medial rectus muscle, inferior oblique, circular muscles, cilliary muscles Functional components a) SE- movements of eyeball b) GSE- contraction of pupil & accommodation c) GSA- for impulses from muscles of eyeball Exit from skull: Superior Orbital Fissure 1/13/2019 20
Applied anatomy of occulomotor nerve • Lesions: tumors, hemorrhage, aneurysm of circle of Willis that completely paralyze the nerve shows :mydriasis, divergent strabismus, diplopia, loss of light and accommodation reflexes, slight proptosis. • Weber’s syndrome: midbrain lesion causing contra lateral hemiplegia and ipsilateral paralysis 1/13/2019 21
Clinical testing of 3rd nerve • Finger following tests: patient instructed to follow examiner’s finger. Determine whether paralysis of one or more extra ocular muscles. • A pocket torch shown onto the eye, from the side to eliminate an accommodation reflex . This is tested by asking to focus upon an object approaching him. 1/13/2019 22 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
4. TROCHLEAR NERVE  Functional components SE: movements of eyeball GSE: For impulses from superior oblique muscles  Function: innervates Superior oblique muscle  Exit from skull: superior orbital fissure 1/13/2019 23 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Applied anatomy of trochlear nerve • When trochlear nerve is damaged: diplopia occurs on looking downwards. Vision is single so long as the eyes look above the horizontal plane. Cause: brainstem lesion along nerve course -orbital fracture 1/13/2019 24 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
1/13/2019 BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition 25
5. Trigeminal Nerve • V cranial nerve • Largest among all cranial nerves • Mixed nerve (motor + sensory) • Functional Components: GSA,SVE Sensory supply • To face • The greater part of the scalp, • The teeth, • The oral • Nasal cavities Motor supply • muscles of mastication • Anterior belly of diagastric • Mylohyoid • Tensor tympani 1/13/2019 26• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition th
1/13/2019 27 Frank H. Netter Atlas Of Human Anatomy-7th Edition
Nucleus of trigeminal nerve • A cranial nerve nucleus is collection of neurons in the brain stem that is associated with one or more cranial nerves. • Axons carrying information to and from the cranial nerves form a synapse first at these nuclei . There are four nuclei, one motor & three sensory. • Branchial Efferent: Motor nucleus of trigeminal in upper pons, for masticatory muscles, mylohyoid & tensor palati. 1/13/2019 28 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
• Somatic Efferent: Three sensory nuclei of trigeminal a. Mesencephalic nucleus - mid brain, for proprioception from muscles of mastication, TMJ and teeth. b. Principle sensory nucleus - upper pons, for touch & pressure. c. Spinal nucleus - lower pons, medulla & upper cervical spinal cord, for pain and temprature from face 1/13/2019 29 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Sensory root Fibers of sensory root Reach semilunar ganglion Present at petrous part of temporal bone in Meckel's cave Lateral aspect pons and terminate Three branches 1/13/2019 30
Motor root Fibers from motor nucleus Located in upper pons Pass from pons along medial side Medial side of semilunar ganglion Leave foramen ovale Supply muscles of mastication 1/13/2019 31
Ganglion • A collection of the nerve cell bodies outside the central nervous system • Within the middle cranial fossa, the sensory root expands into the trigeminal ganglion • Located lateral to the cavernous sinus, in a depression of the temporal bone known as the trigeminal cave or Meckel’s cave. 1/13/2019 32 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
1/13/2019 33 Frank H. Netter Atlas Of Human Anatomy-7th Edition
1/13/2019 34
1. Ophthalmic Division of Trigeminal Nerve  Smallest branch of trigeminal nerve  Superior division  Sensory only  Supplies : eyeballs, conjunctiva, lacrimal gland, mucosa of nose ,paranasal sinus, skin of forehead and eyelid 1/13/2019 35• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Emerges from antero-medial part of trigeminal ganglion travel anteriorly through lateral aspect of cavernous sinus exit the skull through superior orbital fissure Trunk 2.5 cm long Just before exit 3 branches: Nasocilliary ,frontal ,lacrimal Course 1/13/2019 36
Distribution of ophthalmic nerve 1/13/2019 37 Frank H. Netter Atlas Of Human Anatomy-7th Edition
Trigeminal Lateral wall of Ganglion Cavernous Sinus Nasociliary Frontal Lacrimal Lacrimal Gland, Conjunctivae & Skin of upper eyelid Supraorbital Supratrochlear Upper Eyelid, Upper Eyelid, Conjunctivae Conjunctivae, & Scalp & Skin of forehead Frontal sinus MM1/13/2019 38
1/13/2019 BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition 39
2.Maxillary Division of Trigeminal Nerve • Entirely sensory • Origin: semilunar ganglion • Exit from skull: foramen rotundum • Branches in 4 regions: -middle cranial fossa -pterygopalatine fossa -infraorbital groove & canal -terminal branches on face 401/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Origin from ganglion Runs along lower part of cavernous sinus Middle meningeal nerve Pass through foramen rotundum Leaves cranial fossa Enters pterygo-palatine fossa Zygomatic Spenopalatine PSA Enters the infra orbital groove 1/13/2019 41
1/13/2019 42 Frank H. Netter Atlas Of Human Anatomy-7th Edition
Maxillary nerve zygomatic Zygomatico-temporal Zygomatico-frontal Posterior superior alveolar Mm of max. sinus Molars and gingiva Spenopalatine Infraorbital Anterior superior alveolar Middle superior alveolar 1/13/2019 43
3.Mandibular Division of Trigeminal Nerve Largest branch of trigeminal nerve Emerges from inferior most part of trigeminal ganglion Nerve of first branchial arch Exit from skull: foramen Ovale It has two roots - Sensory -Motor 1/13/2019 44 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
Course • Motor root- from motor nucleus in pons • sensory root- gasserian ganglion a a small ant. division exit through foramen ovale greater wing of sphenoid trunk which remain 2-3 mm undivided infra-temporal fossa 1/13/2019 45
1/13/2019 46Frank H. Netter Atlas Of Human Anatomy-7th Edition
1/13/2019 47 Handbook of Local Anesthesia By Stanley Malamed – 6th Edition
Applied Anatomy of Trigeminal Nerve Injury to 1.Opthalmic Nerve- loss of corneal blink reflex 2.Maxillary Nerve- loss of Sneeze reflex 3.Mandibular Nerve- loss of jaw jerk reflex Hypoacusis- Paralysis of tensor tympani Muscles Flaccid Paralysis of muscles of mastication Shingles- Harbors Herpes Zoster Virus Needle Breakage-asso. with IANB Trismus 1/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition 48
Hematoma 1/13/2019 • Handbook of Local Anesthesia By Stanley Malamed – 6th Edition • Gray’s Anatomy-40th Edition 49 Management: Apply pressure -Immediate application of ice pack -Takes 7 to 14 days to heal -Keep moist warm towel in affected area after 24 hours. Prevention: -Don’t penetrate the needle too deep -Avoid using long needles
Parasthesia -Most commonly associated with lingual and inferior alveolar nerve. -One of the most frequent cause of dental malpractice. Causes: -Administration of local anesthetic solution contaminated with alcohol or sterilizing solution. -Direct trauma to nerve -Hemorrhage around nerve sheath 1/13/2019 Handbook of Local Anesthesia By Stanley Malamed – 6th Edition 50
Trigeminal Neuralgia -John Locke in 1677 gave first full description with treatment. -Nicholaus Andre in 1756 coined the term “Tic Doulourex”. -John Fothergill in 1773 pubished detailed description. -Sudden, Usually Unilateral, Sharp Shooting, Severe, Stabbing, lancinating, paroxysmal pain in the distribution of 5th cranial nerve. 1/13/2019 • Handbook of Local Anesthesia By Stanley Malamed – 6th Edition • Gray’s Anatomy-40th Edition 51
Etiology of Trigeminal Neuralgia PERIPHERAL: -Dental etiology -Infections- Herpes zoster -Multiple sclerosis -Injuries to nerve -Nerve compression CENTRAL: -Post-traumatic neuralgia -Intracranial tumors -Intracranial vascular abnormalities (aneurisms) -Segmental demyelination 1/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition 52
Clinical Appearance- *Typical appearance of patient: *Unshaved face *Poor oral hygiene *Frozen or mask like face *H/O multiple dental extractions *Triggered by a non painful stimulus 1/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition 53 Diagnosis *Trigger point *Paroxysmal pain *Self limiting *Refractory period *Multiple extractions *Response to carbamazepine
1/13/2019 54 Differential diagnosis • Migrane • Sinusitis • Odontogenic pain • Orofacial pain • Tempromandibular joint disorders • Post herpetic neuralgia • Multiple sclerosis • Glossopharyngeal neuralgia
1/13/2019 Essentials of Medical Pharmacology-K D Tripathi -6th Edition Textbook Of Oral Medicine- Anil Ghom’s 55 Medicinal Management Drugs given in combination of carbamazepine Are: • Sodium valproate 600mg/day. • Phenytoin 100mg/day. • Gabapentin 200mg/day • Lamotrigine 200mg/day Tab Clonazepam 1.5 mg/day Side effects: drowsiness, fatigue, lethargy. Tab Phenytoin: 100 mg thrice daily. Side effects: slurred speech, abnormal movements ,gingival hypertrophy, folate deficiency.
1/13/2019 56 Peripheral management: 1.Non-destructive: -Peripheral long acting anesthetic injections -Nerve decompression 2.Destructive: -Peripheral Alcohol / Glycerol injections -Peripheral neurectomy
1/13/2019 57 Surgical Management • Internal decompression: - Nerve exposed in fallopian canal and pressure is relieved. - Epineural sheath is opened to visualize the nerve fibers and release adhesions or re-establish continuity. • External decompression by releasing of epineural sheath from surrounding scar tissue, bone or foreign body.
1/13/2019 58 Instructions • Not to drive vehicles • Not to swim • Critical jobs like railway driver, signalman, pilots, working near furnaces, boilers, towers etc be avoided • Periodic CBC to rule out hematopoeitic depression
• Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition • A.K. Datta Essentials Of Human Anatomy Head And Neck. 4th Edition • Frank H. Netter Atlas Of Human Anatomy-7th Edition • Inderbir Singh – Human Embryology – 10th Edition • Handbook of Local Anesthesia By Stanley Malamed – 6th Edition • Essentials of Medical Pharmacology-K D Tripathi -6th Edition • Textbook Of Oral Medicine- Anil Ghom’s References 1/13/2019 59
Thank You 1/13/2019 60
1/13/2019 61
Content  Abducent Nerve  Facial Nerve  Vestibulocochlear Nerve  Glossopharyngeal Nerve  Vagus Nerve  Accessory Nerve  Hypoglossal Nerve  Terminal Nerve 1/13/2019 62
6.Abducent Nerve -Entirely Motor -Supplies Lateral Rectus Muscle of eyeball -Nucleus: Situated in pons -Functional Components: SE 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 63
Course of Abducent Nerve Emerges from pons(groove between pons &medulla oblongata) Passes through Cavernous sinus Lies below Internal Carotid Artery Enters Orbit through Superior Orbital Fissure 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 64
Applied Anatomy Of Abducent Nerve 1.Lesions- damage due to head injuries, cavernous sinus thrombosis, aneurysm of internal carotid artery 2.Internal Strabismus-Patient Cannot Turn Eye Laterally 3.Paralysis-due to increased intracranial pressure 4.Diplopia-due to paralysis of lateral rectus muscle 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 65
7.Facial Nerve • Also Known as “Nerve Of Facial Expression:” • It is mixed nerve • Sensory function-taste from anterior 2/3rd of tongue • Motor Function-Supplies facial muscles, scalp muscles of neck • Functional Components: GVE,SVE,SVA & GSA • Foramen: Internal Acaustic Meatus & Stylomastoid Foramen(Facial Canals) 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 66
1/13/2019 67 FUNCTIONAL COMPONENT NUCLEI DISTRIBUTION FUNCTION GVE Superior salivatory nucleus (lies in the pons lateral to the main motor nucleus of VII ) Submandibular and sublingual salivary glands. Secretomotor SVE Motor nucleus of facial nerve (lies in lower part of pons) Muscles of facial expression, stylohyoid, posterior belly of digastric, platysma and stapedius. Facial expression SVA Nucleus of tractus solitarius (lies in medullla) Taste buds in the anterior 2/3rd of tongue except vallate papillae Taste sensations GSA Spinal nucleus of Vth nerve Part of skin of external ear Exteroceptive sensation
Functions Of Facial Nerve • Carries taste sensations from the anterior two thirds of the tongue and oral cavity • Controls the muscles of facial expression • It also supplies preganglionic parasympathetic fibres to several head and neck ganglia 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 68
 Embryology  The facial nerve is developmentally derived from the hyoid arch, which is the second branchial arch  The motor division of facial nerve is derived from the basal plate of the embryonic pons  The sensory division originates from the cranial neural crest 1/13/2019 A.K. Datta Essentials Of Human Anatomy Head And Neck. 4th Edition I B SINGH Textbook of Embrology 11th edition 69
• Facial nerve course, branching pattern, and anatomical relationships are established during the first 3 months of prenatal life • 3rd wk : facioacoustic (acousticofacial) primordium • Early 5th week, the geniculate ganglion forms from distal part of primordium 1/13/2019 I B SINGH Textbook of Embrology 11th edition 70
It separates into 2 branches: main trunk of facial nerve and chorda tympani Proximal branches formed in the 6th week, posterior auricular branch, branch of digastric and stylohyoid Late 8th week, 5 major peripheral subdivisions present 1/13/2019 I B SINGH Textbook of Embrology 11th edition 71
GANGLIA ASSOCIATED WITH THE FACIAL NERVE 1/13/2019 Netters : Colour Atlas of Anatomy 72
1. GENICULATE GANGLION -Derived from Latin GENU = “KNEE” -L-shaped collection of fibers and sensory neurons of the facial nerve located in the facial canal of the head. -Receives fibers from the motor, sensory, and parasympathetic components of the facial nerve 1/13/2019 I B SINGH Textbook of Embrology 11th edition 73
Innervates i. Lacrimal glands ii. Submandibular glands iii. Sublingual glands iv. Tongue v. Palate vi. Pharynx vii. External auditory meatus viii. Stapedius ix. Posterior belly of the digastric muscle x. Stylohyoid muscle xi. Muscles of facial expression 1/13/2019 74 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition
2.SUBMANDIBULAR GANGLION - Small and fusiform in shape. -Situated above the deep portion of the submandibular gland -The ganglion 'hangs' by two nerve filaments one anterior and one posterior. -Receives a branch from the chorda tympani nerve which runs in the sheath of the lingual nerve -Innervates submandibular and sublingual salivary glands 1/13/2019 Vishram Sinagh Textbook of Head and Neck Anatomy 3rd edition 75
3.PTERYGOPALATINE GANGLION (meckel's ganglion, nasal ganglion or sphenopalatine ganglion) -Ganglion found in the pterygopalatine fossa -It's largely innervated by the greater petrosal nerve (a branch of the facial nerve); and its axons project to the lacrimal glands and nasal mucosa 1/13/2019 Vishram Sinagh Textbook of Head and Neck Anatomy 3rd edition 76
Branches of facial nerve 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 77 Intracranial Greater petrosal nerve Nerve to stapaedius Chorda tympani Extracranial Posterior Auricular Nerve Digastric nerve Stylohyoid nerve Terminal Branches Temporal branch Zygomatic branch Buccal branch Marginal mandibular branch Cervical branch
1/13/2019 Netters : Colour Atlas of Anatomy 78
Various facial Expressions 1/13/2019 79Depressor Anguli Oris Buccinator +Orbicularis oris muscle Levator anguli oris + risorius Levator Anguli Oris platysmaMentalisOrbicularis Zygomaticus major & minor OccipitoFrontali s Levator labii superioris alaeque nasi Risorius Orticularis OrisNasalis + procerus Nasalis
Applied Anatomy of Facial Nerve • DISORDERS OF FACIAL NERVE Facial nerve lesions: 1. Supra-nuclear type 2. Nuclear type 3. Peripheral lesions (infranuclear) -Injury at internal acoustic meatus -Injury distal to geniculate ganglion -Injury at stylomastoid foramen1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 80
1/13/2019 81
1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 82 SUPRA NUCLEAR TYPE: Features: -Paralysis of lower part of face (opposite side) -Normal taste and saliva secretion -Stapedius not paralyzed NUCLEAR TYPE Features: -Paralysis of facial muscle (same side) -Paralysis of lateral rectus -Internal strabismus (inward deviation)
PERIPHERAL LESION (At internal acoustic meatus) Features -Paralysis of secretomotor fibers -Hyper acusis -Loss of corneal reflex -Taste fibers unaffected -Facial expression and movements paralyzed 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 83
Injury at stylomastoid foramen Condition known as Bell’s Palsy Weakness of muscles to perform its functions is called ‘Paresis’ Total flaccidity of facial muscles to perform motor functions is called ‘Facial Paralysis’ 1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 84
Causes 1. Central/Supranuclear causes (Facial muscle paralysis with forehead spared) -Cerebral mass lesion (e.g. tumor) -Cerebrovascular Accident (typically with ipsilateral Hemiparesis or Hemiplegia) -Multiple Sclerosis 1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 85 2.Traumatic causes -Cortical injury -Temporal Bone Fracture -Brain Stem injury -Penetrating middle ear injury -Scuba Diving
1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 86 4.Endocrine causes -Diabetes Mellitus -Pregnancy -Hypertension -Alcohol Abuse (Alcoholic - Neuropathy) 3.Infectious Causes -Malignant Otitis Externa (skull base Osteomyelitis) -Mastoiditis Varicella Zoster Virus (Chicken Pox) -Herpes Zoster Oticus (Ramsey-Hunt Syndrome) - Herpetic Vesicles at auricle and external canal -HIV Infection -Influenza -Parotitis -Meningitis -Encephalitis -Mums 5.Birth Causes -Facial Nerve Injury from Birth Trauma (forceps delivery) -Congenital Facial Palsy
1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 87 6. Tumors -Facial Nerve neuroma -Cholesteatoma -Glomus jugular tumor -Primary Temporal Bone tumors -Meningiomas -Hemangioblastoma -Pontine glioma -Parotid tumor 7.Idiopathic Causes: -Myasthenia Gravis -Guillain-Barre Syndrome -Sarcoidosis -Familial Bell's Palsy 8.Iatrogenic Causes -Mandibular block anesthesia -Head and neck surgery -Parotid surgery
Testing Of Facial Nerve • Ask the patient to close his eyes firmly. • Ask the patient to smile. • Ask patient to fill the mouth with air. Press the cheek with your finger and compare the resistance on two sides 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 88
1/13/2019 Netters : Colour Atlas of Anatomy 89
Bell’s Palsy -First described more than a century ago by Sir Charles Bell -Bell palsy is certainly the most common cause of facial paralysis worldwide -It is caused due to inflammation of facial nerve near stylo-mastoid foramen or compression of its fibers near facial canal. 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 90
Etiology -Main cause of Bell's palsy is latent herpes viruses (herpes simplex virus type 1 and herpes zoster virus), which are reactivated from cranial nerve ganglia -Polymerase chain reaction techniques have isolated herpes virus DNA from the facial nerve during acute palsy -Cold hypothesis -Rheumatic -Immunologic -Ischemic hypothesis 1/13/2019 Benjamin Stew and Huw Williams. Williams British Journal of General Practice 2013; 63:109–110. 91
 Clinical Features 1.Unilateral involvement 2.Inability to smile 3.Inability close eye or raise eyebrow 4.Whistling impossible 5.Inability to close eyelid (Bell’s sign) 6.Inability to wrinkle forehead 7.Slurred speech 8.Mask like appearance of face 9.Dribbling of saliva 10.Epiphora 1/13/2019 Benjamin Stew and Huw Williams British Journal of General Practice 2013; 63: 109–110. 92
1/13/2019 Netters : Colour Atlas of Anatomy 93
Management • Physiotherapy -Facial massage -NeuroMuscular Retraining • Ocular protection is essential to protecting vision in both the short term and long term in patients with facial paralysis. • Eye drops-hypromellose drops • Artificial tears are combined with ointment at night (Mavrikakis, 2008) 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 94
8. Vestibulocochlear Nerve • Also called as Auditory Nerve • It is a sensory Nerve • Consists of Two Roots - • 1.Vestibular -Transmits impulses from vestibular apparatus (balance) • 2.Cochlear-Transmits impulses from auditory apparatus (sound) • Functional Components- SSA 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 95
Functions Auditory Nerve transmits sound and equilibrium (balance) information from Internal Ear To Brain 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 96
Applied Anatomy Deafness 1. Conductive-Failure of sound waves to reach cochlea 2. Sensorineural-Failure of production or transmission (cochlear disease) 3. Cortical Deafness-Bilateral posterior temporal lobe lesion 4. Vertigo-Illusion of rotary Movement due to disturbed orientation of body in space 5. Tinnitis-Sensation of burring,ringing,hissing/singing quality 6. Acoustic Neuroma-Slow growing Benign Tumour1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 97
9. Glossopharyngeal Nerve • Originates from Medulla Oblongata • Nuclei-Inferior salivatory nucleus,Nucleus ambiguus,Nucleus Solitory Tract • Functional components- GVE,SVA,GVA • Foramen-Jugular Foramina 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 98
1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 99
Functions • Sensory Function- Taste sensation from posterior 1/3rd of tongue, pharynx • Motor Function-Muscles of speech & swallowing, parotid salivary gland • Somatic Motor Function-Muscles of pharynx, tongue • Autonomic Motor Function-Saliva Production 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 100
 Branches of Glossopharyngeal Nerve 1.Tympanic Nerve (S) 2.Branch to Carotid sinus (S) 3.Branch to Stylopharyngeus Muscle (M) 4.Tonsillar Branches (S) 5.Lingual Branches (S) 6.Pharyngeal Branches (M) 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 101
Applied Anatomy 1. Lesion to the nerve cause decreased secretion of parotid gland 2. Absence of taste from post. 1/3rd of tongue 3. No gag Reflex 4. Loss of sensation from tongue, pharynx, tonsils, soft palate 5. Glossopharyngeal Neuralgia 6. Jugular Foramen Syndrome-Multiple Cranial Palsies 7. Pharyngitis- Refered pain in ear 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 102
Glossopharyngeal Neuralgia • Glossopharyngeal neuralgia is an irritation of the ninth cranial nerve causing extreme pain in the back of the throat, tongue and ear. • Attacks of intense, electric shock-like pain can occur without warning or can be triggered by swallowing. • Symptoms include pain in Nasopharynx, or back of the nose and throat, Back of the tongue, Ear, Tonsil area, Larynx or voice box. 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 103
Treatment For Glossopharyngeal Neuralgia 1. Pain control 2. Antiseizure drugs like Carbamazepine 3. Antidepresssant Drugs 4. Surgical Management 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 104
10. Vagus Nerve • Also known as ”Wandering Nerve” • Originates from medulla oblongata • Foramen- Jugular Foramina • Nuclei-nucleus ambigus ,nucleus solitary(superior part & inferior part) • Sensory Function-supplies skin of back of ear, external acaustic meatus, part of tympanic membrane, larynx, trachea, oesophagus, thoracic & abdominal viscera, epiglottis, root of tongue. 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 105
• Motor Function-supplies throat, Heart, Lungs, abdominal Viscera, soft palate • Associated with Derivatives of fourth pharyngeal arch • 8-10 rootlets are present • Functional Components- SVA,SVE,GSE,GVE,SSA,GSA • Types of Fibers- 1.Brachial Motor 2.Visceral Motor 3.Visceral Sensory 4.Special Sensory 5.General Sensory 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 106
Vagus Nerve Carotid Sheath Travels inferiorly with internal jugular vein & Common Carotid artery At the base of neck divides into Right & Left 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 107 Right nerve passes anterior to subclavian artery & posterior to sternoclavicular joint entering Thorax Left nerve passes inferiorly between the left common carotid & left subclavian artery, posterior to sternoclavicular artery entering Thorax
 Applied Anatomy Of Vagus Nerve 1. Lesion -Difficulty in swallowing, speech(affects pharyngeal & superior laryngeal branches) 2. Recurrent Laryngeal Nerve Palsies-common due to malignant disease & due to damage during surgical operations 3. Vagus Nerve Palsy- Uvula Pulled Towards Normal Side 4. Aphonia- Paralysis of both vocal cords 5. Viral infection(Sensory Ganglion)-Herpes Zoaster 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 108
11. Accessory Nerve • Foramen- Jugular Foramena • General Destination-soft palate, throat, muscles of neck • Nucleus- Hypoglossal Nucleus • Somatic Motor Function- Swallowing & Head Movement (trapezius & sternocleidomastoid) • Functional Components- SVE,GSE 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 109
Course Medulla Oblongata Hypoglossal Canal Behind Vagus Nerve Between IJV & ICA Posterior Belly of Digatric Tongue(Extrinsic & Intrinsic Muscles 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 110
It Supplies • Extrinsic Muscles-Genioglossus, Hyoglossus, Styloglossus • Intrinsic Muscles- Superior Longitudinal, Inferior Longitudinal, Verticals, Tranversus 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 111
1/13/2019 Netters : Colour Atlas of Anatomy 112
Applied Anatomy of Spinal Accessory Nerve • Torticollis/wry neck • Lesion-Drooping of shoulder & Inability to turn chin to opp. Side • Unilateral motor neuron weakness 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 113
12. Hypoglossal Nerve • It is a Motor nerve • Functional Components- GSE • Supplies intrinsic & Extrinsic Muscles of tongue • Foramen- Hypoglossal Canal • Somatic Motor Function- Speech & swallowing via muscles of tongue 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 114
1/13/2019 115 2. Extracranial segment Nasopharyngeal Carotid space Sublingual Segment a.Medullary Segment b. Cisternal Segment c. Canalicular Segment Hypoglossal Nucleus 1. Intracranial Segment
1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 116
 Applied Anatomy of Hypoglossal Nerve • Supranuclear Lesion-Parlysis eithout wasting-tongue moves sluggishly • Defective speech • Tongue Deviates on Protrusion- Unilateral Lingual Paralysis • Injury to the nerve causes dysarthria & dysphagia 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 117
Causes -The causes may be central or peripheral & include cerebrovascular accidents, brain stem tumours & infections Speech Characteristics- abnormality of tongue leads to misarticulation -Problem while saying (T, D, L, I, J, N, K, G) 1/13/2019 118
Managent • Speech therapy should be given • Exercise for treatment of dysarthria may improve tongue co-ordination & strength • Surgical management for hypoglossal nerve injuries 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 119
13. Terminal Nerve • Also known as “Zero Nerve” • Initially referred as nerve of Pinkus. • First discovered in 1870 in sharks and other types of fish • Termed as Terminal –it was observed to extend into the region of lamina terminalis • Published 1987 as X||| Cranial nerve as Zero nerve –it is more rostral than other cranial Nerves 1/13/2019 120
1/13/2019 121 • References • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition • Netters : Colour Atlas of Anatomy • I B SINGH Textbook of Embrology 11th edition • Fujiwara T et al. High-dose corticosteroids improve the prognosis of Bell’s palsy compared with low-dose corticosteroids: A propensity score analysis. Auris Nasus Larynx (2017) • Alptekin D O. Acupuncture and Kinesio Taping for the acute management of Bell’s palsy: A case report Complementary Therapies in Medicine 35 (2017) 1–5.
1/13/2019 122

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Nerve Supply of Head and Neck & Its Applied anatomy

  • 2. Presented By: DR. SUSMITA SHAH MDS Part- I Department of Paediatrics & Preventive Dentistry K.M.S.D.C.H 1/13/2019 2
  • 3. CONTENT: • Introduction • Basic Neuroanatomy • Origin Of Nervous System • Division Of Nervous system • Cranial Nerves • Applied Anatomy • References 1/13/2019 3
  • 4. Introduction: • Nervous system is an organ system containing a network of specialized cells called Neurons that transmit signals between different parts of the body & co-ordinate the actions. • Consists of - 1.Central Nervous System 2.Peripheral Nervous System 1/13/2019 4• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 5. Terminologies • NUCLEUS: Applies to an aggregate of nerve cell bodies located within the CNS • GANGLION: is a group of nerve cell bodies situated outside the brain and spinal cord. • TRACT: defined as a group of nerve cell processes within the CNS. • NERVE: is a bundle of neuronal processes outside the CNS. • PLEXUS: site of intermingling and regrouping of peripheral nerve fibers deriving from diverse origins 1/13/2019 5• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 6. FUNCTIONAL COMPONENTS: • Functions performed by each type of fiber contained within a given nerve, as a class the several specialized fiber types referred by the generic term Functional Components A)1.General: refers to stimuli conducted throughout the entire body, common to both cranial & spinal nerves 2.SPECIAL: Afferent information is encoded by highly specialized sense organs and transmitted to the brain in certain cranial nerves (I, II, VII, VIII, IX) B)1.SOMATIC: Refers to skin and muscles of body wall 2.VISCERAL: Organs within the body cavities 1/13/2019 6 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 7. C) 1.AFFERENT: or sensory means the direction of conduction is towards the CNS 2.EFFERENT: or motor means the direction of conduction is away from CNS ( Brain to effector ) D) 1.GENERAL AFFERENT: fibers carry sensations of pain, temperature, touch and pressure from widely distributed receptors to brain. 2.GENERAL EFFERENT: Includes all motor fibers to skeletal muscles, smooth muscles, cardiac muscle or glands. 1/13/2019 7• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 8. Various combinations of terms to describe 4 General Functional Component Types: 3 Special Functional Component Types V SSA SVA SVE GSA GSE GVA GVE 1/13/2019 8• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 9. Origin Of Nervous System 1/13/2019 9 • Frank H. Netter Atlas Of Human Anatomy-7th Edition • Inderbir Singh – Human Embryology – 10th Edition
  • 11. CENTRAL NERVOUS SYSTEM Brain- control center of nervous system receives sensory input from spinal cord as well its own nerves. ex: olfactory, optic Spinal cord- conducts sensory information from PNS to brain. • Conducts motor information from brain to our various effectors • Serves as minor reflex center 1/13/2019 11
  • 12. Peripheral Nervous System • Cranial nerves: means by which receives information from and controls activities of head and neck and to a lesser extent the thoracic and abdominal viscera. • Spinal nerves: means by which CNS receives information from and controls activities of trunk and limbs. 1/13/2019 12
  • 13. Autonomic Nervous System • Division of PNS. • Automatically controls involuntary functions. • Consists motor neurons arising from brainstem and spinal cord that carry nerve impulses to smooth muscle in glands, blood vessels, cardiac muscle and other organs. 1/13/2019 13
  • 14. Divisions of ANS SYMPATHETIC NERVOUS SYSTEM: Typically excitatory, prepares body for stress. Ex: increase in heart rate, slowing the movement of intestines. PARA SYMPATHETIC NERVOUS SYSTEM: Restores /maintains energy. Ex: slowing heart rate, speeding up movement of intestines. 1/13/2019 14
  • 15. Names of Cranial Nerves I. Olfactory nerve II. Optic nerve III. Oculomotor nerve IV. Trochlear nerve V. Trigeminal nerve VI. Abducent nerve VII. Facial nerve VIII.Vestibulocochlear nerve IX. Glossopharyngeal nerve X. Vagus nerve XI. Accessory nerve XII. Hypoglossal nerve XIII. Terminal Nerve 1/13/2019 15• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 16. 1. OLFACTORY NERVE Function: smell Cells of origin: olfactory mucosa in the nasal cavity Component: SA Exit from skull: cribriform plate of ethmoid bone It carries SA fibers, its sensory neurons have Peripheral processes receptors in the nasal mucosa Central processes- return information to brain 1/13/2019 16• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 17. Applied Anatomy of Olfactory Nerve  Anosmia: loss of olfaction unilateral/bilateral  Hyperosmia: Hysterias Unilateral- frontal lobe tumors Bilateral- Common colds,other forms of rhinitis,severe anterior cranial fossa injury • Clinical Testing- Each nostril tested separately using common test odours. 1/13/2019 17• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 18. 2. OPTIC NERVE • Nerve of sight Functional component: SA Exit from skull: optic canal • Structure: - each optic nerve contains 1.2 million myelinated fibers - 4 cm long - enclosed in 3 meningeal sheaths 1/13/2019 18• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 19. Applied Anatomy of Optic Nerve • Lesions involving the retina or optic nerve on one side result in unilateral symptoms. Optic Nerve Hypoplasia – underdevelopment Optic Neuritis – Inflammation of Optic Nerve Unilateral blindness - complete destruction  Scotoma -partial alteration in vision Optic atrophy - primary/secondary Injury to the Optic Nerve- congenital or hereditary problems, trauma ,toxicity, inflammation or aneurysms 1/13/2019 19• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 20. 3. OCCULOMOTOR NERVE Supplies muscles of eye, superior ,inferior, medial rectus muscle, inferior oblique, circular muscles, cilliary muscles Functional components a) SE- movements of eyeball b) GSE- contraction of pupil & accommodation c) GSA- for impulses from muscles of eyeball Exit from skull: Superior Orbital Fissure 1/13/2019 20
  • 21. Applied anatomy of occulomotor nerve • Lesions: tumors, hemorrhage, aneurysm of circle of Willis that completely paralyze the nerve shows :mydriasis, divergent strabismus, diplopia, loss of light and accommodation reflexes, slight proptosis. • Weber’s syndrome: midbrain lesion causing contra lateral hemiplegia and ipsilateral paralysis 1/13/2019 21
  • 22. Clinical testing of 3rd nerve • Finger following tests: patient instructed to follow examiner’s finger. Determine whether paralysis of one or more extra ocular muscles. • A pocket torch shown onto the eye, from the side to eliminate an accommodation reflex . This is tested by asking to focus upon an object approaching him. 1/13/2019 22 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 23. 4. TROCHLEAR NERVE  Functional components SE: movements of eyeball GSE: For impulses from superior oblique muscles  Function: innervates Superior oblique muscle  Exit from skull: superior orbital fissure 1/13/2019 23 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 24. Applied anatomy of trochlear nerve • When trochlear nerve is damaged: diplopia occurs on looking downwards. Vision is single so long as the eyes look above the horizontal plane. Cause: brainstem lesion along nerve course -orbital fracture 1/13/2019 24 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 25. 1/13/2019 BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition 25
  • 26. 5. Trigeminal Nerve • V cranial nerve • Largest among all cranial nerves • Mixed nerve (motor + sensory) • Functional Components: GSA,SVE Sensory supply • To face • The greater part of the scalp, • The teeth, • The oral • Nasal cavities Motor supply • muscles of mastication • Anterior belly of diagastric • Mylohyoid • Tensor tympani 1/13/2019 26• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition th
  • 27. 1/13/2019 27 Frank H. Netter Atlas Of Human Anatomy-7th Edition
  • 28. Nucleus of trigeminal nerve • A cranial nerve nucleus is collection of neurons in the brain stem that is associated with one or more cranial nerves. • Axons carrying information to and from the cranial nerves form a synapse first at these nuclei . There are four nuclei, one motor & three sensory. • Branchial Efferent: Motor nucleus of trigeminal in upper pons, for masticatory muscles, mylohyoid & tensor palati. 1/13/2019 28 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 29. • Somatic Efferent: Three sensory nuclei of trigeminal a. Mesencephalic nucleus - mid brain, for proprioception from muscles of mastication, TMJ and teeth. b. Principle sensory nucleus - upper pons, for touch & pressure. c. Spinal nucleus - lower pons, medulla & upper cervical spinal cord, for pain and temprature from face 1/13/2019 29 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 30. Sensory root Fibers of sensory root Reach semilunar ganglion Present at petrous part of temporal bone in Meckel's cave Lateral aspect pons and terminate Three branches 1/13/2019 30
  • 31. Motor root Fibers from motor nucleus Located in upper pons Pass from pons along medial side Medial side of semilunar ganglion Leave foramen ovale Supply muscles of mastication 1/13/2019 31
  • 32. Ganglion • A collection of the nerve cell bodies outside the central nervous system • Within the middle cranial fossa, the sensory root expands into the trigeminal ganglion • Located lateral to the cavernous sinus, in a depression of the temporal bone known as the trigeminal cave or Meckel’s cave. 1/13/2019 32 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 33. 1/13/2019 33 Frank H. Netter Atlas Of Human Anatomy-7th Edition
  • 35. 1. Ophthalmic Division of Trigeminal Nerve  Smallest branch of trigeminal nerve  Superior division  Sensory only  Supplies : eyeballs, conjunctiva, lacrimal gland, mucosa of nose ,paranasal sinus, skin of forehead and eyelid 1/13/2019 35• BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 36. Emerges from antero-medial part of trigeminal ganglion travel anteriorly through lateral aspect of cavernous sinus exit the skull through superior orbital fissure Trunk 2.5 cm long Just before exit 3 branches: Nasocilliary ,frontal ,lacrimal Course 1/13/2019 36
  • 37. Distribution of ophthalmic nerve 1/13/2019 37 Frank H. Netter Atlas Of Human Anatomy-7th Edition
  • 38. Trigeminal Lateral wall of Ganglion Cavernous Sinus Nasociliary Frontal Lacrimal Lacrimal Gland, Conjunctivae & Skin of upper eyelid Supraorbital Supratrochlear Upper Eyelid, Upper Eyelid, Conjunctivae Conjunctivae, & Scalp & Skin of forehead Frontal sinus MM1/13/2019 38
  • 39. 1/13/2019 BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition 39
  • 40. 2.Maxillary Division of Trigeminal Nerve • Entirely sensory • Origin: semilunar ganglion • Exit from skull: foramen rotundum • Branches in 4 regions: -middle cranial fossa -pterygopalatine fossa -infraorbital groove & canal -terminal branches on face 401/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 41. Origin from ganglion Runs along lower part of cavernous sinus Middle meningeal nerve Pass through foramen rotundum Leaves cranial fossa Enters pterygo-palatine fossa Zygomatic Spenopalatine PSA Enters the infra orbital groove 1/13/2019 41
  • 42. 1/13/2019 42 Frank H. Netter Atlas Of Human Anatomy-7th Edition
  • 43. Maxillary nerve zygomatic Zygomatico-temporal Zygomatico-frontal Posterior superior alveolar Mm of max. sinus Molars and gingiva Spenopalatine Infraorbital Anterior superior alveolar Middle superior alveolar 1/13/2019 43
  • 44. 3.Mandibular Division of Trigeminal Nerve Largest branch of trigeminal nerve Emerges from inferior most part of trigeminal ganglion Nerve of first branchial arch Exit from skull: foramen Ovale It has two roots - Sensory -Motor 1/13/2019 44 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition
  • 45. Course • Motor root- from motor nucleus in pons • sensory root- gasserian ganglion a a small ant. division exit through foramen ovale greater wing of sphenoid trunk which remain 2-3 mm undivided infra-temporal fossa 1/13/2019 45
  • 46. 1/13/2019 46Frank H. Netter Atlas Of Human Anatomy-7th Edition
  • 47. 1/13/2019 47 Handbook of Local Anesthesia By Stanley Malamed – 6th Edition
  • 48. Applied Anatomy of Trigeminal Nerve Injury to 1.Opthalmic Nerve- loss of corneal blink reflex 2.Maxillary Nerve- loss of Sneeze reflex 3.Mandibular Nerve- loss of jaw jerk reflex Hypoacusis- Paralysis of tensor tympani Muscles Flaccid Paralysis of muscles of mastication Shingles- Harbors Herpes Zoster Virus Needle Breakage-asso. with IANB Trismus 1/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition 48
  • 49. Hematoma 1/13/2019 • Handbook of Local Anesthesia By Stanley Malamed – 6th Edition • Gray’s Anatomy-40th Edition 49 Management: Apply pressure -Immediate application of ice pack -Takes 7 to 14 days to heal -Keep moist warm towel in affected area after 24 hours. Prevention: -Don’t penetrate the needle too deep -Avoid using long needles
  • 50. Parasthesia -Most commonly associated with lingual and inferior alveolar nerve. -One of the most frequent cause of dental malpractice. Causes: -Administration of local anesthetic solution contaminated with alcohol or sterilizing solution. -Direct trauma to nerve -Hemorrhage around nerve sheath 1/13/2019 Handbook of Local Anesthesia By Stanley Malamed – 6th Edition 50
  • 51. Trigeminal Neuralgia -John Locke in 1677 gave first full description with treatment. -Nicholaus Andre in 1756 coined the term “Tic Doulourex”. -John Fothergill in 1773 pubished detailed description. -Sudden, Usually Unilateral, Sharp Shooting, Severe, Stabbing, lancinating, paroxysmal pain in the distribution of 5th cranial nerve. 1/13/2019 • Handbook of Local Anesthesia By Stanley Malamed – 6th Edition • Gray’s Anatomy-40th Edition 51
  • 52. Etiology of Trigeminal Neuralgia PERIPHERAL: -Dental etiology -Infections- Herpes zoster -Multiple sclerosis -Injuries to nerve -Nerve compression CENTRAL: -Post-traumatic neuralgia -Intracranial tumors -Intracranial vascular abnormalities (aneurisms) -Segmental demyelination 1/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition 52
  • 53. Clinical Appearance- *Typical appearance of patient: *Unshaved face *Poor oral hygiene *Frozen or mask like face *H/O multiple dental extractions *Triggered by a non painful stimulus 1/13/2019 • BD Chaurasia’s Human Anatomy(Vol. 3)-5th Edition • Gray’s Anatomy-40th Edition 53 Diagnosis *Trigger point *Paroxysmal pain *Self limiting *Refractory period *Multiple extractions *Response to carbamazepine
  • 54. 1/13/2019 54 Differential diagnosis • Migrane • Sinusitis • Odontogenic pain • Orofacial pain • Tempromandibular joint disorders • Post herpetic neuralgia • Multiple sclerosis • Glossopharyngeal neuralgia
  • 55. 1/13/2019 Essentials of Medical Pharmacology-K D Tripathi -6th Edition Textbook Of Oral Medicine- Anil Ghom’s 55 Medicinal Management Drugs given in combination of carbamazepine Are: • Sodium valproate 600mg/day. • Phenytoin 100mg/day. • Gabapentin 200mg/day • Lamotrigine 200mg/day Tab Clonazepam 1.5 mg/day Side effects: drowsiness, fatigue, lethargy. Tab Phenytoin: 100 mg thrice daily. Side effects: slurred speech, abnormal movements ,gingival hypertrophy, folate deficiency.
  • 56. 1/13/2019 56 Peripheral management: 1.Non-destructive: -Peripheral long acting anesthetic injections -Nerve decompression 2.Destructive: -Peripheral Alcohol / Glycerol injections -Peripheral neurectomy
  • 57. 1/13/2019 57 Surgical Management • Internal decompression: - Nerve exposed in fallopian canal and pressure is relieved. - Epineural sheath is opened to visualize the nerve fibers and release adhesions or re-establish continuity. • External decompression by releasing of epineural sheath from surrounding scar tissue, bone or foreign body.
  • 58. 1/13/2019 58 Instructions • Not to drive vehicles • Not to swim • Critical jobs like railway driver, signalman, pilots, working near furnaces, boilers, towers etc be avoided • Periodic CBC to rule out hematopoeitic depression
  • 59. • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition • A.K. Datta Essentials Of Human Anatomy Head And Neck. 4th Edition • Frank H. Netter Atlas Of Human Anatomy-7th Edition • Inderbir Singh – Human Embryology – 10th Edition • Handbook of Local Anesthesia By Stanley Malamed – 6th Edition • Essentials of Medical Pharmacology-K D Tripathi -6th Edition • Textbook Of Oral Medicine- Anil Ghom’s References 1/13/2019 59
  • 62. Content  Abducent Nerve  Facial Nerve  Vestibulocochlear Nerve  Glossopharyngeal Nerve  Vagus Nerve  Accessory Nerve  Hypoglossal Nerve  Terminal Nerve 1/13/2019 62
  • 63. 6.Abducent Nerve -Entirely Motor -Supplies Lateral Rectus Muscle of eyeball -Nucleus: Situated in pons -Functional Components: SE 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 63
  • 64. Course of Abducent Nerve Emerges from pons(groove between pons &medulla oblongata) Passes through Cavernous sinus Lies below Internal Carotid Artery Enters Orbit through Superior Orbital Fissure 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 64
  • 65. Applied Anatomy Of Abducent Nerve 1.Lesions- damage due to head injuries, cavernous sinus thrombosis, aneurysm of internal carotid artery 2.Internal Strabismus-Patient Cannot Turn Eye Laterally 3.Paralysis-due to increased intracranial pressure 4.Diplopia-due to paralysis of lateral rectus muscle 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 65
  • 66. 7.Facial Nerve • Also Known as “Nerve Of Facial Expression:” • It is mixed nerve • Sensory function-taste from anterior 2/3rd of tongue • Motor Function-Supplies facial muscles, scalp muscles of neck • Functional Components: GVE,SVE,SVA & GSA • Foramen: Internal Acaustic Meatus & Stylomastoid Foramen(Facial Canals) 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 66
  • 67. 1/13/2019 67 FUNCTIONAL COMPONENT NUCLEI DISTRIBUTION FUNCTION GVE Superior salivatory nucleus (lies in the pons lateral to the main motor nucleus of VII ) Submandibular and sublingual salivary glands. Secretomotor SVE Motor nucleus of facial nerve (lies in lower part of pons) Muscles of facial expression, stylohyoid, posterior belly of digastric, platysma and stapedius. Facial expression SVA Nucleus of tractus solitarius (lies in medullla) Taste buds in the anterior 2/3rd of tongue except vallate papillae Taste sensations GSA Spinal nucleus of Vth nerve Part of skin of external ear Exteroceptive sensation
  • 68. Functions Of Facial Nerve • Carries taste sensations from the anterior two thirds of the tongue and oral cavity • Controls the muscles of facial expression • It also supplies preganglionic parasympathetic fibres to several head and neck ganglia 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 68
  • 69.  Embryology  The facial nerve is developmentally derived from the hyoid arch, which is the second branchial arch  The motor division of facial nerve is derived from the basal plate of the embryonic pons  The sensory division originates from the cranial neural crest 1/13/2019 A.K. Datta Essentials Of Human Anatomy Head And Neck. 4th Edition I B SINGH Textbook of Embrology 11th edition 69
  • 70. • Facial nerve course, branching pattern, and anatomical relationships are established during the first 3 months of prenatal life • 3rd wk : facioacoustic (acousticofacial) primordium • Early 5th week, the geniculate ganglion forms from distal part of primordium 1/13/2019 I B SINGH Textbook of Embrology 11th edition 70
  • 71. It separates into 2 branches: main trunk of facial nerve and chorda tympani Proximal branches formed in the 6th week, posterior auricular branch, branch of digastric and stylohyoid Late 8th week, 5 major peripheral subdivisions present 1/13/2019 I B SINGH Textbook of Embrology 11th edition 71
  • 72. GANGLIA ASSOCIATED WITH THE FACIAL NERVE 1/13/2019 Netters : Colour Atlas of Anatomy 72
  • 73. 1. GENICULATE GANGLION -Derived from Latin GENU = “KNEE” -L-shaped collection of fibers and sensory neurons of the facial nerve located in the facial canal of the head. -Receives fibers from the motor, sensory, and parasympathetic components of the facial nerve 1/13/2019 I B SINGH Textbook of Embrology 11th edition 73
  • 74. Innervates i. Lacrimal glands ii. Submandibular glands iii. Sublingual glands iv. Tongue v. Palate vi. Pharynx vii. External auditory meatus viii. Stapedius ix. Posterior belly of the digastric muscle x. Stylohyoid muscle xi. Muscles of facial expression 1/13/2019 74 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition
  • 75. 2.SUBMANDIBULAR GANGLION - Small and fusiform in shape. -Situated above the deep portion of the submandibular gland -The ganglion 'hangs' by two nerve filaments one anterior and one posterior. -Receives a branch from the chorda tympani nerve which runs in the sheath of the lingual nerve -Innervates submandibular and sublingual salivary glands 1/13/2019 Vishram Sinagh Textbook of Head and Neck Anatomy 3rd edition 75
  • 76. 3.PTERYGOPALATINE GANGLION (meckel's ganglion, nasal ganglion or sphenopalatine ganglion) -Ganglion found in the pterygopalatine fossa -It's largely innervated by the greater petrosal nerve (a branch of the facial nerve); and its axons project to the lacrimal glands and nasal mucosa 1/13/2019 Vishram Sinagh Textbook of Head and Neck Anatomy 3rd edition 76
  • 77. Branches of facial nerve 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 77 Intracranial Greater petrosal nerve Nerve to stapaedius Chorda tympani Extracranial Posterior Auricular Nerve Digastric nerve Stylohyoid nerve Terminal Branches Temporal branch Zygomatic branch Buccal branch Marginal mandibular branch Cervical branch
  • 78. 1/13/2019 Netters : Colour Atlas of Anatomy 78
  • 79. Various facial Expressions 1/13/2019 79Depressor Anguli Oris Buccinator +Orbicularis oris muscle Levator anguli oris + risorius Levator Anguli Oris platysmaMentalisOrbicularis Zygomaticus major & minor OccipitoFrontali s Levator labii superioris alaeque nasi Risorius Orticularis OrisNasalis + procerus Nasalis
  • 80. Applied Anatomy of Facial Nerve • DISORDERS OF FACIAL NERVE Facial nerve lesions: 1. Supra-nuclear type 2. Nuclear type 3. Peripheral lesions (infranuclear) -Injury at internal acoustic meatus -Injury distal to geniculate ganglion -Injury at stylomastoid foramen1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 80
  • 82. 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 82 SUPRA NUCLEAR TYPE: Features: -Paralysis of lower part of face (opposite side) -Normal taste and saliva secretion -Stapedius not paralyzed NUCLEAR TYPE Features: -Paralysis of facial muscle (same side) -Paralysis of lateral rectus -Internal strabismus (inward deviation)
  • 83. PERIPHERAL LESION (At internal acoustic meatus) Features -Paralysis of secretomotor fibers -Hyper acusis -Loss of corneal reflex -Taste fibers unaffected -Facial expression and movements paralyzed 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 83
  • 84. Injury at stylomastoid foramen Condition known as Bell’s Palsy Weakness of muscles to perform its functions is called ‘Paresis’ Total flaccidity of facial muscles to perform motor functions is called ‘Facial Paralysis’ 1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 84
  • 85. Causes 1. Central/Supranuclear causes (Facial muscle paralysis with forehead spared) -Cerebral mass lesion (e.g. tumor) -Cerebrovascular Accident (typically with ipsilateral Hemiparesis or Hemiplegia) -Multiple Sclerosis 1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 85 2.Traumatic causes -Cortical injury -Temporal Bone Fracture -Brain Stem injury -Penetrating middle ear injury -Scuba Diving
  • 86. 1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 86 4.Endocrine causes -Diabetes Mellitus -Pregnancy -Hypertension -Alcohol Abuse (Alcoholic - Neuropathy) 3.Infectious Causes -Malignant Otitis Externa (skull base Osteomyelitis) -Mastoiditis Varicella Zoster Virus (Chicken Pox) -Herpes Zoster Oticus (Ramsey-Hunt Syndrome) - Herpetic Vesicles at auricle and external canal -HIV Infection -Influenza -Parotitis -Meningitis -Encephalitis -Mums 5.Birth Causes -Facial Nerve Injury from Birth Trauma (forceps delivery) -Congenital Facial Palsy
  • 87. 1/13/2019 Grays Anatomy : Textbook of Anatomy 39th Edition 87 6. Tumors -Facial Nerve neuroma -Cholesteatoma -Glomus jugular tumor -Primary Temporal Bone tumors -Meningiomas -Hemangioblastoma -Pontine glioma -Parotid tumor 7.Idiopathic Causes: -Myasthenia Gravis -Guillain-Barre Syndrome -Sarcoidosis -Familial Bell's Palsy 8.Iatrogenic Causes -Mandibular block anesthesia -Head and neck surgery -Parotid surgery
  • 88. Testing Of Facial Nerve • Ask the patient to close his eyes firmly. • Ask the patient to smile. • Ask patient to fill the mouth with air. Press the cheek with your finger and compare the resistance on two sides 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 88
  • 89. 1/13/2019 Netters : Colour Atlas of Anatomy 89
  • 90. Bell’s Palsy -First described more than a century ago by Sir Charles Bell -Bell palsy is certainly the most common cause of facial paralysis worldwide -It is caused due to inflammation of facial nerve near stylo-mastoid foramen or compression of its fibers near facial canal. 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 90
  • 91. Etiology -Main cause of Bell's palsy is latent herpes viruses (herpes simplex virus type 1 and herpes zoster virus), which are reactivated from cranial nerve ganglia -Polymerase chain reaction techniques have isolated herpes virus DNA from the facial nerve during acute palsy -Cold hypothesis -Rheumatic -Immunologic -Ischemic hypothesis 1/13/2019 Benjamin Stew and Huw Williams. Williams British Journal of General Practice 2013; 63:109–110. 91
  • 92.  Clinical Features 1.Unilateral involvement 2.Inability to smile 3.Inability close eye or raise eyebrow 4.Whistling impossible 5.Inability to close eyelid (Bell’s sign) 6.Inability to wrinkle forehead 7.Slurred speech 8.Mask like appearance of face 9.Dribbling of saliva 10.Epiphora 1/13/2019 Benjamin Stew and Huw Williams British Journal of General Practice 2013; 63: 109–110. 92
  • 93. 1/13/2019 Netters : Colour Atlas of Anatomy 93
  • 94. Management • Physiotherapy -Facial massage -NeuroMuscular Retraining • Ocular protection is essential to protecting vision in both the short term and long term in patients with facial paralysis. • Eye drops-hypromellose drops • Artificial tears are combined with ointment at night (Mavrikakis, 2008) 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 94
  • 95. 8. Vestibulocochlear Nerve • Also called as Auditory Nerve • It is a sensory Nerve • Consists of Two Roots - • 1.Vestibular -Transmits impulses from vestibular apparatus (balance) • 2.Cochlear-Transmits impulses from auditory apparatus (sound) • Functional Components- SSA 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 95
  • 96. Functions Auditory Nerve transmits sound and equilibrium (balance) information from Internal Ear To Brain 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 96
  • 97. Applied Anatomy Deafness 1. Conductive-Failure of sound waves to reach cochlea 2. Sensorineural-Failure of production or transmission (cochlear disease) 3. Cortical Deafness-Bilateral posterior temporal lobe lesion 4. Vertigo-Illusion of rotary Movement due to disturbed orientation of body in space 5. Tinnitis-Sensation of burring,ringing,hissing/singing quality 6. Acoustic Neuroma-Slow growing Benign Tumour1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 97
  • 98. 9. Glossopharyngeal Nerve • Originates from Medulla Oblongata • Nuclei-Inferior salivatory nucleus,Nucleus ambiguus,Nucleus Solitory Tract • Functional components- GVE,SVA,GVA • Foramen-Jugular Foramina 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 98
  • 99. 1/13/2019 • Textbook of Human Anatomy-B D Chaurasia(Vol.3)5ttEdition • Gray’s Anatomy-40th Edition 99
  • 100. Functions • Sensory Function- Taste sensation from posterior 1/3rd of tongue, pharynx • Motor Function-Muscles of speech & swallowing, parotid salivary gland • Somatic Motor Function-Muscles of pharynx, tongue • Autonomic Motor Function-Saliva Production 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 100
  • 101.  Branches of Glossopharyngeal Nerve 1.Tympanic Nerve (S) 2.Branch to Carotid sinus (S) 3.Branch to Stylopharyngeus Muscle (M) 4.Tonsillar Branches (S) 5.Lingual Branches (S) 6.Pharyngeal Branches (M) 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 101
  • 102. Applied Anatomy 1. Lesion to the nerve cause decreased secretion of parotid gland 2. Absence of taste from post. 1/3rd of tongue 3. No gag Reflex 4. Loss of sensation from tongue, pharynx, tonsils, soft palate 5. Glossopharyngeal Neuralgia 6. Jugular Foramen Syndrome-Multiple Cranial Palsies 7. Pharyngitis- Refered pain in ear 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 102
  • 103. Glossopharyngeal Neuralgia • Glossopharyngeal neuralgia is an irritation of the ninth cranial nerve causing extreme pain in the back of the throat, tongue and ear. • Attacks of intense, electric shock-like pain can occur without warning or can be triggered by swallowing. • Symptoms include pain in Nasopharynx, or back of the nose and throat, Back of the tongue, Ear, Tonsil area, Larynx or voice box. 1/13/2019 B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 103
  • 104. Treatment For Glossopharyngeal Neuralgia 1. Pain control 2. Antiseizure drugs like Carbamazepine 3. Antidepresssant Drugs 4. Surgical Management 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 104
  • 105. 10. Vagus Nerve • Also known as ”Wandering Nerve” • Originates from medulla oblongata • Foramen- Jugular Foramina • Nuclei-nucleus ambigus ,nucleus solitary(superior part & inferior part) • Sensory Function-supplies skin of back of ear, external acaustic meatus, part of tympanic membrane, larynx, trachea, oesophagus, thoracic & abdominal viscera, epiglottis, root of tongue. 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 105
  • 106. • Motor Function-supplies throat, Heart, Lungs, abdominal Viscera, soft palate • Associated with Derivatives of fourth pharyngeal arch • 8-10 rootlets are present • Functional Components- SVA,SVE,GSE,GVE,SSA,GSA • Types of Fibers- 1.Brachial Motor 2.Visceral Motor 3.Visceral Sensory 4.Special Sensory 5.General Sensory 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 106
  • 107. Vagus Nerve Carotid Sheath Travels inferiorly with internal jugular vein & Common Carotid artery At the base of neck divides into Right & Left 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 107 Right nerve passes anterior to subclavian artery & posterior to sternoclavicular joint entering Thorax Left nerve passes inferiorly between the left common carotid & left subclavian artery, posterior to sternoclavicular artery entering Thorax
  • 108.  Applied Anatomy Of Vagus Nerve 1. Lesion -Difficulty in swallowing, speech(affects pharyngeal & superior laryngeal branches) 2. Recurrent Laryngeal Nerve Palsies-common due to malignant disease & due to damage during surgical operations 3. Vagus Nerve Palsy- Uvula Pulled Towards Normal Side 4. Aphonia- Paralysis of both vocal cords 5. Viral infection(Sensory Ganglion)-Herpes Zoaster 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 108
  • 109. 11. Accessory Nerve • Foramen- Jugular Foramena • General Destination-soft palate, throat, muscles of neck • Nucleus- Hypoglossal Nucleus • Somatic Motor Function- Swallowing & Head Movement (trapezius & sternocleidomastoid) • Functional Components- SVE,GSE 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 109
  • 110. Course Medulla Oblongata Hypoglossal Canal Behind Vagus Nerve Between IJV & ICA Posterior Belly of Digatric Tongue(Extrinsic & Intrinsic Muscles 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 110
  • 111. It Supplies • Extrinsic Muscles-Genioglossus, Hyoglossus, Styloglossus • Intrinsic Muscles- Superior Longitudinal, Inferior Longitudinal, Verticals, Tranversus 1/13/2019 4tB D CHAURASIA’S Human Anatomy. Volume 3 Edition h 111
  • 112. 1/13/2019 Netters : Colour Atlas of Anatomy 112
  • 113. Applied Anatomy of Spinal Accessory Nerve • Torticollis/wry neck • Lesion-Drooping of shoulder & Inability to turn chin to opp. Side • Unilateral motor neuron weakness 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 113
  • 114. 12. Hypoglossal Nerve • It is a Motor nerve • Functional Components- GSE • Supplies intrinsic & Extrinsic Muscles of tongue • Foramen- Hypoglossal Canal • Somatic Motor Function- Speech & swallowing via muscles of tongue 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 114
  • 115. 1/13/2019 115 2. Extracranial segment Nasopharyngeal Carotid space Sublingual Segment a.Medullary Segment b. Cisternal Segment c. Canalicular Segment Hypoglossal Nucleus 1. Intracranial Segment
  • 116. 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 116
  • 117.  Applied Anatomy of Hypoglossal Nerve • Supranuclear Lesion-Parlysis eithout wasting-tongue moves sluggishly • Defective speech • Tongue Deviates on Protrusion- Unilateral Lingual Paralysis • Injury to the nerve causes dysarthria & dysphagia 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition 117
  • 118. Causes -The causes may be central or peripheral & include cerebrovascular accidents, brain stem tumours & infections Speech Characteristics- abnormality of tongue leads to misarticulation -Problem while saying (T, D, L, I, J, N, K, G) 1/13/2019 118
  • 119. Managent • Speech therapy should be given • Exercise for treatment of dysarthria may improve tongue co-ordination & strength • Surgical management for hypoglossal nerve injuries 1/13/2019 • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th 119
  • 120. 13. Terminal Nerve • Also known as “Zero Nerve” • Initially referred as nerve of Pinkus. • First discovered in 1870 in sharks and other types of fish • Termed as Terminal –it was observed to extend into the region of lamina terminalis • Published 1987 as X||| Cranial nerve as Zero nerve –it is more rostral than other cranial Nerves 1/13/2019 120
  • 121. 1/13/2019 121 • References • Grays Anatomy : Textbook of Anatomy 39th Edition • B D CHAURASIA’S Human Anatomy. Volume 3 Edition 4th • Vishram Singh Textbook of Head and Neck Anatomy 3rd edition • Netters : Colour Atlas of Anatomy • I B SINGH Textbook of Embrology 11th edition • Fujiwara T et al. High-dose corticosteroids improve the prognosis of Bell’s palsy compared with low-dose corticosteroids: A propensity score analysis. Auris Nasus Larynx (2017) • Alptekin D O. Acupuncture and Kinesio Taping for the acute management of Bell’s palsy: A case report Complementary Therapies in Medicine 35 (2017) 1–5.