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Anesthesiology Final Exam

Applied Anatomy: Trigeminal
Things of the skull that will be problematic: Anytime you try to get into the pterygopalatine you have the zygoma blocking your way The mandible is a weird shape and has many knooks and crannies 29 BONES OF THE HEAD Cranial 8 Facial 14 Hyoid 1 (only nonarticulated bone of the body) Auditory 6 (stapes, incus, ossicles malleus) Cranial Bones Bony vault of cranium = calvaria Carnium divided into 2 portions: 1. Anterior visceral ie. the facial cranium, made up of derivatives of the upper end of primitive gut and its associated branchial structures. Consists of 14 bones. 2. The posterior somatic, i.e. the neurocrainium and consists of 8 bones a. Portion of the skull that protects the brain Neurocranium Forms from 3 midline endochondrial bones: ethmoid, sphenoid, and occipital; and 3 pairs of lateral dermal bones (intramembranous) frontal, temporal, and parietal If we perform grafting to the face the difference between these two types is important. Typically we use intramembranous bone to augment the face. A source of bone to graft to the face could be procured from the temporal bone as well as the parietal bone. Greater Wing of Sphenoid and Associated Foramina *Most important bone related to the Trigeminal Nerve Reason why: it contains 4 openings (foramina), and these openings transmit branches of the trigeminal nerve There is a right and left trigeminal nerve. CN 5 starts in the pons in the medulla oblongata, the trigeminal nerve is a mixed nerve (meaning it has both sensory and motor functions). We refer to the trigeminal nerve as a tripartite nerve, that means that it has three branches. Branches of the Trigeminal Nerve and the Openings that go through the Sphenoid Bone Opthalmic Branch (1st Branch) exits the skull via the Superior Orbital Fissure Maxillary Branch (2nd Branch) exits the skull via the Foramen Rotundum (Round) Mandibular Branch (3rd Branch) exits the skull via the Foramen Ovale (Oval) The first and second branches are purely sensory and the third branch is both sensory and motor. The motor branch starts in the middle cranial fossa and joins the sensory branch once it exits the foramen ovale. Topographically when you look at the internal aspect of the skull you can see there are two wings associated with the sphenoid bone: they are the greater and lesser wings. The fourth opening associated with the sphenoid bone is the Foramen Spinosum.

2 Foramina and Associated Structures A. Cavernous Sinus a. Internal carotid artery b. CN III c. CN IV d. CN V1 and V2 e. CN VI i. Board Question: Patients who may have cavernous sinus thrombosis (an infection) will have anesthesia of the forehead via CN V1 and will also demonstrate ocular palsy (the eyeball will not move). B. Superior Orbital Fissure a. CN III b. CN IV c. CN VI d. CN V1 e. Frontal Nerve f. Lacrimal Nerve g. Nasocilliary Nerve h. Superior Opthalmic Vein i. Superior Orbital Fissure Syndrome (infection) with symptoms: palsys of the ocular muscles (CN III, IV, VI), as well as CN V1 (so you will see anesthesia again of the forehead) C. Inferior Orbital Fissure on the floor of the orbit a. Zygomatic Nerves i. Two branches: Zygomaticotemporal and Zygomaticofacial b. Sphenopalatine Branches c. Inferior Opthalmic Vein i. Patients who sustain trauma to the orbit can affect two nerve: Infraorbital Nerve (runs on the floor of the orbit) and if that happens the patients maxillary front teeth are numb ii. With injury to the Zygomatic Nerves the patient will have a numb cheek bone D. Optic Canal a. Optic Nerve b. Opthalmic Artery c. Central Retinal Artery E. Carotid Canal Dont care if you know F. *Jugular Foramen - Board Question a. CN IX b. CN X c. CN XI G. Foramen Lacerum Dont care if you know a. Cartilage b. Vidian Nerve c. Meningeal Branch fo the Ascneding Pharyngeal Artery d. Emissay Vein H. *Foramen Ovale in the Great Wing of the Sphenoid a. CN V3 b. Small Meningeal Artery c. Small Petrosal Nerve d. Emissary Vein I. S MR. MO = Maxillary is Rotundum, Mandibular is Ovale J. Foramen Rotudnum a. CN V2

3 K. Foramen Spinosum important because it transmits an artery a. Middle Meningeal Artery i. A branch of the carotid arterial system so its an avenue by which infections from the face can gain access to the meninges ii. Board Question - What nerve supplies sensation to the Dura Mater? Middle Meningeal Nerve b. Lymphatics The three branches of the trigeminal nerve arise from the ganglion. The ganglion has three names: Trigeminal Ganglion is also called the Semilunar Ganglion and the Gausserian Ganglion. It is located in Meckels Cave (that is a board question). Cranial Nerves I = Olfactory Nerve sensation of smell, purely sensory II = Optic Nerve sensation of sight, purely sensory III = Oculomotor Nerve purely motor All other eye muscles are by CN III IV = Trochlear Nerve purely motor SO4 Superior Oblique is by CN IV V = Trigeminal Nerve mixed nerve, largest CN VI = Abducens Nerve purely motor LR6 Lateral Rectus is by CN VI VII = Facial Nerve purely motor, special efferent (chorda tympani) VIII = Vestibulocochlear Nerve sensation of hearing, purely sensory IX = Glossopharyngeal Nerve participates in swallowing mechanism, mixed nerve X = Vagus Nerve the longest CN, mixed nerve XI = Accessory Nerve responsible for shoulder shrugging, purely motor XII = Hypoglossal Nerve responsible for tongue movement, purely motor Topography The maxilla is almost completely cancellous bone with a cortical plate on either side so infiltration works best of the maxilla due to the thin cortical plate. On the mandible cortical bone is much thicker so consequently infiltration techniques dont work as well. Maxilla: When you look at the maxilla one can see any time you perform anesthesia around the canine and first premolar you will have nasal consequences (the nose will get numb). Trying to provide access to the posterior maxilla the cheek bone apparatus can deflect the needle. The posterior maxilla is kindof a lazy S. There are two vascular structures that are on the posterior aspect of the maxilla. They are: the pterygoid plexus (a venous structure) and much higher up is the internal maxillary artery. The internal maxillary artery is also close to the neck of the mandible. One of the reasons some individuals use short needles to inject the maxillary arch is to prevent nicking the pterygoid plexus. *You need to know that if you stick a needle in something, you always aspirate before you inject the local. If you get a positive aspiration the appropriate maneuver is to withdraw the needle, change the carpule, and then reinsert the needle. Inferior Surface of the Skull You can see when we look at the inferior surface of the skull there is one nerve of the trigeminal system that crosses the midline: that is the Nasopalatine Nerve. Another way one might see that described is the Nerve of the Premaxilla (another name).

4 Palate There are two nerves associated with the palate. The primary nerve is the Greater Palatine Nerve. It typically is associated with the hard palate. The second foramen associated with the palate and posterior to the Greater Palatine is the Lesser Palatine Nerve, which is the nerve of the soft palate. Maxillary Pulpal Sensation There is a nerve associated with the second division that is responsible for pulpal sensation to the premolars and the anterior incisors. The primary nerve of course is the terminal branch of the second division of the Trigeminal Nerve. The terminal branch of the second division is referred to as the Infraorbital Nerve. The branches from the Infraorbital Nerve to the anterior incisors is the Anterior Superior Alveolar Nerve, we will call it the ASA (It goes to the Central, Lateral, and Canine). The second dental branches off the Infraorbital Nerve go to both of the premolars and the mesiobuccal root of the first molar, the name of this branch is the Middle Superior Alveolar Nerve, we call it the MSA. The dental branch that supplies the first molar, second molar, and third molar comes off the second division in the Pterygopalatine Fossa, we refer to that nerve as the Posterior Superior Alveolar Nerve, or the PSA. It is kindof funny, it is one of the few nerves that goes through the posterior maxilla through two small holes (foramena). Maxillary Sinus Sensation Sensation to the maxillary sinus is provided by the second division of the Trigeminal Nerve. So a consequence of Maxillary Sinusitis is posterior tooth pain or molar pain. This is the anatomical basis. *If you want to get up into the Pterygopalatine Fossa you can go up the Greater Palatine Foramen with a needle. A way of method that you can anesthetize with one shot the second division of the Trigeminal Nerve is via the Greater Palatine Foramen. Mandible The rami of the mandible flare laterally. The nerve associated with the lower arch is the Mandibular Nerve. The Mandibular Nerve provides sensation to the teeth, the mucosa, and the tongue, but it also supplies motor innervations to eight muscles. Those muscles are the muscles of mastication: Medial and Lateral Pterygoid, Masseter, and Temporalis. The other four muscles are: Mylohyoid, Anterior Belly of the Digastric (Posterior Belly is by CN VII), Tensor Tympani, and Tensor Velli Palatini (typically asked on Boards). There is a little piece of bone that guards the mandibular foramen. That little piece of bone is located on the medial aspect of the ramus, we refer to it as the Lingula. It is important because it serves as an attachment for the sphenomandibular ligament (Board Question). Trigeminal Nerve Most important nerve of the middle cranial fossa (starts there) Largest of all cranial nerves Roots: (2) Sensory portio major (bigger), Motor portio minor (smaller) o The roots arise from the lateral pontine region (pons and the medulla oblongata). There are three divisions associated with the trigeminal nerve o Smallest = Ophthalmic division o Largest = Mandibular division Is the great afferent nerve of the face, of the mucous membranes of the head (meninges, paranasal sinuses, and conjunctiva of the eye), of internal cranial structures, afferent nerve of the teeth and TMJs, and the efferent (motor) nerve of the first branchial arch.

5 Mixed: so it has efferent innervations to 8 muscles 4 muscles of mastication: medial pterygoid, lateral pterygoid, masseter, and temporalis Other muscles: mylohyoid, anterior belly of the digastric, tensor veli palatini, tensor tympani o Board Question: The primary sensory innervations to the temporomandibular joint is the Auriculotemporal Nerve. The sensory root bears the large trigeminal (or semilunar or Gasserian) ganglion and is like the dorsal root ganglion of a spinal nerve. The 3 great branches (V1, V2, V3) arise from the ganglion. It should be noted that there is 1 ganglion for each side of the face (a right and left ganglion), and this ganglion is located in the Trigeminal or Meckels Cave (fold of dura mater). o There are no nerve synapses within the ganglion o Board Question: If a patient has Trigeminal Neuralgia, where would you section the nerve? In Meckels Cave. It is a fold of dura mater that gives us the location of the ganglion Also called the Trigeminal Cave o Like a spinal (dorsal root) ganglion, ie. it consist of a collection of pseudo-unipolar cells, each of which has an axon passing into the brainstem and a dendrite extending peripherally to a sensory nerve ending. Synapses do not occur within the ganglion, and uniquely, cell bodies derived from neural crest cells. o Board Question: The cell bodies of the trigeminal nerve embryologically arises from the neural crest cells o

Intracranial Aspects of the Trigeminal Nerve 4 Nuclei (ON EXAM) o Main Sensory Nucleus located in pontine tegmentum, se\nsation of touch o Spinal V Tract and Nucleus has 3 parts: Pars oralis, Pars interpolaris, Pars caudalis Fibers concerned with pain and thermal sensitivity Nerve subtypes associated with pain are A delta and C fibers o Motor Nucleus branchiomotor component (efferent component) o Mesencephalic Nucleus responsible for proprioception/jaw position and movement Cranial Nerve V Responsibilities Motor: muscles of mastication (masseter, temporalis, medial and lateral pterygoid) Also to the mylohyoid, anterior belly of the digastric, tensors tympani and veli palatini Sensory: to entire face o V1: scalp anterior to the ears, mucous membranes of the cranial viscera, nose and sinuses, cornea and conjunctiva Board Question: Paralysis of the first division will produce: insensate conjunctiva or obliteration of the corneal reflex (blink reflex) o V2: sensory to the gingiva/teeth of maxilla, upper lip and orbit o V3: sensory to tongue, gingiva/teeth of mandible, skin of cheek, lower jaw and lip The 3 divisions embryologically supply: (ON NBDE) o Ophthalmic branch = frontonasal process o Maxillary branch = maxillary process o Mandibular branch = 1st brachial (pharyngeal) arch

6 Brachial Arch Nerve Associations (NBDE) Arch 1 CN 5 Arch 2 CN 7 Arch 3 CN 9 Arch 4 CN 10/11 superior laryngeal Arch 6 CN 10/11 recurrent laryngeal o There is a fold of dura mater that gives us the location of the ganglion Board Questions: Mylohyoid nerve provides accessory innervations to the mandibular incisors and the mesial root of the mandibular first molar. The long buccal nerve innervates the buccinators NO, that is done by CN 7, it innervates the masseter, medial pterygoid, and another nerve. The lingula is important because it is an attachment for the The parotid gland receives secretomotor innervations via the auriculotemporal nerve and the branches come out of the otic ganglion. Why do patients point at their ear when they have TMJ pain and disfunction? The auriculotemporal also supplies sensory sensation to the TMJ, the external auditory meatus, and the tympanic membrane. Table V-1 Components of the Trigeminal Nerve o Branchial motor: o Genergay Sensory (GSA): face and scalp as far as the top of the head, conjunctiva, bulb of the eye, mucous membranes of the paranasal sinuses, and nasal an oral cavities including tongue and teeth, part of the exteranl aspect of the tympanic membrane and the meninges of the anterior and middle cranial fossa So it mediate the headache associated with meningitis Great Branches of CN 5 V1 Ophthalmic Division: exlusively sensory and smallest of the 3 branches. o The main branches number 3: Frontal (supraorbital and supratrochlear) Nasocilliiary (ciliargy ganglion with the long and short ciliary nerves, anterior and posterior ethmoidal nerve, infratrochlear) Lacrimal o Exits the cranium via the supraorbital fissure (superior orbital fissure) o If paralyzed will have a problem with an insensate conjunctiva and the corneal reflex will be affected V2 Maxillary Division: exclusively sensory o Exits the skull via the foramen rotundum in the greater wing of the sphenoid o Enters the orbit gvia the inferior orbital fissure and within orbit lies in the infraorbital groove to exit the orbit via the infraorbital foramen o Branches in 4 regions: Within the cranium (middle meningeal nerve to the dura) In pterygopalatine fossa (maxillary nerve with the pterygopalatine ganglion (parasympathetic ganglion)) o While in the pterygopalatine fossa, 3 branches are given off Pterygopalatine nerve PSA Supplies the third molar, second molar, and first molar except for the mesial buccal root of the first molar

7 Zygomatic Sensation to the skin of the cheek o Zygomaticotemporal and Zygomaticofacial Branches to the nose pass through the sphenopalatine foramen just behind the middle nasal concha and divides into the medial and lateral posterior superior branches. The nasopalatine nerve is a branch of the medial posterior superior nasal branch and rusn through the incisive canal to end in the incisive (or nasopalatine) formane, covered by the incisive papilla. The nasopalatine nerve is the only nerve to cross the midline, and goes to the premaxilla Greater palatine goes to the hard palate up to and around the first premolar Lesser palatine goes to the soft palate They participate in sensation to the lateral pharyngeal wall o Branches to the palate: greater and lesser palatine nerves The greater palatine nerve is responsible for sensory innervations to palateal soft tissues up to the area of the first premolar where it anastamoses with branches of the nasopalatine nerve The lesser palatine nerve supplies the mucous membrane of the soft palate Question: we want to extract the maxillary first molar, what do we need to anesthetize? The PSA, MSA, and Greater Palatine o 3rd area of branching for the maxillary nerve is in the infraorbital canal 2 main branches include the MSA (to the mesial buccal root of the first molar and both premolars) and the ASA (to the canines, lateral, and central incisors) o Finally, V2 branches onto the face (through the foramen) and are terminal branches of the infraorbital nerve and include the superior labial, inferior palpebral (to the lower eyelid), and the external/lateral nasal. In the cranial cavity Meningeal In the pterygopalatine fossa Ganglionic, Zygomatic, Posterior Superior Alveolar In the infraorbital canal Middle Superior Alveolar, Anterior Superior Alveolar On the face Palpebral, Nasal, Superior Labial o Sensory Innervation to the Palate CN 5, 7, and 9 5 = Greater palatine, lesser palatine, and nasopalatine 7 = greater petrosal 9 = tympanic (or tonsillar) plexus and lesser petrosal V3 Mandibular Division: mixed nerve o Largest branch o f the trigeminal nerve o The 2 root emerge separately out of the foramen ovale then unite, but ultimately splint into an anterior and posterior division o Prior to the split into the anterior and posterior division however the otic ganglion is attached o *Long buccal to masseter******************* o Posterior division includes the following branches: auriculotemporal, inferior alveolar, and its terminal branches (metnal and incisive nerve), lingual and mylohyoid o The mandibular foramen is located 1.5-2 cm below the mandibular notch or 1-19 mm above the occlusal plane (in 99% of the population) Anterior portion of the notch = coronoid process

8 Posterior portion = condyle You can use this as a site to form the inferior alveolar block If you take your needle and inject 20 mm above the occlusal plane 99% of the time you will have profound anesthesia, the reason for not having this is you shot too low

Maxillary Artery Passes horizontally between the ramus of the mandible and the sphenomanidbular ligament and is embedded in the pterygoid plexus of veins Usually described as having 3 parts: o 1st: deep auricular, anterior tympanic, middle meningeal, and inferior alveolar In advertently get anesthetic in the inferior alveolar you can see it go into the middle meningeal and go out into the brain o 2nd: massentetic, deep temporal, branches to the pterygoids o 3rd: PSA, infraorbital, descending palatine and sphenopalatine (most common source of bleeding from maxillary artery) Nose bleed = epistaxis, most common cause is the sphenopalatine artery S