Trigeminal neuropathy

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The trigeminal nerve got its name due to the presence of 3 branches: the ophthalmic, maxillary and mandibular. And if the first two contain only sensory fibers, then the third, in addition to sensitivity, also provides movement of the masticatory muscles. Inflammation of the trigeminal nerve (neuralgia, trigeminal neuralgia) is a fairly common disease that most often affects women over 50, mainly affecting the branches of the trigeminal nerve on the right side of the face.

Inflammation of the trigeminal nerve: types

Trigeminal neuralgia is of two types: true or secondary. True neuralgia is a disease that occurs due to compression of a nerve or if its blood circulation is impaired. Secondary neuralgia is usually a symptom of some underlying disease.

Most often, neuralgia occurs in one of the three branches of the facial nerve on one side of the face, but there are cases when two or three branches of the nerve become inflamed at the same time. Inflammatory processes are possible on both sides of the face.

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Maxillary nerve (human anatomy)

Maxillary nerve

, n. maxillaris, the second branch of the trigeminal nerve, it is mainly sensory. Has a thickness of 2.5-4.5 mm; consists of 25-70 small bundles containing from 30,000 to 80,000 papillary nerve fibers of predominantly small diameter (up to 5 microns).

The maxillary nerve innervates the dura mater, the skin of the lower eyelid, the outer corner of the eye, the anterior part of the temporal region, the upper part of the cheek, the wings of the nose, the skin and mucous membrane of the upper lip, the mucous membrane of the posterior and lower parts of the nasal cavity, the mucous membrane of the sphenoid sinus, palate, dental organs and teeth of the upper jaw. Upon exiting the skull through the foramen rotundum, the nerve enters the pterygopalatine fossa, passes from back to front and from inside to outside. The length of the segment and its position in the fossa are related to the shape of the skull. With brachycephaly, the length of the nerve segment in the fossa is 15-22 mm; it is located deep in the fossa - up to 5 cm from the middle of the zygomatic arch. Sometimes the nerve in the pterygopalatine fossa is covered by a bone crest. With dolichocephaly, the length of the nerve section in question is 10-15 mm and it is located more superficially - up to 4 cm from the middle of the zygomatic arch.

Within the pterygopalatine fossa, the maxillary nerve gives off the ramus meningeus to the dura mater and is divided into three branches: 1) pterygopalatine nerves, nn. pterygopalatini, going to gangl. pterygopalatinum; 2) zygomatic nerve, n. zygomaticus; 3) inferior orbital nerve, n. infraorbitals, which is a direct continuation of the maxillary nerve (Fig. 232, 233).

Rice. 232. Scheme of the structure of the maxillary nerve

1. Pterygopalatine nerves, nn. ptery go palatini, very variable in number (1-7) and length (9-30 mm); depart from the maxillary nerve at a distance of 1-2.5 mm from the round foramen and go to the pterygopalatine ganglion, giving sensory fibers to the nerves starting from the ganglion. Some pterygopalatine nerves bypass the ganglion and join its branches.

Pterygopalatine ganglion, gangl. pterygopalatinum, - the formation of the parasympathetic part of the autonomic nervous system. The node is triangular in shape, 3-5 mm long, contains multipolar cells and has three roots: a) sensitive - nn. pterygopalatine b) parasympathetic - greater petrosal nerve, n. petrosus major, a branch of the intermediate nerve that carries secretory fibers to the lacrimal gland, to the glands of the nasal cavity and palate; c) sympathetic - deep petrosal nerve, n. petrosus profundus, a branch of the plexus caroticus internus, containing postganglionic sympathetic nerve fibers from the cervical ganglia. Branches extend from the node, including secretory (parasympathetic and sympathetic) and sensory fibers: orbital branches, rami orbitales; posterior superior nasal branches, rami nasales posteriores superiores; palatine nerves, nn. palatini (see Fig. 233).

Rice. 233. Olfactory nerve, pterygopalatine ganglion and branches of the trigeminal nerve. 1 - lower nasal passage; 2, 4, 7 - lower, middle and upper turbinates; 3 - middle nasal passage; 5 - olfactory bulb; 6 - olfactory nerves; 8 - sphenoid sinus; 9 - optic nerve; 10, 23 - internal carotid artery; 11 - oculomotor nerve; 12 - pterygopalatine node; 13 - orbital nerve; 14 - maxillary nerve; 15 - trigeminal node; 16 - nerve of the pterygoid canal; 17 - trigeminal nerve; 18 - greater petrosal nerve; 19 - deep petrosal nerve; 20, 31 - facial nerve; 21 - vestibulocochlear nerve; 22 - internal carotid nerve plexus; 24 - lingual nerve; 25 - lower alveolar nerve; 26 - drum string; 27 - middle artery of the meninges; 28 - maxillary artery; 29 - styloid process; 30 - mastoid process; 32 - parotid salivary gland; 33 - perpendicular plate of the palatine bone; 34 - medial pterygoid muscle; 35 - palatine nerves; 36 - soft palate; 37 - hard palate; 38 - upper lip

The orbital branches, rami orbitales, in the amount of 2-3 thin stems, penetrate through the lower orbital fissure into the orbit and further along with n. ethmoidalis posterior go through small openings in the sutura sphenoethmoidalis to the mucous membrane of the posterior cells of the ethmoid labyrinth and the sphenoid sinus.

The posterior superior nasal branches, rami nasales posteriores superiores, in the number of 8-14 stems, emerge from the pterygopalatine fossa through the foramen sphenopalatinum into the nasal cavity, concentrated in two groups: lateral and medial. The lateral branches, rami nasales posteriores superiores laterales (6-10 stems), go to the mucous membrane of the posterior sections of the superior and middle nasal concha and nasal passages, the posterior cells of the ethmoid sinus, the upper surface of the choanae and the pharyngeal opening of the auditory tube. The medial branches (2-3 trunks) branch in the mucous membrane of the upper part of the nasal septum. One of the medial branches is the nasopalatine nerve, n. nasopalatinus, passes between the periosteum and the mucous membrane of the septum together with a. nasalis posterior septi forward to the nasal opening canalis incisivus, through which it reaches the mucous membrane of the anterior part of the palate. Forms a connection with ramus nasalis n. alveolaris superior.

Palatine nerves, nn. palatini, spread from the node through the canalis palatinus major, forming three groups of nerves: a) greater palatine nerve, n. palatinus major; b) small palatine nerves, nn. palatini minores; c) lower posterior lateral nasal branches, rami nasales posteriores inferiores laterales.

Greater palatine nerve, n. palatinus major, the thickest branch, exits through the foramen palatinum majus to the palate, where it splits into 3-4 branches that innervate most of the mucous membrane of the palate and its glands in the area from the canines to the soft palate.

Lesser palatine nerves, nn. palatini minores, enter the oral cavity through the small palatine openings, branch in the mucous membrane of the soft palate and the region of the palatine tonsil, as well as in m. levator veli palatini (motor fibers come from n. facialis through n. petrosus major).

The lower posterior lateral nasal branches, rami nasales posteriores inferiores laterales, enter the canalis palatinus majus, leave it through small openings and, at the level of the inferior nasal concha, penetrate the nasal cavity, innervating the mucous membrane of the inferior concha, the middle and lower nasal passages and the maxillary sinus.

2. Zygomatic nerve, n. zygomaticus, branches off from the maxillary nerve within the pterygopalatine fossa and penetrates through the inferior orbital fissure into the orbit, where it runs along its outer wall and exits through the foramen zygomaticoorbitale, dividing into two branches.

The zygomaticofacial branch, ramus zygomaticofacialis, exits through the foramen zygomaticofaciale onto the anterior surface of the zygomatic bone, branches in the skin of the upper part of the cheek and the region of the outer canthus. Gives a connecting branch to n. facialis.

The zygomaticotemporal branch, ramus zygomaticotemporalis, leaves the orbit through the opening of the same name in the zygomatic bone, pierces the temporal muscle and its fascia, and innervates the skin of the anterior part of the temporal and posterior part of the frontal regions. Gives a connecting branch to n. lacrimalis, sending secretory parasympathetic fibers to the lacrimal gland.

3. Inferior orbital nerve, n. infraorbitalis, is a continuation of the maxillary nerve, receiving its name from the origin of the last branches mentioned above. The inferior orbital nerve leaves the pterygopalatine fossa through the inferior orbital fissure, lies together with the vessels of the same name on the lower wall of the orbit in the sulcus infraorbitalis (in 15% of cases there is a bone canal instead of a groove) and exits through the foramen infraorbitale under the quadratus labii muscle, dividing into terminal branches . The length of the inferior orbital nerve varies. In brachycephals, the nerve trunk is 20-27 mm, and in dolichocephals it is 27-32 mm. The position of the nerve in the orbit corresponds to the parasagittal plane, drawn through the sutura infraorbitalis. The nature of the origin of the branches can also be different: scattered, in which numerous thin nerves with a large number of connections depart from the trunk, or main with a small number of large nerves. Along its path, the infraorbital nerve gives off the following nerves:

Superior alveolar nerves, nn. alveolares superiores, innervating the teeth and upper jaw. The following branches of the superior alveolar nerves are distinguished: a) posterior, b) middle, c) anterior (Fig. 234).

Rice. 234. Maxillary nerve. 1 - posterior upper alveolar branches; 2 - zygomatic nerve; 3 - maxillary nerve; 4 - nerve of the pterygoid canal; 5 - orbital nerve; 6 - trigeminal nerve; 7 - mandibular nerve; 8 - drum string; 9 - ear node; 10 - connecting branches of the pterygopalatine ganglion with the maxillary nerve; 11 - chewing nerve; 12 - inferior alveolar nerve; 13 - lingual nerve; 14 - pterygopalatine node; 15 - inferior orbital nerve; 16 - anterior upper alveolar branches

The posterior superior alveolar branches, rami alveolares superiores posteriores, branch from the lower orbital nerve, usually in the pterygopalatine fossa in an amount of 4 to 8 and spread together with the vessels of the same name along the surface of the tubercle of the upper jaw. Part of the most posterior nerves runs along the outer surface of the tubercle down to the alveolar process. The rest enter through the foramina alveolaria posteriora into the canalis alveolaris, from which they exit onto the outer surface and into the bone canaliculi of the upper jaw, forming with other upper alveolar branches the superior dental plexus, plexus dentalis superior. The plexus lies in the alveolar process of the upper jaw above the apices of the roots; it is quite dense, broadly looped, stretched along the entire length of the alveolar process. From the plexus extend the upper gingival branches, rami gingivales superiores, to the periodontium and periodontium, i.e., to the mucous membrane of the alveolar process, gum and socket in the area of ​​the upper molars, and the upper dental branches, rami dentales superiores, to the apices of the roots and foramina apicalia of the large molars, in the pulp cavity of which they branch. In addition, the posterior superior alveolar branches send thin nerves to the mucous membrane of the maxillary sinus.

The middle superior alveolar branch, ramus alveolaris superior medius, in the form of a stem, rarely 2, branches from the inferoorbital nerve, often in the pterygopalatine fossa and less often within the orbit, passes in one of the alveolar canals and branches in the bone canaliculi of the upper jaw as part of the plexus dentalis superior. It has connecting branches with posterior and anterior superior alveolar branches. Innervates the periodontium and periodontium through the upper desial branches in the area of ​​the upper premolars and the upper dental branches - the upper premolars.

The anterior superior lunate branches, rami alveolares superiores anteriores, usually in the amount of 1-2 trunks, rarely 3, arise from the inferoorbital nerve in the anterior part of the orbit; they leave it through the foramina alveolaria anteriora and exit through the canalis alveolaris onto the anterior surface of the upper jaw, where they form part of the plexus dentalis superior. The mucous membrane of the alveolar process, gums and sockets in the area of ​​the upper canines and incisors and the upper dental branches - the upper canines and incisors - are innervated by means of the upper desi branches. In addition, the anterior superior alveolar branches send a thin nasal branch to the mucous membrane of the anterior nasal cavity.

2. The lower eyelid branches, rami palpebrales inferiores, branch from the lower orbital nerve at the exit from the foramen infraorbitale, penetrate through the quadratus muscle of the upper lip and, branching, innervate the skin of the lower eyelid.

3. The external nasal branches, rami nasales externi, innervate the skin in the area of ​​the wing of the nose.

4. The internal nasal branches, rami nasales interni, supply the mucous membrane of the nasal vestibule.

5. The superior labial branches, rami labiates superiores, in the amount of 3-4 stems, run down between the upper jaw and the quadratus muscle of the upper lip, innervating the skin and mucous membrane of the upper lip to the corner of the mouth. All of the listed external branches of the inferior orbital nerve form connections with the branches of the facial nerve.

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Inflammation of the trigeminal nerve: causes

The main cause of neuralgia is compression of the trigeminal nerve. It can be external or internal.

Internal compression of the trigeminal nerve occurs after injuries, due to which tumors and adhesions form. Even more often, compression is detected due to a displacement of the location of veins and arteries near the trigeminal nerve.

External compression occurs due to the appearance of inflammation of various etiologies in the nasal cavity and sinuses, and in the oral cavity. What could be the dental causes of inflammation of the trigeminal nerve:

• Periodontitis in the last stage.
• Incorrectly installed seal.
• Injuries during tooth extraction.
• Inflammation of the gums due to gingivitis.
• Gum abscess.
• Pulpitis.
• Periodontitis and other carious complications.

Some general diseases can also lead to neuralgia:

• Allergies (some forms).
• Endocrine system disorders.
• Vascular diseases.
• Reduced immunity.
• Metabolic disease.
• Herpetic infection.
• Mental disorders.
• Multiple sclerosis.

Innervation of the eyeball

All nerves involved in the functioning of the eye originate in groups of nerve cells localized in the brain and nerve ganglia. The task of the nervous system of the eye is to regulate muscle function, ensure sensitivity of the eyeball, and the auxiliary apparatus of the eye. In addition, it regulates metabolic reactions and blood vessel tone.

The innervation of the eye involves 5 pairs of 12 available cranial nerves: oculomotor, facial, trigeminal, as well as abducens and trochlear.

The oculomotor nerve originates from nerve cells in the brain and has a close connection with the nerve cells of the abducens and trochlear nerves, as well as the auditory and facial nerves. In addition, there is its connection with the spinal cord, providing a coordinated reaction of the eyes, torso and head in response to auditory and visual stimuli or changes in the position of the torso.

The oculomotor nerve enters the orbit through the opening of the superior orbital fissure. Its role is to raise the upper eyelid, ensuring the work of the internal, superior, inferior rectus muscles, as well as the inferior oblique muscle. Also, the oculomotor nerve includes branches that regulate the activity of the ciliary muscle and the work of the pupillary sphincter.

Together with the oculomotor nerve, 2 more nerves enter the orbit through the opening of the superior orbital fissure: the trochlear nerve and the abducens nerve. Their task is to innervate, respectively, the superior oblique and external rectus muscles.

The facial nerve contains motor nerve fibers, as well as branches that regulate the activity of the lacrimal gland. It regulates the facial movements of the facial muscles and the work of the orbicularis oculi muscle.

The function of the trigeminal nerve is mixed; it regulates muscle function, is responsible for sensitivity and includes autonomic nerve fibers. In accordance with its name, the trigeminal nerve splits into three large branches.

The first main branch of the trigeminal nerve is the ophthalmic nerve. Passing into the orbit through the opening of the superior orbital fissure, the optic nerve gives rise to three main nerves: nasociliary, frontal and lacrimal.

The nasolacrimal nerve passes through the muscular funnel, in turn dividing into ethmoidal (anterior and posterior), long ciliary, and nasal branches. It also gives off a connecting branch to the ciliary ganglion.

The ethmoidal nerves are involved in providing sensitivity to cells in the ethmoidal labyrinth, the nasal cavity, and the skin of the tip of the nose and its wings.

The long ciliary nerves lie in the sclera in the area of ​​the optic nerve. Then their path continues in the supravascular space in the direction of the anterior segment of the eye, where they and the short ciliary nerves extending from the ciliary ganglion create a nerve plexus around the circumference of the cornea and the ciliary body. This nerve plexus regulates metabolic processes and provides sensitivity to the anterior segment of the eye. Also, the long ciliary nerves include sympathetic nerve fibers that branch from the nerve plexus belonging to the internal carotid artery. They regulate the activity of the pupillary dilator.

The short ciliary nerves begin in the region of the ciliary ganglion; they run through the sclera, surrounding the optic nerve. Their role is to ensure nervous regulation of the choroid. The ciliary ganglion, also called the ciliary ganglion, is a union of nerve cells that take part in the sensory (via the nasociliary root), motor (via the oculomotor root), and also the autonomic (via sympathetic nerve fibers) direct innervation of the eye. The ciliary ganglion is localized at a distance of 7 mm posterior to the eyeball below the external rectus muscle, in contact with the optic nerve. At the same time, the ciliary nerves jointly regulate the activity of the pupillary sphincter and dilator, providing special sensitivity to the cornea, iris, and ciliary body. They maintain the tone of blood vessels and regulate metabolic processes. The subtrochlear nerve is considered the last branch of the nasociliary nerve; it is involved in the sensitive innervation of the skin of the root of the nose, as well as the inner corner of the eyelids, part of the conjunctiva of the eye.

Entering the orbit, the frontal nerve splits into two branches: the supraorbital nerve and the supratrochlear nerve. These nerves provide sensitivity to the skin of the forehead and the middle zone of the upper eyelid.

The lacrimal nerve, at the entrance to the orbit, splits into two branches - upper and lower. At the same time, the upper branch is responsible for the nervous regulation of the lacrimal gland, as well as the sensitivity of the conjunctiva. At the same time, it provides innervation to the skin of the outer corner of the eye, covering the area of ​​the upper eyelid. The inferior branch unites with the zygomaticotemporal nerve, a branch of the zygomatic nerve, and provides sensation to the skin of the cheekbone.

The second branch becomes the maxillary nerve and is divided into two main lines - the infraorbital and zygomatic. They innervate the auxiliary organs of the eye: the middle of the lower eyelid, the lower half of the lacrimal sac, the upper half of the lacrimal duct, the skin of the forehead and zygomatic region.

The last, third branch, having separated from the trigeminal nerve, does not take part in the innervation of the eye.

Inflammation of the trigeminal nerve: symptoms

The main symptoms are sharp and unexpected pains that feel like an electric shock. As a rule, they are periodic and characterized by high intensity. The duration of the attack of pain is no more than 2 minutes.

Pain may appear without any effect or apparent cause. It often resembles a toothache and is localized in the upper and lower jaw, in some cases extending to the ear, eye, neck or chin. Basically, pain in trigeminal neuralgia is clearly localized and manifests itself strictly within the boundaries of the branches of the trigeminal nerve.

In some cases, an attack of pain may be triggered by activities that affect one part of the face, such as brushing teeth, washing your face, applying makeup, or shaving. Trigger zones (places the touch of which can provoke a painful attack) are located in the area of ​​the nasolabial triangle. Pain can also appear during laughter, after smiling, or during a conversation.

If the case of inflammation is atypical, then the pain is felt throughout the entire face and it is impossible to determine its source. It can be constant or appear after short breaks. Atypical cases of neuralgia are much more difficult to treat than typical ones.

Sometimes an attack of pain is accompanied by a muscle spasm, then a painful tic appears on the affected side of the face.

Traumatic neuropathy. Etiology.

Traumatic neuropathy most often occurs in the case of surgical interventions on teeth (traumatic extraction of teeth, removal of filling material beyond the apex of the tooth root, anesthesia with injury to the nerve trunks, removal of bone or tumor of the jaws), as well as in cases of surgical interventions on the paranasal sinuses and infraorbital canal.

Damage to the first branch of the trigeminal nerve, as a rule, is practically not observed. Most often, the third branch of the trigeminal nerve is affected, which is apparently due to the anatomical location of the inferior alveolar nerve, which makes it easily accessible during a variety of traumatic dental procedures. This is especially true for dental interventions on third molars. The cause of traumatic neuropathy of the inferior alveolar nerve can also be filling the mental canal during the treatment of pulpitis of the 4th and 5th teeth of the lower jaw.

Combined damage to the I and II branches of the trigeminal nerve can occur after inflammatory diseases of the brain with the development of adhesions or in the case of sinusitis, when the maxillary and frontal sinuses are simultaneously involved in the inflammatory process.

Clinic.

Patients complain of constant aching, sometimes pulsating pain in the area of ​​innervation of the injured nerve, a feeling of numbness and “crawling goosebumps”. In case of injury to the mandibular nerve, tooth alignment occurs, which is associated with damage to the motor part of the nerve; patients cannot eat or talk. Trigger zones on the face and in the oral cavity are not identified.

During an objective examination, hypoesthesia or anesthesia (hyperpathy is also possible) of the skin and mucous membrane in the area of ​​nerve innervation is detected. On palpation, pain is noted at the exit points of the II and III branches of the trigeminal nerve, as well as in the case of vertical percussion of the teeth and deep palpation of the lower jaw.

Diagnostics.

The main diagnostic criterion is the occurrence of pain after interventions on the dental system. The disease is characterized by clinical polymorphism and significant duration. During weather changes, stressful situations and in the presence of somatic diseases, exacerbation of the pain syndrome may occur.

In the event of scar changes in the nerves or retraction of the nerve into the scar of soft tissues (after gunshot wounds, in the case of defects of soft and bone tissues after resection of the jaws), constant aching pain of unexpressed intensity with persistent sensory disturbances is observed.

Inflammation of the trigeminal nerve: treatment methods

Trigeminal neuralgia is difficult to treat. In most cases, treatment of neuralgia becomes long-term and multifaceted.

If the case is severe, when attacks of pain last more than a day, the patient is sent for treatment to the neurological department of the hospital. There, active therapy is carried out to interrupt the pathological chain and prevent the disease from becoming chronic. For this purpose, anti-neurotic and hormonal drugs are prescribed.

In addition to medications, physiotherapy procedures are prescribed:

• Electrophoresis.
• Ultrasound.
• Acupuncture.
• Treatment with pulsed low-frequency currents.
• Laser procedures.
• Electromagnetic treatment.
• Ultraviolet and infrared radiation.

Inflammation of the trigeminal nerve: identifying and eliminating the causes

Treatment of inflammation of the trigeminal nerve begins with the elimination of pain symptoms and alleviation of the patient’s general condition. For treatment to be effective, it is very important to correctly identify the causes that triggered the onset of the disease. Specialists conduct a full-scale examination of the patient, and, if necessary, prescribe various tests.

• If an x-ray reveals that the cause of neuralgia is an incorrectly installed filling, then the tooth must be retreated.
• When it is discovered that the trigeminal nerve is affected by inflammation in the gums, doctors focus on stopping them.
• If pulpitis is detected, the nerve is removed from the tooth and the canals are sealed.
• If inflammatory processes are detected in the sinuses, they are eliminated.
• After consultation with specialized specialists (infectious disease specialist, endocrinologist, allergist, etc.), treatment is carried out depending on the detected diseases.

Very often, in order to cure neuralgia, it is enough to improve the functioning of the blood vessels in the brain, cure inflammation in the sinuses, relieve the patient from a nervous condition or insomnia, and, if necessary, conduct a course of antiviral treatment.

If this is not enough, then more thorough treatment is prescribed.

Treatment of neuralgia with tablets begins with carbamazepine (finlepsin, tegretol). First, the minimum dose of the drug is prescribed, then it is increased and gradually brought to the most effective one. Carbamazepine cannot be used for a very long time, because its effectiveness gradually decreases, in addition, the drug has a large number of side effects.

Trigeminal neuralgia can also be treated with other drugs:

Anticonvulsants	Diphenine or phenytoin
Medicines based on valproic acid.	Depakin, convulex, etc.
Drugs that compensate for amino acid deficiency	Pantogam, baclofen, phenibut
Medicines to relieve acute pain symptoms during crises	Sodium hydroxybutyrate, administered intravenously in glucose solution
Additional agents (amino acids) that are inhibitory mediators of the central nervous system	Glycine
Auxiliary therapy (antidepressants as well) dulls the perception of pain, relieves depression, and makes adjustments to the functional state of the brain.	Amitriptyline
Neuroleptics	Pimozide
Tranquilizers provide relief	Diazepam
Vasoactive drugs (for patients who suffer from vascular diseases)	Cavinton, trental, etc.
To relieve pain at the acute stage of inflammation, local anesthetics are used	Lidocaine, chloroethyl, trimecaine.
Glucocorticoids (in the presence of allergic reactions or autoimmune processes)	Prednisolone, dexamethasone