8/12/2014 Trigeminal Nerve Anatomy

http://emedicine.medscape.com/article/1873373-overview#showall 1/13
Trigeminal Nerve Anatomy
Author: Ted L Tewfik, MD; Chief Editor: Arlen D Meyers, MD, MBA more...

Updated: Jun 19, 2013
Gross Anatomy
The trigeminal nerve is the largest and most complex of the 12 cranial nerves (CNs). It supplies sensations to the
face, mucous membranes, and other structures of the head. It is the motor nerve for the muscles of mastication
and contains proprioceptive fibers. It exits the brain by a large sensory root and a smaller motor root coming out of
the pons at its junction with the middle cerebral peduncle. It passes laterally to join the gasserian (semilunar)
ganglion in the Meckel cave. (See the image below.)
Schematic representation of the trigeminal nerve with its central connections.
Nuclei
The sensory nucleus, located in the pons, is quite extensive. It receives ordinary sensations from the main 3
branches of the trigeminal. The ophthalmic division is in the lower part of the nucleus, and the mandibular branch
is in the upper part. The large rostral head is the main sensory nucleus. The caudal tapered part is the spinal tract,
which is continuous with substantia gelatinosa of Rolando in the spinal cord. The spinal tract is the sensory
nucleus, primarily for pain and temperature. The main sensory nucleus serves mostly for discrimination sense.
[1, 2,
3, 4, 5]
The motor nucleus is ventromedial to the sensory nucleus. It lies near the lateral angle of the fourth ventricle in the
rostral part of the pons. The mesencephalic nucleus is in the midbrain and receives proprioceptive fibers from all
muscles of mastication.
Connections
The main sensory nucleus receives its afferents (as the sensory root) from the semilunar ganglion through the
lateral part of the pons ventral surface. Its axons cross to the other side, ascending to the thalamic nuclei to relay
in the postcentral cerebral cortex. The descending sensory fibers from the semilunar ganglion course through the
pons and medulla in the spinal tract of CN V to end in the nuclei of this tract (as far as the second cervical
segment). (See tables 1 and 2, below.)
The axons of these nuclei cross to the opposite side, ascending in the spinothalamic tract, to relay in the thalamic
nuclei; from there, they end in the cerebral cortex. The sensory nucleus of CN V is connected to other motor
nuclei of the pons and medulla. In addition, the descending sensory spinal tract receives somatic sensory fibers
from CNs VII, IX, and X.
The proprioceptive fibers of CN V arise from the muscles of mastication and the extraocular muscles. They
terminate in the mesencephalic nucleus. This nucleus has connections to the motor nucleus of CN V.
The motor nucleus of CN V receives cortical fibers for voluntary control of the muscles of mastication. These fibers
are mostly crossed. It also receives input from the mesencephalic and sensory nuclei. The axons emerge anterior
to the sensory root from the lateral surface of the pons. This motor root joins the semilunar ganglion together with
the sensory root.
The semilunar (gasserian or trigeminal) ganglion is the great sensory ganglion of CN V. It contains the sensory cell
bodies of the 3 branches of the trigeminal nerve (the ophthalmic, mandibular, and maxillary divisions). The
News & Perspective
Drugs & Diseases
CME & Education
Log In
Register

8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 2/13
ophthalmic and maxillary nerves are purely sensory. The mandibular nerve has sensory and motor functions.
The gasserian ganglion lies in a depression on the petrous apex, within a dural fold called the Meckel cave. The
sensory roots of the 3 branches of CN V are received anteriorly. They then pass from the posterior aspect of the
ganglion to the pons. The motor root passes under the ganglion to join the sensory division of the mandibular nerve
and exits the skull through foramen ovale. The carotid plexus contributes sympathetic fibers to the gasserian
ganglion.
Table 1. Summary of the Components, Function, Central Connections, Cell Bodies, and Peripheral Distribution of
CN V. (Open Table in a new window)
Components Function
Central
connection
Cell bodies Peripheral distribution
Afferent
general
somatic
General
sensibility
Sensory
nucleus V
Gasserian
ganglion
Sensory branches of the ophthalmic, maxillary, and
mandibular nerves to skin, mucous membranes of
the face and head
Efferent
special
visceral
Mastication Motor nucleus
V
Motor nucleus
V
Branches to temporalis, masseter, pterygoids,
mylohyoid, tensor tympani, and palati
Afferent
proprioceptive
Muscular
sensibility
Mesencephalic
nucleus V
Mesencephalic
nucleus V
Sensory endings in muscles of mastication
Table 2. Summary of the Types of Fibers, Function, and Pathways of the Trigeminal Nerve. (Open Table in a new
window)
Type Function Pathway
Branchial
motor
Motor to muscles of
mastication
CN V innervates the muscles of mastication, mylohyoid, tensor tympani, tensor
veli palate, anterior belly of digastric
General
sensory
Sensory from
surface of head and
neck, sinuses,
meninges and TM
The Gasserian ganglion receives the ophthalmic, maxillary and mandibular
divisions of CN V and sympathetic fibers from the carotid plexus and sends
branches to the dura. The four accessory ganglia are anatomically but not
functionally associated with CN V
Branches of the Trigeminal Nerve
The ophthalmic, maxillary, and mandibular branches of the trigeminal nerve leave the skull through 3 separate
foramina: the superior orbital fissure, the foramen rotundum, and the foramen ovale, respectively. (See the image
below.)
Diagram of the trigeminal nerve with its 3 main branches.
The ophthalmic nerve
The ophthalmic nerve is the first branch of the trigeminal nerve. It arises from the convex surface of the gasserian
ganglion, in the dura of the lateral wall of the cavernous venous sinus under CN IV and above the maxillary nerve,
as seen in the image below.
Diagram showing the structures in the cavernous sinus.
The ophthalmic nerve carries sensory information from the scalp and forehead, the upper eyelid, the conjunctiva
and cornea of the eye, the nose (including the tip of the nose, except alae nasi), the nasal mucosa, the frontal
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 3/13
sinuses, and parts of the meninges (the dura and blood vessels).
The ophthalmic nerve receives sympathetic filaments from the cavernous sinus and communicating branches from
CN III and IV. Just before it exits the skull through the superior orbital fissure, it gives off a dural branch, and then
divides into 3 branches: the frontal, lacrimal, and nasociliary. (See the image below.)
Diagram of the f irst branch (ophthalmic) of the trigeminal nerve with its branches.
Frontal nerve
This is the largest branch of the ophthalmic nerve (see Table 3, below). It passes in the lateral part of the superior
orbital fissure, below the lacrimal nerve and above CN IV, between the periorbita and levator palpebrae superioris. It
divides in the middle of the orbit into the supraorbital (larger branch) and supratrochlear nerves.
Table 3. The Ophthalmic Nerve Branches and Distribution. (Open Table in a new window)
Nerve Branches Distribution
Frontal nerve Supraorbital nerve
Supratrochlear nerve
Upper lid, frontalis muscle, scalp
Conjunctiva, upper lid, forehead
Lacrimal nerve Receives branch from the zygomatic nerve of the
maxillary
Lacrimal gland, conjunctiva, upper lid
Nasociliary
nerve
Anterior ethmoid nerve
Branches to ciliary ganglion
Posterior ethmoid nerve
2-3 long ciliary nerves
Frontal, anterior, ethmoid sinuses
Anterior septum, nasal wall
Cornea, iris, ciliary body
Posterior ethmoid sphenoid
sinuses
Eye
The supraorbital nerve exits the skull through the supraorbital notch (or foramen). It supplies the upper lid and then
turns superiorly under the frontalis muscle to supply the scalp (via lateral and medial branches) as far posteriorly
as the lambdoid suture.
The supratrochlear nerve exits the medial orbit and gives branches to the conjunctiva and the skin of the upper lid,
as well as to the lower and medial parts of the forehead. The branch to the frontal sinus pierces it in the
supraorbital notch to supply the frontal sinus mucosa.
Lacrimal nerve
The lacrimal nerve arises in the narrow, lateral part of the superior orbital fissure and courses between the lateral
rectus and the periorbita. It supplies the lacrimal gland, conjunctiva, and upper lid. In the orbit, it receives a
communication from the zygomatic branch of the maxillary nerve. This represents postganglionic parasympathetic
secretory fibers from the sphenopalatine ganglion to the lacrimal gland. The preganglionic fibers reach the ganglion
via the greater petrosal and vidian nerves from CN VII.
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 4/13
Nasociliary nerve
After passing through the superior orbital fissure, the nasociliary nerve gives origin to the anterior ethmoid nerve
that passes to the anterior ethmoid foramen lateral to the crista galli, to supply the fontal and anterior ethmoid
sinuses. After dropping in the nose, it supplies the anterior part of the septum and lateral nasal wall. After
emerging from the nose as the external nasal nerve, it supplies the skin of the nasal tip.
The nasociliary nerve gives a branch to the ciliary ganglion that passes without synapsing to the cornea, iris, and
ciliary body. The posterior ethmoid nerves are given off before the anterior ethmoid and supply the posterior
ethmoid and sphenoid sinuses. The nasociliary nerve gives off 2-3 long ciliary nerves that enter the globe with the
short ciliary nerves of the ciliary ganglion.
Maxillary nerve
The maxillary nerve carries sensory information from the lower eyelid and cheek, the nares and upper lip, the upper
teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid
sinuses, and parts of the meninges. (See the image below.) The maxillary nerve is divided into 3 branches: the
zygomatic, pterygopalatine (or sphenopalatine), and posterior superior alveolar nerves.
Diagram of the second branch (maxillary) of the trigeminal nerve with its branches.
As it leaves the semilunar ganglion, the maxillary nerve passes through the dura of the lateral wall of the cavernous
sinus. It exits the skull via the foramen rotundum and crosses the pterygopalatine fossa to enter the orbit through
the inferior orbital fissure, where it becomes the infraorbital nerve. Before entering the foramen, it gives off a dural
branch (middle meningeal nerve). The zygomatic, pterygopalatine (or sphenopalatine) and posterior superior
alveolar branches are given off in the pterygopalatine fossa.
The zygomatic branch divides into the zygomaticotemporal and zygomaticofacial nerves.
In the lateral wall of the orbit, it gives off a branch to the lacrimal nerve, which carries postganglionic fibers from the
sphenopalatine ganglion for lacrimation. The zygomaticofacial is inferiorly situated and supplies the skin of the
cheek.
The pterygopalatine (or sphenopalatine) nerves are 2 nerves that unite the sphenopalatine ganglion to the maxillary
nerve. They transmit afferent sensations from the nose, palate, and pharynx. They also carry parasympathetic
fibers to the lacrimal nerve that go to the lacrimal gland. These preganglionic fibers are derived from CN VII via the
greater petrosal and vidian nerves. The other branches of the sphenopalatine nerves and their distribution are
summarized in Table 4, below.
Table 4. The Maxillary Nerve Branches and Distribution. (Open Table in a new window)
Nerve Branches Distribution
Middle meningeal
nerve
Dura
Zygomatic nerve Zygomatico-temporal
Zygomatico-facial
Lacrimal gland
Forehead
Cheek
Pterygopalatine
nerve
2 branches unite sphenopalatine
ganglion and maxillary nerve
Greater palatine nerve
Posterior superior nasal nerve
Nasal cavity, pharynx, palate
Soft and hard palate
Superior, middle turbinate, septum
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 5/13
Pharyngeal
Nasopharynx
Posterior superior
alveolar nerve
Middle, anterior, superior alveolar, and
nasal nerves
Gums, posterior cheek, teeth (canine,
incisors, premolar), nasal floor
The posterior superior alveolar nerves are usually 2 in number. They supply the mucosa of the posterior cheek and
gingiva; Table 4 has their distribution and the other small branches.
The mandibular nerve
The mandibular nerve is the largest branch of the trigeminal nerve, as seen in the image below. It has mixed
sensory and motor fibers (see Table 5, below).
Diagram of the third branch (mandibular) of the trigeminal nerve with its branches.
The mandibular nerve carries sensory information from the lower lip, the lower teeth, gums, the chin and jaw
(except the angle of the mandible, which is supplied by C2-C3), parts of the external ear, and parts of the
meninges. The mandibular nerve carries touch/position and pain/temperature sensations from the mouth. It does
not carry taste sensation (the chorda tympani is responsible for taste), but one of its branches, the lingual nerve,
carries multiple types of nerve fibers that do not originate in the mandibular nerve.
Motor branches of the trigeminal nerve are distributed in the mandibular nerve. These fibers originate in the motor
nucleus of the fifth nerve, which is located near the main trigeminal nucleus in the pons. (See the image below.)
Diagram of the sensory and motor supply of the f ace.
The mandibular nerve has the following 9 branches:
Recurrent meningeal nerve - This nerve enters the skull via the foramen spinosum with the meningeal artery
Medial pterygoid nerve - After passing through the otic ganglion without synapsing, this nerve supplies the
medial pterygoid, tensor veli palatini, and tensor tympani muscles
Masseteric nerve - This nerve passes through the mandibular notch to innervate the masseter muscle and
temporomandibular joint (TMJ)
Deep temporal nerves - The anterior and posterior branches supply the temporal muscle
Lateral pterygoid nerve
Buccal nerve - This nerve divides into the temporal and buccinator branches
Auriculotemporal nerve - This nerve begins as 2 roots that encircle the middle meningeal artery, then forms
a single trunk medial to the neck of the mandible; it emerges superficially between the ear and the
mandibular condyle deep to the parotid gland and ends in 2 superficial temporal branches (for autonomic
supply to the parotid gland, see below)
Lingual nerve - This nerve runs parallel to the inferior alveolar nerve, is joined by the chorda tympani nerve of
the facial nerve (CN VII) near the internal maxillary artery, courses forward between the hyoglossus muscle
and the deep part of the submandibular gland, and, as it passes forward, crosses the submandibular
(Wharton) duct; the lingual nerve could be injured in this location during surgery on the floor of mouth or
during excision of the submandibular gland (for more details regarding the nerve supply of the salivary
glands, see below)
Inferior alveolar nerve - This nerve accompanies the inferior alveolar artery in the mandibular foramen and
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 6/13
courses into the mandibular canal to exit through the mental foramen; the different branches are listed in
Table 5, below
Table 5. Mandibular Nerve Branches and Distribution. (Open Table in a new window)
Nerve Branches Distribution
Recurrent
meningeal
Dura
Medial pterygoid Medial pterygoid, tensor veli palatini, tensor tympani
muscles
Masseteric Masseter muscle, temporomandibular joint
Deep temporal
(x2)
Temporalis muscle
Lateral pterygoid Lateral pterygoid muscle
Buccal Temporal nerve (upper)
Buccinator nerve (lower)
Skin of cheek, mucous membrane of mouth, and gingiva
Auriculotemporal Communication with facial
nerve, and otic ganglion,
Articular nerve
Parotid gland
Parasympathetic and sympathetic supply to the parotid
gland, after relay in the otic ganglion
8) Lingual Communicates with CN VII via
chorda tympani
Taste sensations to the anterior third of tongue
9) Inferior
alveolar
Mylohyoid
Dental
Incisive
Mental
Mylohyoid, anterior, belly of digastric, molars, premolars,
canine, incisors lower lip, and chin
Microscopic Anatomy
Sensory nerve endings that respond to stimuli and convert them to nervous energy toward the central nervous
system are called receptors or central transducers. Sensory receptors are classified into the following 3 main
groups: exteroreceptors, interoreceptors, and proprioceptors.
[6, 7, 8]
Exteroreceptors
These are stimulated by the external environment. Examples of these types of receptors include the following:
Merkel corpuscles - Located in submucosa of the tongue and oral cavity (see the image below)
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 7/13
(2) Merkel disc ending. Horseradish peroxidase (HRP) has dif f used into the hair shaf t and surrounded the disc-shaped nerve
terminal. Key: Merkel cell (M), nerve terminal (nt). Inset: Incorporated HRP in the nerve terminal, x8, 750. Inset: x32, 4003 (3 and
4). Detail of a Merkel disc ending. HRP is seen in various vacuoles in the nerve terminal. x 39,000.
Meissner corpuscles - Tactile receptors in the skin
Ruffini corpuscles - Pressure and warmth receptors
Krause corpuscles or end bulbs - Cold receptors
Free nerve endings - Perceive superficial pain and tactile sensations
Interoreceptors
These are located in and transmit sensations from body cavities. Most of the sensations for these structures deal
with body functions and are below the conscious level. Examples include the following:
Pacinian corpuscles - Detect pressure sense
Free nerve endings - Perceive visceral or other sensations
Proprioceptors
The sensations associated with proprioceptors are also below conscious level; examples include the following:
Muscle spindles - Respond to passive stretch of the muscle
Golgi tendon organs - Located in tendons and respond to muscle tension (contraction and stretching)
Pacinian corpuscles - Respond to pressure
Proprioceptors - Respond to periodontal sensation
Sensory nerve endings - Perceive deep somatic pain
Natural Variants
Different anatomic variations have been described regarding the trigeminal nerve, its branches, and its
subdivisions. Examples include the very rare occurrence of unilateral trigeminal nerve hypoplasia, in which no
corneal sensitivity exists on the affected side and facial sensitivity is reduced in all branches of the trigeminal
nerve. Anomalies may coexist also in association with craniofacial anomalies, such as hypoplasia of the
trigeminal nerve in Goldenhar syndrome (oculo-auriculo-vertebral dysplasia). A few other examples affecting the
different divisions are described below.
[9, 10, 11, 12, 13, 14]
Frontal nerve
A variation has been reported in which the frontal nerve divides at a variable point before leaving the orbit to form
the supratrochlear and supraorbital branches. In such cases, the supraorbital branch passes through the
supraorbital foramen, through which the undivided nerve ordinarily passes. When the foramen is absent, it may
have a special groove, the frontal notch (Henle notch).
The frontal nerve runs, at first forward, in a sagittal direction. In approximately 90% of subjects, it divides during its
course within the orbit, but in 10% of persons it remains undivided. It divides into the larger lateral supraorbital
nerve and smaller supratrochlear nerve, which runs medially. In 60% of subjects, the supraorbital nerve does not
divide, but in 30% it divides into the medial branch, which leaves the orbit through the frontal foramen or notch, and
the lateral branch passes out through the frontal foramen. In about 90% of subjects, the supratrochlear nerve runs
along the surface of the superior oblique muscle. In 4% of subjects, 2 supratrochlear nerves exist.
Ethmoidal nerve
This nerve may be limited to the nasal cavity. It may also traverse the posterior ethmoidal foramen to gain entrance
to the cranial cavity.
Lacrimal nerve
This nerve may appear to be derived from the trochlear nerve. However, the probable source in such cases is the
ophthalmic nerve, through its communicating branch to the trochlear nerve (CN IV) in the cavernous sinus.
The lacrimal nerve may be small at its origin, increasing in size later in its course by the addition of fibers derived
from the temporal branch of the maxillary division of the trigeminal nerve. The lacrimal nerve may be absent and
replaced by the temporal branch of the maxillary division of the trigeminal nerve.
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 8/13
The lacrimal nerve occasionally gives rise to a ciliary nerve, or it receives a branch from a long ciliary nerve of the
ciliary ganglion or a branch from the ganglion directly. It may receive accessory roots from the supraorbital or
nasociliary nerves.
The bifurcation of the lacrimal into its terminal branches may occur on the posterior wall of the orbital cavity. A
branch of the lacrimal has been noted to pierce the sclera.
The lacrimal nerve may exchange fibers with the ciliary ganglion.
Nasociliary (nasal) nerve
Several variations in the branches of this nerve have been reported. The nasociliary nerve may send branches to
the superior rectus, medial rectus, and levator palpebral superioris muscles. Branches emanating from a small
ganglion connected to the nasal nerve have been followed to the oculomotor (CN III) and abducens (CN VI) nerves.
The infratrochlear branch of the nasal (nasociliary) nerve may be missing, in which case the areas normally
supplied by this branch (skin of the upper eyelid, root of nose, conjunctiva, lacrimal sac) receive their supply from
the supratrochlear branch of the frontal nerve.
Branches of the nasal nerve have been described passing to the frontal, ethmoid, and sphenoid sinuses. The
branches to the frontal and anterior ethmoid sinuses arise in the anterior ethmoid foramen; branches to the
sphenoid and posterior ethmoid sinuses arise in the posterior ethmoid foramen. The branches to the sphenoid
sinuses are known as sphenoid branches, whereas the branches to the posterior ethmoid sinuses are known as
sphenoethmoid or posterior ethmoid branches. An anastomosis between the nasal and lacrimal nerves has been
reported.
Maxillary division (V2)
The maxillary nerve may split into 2 trunks, each entering the skull through a separate foramen
Zygomatic nerve
The following variations have been reported in this nerve or its 2 branches (the temporal or facial or malar). The
nerve may pass through the zygomatic bone before it divides into 2 branches, or the 2 branches may pass
separately through foramina in the zygomatic bone instead of passing through a common foramen
(sphenozygomatic foramen). The temporal branch in some cases passes through the sphenomaxillary fissure into
the temporal fossa.
Either branch of the zygomatic may be absent or smaller than normal, in which case the other branch
compensates by carrying the additional nerve fibers. The area usually supplied by the zygomatic branch (skin of
the zygomatic region) may be supplied instead by the infraorbital nerve. The area usually supplied by the temporal
branch (skin of the anterior temporal region) may be supplied solely or additionally by the lacrimal nerve.
Posterior superior alveolar nerve
In the absence of the buccal nerve, the posterior superior alveolar nerve distributes branches to the areas normally
supplied by this nerve (mucous membrane and skin of the cheek).
Inferior alveolar nerve
The inferior alveolar nerve may form a single trunk with the lingual nerve, extending as far as the mandibular
foramen. The inferior alveolar nerve is sometimes perforated by the internal (medial) maxillary artery. It may have
accessory roots from other divisions of the mandibular nerve. In some cases, the mylohyoid branch of the inferior
alveolar gives rise to a branch that pierces the mylohyoid muscle and joins the lingual nerve.
Branches have been described arising from the mylohyoid branch and supplying the depressor anguli oris muscle
and parts of the platysma (that are usually supplied by the facial nerve), the skin below the chin, and the
submandibular (submaxillary) gland (which is usually supplied by the facial nerve). The inferior alveolar may form
connections with the auriculotemporal nerve. In one case, the roots of the third lower molar tooth were found to be
surrounding the inferior alveolar nerve.
Auriculotemporal nerve
This nerve carries the otic ganglion, which is derived from glossopharyngeal neurons. The nerve usually arises by 2
roots from the posterior division of the mandibular nerve. The 2 roots usually surround the middle meningeal nerve
before joining to form a single trunk. A variation in this relationship has been described in which the middle
meningeal artery pierces the anterior root instead of passing between the 2 roots.
According to Baumel et al, the auriculotemporal nerve is commonly misrepresented in illustrations and textbooks.
[11]
Their 85 dissections of the nerve demonstrated that the roots of the "typical" auriculotemporal nerve do not
form a tight buttonhole around the middle meningeal artery. Instead, the roots outline an elongated, V-shaped
interval, with the roots widely separated from one another. At their junction, the roots form a short trunk that
immediately breaks up in line with the posterior border of the mandible into a spray of branches.
The superficial temporal ramus of the auriculotemporal nerve should not be considered as the main continuation of
the nerve but merely as its largest branch. A substantial portion of the nerve makes up its 2 communicating rami
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 9/13
with the facial nerve; these are the strongest and most consistent of the many peripheral communications between
trigeminal and facial nerves. Common variations in configuration, branching, and relationships of the nerve are
discussed in the report by Baumel et al.
Lingual nerve
A minute sublingual ganglion has been described arising from the lingual nerve or submandibular ganglion (a
ganglion of the facial nerve carried by the lingual nerve), supplying the sublingual gland. This nerve may pierce the
lateral pterygoid muscle rather than pass between the 2 pterygoid muscles. It occasionally provides motor
branches to the medial and lateral pterygoids and to the palatoglossus muscle.
Relationships to superior petrosal sinus
Vascular relationships are important during intracranial approaches to the skull base. The relationship between the
superior petrosal sinus (SPS) and the opening of the Meckel cave (MC) was studied by Tubbs et al (2013), who
found (through cadaver dissections) 3 types of relationships, as follows
[15]
:
SPSs traveled superior to the opening of the MC in 68%
SPSs traveled inferior to the opening of the MC in 18%
SPSs traveled around to the opening of the MC in 16% of cadavers
In the third variety, a venous ring was formed around the proximal trigeminal nerve. In these cases, the opening
was narrowed on sides found to have an SPS that encircled this region. No statistically significant differences were
noted between persons of different sex or age or in regard to the side of the head. They concluded that some
individuals may retain the early embryonic position of their SPS in relation to the fifth nerve.
Pathophysiological Variants
Trigeminal neuralgia and neuropathy are thought to arise from damage or pressure on the trigeminal nerve,
whereas temporomandibular disorders (TMDs) result primarily from peripheral nociceptor activation. Wilcox et al
(2013) used T1-weighted magnetic resonance images to assess the volume and microstructure of the trigeminal
nerve in these 3 conditions.
[16]
They found that trigeminal neuralgia patients displayed a 47% decrease in nerve
volume, but no change in diffusion-tensor images (DTIs). On the other hand, trigeminal neuropathy patients
displayed a 40% increase in nerve volume but no changes in DTI values. In contrast, TMD subjects displayed no
change in volume or DTIs. This publication revealed that orofacial pain conditions are associated with changes in
nerve volume, whereas nonneuropathic pain is not associated with any volume change.
Regarding trigeminal neuralgia (also known as tic douloureux), the differential diagnoses is as follows (also, see
Table 6 and text below)
[6, 17, 18, 19, 20, 21]
:
Cluster headache (CH): The pain and symptoms of CH result from activation of the trigeminal
parasympathetic reflex, mediated through the sphenopalatine ganglion (SPG). Schoenen et al (2012)
investigated the safety and efficacy of on-demand SPG stimulation for chronic CH (CCH).
[22]
A multicenter
study of an implantable on-demand SPG neurostimulator was conducted in patients suffering from
refractory CCH. Most patients (81%) experienced transient, mild/moderate loss of sensation within distinct
maxillary nerve regions; 65% of events resolved within 3 months. Results showed that the on-demand SPG
stimulation using this neurostimulation system is an effective novel therapy for CCH, with dual beneficial
effects, acute pain relief and observed attack prevention, and has an acceptable safety profile compared
with similar surgical procedures.
Low-grade astrocytoma
Arteriovenous malformations
Brainstem gliomas
Meningioma
Cavernous sinus syndromes
Migraine headache
Trigeminal neuropathy
Trigeminal neuritis
Chronic paroxysmal hemicrania
Migraine variants
Multiple sclerosis
Craniopharyngioma
Persistent idiopathic facial pain
Glioblastoma multiforme
Polyarteritis nodosa
Hemifacial spasm
Postherpetic neuralgia
Hydrocephalus
Subarachnoid hemorrhage
Atypical facial pain
Ramsay Hunt syndrome
Glossopharyngeal neuralgia
Malignant and nonmalignant pain syndromes
Occipital neuralgia
Tic convulsif
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 10/13
Cerebral aneurysms
Brainstem syndrome
Table 6. The Difference Between Atypical Facial Pain and Trigeminal Neuralgia. (Open Table in a new window)
Feature Trigeminal Neuralgia Atypical Facial Pain
Prevalence Rare Common
Main location Trigeminal area Face, neck, ear
Pain duration Seconds to 2 minutes Hours to days
Character Electric jerks, stabbing Throbbing, dull
Pain intensity Severe Mild to moderate
Provoking factors Light touch, washing, shaving, eating, talking Stress, cold
Associated symptoms None Sensory abnormalities
TN has a reported incidence of 5.9 cases in 100 000 women and 3.4 cases in 100 000 men in the United States.
The exact pathophysiology is still unclear, but demyelization leading to abnormal discharge in fibers of the
trigeminal nerve is a probable cause. In most cases, no structural lesion is detected, but in almost 15% of
patients, medical imaging methods like MRI, CT,or angiography can identify a vein or artery that compresses the
nerve, which results in focal demyelization. Sava et al (2012) investigated a case of TN using MRI and identified
compression of the nerve 9 mm after emerging the pons by the superior cerebellar artery.
[23]
In the article, they
reviewed MRI anatomy of the trigeminal nerve.
Marcus Gunn phenomenon
Marcus Gunn phenomenon (also known as Marcus-Gunn jaw-winking or trigemino-oculomotor synkineses) is an
autosomal-dominant condition with incomplete penetrance, in which nursing infants have rhythmic upward jerking
of their upper eyelid. This condition has been associated with amblyopia (in 54% of cases), anisometropia (26%),
and strabismus (56%).
Marcus Gunn phenomenon is an exaggeration of a very weak physiologic cocontraction that has been disinhibited
secondary to a congenital brainstem lesion. The stimulation of the trigeminal nerve by contraction of the pterygoid
muscles results in the excitation of the branch of the oculomotor nerve (CN III) that innervates the levator palpebrae
superioris ipsilaterally.
Inverse Marcus Gunn phenomenon or Marin-Amat syndrome
Marin-Amat syndrome or inverse Marcus Gunn phenomenon is a rare condition that causes the eyelid to fall upon
opening of the mouth. In this case, trigeminal innervation to the pterygoid muscles is associated with an inhibition
of the branch of the oculomotor nerve to the levator palpebrae superioris, as opposed to stimulation in Marcus
Gunn jaw-winking. Garcia Ron et al (2011) presented one acquired case, after the surgery of tuberculosus cervical
adenitis, and another congenital case. The syndrome is rare in children, with few reported cases.
[24]
The diagnosis
is clinical and does not require additional tests. EMG may be useful to demonstrate the synkinesis.
Tolosa-Hunt syndrome
Tolosa-Hunt syndrome (THS) is a painful ophthalmoplegia caused by nonspecific inflammation of the cavernous
sinus or superior orbital fissure. Ophthalmoparesis or disordered eye movements occur when CNs III, IV, and VI
are damaged by granulomatous inflammation. Pupillary dysfunction may be present and is related to injury to the
sympathetic fibers or oculomotor nerve. Trigeminal nerve involvement (primarily V1) may cause paresthesias of the
forehead.
Lateral medullary syndrome
This condition is also called Wallenberg syndrome or posterior inferior cerebellar artery (PICA) syndrome. The
PICA supplies the lower cerebellum, the lateral medulla, and the choroid plexus of the fourth ventricle. In lateral
medullary syndrome, the patient has dysphagia and/or difficulty speaking owing to 1 or more patches of infarction
caused by interrupted blood supply to parts of the brainstem. For features of lateral medullary syndrome, see
Table 7, below.
Table 7. Features of Lateral Medullary Syndrome. (Open Table in a new window)
Dysfunction Effects
Vestibular nucleus Vestibular system: vertigo, diplopia, nystagmus,
vomiting
Inferior cerebellar peduncle Ipsilateral cerebellar signs, including ataxia
Central tegmental tract Palatal myoclonus
Lateral spinothalamic tract Contralateral deficits in pain and temperature
sensation from body
Spinal trigeminal nucleus Ipsilateral loss of touch pain and temperature
sensation from face
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 11/13
Nucleus ambiguus (which affects vagus X and
glossopharyngeal nerves IX)
Dysphagia, hoarseness, diminished gag reflex
Descending sympathetic fibers Ipsilateral Horner syndrome
Parasympathetic Ganglia
Four small parasympathetic (accessory) ganglia are associated anatomically (but not functionally) with the
branches of the trigeminal nerve.
[2, 4]
They are as follows:
Ciliary ganglion
Sphenopalatine (or pterygopalatine) ganglion
Otic ganglion
Submandibular ganglion
The ciliary ganglion is associated with the ophthalmic nerve. It is the size of a pinhead and has the following 3
roots:
The parasympathetic root from the nerve to inferior oblique (CN III) from Edinger Westphal nucleus and
caudal central nucleus to supply the sphincter papillae and ciliary muscles
Sympathetic root from the nasociliary nerve to dilator papillae muscle of the eye
Sensory root from the nasociliary nerve to the cornea
The sphenopalatine ganglion is associated with the maxillary nerve. It receives its parasympathetic fibers from CN
VII (as seen in the image below). The otic and submandibular ganglia are associated with the mandibular nerve.
They receive parasympathetic fibers from CNs IX and VII, respectively.
Sphenopalatine ganglion and its connections. Parasympathetic f ibers are dashed.
Autonomic supply to the salivary glands
Submandibular gland
Parasympathetic fibers arise from the superior salivary nucleus in the pons. Fibers pass through the facial nerve to
the chorda tympani and then to the lingual nerve. Synapsing occurs in the submandibular ganglion and from there
to the submandibular salivary gland. Sympathetic supply is from the plexus around the facial artery.
Parotid gland
Parasympathetic fibers arise from the inferior salivary nucleus in the medulla oblongata, pass through the
glossopharyngeal nerve (CN IX), and then travel through its tympanic branch to the tympanic plexus (Jacobson
nerve). They emerge from the middle ear through a hiatus on the anterior surface of the petrous temporal bone, as
the lesser superficial petrosal nerve. This nerve passes via the foramen ovale to the otic ganglion (which hangs
from the medial side of the mandibular nerve).
Relay occurs in the otic ganglion, and from there it is distributed to the parotid gland via the auriculotemporal
nerve. Sympathetic fibers are from the superior cervical ganglion; they go to the plexus around the meningeal
artery and from there to the auriculotemporal nerve, which distributes them to the parotid salivary gland.

Contributor Information and Disclosures
Author
Ted L Tewfik, MD Professor, Department of Otolaryngology-Head and Neck Surgery, Director of Continuing
Medical Education of Otolaryngology; and Professor of Pediatric Surgery, McGill Faculty of Medicine, Senior
Staff Montreal Children's Hospital, Montreal General Hospital and Royal Victoria Hospital
Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology
and Canadian Society of Otolaryngology-Head & Neck Surgery
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado
School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic
and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 12/13
Head and Neck Society
Disclosure: Axis Three Corporation Ownership interest Consulting; Medvoy Ownership interest Management
position; Cerescan Imaging Honoraria Consulting
References
1. Agur AMR, Dalley AE. The Cranial Nerves. In: Grant's Atlas of Anatomy. Baltimore: Williams & Wilkins;
2004.
2. Sooy CD, Boles R. Neuroanatomy for the Otolaryngologist Head and Neck Surgeon. In: Paparella MM,
and Shumrich DA. Otolaryngology: Basic Sciences and Related Principles. Philadelphia: WB Saunders;
1991.
3. Moore KL, Dalley AL. Clinically Oriented Anatomy. 4th. Philadelphia: Lippincott Williams & Wilkins; 1999.
4. Martin JH. Neuroanatomy Text and Atlas. 3
rd
ed. McGraw-Hill; 2003.
5. Ropper AH, Brown RH. Adam's and Victor's Principles of Neurology. 8th. McGraw-Hill; 2001.
6. Bell WE. Orofacial Pains: Differential Diagnosis. 2nd. Year Book Medical Publisher; 1979.
7. Miller MR. Pain: Morphological Aspects. In: Way EL (ed). New Concepts in Pain. Philadelphia: FA Davis
Co; 1967.
8. Persson LA, Kristensson K. Uptake of horseradish peroxidase in sensory nerve terminals of mouse
trigeminal nerve. Acta Neuropathol. May 15 1979;46(3):191-6. [Medline].
9. Wilson-Pauwels, L, Akesson EJ, Stewart PA. Cranial Nerves: Anatomy and Clinical Comments. BC
Decker Inc; 1998.
10. Tewfik TL, Teebi, AS, Der Kaloustian VM. Selected Syndromes and Conditions. In: Tewfik TL, Der
Kaloustian VM (eds). Congenital Anomalies of the Ear, Nose, and Throat. New York: Oxford University
Press; 1997.
11. Baumel JJ, Vanderheiden JP, McElenney JE. The auriculotemporal nerve of man. Am J Anat. Apr
1971;130(4):431-40. [Medline].
12. Bergman RA. Anatomy Atlases. Available at http://anatomyatlases.org.
13. Ries MW, Tetz MR, Egelhof T, Volcker HE. [Unilateral trigeminal nerve hypoplasia]. Klin Monbl
Augenheilkd. Jul 1997;211(1):60-4. [Medline].
14. Villanueva O, Atkinson DS, Lambert SR. Trigeminal nerve hypoplasia and aplasia in children with
goldenhar syndrome and corneal hypoesthesia. J AAPOS. Apr 2005;9(2):202-4. [Medline].
15. Tubbs RS, Mortazavi MM, Krishnamurthy S, Verma K, Griessenauer CJ, Cohen-Gadol AA. The
relationship between the superior petrosal sinus and the porus trigeminus: an anatomical study. J
Neurosurg. May 24 2013;[Medline].
16. Wilcox SL, Gustin SM, Eykman EN, Fowler G, Peck CC, Murray GM, et al. Trigeminal Nerve Anatomy in
Neuropathic and Nonneuropathic Orofacial Pain Patients. J Pain. May 16 2013;[Medline].
17. Trigeminal neuralgia. Medscape Reference. Available at http://emedicine.medscape.com/article/1145144-
diagnosis. Accessed March 2010.
18. Medcyclopaedia. Trigeminal Neuropathy. Available at
http://www.medcyclopaedia.com/library/topics/volume_vi_2/t/trigeminal_neuropathy.aspx. Accessed
March 2010.
19. Cates CA, Tyers AG. Results of levator excision followed by fascia lata brow suspension in patients with
congenital and jaw-winking ptosis. Orbit. 2008;27(2):83-9. [Medline].
20. Yamada K, Hunter DG, Andrews C, Engle EC. A novel KIF21A mutation in a patient with congenital
fibrosis of the extraocular muscles and Marcus Gunn jaw-winking phenomenon. Arch Ophthalmol. Sep
2005;123(9):1254-9. [Medline].
21. Tolosa-Hunt Syndrome. Medscape Reference. Available at
http://emedicine.medscape.com/article/1146714-overview. Accessed March 2010.
22. Schoenen J, Jensen RH, Lantri-Minet M, Linez MJ, Gaul C, Goodman AM, et al. Stimulation of the
sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: A randomized, sham-
controlled study. Cephalalgia. Jan 11 2013;[Medline].
23. Sava A, Furnica C, Petreus T, Chistol RO, Motoc AG. Trigeminal nerve: MRI anatomy and case
presentation of trigeminal neuralgia due to arterial compression. Rom J Morphol Embryol.
2012;53(4):1097-102. [Medline].
24. Garca Ron A, Jensen J, Garriga Braun C, Gmez E, Sierra J. [Marin-Amat and inverted Marcus-Gunn
8/12/2014 Trigeminal Nerve Anatomy
http://emedicine.medscape.com/article/1873373-overview#showall 13/13

Medscape Reference 2011 WebMD, LLC
syndrome. Two case reports]. An Pediatr (Barc). May 2011;74(5):324-6. [Medline].