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Objective: Identifying the nerve of origin in head and neck schwannomas is a diagnostic challenge. Surgical management leads to a risk of permanent deficit. Accurate identification of the nerve would improve operative planning and patient counselling., Methods: Three patients with head and neck schwannomas underwent a diagnostic procedure hypothesised to identify the nerve of origin. The masses were infiltrated with 1 per cent lidocaine solution, and the patients were observed for neurological deficits., Results: All three patients experienced temporary loss of nerve function after lidocaine injection. Facial nerve palsy, voice changes with documented unilateral same-side vocal fold paralysis, and numbness in the distribution of the maxillary nerve (V2), respectively, led to a likely identification of the nerve of origin., Conclusion: Injection of lidocaine into a schwannoma is a safe, in-office procedure that produces a temporary nerve deficit, which may enable accurate identification of the nerve of origin of a schwannoma. Identifying the nerve of origin enhances operative planning and patient counselling.

Introduction: Schwannomas are benign tumours that are relatively common in the head, however the involvement of the sinunasal region is rare and there are only 5 cases reported in the maxilla in current literature, representing less than 1% of bone tumours., Clinical Case: We report the case of a woman with a right maxillary schwannoma who underwent a complete resection of the lesion. Emphasis is placed on the rarity of the lesion in terms of its location and includes a review of clinical behaviour, diagnosis and current treatment options., Conclusions: Maxillary trigeminal schwannoma must be suspected if vague sinunasal symptoms, paranasal mass or, as in this case, trigeminal neuralgia present. Surgical treatment is indicated, and approaches vary according to location and tumour size., (Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.)

Introduction: The aim of this study was to describe the anatomical landmarks for maxillary nerve block in the pterygopalatine fossa. The risk of injury to the skull base and maxillary artery was assessed., Methods: This retrospective study was based on the analysis of 61 consecutive computed tomography angiographies obtained from patients suffering from different pathologies. Anatomical relationships between optic canal (OC), foramen rotundum (FR), inferior orbital fissure (IOF) and puncture point (PP) were assessed. A "maxillary section" was virtually carried out on the CTs, following a plane passing through PP, IOF and FR in order to mimic the anaesthesia needle route., Results: No gender difference was observed except for the PP-OC distance that was longer in men. The mean PP-IOF distance was of 31.9 (± 0.7mm). PP-OC (43.9±0.5) and PP-FR (44.2±0.7) distances increased significantly with the patients height (PP-FR=17.25+0.16×height (cm); PP-OC=20.54+0.13×height (cm)). The route to the skull base was curved, with an angle of 168±1.6° at the FR level. The angle to reach the OC was greater than 7°., Discussion: With a 35-mm needle length, the probability to reach the IOF was high (79%), while the risk to injure the skull base (2%) and the optical nerve (0%) was low. Artery injuries were only found in 13% of cases. Therefore, a 35-mm needle length allows for the best efficacy/risk ratio in maxillary nerve block., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Inflammatory pseudotumor (IPT) is a rare benign mass-forming disease that can arise anywhere throughout the body, mimicking a wide spectrum of other conditions. Its diagnosis can be challenging, especially when it involves uncommon sites. The authors report a patient of an atypical localization of IPT, occurred as an enlarging bulk in the infraorbital nerve channel in a patient who presented with facial numbness. Clinical and radiological aspects similar to schwannoma led to misdiagnosis and over-treatment. The differential diagnosis of an infraorbital mass should include IPT and the least invasive treatment should be preferred, as steroid therapy being the first-line treatment for IPT.

Purpose: To investigate the clinical characteristics of idiopathic orbital inflammatory (IOI) disease with infraorbital nerve (ION) enlargement., Design: Retrospective, comparative case series., Participants: Consecutive patients who were diagnosed with IOI between January 2009 and December 2013 were identified. The study included patients whose medical and radiological data at diagnosis were available and whose follow-up period was more than 12 months after treatment. The patients were divided into two groups according to accompaniment of ION enlargement and were compared., Main Outcome Measures: clinical manifestation, radiology and treatment outcome., Results: Among 89 patients with IOI, 12 (13.5%) were identified to have ION enlargement. The ION-enlarged group showed a higher percentage of the patients with diffuse inflammation (66.7%, p<0.001). 91.7% of the ION-enlarged group showed inferiorly located inflammation. Patients with ION enlargement showed a significantly higher incidence rate of proptosis (p=0.013), pain (p=0.004) and altered sensation (p<0.001). The recurrence rate was significantly higher in the ION-enlarged group (83.3%) than in the other group (33.8%) (p=0.001). Repetitive inflammation (recurrence ≥3) with steroid dependency was found only in 19.5% patients without ION enlargement but in 66.7% patients with ION enlargement., Conclusions: Patients with ION-enlarged IOI showed distinct clinical and radiological characteristics. As IOI accompanied by ION enlargement showed significantly higher steroid dependency and recurrence rate, a more careful follow-up of patients during steroid tapering might be helpful to prevent recurrence of IOI., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

This study aimed to evaluate the relationship among the pain region, branches of trigeminal nerve, and the neurovascular compression (NVC) location. A total of 123 consecutive patients with trigeminal neuralgia (TN) underwent endoscope-assisted microvascular decompression according to positive preoperative tomographic angiography. V2 alone was in 51 cases and V3 alone was in 64 cases. The location of NVC was classified into cranial, caudal, medial, or lateral sites. Some patients with multiple regions were recorded as medial + cranial, lateral + cranial, medial + caudal, and lateral + caudal. Twenty-eight (71.8%) of 39 patients with TN (V2) had their NVC at the medial site of the nerve. Twenty-seven (64.3%) of 42 patients with TN (V3) had their NVC at the lateral site of the nerve. There was a statistically significant difference (P = 0.0011 < 0.01, χ2 test). Sixteen (69.6%) of 23 patients with TN(V2) had their NVC at the cranial site of the nerve. Thirty-four (69.4%) of 49 patients with TN (V3) had their NVC at the caudal site of the nerve. There was no statistical difference (P = 0.3097 > 0.01). Evaluation of the relationship between the pain region and the NVC location by endoscopic images during microvascular decompression is more accurate. The second branch is mostly distributed in the medial area, and third branch is mainly distributed in the lateral area.

Objectives: Recent studies revealed that Mikulicz's disease (MD) should be considered as an immunoglobulin (Ig) G4-related disease with aspects of systemic disorders involving the orbit. This study aimed to analyze the relationship between Immunoglobulin G4 (IgG4)-related MD and infraorbital nerve thickness., Methods: We measured infraorbital nerve thickness in 68 patients diagnosed as IgG4-related MD at our hospital and performed computed tomography scans of the head and neck region before treatment and compared these scans with those of the control group., Results: The mean infraorbital nerve diameter (± standard deviation) was 3.2 ± 1.2 mm in patients with IgG4-related MD, and 2.6 ± 0.3 mm in the control group. Infraorbital nerves were significantly thicker in patients with IgG4-related MD. Nerve swelling was found in 20 of 68 patients (29.4%) with a cutoff value of 3.3 mm because this value was obtained from diameter of nerves in the control group + 2 standard deviation mm. No patients in the control group showed nerve swelling. In addition, we found significant correlations between infraorbital nerve swelling and serum IgG4 levels as well as the existence of multiple organ lesions., Conclusions: We found that significant infraorbital nerve swelling occurred in patients with IgG4-related MD and was thought to be a part of IgG4-related disease.

Objective: To describe the clinical, histopathologic, and radiologic features of a recently identified cause for enlargement of the infraorbital canal., Design: Retrospective, noncomparative case series., Participants: Consecutive patients were identified from the orbital databases at Moorfields Eye Hospital, London, England, and the Royal Victorian Eye and Ear Hospital, Melbourne, Australia., Methods: A retrospective, noncomparative review of the clinical case notes, radiology, and histopathology was performed. The English-language medical literature was reviewed for reports of enlargement of the infraorbital canal or nerve., Main Outcome Measures: Extent of clinical and radiologic changes in patients with enlargement of the infraorbital canal., Results: A total of 14 patients (10 male) presented between the ages of 29 and 76 years with proptosis, eyelid swelling or a mass (10/14 cases), and periocular ache (5/14 cases). Clinical evidence of bilateral involvement was present in 6 of 14 patients. None had impairment of visual functions or facial sensation, but 4 of 14 patients had some reduction in ocular motility. Imaging showed a focal orbital mass in 10 of 14 patients (16/28 orbits), and all patients (22/28 orbits) had enlargement of some extraocular muscles. The infraorbital canal was enlarged in 20 of the 28 orbits, with associated ipsilateral orbital changes in 19 of 20 (all 14 patients) and ipsilateral maxillary sinus changes in 12 of 20 (11 patients). Biopsy-proven chronic orbital inflammation was present in all patients; this resembled reactive lymphoid hyperplasia (RLH) in 7 patients and immunoglobulin (Ig) G4-related sclerosing inflammation in 7 patients. When tested, serum IgG4 was elevated in 6 of 7 patients. Clinical or histologically proven enlargement of cervical lymph nodes was present in 7 of 14 patients. All patients responded well to systemic corticosteroid therapy, although some had a relapse upon withdrawal. One patient developed diffuse large B-cell lymphoma and subsequently leukemia, of which he later died 20 years after presentation., Conclusions: Enlargement of the infraorbital nerve and canal is rare and strongly suggests a diagnosis of RLH or IgG4-related disease, especially in the presence of ipsilateral extraocular muscle enlargement, sinus disease, or focal orbital disease., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Infraorbital nerve (ION) transection in neonatal rats leads to disruption of whisker-specific neural patterns (barrelettes), conversion of functional synapses into silent synapses, and reactive gliosis in the brain stem trigeminal principal nucleus (PrV). Here we tested the hypothesis that neonatal peripheral nerve crush injuries permit better functional recovery of associated central nervous system (CNS) synaptic circuitry compared with nerve transection. We developed an in vitro whisker pad-trigeminal ganglion (TG)-brain stem preparation in neonatal rats and tested functional recovery in the PrV following ION crush. Intracellular recordings revealed that 68% of TG cells innervate the whisker pad. We used the proportion of whisker pad-innervating TG cells as an index of ION function. The ION function was blocked by ∼64%, immediately after mechanical crush, then it recovered beginning after 3 days postinjury and was complete by 7 days. We used this reversible nerve-injury model to study peripheral nerve injury-induced CNS synaptic plasticity. In the PrV, the incidence of silent synapses increased to ∼3.5 times of control value by 2-3 days postinjury and decreased to control levels by 5-7 days postinjury. Peripheral nerve injury-induced reaction of astrocytes and microglia in the PrV was also reversible. Neonatal ION crush disrupted barrelette formation, and functional recovery was not accompanied by de novo barrelette formation, most likely due to occurrence of recovery postcritical period (P3) for pattern formation. Our results suggest that nerve crush is more permissive for successful regeneration and reconnection (collectively referred to as "recovery" here) of the sensory inputs between the periphery and the brain stem.

The vast majority of periocular squamous cell carcinoma spreads intraorbitally along the supraorbital and infraorbital nerves into the cavernous sinus. A patient presented with a history of resected squamous cell carcinoma and pain in the zygomatic distribution. She was found to have temporalis involvement of the malignancy and invasion of the zygomaticotemporal nerve by histopathology. She underwent aggressive resection and adjuvant treatment with no evidence of recurrence at 8-month follow up. This case illustrates an uncommon route of squamous cell carcinoma spread through the zygomaticotemporal sensory nerve distribution.

Background: Infraorbital schwannoma is a benign tumor of the peripheral nerve seath composed of Schwann cells. Usually occurs between 20 and 70 years of age, are usually asymptomatic and can cause progressive, painless proptosis during growth., Clinical Case: A 32-year-old male admitted to ophthalmologic hospital with a painless, slowly progressive mass above the left lacrimal sac. At the ophthalmologic examination the tumor had a rubbery consistency and was firmly attached to the surrounding structures. The transillumination was negative. The B mode ultrasound disclosed a phakic eye as well as an infraorbital well-circumscribed homogeneous mass with a largest diameter of 19.7 mm, without involvement of the lacrimal pathway. The A mode ultrasound showed medium-high reflectivity with small internal vascularity. The computed tomography showed a homogeneous wellcircumscribed solid mass anterior and inferior to the left globe without bony erosion. Through subdermic incision the mass was excised. The histopathological diagnosis was "Infraorbital schwannoma"., Conclusions: The schwannoma is a rare benign tumor in the orbit, few cases have been reported. The definitive diagnosis is made by histopathologic findings as the presence of a true capsule, hyper-and hypocellular areas, thickening and hyalinization of the vessel walls. When these findings are not be confused with benign fusocellular tumors. We report a new case of infraorbital schwannoma and compared it with those cases previously reported.

The zygomatic nerve (ZN), which originates from the maxillary nerve at the pterygopalatine fossa, enters the orbit through the inferior orbital fissure. Within the lateral region of the orbit, the ZN divides into the zygomaticofacial (ZF) and zygomaticotemporal (ZT) nerves. The ZF and ZT nerves then pass on to the face and temporal region through the zygomaticoorbital foramen and enter their own bony canals within the zygomatic bone. However, multiple zygomaticofacial and zygomaticotemporal canals (ZFCs and ZTCs, respectively) can be observed, and their detailed intrabony courses are unknown. The aim of this study was clarify the three-dimensional intrabony courses and running patterns of the ZFCs and ZTCs, both to obtain a detailed anatomical description and for clinical purposes. Fourteen sides of the zygomatic bones were scanned as two-dimensional images using a micro-computed tomography (CT), with 32-μm slice thickness. Intrabony structures of each canals were three-dimensionally reconstructed and analyzed using Mimics computer software (Version 10.01; Materialise, Leuven, Belgium). We found that some ZTC was originated from ZFC. In 71.4% of the specimens, the ZTC(s) divided from the intrabony canal along the course of the ZFC(s). In other cases, 28.6% of ZTCs were opened through each corresponding ZT foramen. Zygomaticofacial canal originates from zygomaticoorbital foramen, divided into some of ZTCs, and is finally opened as ZF foramen. This new anatomical description of the intrabony structures of the ZFC(s) and ZTC(s) within the zygomatic bone by micro-CT technology provided helpful information to surgeons performing clinical procedures such as Le Fort osteotomy and reconstructive surgeries in the midface region.

Introduction: Accurate localisation of the greater palatine foramen (GPF) is imperative while negotiating the greater palatine canal for blocking the maxillary nerve within the pterygopalatine fossa. The aim of this study was to define the position of the foramen relative to readily identifiable intraoral reference points in order to help clinicians judge the position of the GPF in a consistently reliable manner., Methods: The GPF was studied in 100 dried, adult, unsexed skulls from the state of Maharashtra in western India. Measurements were made using a vernier caliper., Results: The mean distances of the GPF from the midline maxillary suture, incisive fossa, posterior palatal border and pterygoid hamulus were 14.49 mm, 35.50 mm, 3.40 mm and 11.78 mm, respectively. The foramen was opposite the third maxillary molar in 73.38% of skulls, and the direction in which the foramen opened into the oral cavity was found to be most frequently anteromedial (49.49%). In one skull, the greater and lesser palatine foramina were bilaterally absent. Except for the invariably present incisive canals, there were no accessory palatal foramina, which might have permitted passage of the greater palatine neurovascular bundle in lieu of the absent GPF. To the best of our knowledge, this is the first study of such a non-syndromic presentation., Conclusion: The GPF is most frequently palatal to the third maxillary molar. For an edentulous patient, the foramen may be located 14-15 mm from the mid-palatal raphe or about 12 mm anterior to the palpable pterygoid hamulus.

Purpose: To investigate the frequency of infraorbital nerve enlargement (IONE) in orbital lymphoproliferative disorders, and to show that IONE can contribute to the clinical diagnosis of IgG4-related orbital diseases (IgG4-ROD)., Subjects and Methods: 71 cases in which orbital lymphoproliferative disorders were diagnosed at Okayama Medical Center and Mitoyo General Hospital from April, 2004 to March, 2011 were investigated. The male-to-female ratio was 39:32, and the age range 27-87 years old (average age 64.1 years). Whenever the coronal section of the infraorbital nerve was larger than that of the optic nerve on MRI, it was defined as IONE., Results: The breakdown of the 71 cases was: 45 cases of non-Hodgkin lymphoma, 16 cases of IgG4-ROD, 5 cases of reactive lymphoid hyperplasia, and 5 cases of idiopathic orbital inflammation. Of these, a total of 9 cases had IONE. The incidence of IONE was compared between the IgG4-ROD patient group and the non-IgG4-ROD patient group and was significantly higher in the IgG4-ROD patient group (p < 0.0001)., Conclusion: If IONE is observed in a case of orbital lymphoproliferative disorders on MRI, then it is highly possible that such a case is IgG4-ROD.

Purpose: The aim of our study was to examine the relation between autoimmune pancreatitis (AIP) and infraorbital nerve swelling., Materials and Methods: A total of 11 AIP patients underwent magnetic resonance imaging (MRI) examination of the head and neck region. The infraorbital nerve thicknesses were measured on coronal images and compared with those of a control group. We also examined whether the infraorbital nerve thicknesses were altered from before to after steroid therapy in nine patients who underwent MRI examination after such therapy., Results: The mean thicknesses were 3.8 ± 2.0 mm in the AIP group and 2.6 ± 0.5 mm in the control group (P < 0.05). The nerve thicknesses were >5 mm in 5 of 11 patients (45%) in the AIP group, and <5 mm in all of the control group. Among the nine patients who underwent MRI examination after steroid therapy, three had shown nerve swelling before steroid therapy; the therapy diminished the swelling in all three patients., Conclusion: Infraorbital nerve swelling was observed more frequently in AIP patients than in patients without a history of AIP. Therefore, such swelling seems to be an extrapancreatic lesion of AIP.

A 66-year-old man came to the hospital with pain in the frontal left side of his upper jaw. Pressure along the left nostril could evoke a sharp pain, which radiated upwards. The patient had already consulted several specialists. After extended clinical and radiological investigation a mesiodens was found that gave pressure on the nasopalatine nerve.

Background: Endonasal and infrazygomatic pterygopalatine ganglion (PPG) block for facial pain provides pain relief in a broader area than expected on anatomic grounds. The aim of this study was to search for neural structures in the pterygopalatine fossa (PPF) that could explain unexpected pain relief after PPG blockage., Methods: The neural PPF content was explored through human cadaver study and nerve-specific staining. Five human PPF specimens were dissected as whole-mount preparations with the aid of an operation microscope and stained for acetylcholinesterase. One of these specimens was partially sectioned and analyzed through nitric oxide synthase (NOS) immunohistochemistry., Results: A previously unknown nerve was identified. The nerve runs between the PPG and the ophthalmic nerve and was identified in all five specimens. NOS-containing nerve fibers were present but did not occupy the complete nerve area., Conclusion: Because it is likely that the nerve contains sensory fibers, our findings may provide an anatomic basis for unexplained pain relief in the ophthalmic area after PPG blockage.

Objectives: We investigated the bulging and dehiscence of neurovascular structures in the sphenoid sinus and their relationships to the pneumatization of the sphenoid sinus., Methods: One hundred sagittally hemisected cadaveric heads were examined. The degree of pneumatization of the sphenoid sinus was determined. Bulging and dehiscence of the internal carotid artery (ICA), optic nerve, maxillary nerve, and vidian nerve were examined, and the distances between these structures and the anterior or superior wall of the sphenoid sinus were measured. Additionally, the degree of bony thickness over these structures was determined., Results: The prevalences of bulging of the optic nerve, segments 1 and 3 of the ICA, and the maxillary and vidian nerves were 56%, 34%, 65%, 41%, and 52%, respectively. The greater the degree of pneumatization, the more frequently did the structures bulge into the sphenoid sinus. The optic nerve was found to be in close proximity to the anterior and superior walls of the sphenoid sinus. The bone over the surrounding structures was very thin, especially for the complete sellar type., Conclusions: The prevalence of bulging of the optic nerve, the ICA, and the maxillary and vidian nerves increased in proportion to the degree of sphenoid sinus pneumatization.

Introduction: The intracranial evolution of cutaneous melanoma is usually due to metastases. Neurotropic invasion mainly concerns the trigeminal and the facial nerves. The melanoma is a rare entity among neurotropic tumors., Observation: A patient presented with a desmoplastic melanoma of the lower lid, complicated by a perineural extension to the cavernous sinus and the mandibular nerve via the maxillary nerve., Discussion: This neurotropic evolution should be carefully monitored when close to a nerve. Extensive surgical excision including peripheral nerves in the vicinity of such tumors is recommended. MRI should be performed when a motor or sensitive disorder appears in the course of a desmoplastic melanoma.

Object: Achieving microscopically tumor-free margins during resection of skull base malignancies has consistently been identified as a positive prognostic factor for patient survival. When malignancies extend perineurally into the major nerves traversing the skull base and entering the cavernous sinus, achieving tumor-free margins can be challenging and typically necessitates performing a craniotomy to access the lateral wall of the cavernous sinus. This report describes a novel technique used to access and resect malignancy extending perineurally into the intracranial portion of V2 via the maxillary sinus., Methods: Seven patients with maxillary sinus tumors and perineural extensions along V2, who underwent resection of the primary tumor and transmaxillary intracranial exposure and dissection of the maxillary nerve to achieve maximal tumor resection, were analyzed. Prospectively collected data, including symptoms, clinical signs, diagnostic imaging data, pathological diagnosis, incidence and nature of complications, adjuvant therapies, and oncological outcomes, were retrospectively analyzed., Results: All patients in this cohort had trigeminal nerve symptomatology as well as abnormal enhancement in the pterygopalatine fissure as noted on magnetic resonance imaging. The transmaxillary exploration of the maxillary nerve technique was used in all seven patients, resulting in gross-total resection of the tumors in every patient. At the last follow-up (mean 30 months, range 13-58 months, in four of seven patients for > 2 years), six patients were alive without evidence of local disease. One patient with squamous cell carcinoma died of progressive infratemporal fossa and regional neck disease 26 months after resection. No intracranial or cavernous sinus disease was present., Conclusions: This technique extended the limits of resection without the need for a craniotomy and improved local tumor control in this patient cohort.

Background: Endoscopic endonasal procedures for advanced lesions involving the pterygopalatine fossa (PPF) and its various communications are increasingly performed. The maxillary division of the trigeminal nerve (V2) passes through the foramen rotundum and crosses the upper part of the PPF, with a risk of partial or complete injury during surgery in this complex region. Despite the available knowledge of the sinonasal anatomy, the endoscopic orientation of the V2 remains unclear and requires further analysis from this unique view., Methods: Using an extended endoscopic approach, the PPF was dissected in 20 sides of 10 adult cadaver heads. The V2 also was followed anteriorly from the trigeminal ganglion, toward the infraorbital canal. The course and the neurovascular relationships of the V2 were studied. High-quality endoscopic images have been produced by coupling the video camera to a digital video recording system., Results: The endoscopic course and relations of the V2 were carefully described. Important landmarks to identify and avoid injury of the nerve were discussed in relation to this unique view., Conclusion: This study updates our understanding of the V2 anatomy from an endoscopic perspective. The medial to lateral inclination and drooping of the V2, as well as different relationships of the V2 with the vascular structures are important findings to be taken into consideration while endoscopically addressing related lesions.

Purpose: To present three cases of chronic infraorbital nerve hyperesthesia relieved by surgical decompression of the infraorbital nerve., Methods: Retrospective chart review., Results: We identified three cases of chronic hyperesthesia of the infraorbital nerve. Two cases were related to previous blunt orbital trauma, whereas the third was associated with a long-standing anophthalmic socket with numerous previous surgeries. In each case, patients had dramatic relief of infraorbital nerve hyperesthesia and pain after surgical decompression of the infraorbital nerve., Conclusions: Surgical decompression of the infraorbital nerve can provide significant symptomatic improvement in patients with chronic infraorbital nerve hyperesthesia secondary to nerve compression.

This study was conducted to quantify the change in the number and size of myelinated nerve fibers of the maxillary nerve with tooth loss in humans. We carried out a morphometric analysis to compare the number and size of myelinated nerve fibers in the human maxillary nerve between four dentulous and four edentulous jaw cases. Our results indicated that the number of axons decreased by approximately 13,000 with tooth loss. The average size of axons remained unchanged, but there was a change in the fiber size distribution, namely the loss of a large number of small-sized axons was accompanied by the total disappearance of small number of large-sized axons.

The aim of the study was to evaluate facial pain clinically and to determine the frequency with which structural lesions were diagnosed by means of magnetic resonance imaging in a sample of patients with facial pain, including refractory trigeminal neuralgia and atypical facial pain. Fifty-two patients with facial pain were examined clinically, and treatment protocols were adopted for trigeminal neuralgia and atypical facial pain. The patients with atypical symptoms and those who did not to respond to the treatment underwent magnetic resonance imaging to screen for intracranial lesions. Magnetic resonance images of 38 patients were obtained. The female-to-male ratio of the patient population was 32:20. The mean age of the patients was 57.15 +/- 11.49 years. Intracranial lesions were diagnosed in 24 patients. Ten patients had no intracranial pathoses visible on magnetic resonance images. Four patients had other pathoses that were not related to the facial pain. The most frequently observed extracranial pathologic change was sinusitis. It may not be possible to reliably identify high-risk patients for selective magnetic resonance imaging on the basis of a clinical evaluation alone. Routine magnetic resonance imaging for all patients with facial pain is recommended to exclude intracranial lesions.

Objective: Elevation of the lateral orbital rim and zygomatic arch during an orbitozygomatic craniotomy requires a bone cut across the zygoma, which commonly extends into the lateral edge of the inferior orbital fissure. The zygomaticofacial foramen has been identified as a superficial landmark for the cut that extends into the inferior orbital fissure. This study examined the usefulness of the zygomaticofacial foramen during orbitozygomatic craniotomy., Methods: One-hundred two dry hemicrania were used in this study. The zygomaticofacial foramen was considered to be related to the inferior orbital fissure when it was located on the zygoma in the area between lines extending in the medial-to-lateral direction along the long axis of the fissure and crossing the anterior and posterior ends of the lateral edge of the fissure., Results: The zygomaticofacial foramen varied from being absent to representing as many as four small openings. A single foramen was observed in one-half of the specimens. Of the 115 zygomaticofacial foramina, 93 were related to the inferior orbital fissure. Among the 51 specimens with a single foramen, 49 foramina met the criteria for being related to the inferior orbital fissure; in those cases, there would have been no difference in the amount of bone resected using the inferior orbital fissure or the zygomaticofacial foramen as the landmark for the zygomatic cut., Conclusion: The zygomaticofacial foramen was a reliable landmark for locating the inferior orbital fissure and making the cut across the zygoma in only 50% of the specimens.

Objective: This retrospective study evaluates the results after orthognathic surgery in a group of patients with juvenile rheumatoid arthritis., Methods: The material comprised sixteen patients where genioplasty with or without bilateral sagittal split (BSSO) had been performed during a 10-year period between 1991 and 2000. The patients were recalled for follow-up examination and the clinical records and radiographs of the patients were analysed., Results: All patients reported an improved facial esthetics. Sixty-two% reported altered neurosensory dysfunction in the inferior alveolar nerve, but no patients reported altered feelings to interfere with function. Two patients reported reduction in pain in the TMJ from a score 10 and 7 in the VAS-scale preoperatively, to 0 after the orthognathic surgery. Eight of the patients reported this to be less uncomfortable compared to other surgical procedures because of their JRA. Ninety-four% noted a positive social change after the operation., Conclusion: Orthognathic surgical treatment of the JRA patient improves the facial profile. The described procedures are safe and serious complications were not seen in our study.

Background: Trigeminal neuralgia is a painful neurological disorder that affects one or more of the divisions of the trigeminal nerve. It is characterized by brief attacks of stabbing pain that can be excruciating. These attacks may be triggered by a light touch, shaving, or even eating. There has been much debate over the exact etiology of trigeminal neuralgia. One of the main theories is vascular compression of the trigeminal nerve as it leaves the brainstem. Another theory suggests that intracranial tumors--particularly those located in the posterior fossa--may be the cause. Trigeminal neuralgia is also associated with multiple sclerosis., Case Report and Review: A 79-year-old man came to the eye clinic with signs and symptoms consistent with trigeminal neuralgia involving the ophthalmic and maxillary divisions of the nerve. A neurological evaluation confirmed the diagnosis, and proper medical treatment was subsequently implemented to relieve his pain., Conclusion: Patients who manifest symptoms consistent with trigeminal neuralgia should be referred for a neurological evaluation, including MRI. With the proper medical and/or surgical treatment, the quality of life of these patients can increase dramatically.

Purpose: To report infraorbital nerve dysfunction after laser in situ keratomileusis., Design: Observational case report., Methods: Neuro-ophthalmologic examination with brain and orbital magnetic resonance imaging (MRI) and orbital computed tomography (CT)., Results: During laser in situ keratomileusis, two healthy women, aged 42 and 46 years, experienced acute onset of sharp ipsilateral cheek pain. Both cases occurred during manipulation of the eyelid speculum. Postoperatively, ipsilateral numbness and tingling or pain of the upper cheek was reported, and examination showed decreased sensation in the distribution of the infraorbital nerve. In both cases, brain and orbit MRI and orbit CT were normal. Both patients were managed medically. In one patient, mild symptoms persisted 1 year postoperatively, and in the second patient, moderate discomfort persisted 8 months postoperatively., Conclusion: Infraorbital nerve palsy is a potential complication of laser in situ keratomileusis. Symptoms improve but may persist.

Although inferior alveolar and lingual nerve injuries appear to occur more often, there are undoubtedly cases of ION injury that require evaluation and possible surgical intervention by the oral and maxillofacial surgeon. Patients with ION injuries will require a neurosensory examination for the determination of the level of sensory impairment, or the localization of pain of peripheral origin (centrally mediated pain will not benefit from peripheral nerve surgery). The surgical management of ION injury might be as relatively simple as decompression of the nerve by reduction of a zygomatic complex fracture, or may require extensive mobilization of the nerve and surrounding soft tissue and bone to allow for primary anastomosis or a nerve autograft. In specific instances, improvement in ION sensory function or alleviation of pain within the distribution of the ION can be expected.

We describe the morphology, functional capabilities, and clinical anatomical implications of the medial portion of the temporalis muscle. Although recognized in Brazilian, German, French, and Hispanic American textbooks of anatomy, this portion of the temporalis has been unappreciated in those published in England and the United States. Given its morphology, and functional anatomy as revealed in this paper, we conclude that the medial portion of the temporalis could entrap the maxillary nerve and its zygomatic branches inside the pterygopalatine fossa. On these bases we identify this portion of the temporalis as a possible factor in the etiology of some forms of tic douloureux., (Copyright 2001 Wiley-Liss, Inc.)

Carcinomas of the hard or soft palate are known to spread perineurally along palatine branches of the maxillary nerve. Imaging of perineural tumor spread from the palate has been underemphasized in the imaging literature. We report the findings from eight patients in whom spread from primary cancers of the palate was seen along the palatine nerves. Indications of perineural spread include enlargement or excessive enhancement of a nerve, or abnormal density/signal intensity, enhancement, or widening of the pterygopalatine fossa, cavernous sinus, or Meckel's cave.

Background: Nasopharyngeal carcinoma (NPC) may infiltrate the pterygopalatine fossa (PPF) and the maxillary nerve. This study illustrates involvement of the maxillary nerve in the PPF with perineural spread to the cavernous sinus., Methods: One hundred and fourteen patients with proven NPC were studied using magnetic resonance imaging (MRI) and computed tomography (CT). The images were retrospectively reviewed for PPF infiltration and maxillary nerve involvement., Results: Seventeen (15%) patients showed infiltration of the PPF. Four patients had maxillary nerve involvement and a perineural spread to the cavernous sinus. Of the 17 patients with PPF infiltration, 8 (47%) patients showed hypoesthesia in the distribution of the infraorbital nerve. All 4 patients with contrast-enhancement of the maxillary nerve exhibited infraorbital neuropathy., Conclusion: Infiltration of the maxillary nerve in the PPF with intracranial spread is uncommon but should be suspected in patients with infraorbital neuropathy. This is important as it affects both prognosis and radiation treatment planning.

Following dentofacial surgical procedures, teeth in segments often do not sense thermal or electric stimuli. This study was undertaken to assess changes in the neural component of the dental pulp after posterior maxillary and mandibular segmental osteotomies, with or without interpositional autogenous bone grafting, in 26 Chacma baboons. Innervation was assessed histologically immediately after operation, and at 3, 6, 12 and 18 months. Statistically significant differences were present between the experimental and control groups. Even after 18 months no nerves were present in any of the mandibular teeth. In maxillary teeth, 50 per cent had demonstrable nerves in the graft group and 40 per cent in the no graft group. As nerve degeneration was present in the experimental teeth, patients should be warned of possible change in tooth sensibility, following these operations. Careful post-operative follow up for long periods in humans following dentofacial surgical procedures is thus essential.

Contiguous spread along perineural and endoneural spaces, that is, perineural tumor extension, in cutaneous squamous cell carcinoma is fairly common. Infrequently, these tumors spread and involve intracranial structures. One consequence of this complication is meningeal carcinomatosis which is underrecognized. Herein described is a patient with recurrent cutaneous squamous cell carcinoma with perineural invasion along the maxillary nerve that was subsequently shown by magnetic resonance imaging to the trigeminal root. The patient initially presented with a cavernous sinus syndrome but despite aggressive treatment, extensive meningeal carcinomatosis and cauda equina dysfunction developed. Awareness of perineural invasion and proper evaluation are crucial. Perineural spread intracranially worsens the prognosis and limits treatment options to palliation.

This report describes what the authors believe to be the first reported case of choristoma of the intracranial maxillary nerve. This 12-year-old girl presented with a 5-year history of severe isolated left-sided trigeminal neuralgia. Computerized tomography and magnetic resonance imaging revealed a mass below the anterior portion of the left cavernous sinus, enlarging the foramen rotundum. Total resection was achieved via a pterional extradural approach. Histological examination revealed a choristoma composed of smooth-muscle fibers. The histogenesis of these tumors when they develop in a nerve remains unclear. They may represent abnormal migration or proliferation of neuroectodermal tissue in or close to a peripheral nerve. Total removal of these tumors should be attempted at initial diagnosis.

Vacuum disorders of the paranasal sinuses are well described. Patients with facial pain in the distribution of the infraorbital nerve are often labelled as suffering from a "vacuum maxillary sinusitis" and empirically treated by intranasal antrostomy. A variety of mechanisms have been postulated for the production of symptoms in this condition, but all ignore the fact that the maxillary sinus is a relatively insensitive structure. This article introduces a dehiscence of the bony infraorbital nerve canal within the antrum as an anatomic variant and suggests that it may provide the anatomic basis for vacuum sinusitis in the presence of a small natural ostium. Definitive diagnosis is made by outpatient antroscopy, and surgical treatment takes the form of a middle or inferior meatal antrostomy. Persistent symptoms may benefit from an infraorbital neuropexy to provide added protection to the exposed nerve.

Glycerol was injected into the infraorbital canal of 12 rats to determine neurolytic effects on the peripheral trigeminal nerve. Saline and 90% ethanol were injected in control animals. One week after the injection, histopathological changes were noted in both glycerol and alcohol groups. In the former group, axonolysis and demyelination were restricted to the outer zone of the nerve bundles. Centrally located axons remained undamaged. A total destruction of all axons was found in the alcohol group. Four weeks after the injection in the glycerol group, small sized axons with thin myelin replaced damaged axons at the periphery of the bundle. No signs of regeneration were noted in the alcohol group. A possible mode of action of glycerol injected at the peripheral trigeminal nerve in relieving trigeminal neuralgia is described.

Herpes zoster virus (HZV) infection, particularly of the trigeminal nerve, can be a disabling and disfiguring condition with variable clinical presentations. Acyclovir is a highly effective treatment modality during the acute clinical phase; however, pain control may be very difficult particularly with protracted and severe post herpetic neuralgia (PHN). The clinicopathologic features are reviewed and two cases in immunosuppressed patients with HZV infection of different divisions of the trigeminal nerve are presented.

Seven patients had occult malignant neoplasms either originating in or extending to the infratemporal fossa. Common symptoms were facial pain centered over the temporomandibular joint and facial numbness. These symptoms were sometimes associated with middle ear effusion and trismus. Multiple biopsies are often necessary to establish the diagnosis. The average delay in diagnosis from first symptom was 14 months. Infratemporal fossa neoplasia belongs in the differential diagnosis of facial pain.

The findings of this experimental foetal rat study have shown that transection of the peripheral branches of the maxillary and facial nerves on the 18th day of gestation is followed by axonal degeneration and regeneration. Although these processes are similar to those which occur in the adult animal, they occur more rapidly in the foetus. In this study the regenerating axons had crossed the wound and entered the neural tubes of the distal nerve segments by 24 hours after injury.