Temporal, Infratemporal & Pterygopalatine BY Dr.RIG.pptx

Gross Anatomy

1. Temporal, Infratemporal , Pterygo -palatine Fossa And Pterygopalatine Ganglion Dr. Rabia Inam Gandapore Assistant Professor Head of Department Anatomy (Dentistry-BKCD) B.D.S (SBDC), M.Phil. Anatomy (KMU), Dip. Implant (Sharjah, Bangkok, ACHERS) , CHPE (KMU),CHR (KMU), Dip. Arts (Florence, Italy )

2. Teaching Methodology LGF (Long Group Format) SGF (Short Group Format) LGD (Long Group Discussion, Interactive discussion with the use of models or diagrams) SGD (Short Group) SDL (Self-Directed Learning) DSL (Directed-Self Learning) PBL (Problem- Based Learning) Online Teaching Method Role Play Demonstrations Laboratory Museum Library (Computed Assisted Learning or E-Learning) Assignments Video tutorial method 2

3. Goal/Aim (main objective) To help/facilitate/augment the students about the : Describe features of P terygopalatine G anglion . Explain connections of Pterygopalatine G anglion Describe branches of Pterygopalatine G anglion. Enumerate relevant clinical problems related to Pterygopalatine Ganglion . 3

4. Specific Learning Objectives (cognitive) At the end of the lecture the student will able to: Describe features of Pterygopalatine Ganglion. Explain connections of Pterygopalatine Ganglion Describe branches of Pterygopalatine Ganglion. Enumerate relevant clinical problems related to Pterygopalatine Ganglion. Sketch labeled diagram of Pterygopalatine Ganglion, its connections & branches 4

5. Psychomotor Objective: (Guided response) A student to draw labelled diagram of Pterygopalatine Ganglion, its connections & branches 5

6. Affective domain To be able to display a good code of conduct and moral values in the class. To cooperate with the teacher and in groups with the colleagues. To demonstrate a responsible behavior in the class and be punctual, regular, attentive and on time in the class. To be able to perform well in the class under the guidance and supervision of the teacher. Study the topic before entering the class. Discuss among colleagues the topic under discussion in SGDs. Participate in group activities and museum classes and follow the rules. Volunteer to participate in psychomotor activities. Listen to the teacher's instructions carefully and follow the guidelines. Ask questions in the class by raising hand and avoid creating a disturbance. To be able to submit all assignments on time and get your sketch logbooks checked . 6

7. Lesson contents Clinical chair side question: Students will be asked if they know where is pterygopalatine Ganglion Outline: The facilitator will explain the student's Activity 1 Describe features of Pterygopalatine Ganglion. Explain connections & branches of Pterygopalatine Ganglion Enumerate relevant clinical problems related to Pterygopalatine Ganglion . Activity 2 The facilitator will ask the students to make a labeled diagram of the Pterygopalatine Ganglion, its connections & branches Activity 3 The facilitator will ask the students a few Multiple Choice Questions related to it with flashcards. 7

8. Recommendations Students assessment: MCQs, Flashcards, Diagrams labeling. Learning resources: Langman’s T.W. Sadler, Laiq Hussain Siddiqui, Snell Clinical Anatomy , Netter’s Atlas , BD Chaurasia’s Human anatomy, Internet sources links. 8

9. Temporal Fossa 9

10. Temporal Fossa T emporal fossa is a shallow depression on side of skul l bounded by temporal lines ( Inferior & Superior temporal lines ) & terminating below level of zygomatic arch . 10

11. Boundaries Media l: Os frontale , os parietale , os temporale (Squamous), os sphenoidale , os occipital (bones of neurocranium - Protective covering around brain). Lateral: Temporal fascia Anterior: P osterior surface of frontal process of zygomatic bone & posterior surface of zygomatic process of frontal bone Superior: P air of temporal lines (superior & inferior) that arch across the skull from the zygomatic process of the frontal bone to the supra mastoid crest of the temporal bone Inferior: Z ygomatic arch laterally & by infratemporal crest of greater wing of sphenoid medial . 11

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13. Contents Temporalis muscles & Fascia Deep temporal arteries & Veins Deep temporal nerves (Sensory, brance of anterior division of mandibular division of trigeminal nerve) Superficial temporal artery (from external carotid) Zygomaticotemporal nerve (Parietal) Auriculotemporal nerve (Sensory, V3-Trigeminal) 13

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16. Infra-temporal Fossa 16

17. Infratemporal Fossa I nfratemporal fossa is an irregularly shaped cavity, situated below & medial to zygomatic arch. Boundaries defined by: Anteriorly: by infratemporal surface of maxilla & ridge which descends from its zygomatic process (above Articular tubercle) Posteriorly: by articular tubercle of temporal & spina /spine angularis of sphenoid, Carotid sheath Superiorly (roof): by greater wing of sphenoid below the infratemporal crest & by the under surface of temporal squamous , containing foramen ovale , which transmits the mandibular branch of trigeminal nerve & foramen spinosum , which transmits middle meningeal artery. 17

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21. Inferiorly (floor): by medial pterygoid muscle attaching to mandible Medially: by lateral pterygoid plate Laterally: by ramus of mandible , which contains the mandibular foramen , leading to mandibular canal , through which the inferior alveolar nerve passes. This also contains lingula , a triangular piece of bone that overlies the mandibular foramen anteromedially . Finally, mylohyoid groove descends obliquely transmitting the mylohyoid nerve the only motor branch of posterior division of trigeminal nerve . 21

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23. Contents of infratemporal fossa Muscles: Lower part of temporalis & masseter muscles (origin of masseter muscle: lower margin of the inner surface of the zygomatic bone insertion: the outer surface of ramus of mandible ) Lateral & medial pterygoid muscles 23

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25. Vessels I nternal maxillary vessels, consisting of maxillary artery originating from external carotid artery & its branches. Infratemporal fossa Internal maxillary branches found within the infratemporal fossa include the: Middle meningeal artery Inferior alveolar artery Deep temporal artery Buccal artery 25

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28. Veins and nerves Veins: Pterygoid venous plexus Nerves: Mandibular nerve & branches I nferior alveolar nerve L ingual nerve B uccal nerve C horda tympani nerve (branch of facial) Auriculotemporal Lesser petrosal O tic ganglion. 28

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31. Openings of infratemporal fossa connect it with different cavities and fossae of skull. Foramen ovale : connects infratemporal fossa with middle cranial fossa . It transmits mandibular nerve (CN V3), lesser petrosal nerve, accessory meningeal branch of maxillary artery & emissary vein. Foramen spinosum :   also connects it with middle cranial fossa of internal cranial base. It serves as a passage for meningeal branch of mandibular nerve (CN V3) & middle meningeal artery and vein. Petrotympanic fissure: located on  temporal bone and serves as a passage for chorda tympani (branch of facial nerve, CN VII) between tympanic cavity & infratemporal fossa. Pterygomaxillary fissure:   connects infratemporal fossa with pterygopalatine fossa & transmits the terminal part of maxillary artery, superior alveolar nerve (branch of the maxillary nerve - CN V2). 31

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33. Petrotympanic Fissure 33

34. P etrotympanic fissure Is a small crevice located in the  temporal bone . It splits the mandibular fossa: Anteriorly: via articular tubercle   Posteriorly: via tympanic portion of temporal bone. Via this fissure , chorda tympani travel inside infratemporal fossa . 34

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36. Structure A ppears as a 2 mm long tiny slit. It holds anterior malleus ligament & anterior protuberance . It also allows passage to anterior tympanic branch in internal  maxillary artery . 36

37. Function It enables interaction of middle ear along with TMJ . It gives tongue with special sensory innervation for taste . It transmits: Chorda tympani. Anterior ligament of malleus. Anterior tympanic branch of maxillary artery. 37

38. Relations comprise of connections of  cranial nerve VII  towards the infratemporal fossa. C horda tympani is a branch of cranial nerve VII , travels via the fissure in order to connect with   lingual nerve  towards the anterior two-third of tongue supplying sensory innervation for taste . 38

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41. Contents Contains discomalleolar ligament  that gives a little stability to p osterior connection of disc & anterior malleolar part of sphenomandibular ligament . Petrotympanic fissure conveys: Chorda tympani nerve--branch of facial nerve. Anterior tympanic artery--branch of first part of maxillary artery. Anterior ligament of malleus. 41

42. Clinical Relevance Tension on anterior malleolar ligament  and, discomalleolar ligament is accountable for some of ear-related problems of tympanic membrane damage and hearing damage. 42

43. Pterygopalatine Fossa Insert your name here

44. Pterygo -Maxillary Fissure Vertical fissure that lies within the fossa between the pterygoid process of sphenoid bone & back of maxilla . It leads medially into the pterygo -palatine fossa 44

45. Pterygopalatine or sphenopalatine fossa F ossa in skull . Its cone-shaped paired depression deep to infratemporal fossa & posterior to the maxilla on each side of skull, located between pterygoid process & maxillary tuberosity, close to apex of orbit . Its intended area medial to pterygomaxillary fissure leading into sphenopalatine foramen . 45

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47. Communications It communicates with Oral & nasal cavities: Medially through sphenopalatine foramen Infratemporal fossa: Laterallay through pterygomaxillary fissure O rbit: AnterioSuperiorly through Inferior orbital fissure Pharynx & middle cranial fossa: through eight foramina , Skull: PosterioSuperiorly via foramen rotendum . Palate: Inferiorly Greater & Lesser palatine canals (its nerves & vessels) 47

48. Contents 1 boundaries 2 passages 3 contents 48

49. 1. Boundaries It has the following boundaries: Anterior : superomedial part of infratemporal surface of maxilla Posterior : root of pterygoid process & adjoining anterior surface of the greater wings of sphenoid bone Medial : perpendicular plate of palatine bone & its orbital and sphenoidal processes Lateral : pterygomaxillary fissure Inferior : part of floor is formed by pyramidal process of palatine bone 49

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51. 2. Passages connect fossa with other parts of skull Direction Passage-Contains Connection /Connects Superiorly Foramen rotundum (Opens into pterygopalatine fossa( Pterygopalatine ganglion suspended in it, V2 (maxillary nerve) Middle cranial fossa Posteriorly Pterygoid canal/ Vidian ( ptergopalatine ganglion gives branch posteriorly-- Vidian nerve (enters via foramen lacerum ) Middle cranial fossa, foramen lacerum Anteriorly Inferior orbital fissure (V2 maxillary division of trigeminal) Orbit Medially Sphenopalatine foramen (V2) Posteriorly: Palatovaginal canal / Pharyngeal branch of maxillary nerve V2 -Nasal cavity - Nasopharynx Laterally Pterygomaxillary fissure Infratemporal fossa Inferiorly Lesser & Greater Palatine canal / pterygopalatine ) contains Greater & Lesser Palatine Nerves(V2) Oral cavity 51

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53. 53 Pterygopalatine ganglion/ Sphenopalatine ganglion of hay fever/ meckels ganglion

54. 3. Contents P terygopalatine ganglion is suspended by nerve roots from maxillary nerve . Terminal third of maxillary artery . M axillary nerve V2, which is the nerve of pterygoid canal , a combination of greater petrosal nerv e (preganglionic parasympathetic) & deep petrosal nerve (post ganglionic sysmpathetic ) forms plexus around internal carotid artery and together they go in pterygopalatine canal . To obtain block anesthesia of entire second division of trigeminal nerve , an intraoral injection can be administered into this area 54

55. Pterygopalatine ganglion Pterygopalatine ganglion: largest parasympathetic peripheral ganglion. It serves as relay station for the secretomotor fibres to lacrimal gland, mucous glands of nose, paranasal sinuses, palate & pharynx It is related to the maxillary nerve but functionally connected to facial nerve through its greater Petrosal branch. 55

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57. 57 Step 1 Step 2 Relay in ganglion Step 2 Step 2 Step 1

58. 58 Step 1 Step 2

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63. Exits of the Pterygopalatine Fossa Modalities join & leave together to distribution regions Inferior Orbital Fissure : Infra-Orbital Nerve, Artery & Para-sympathetic to communicating branch on way to lacrimal gland Sphenopalatine Foramen: Spheno -palatine artery, Nasopalatine nerve & autonomics to nasal cavity (to keep it moist)’ Palatine Canal: Descending palatine artery, greater & lesser palatine nerve carrying taste, general sensation from palate & autonomics to the wet mucosa of palate . 63

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65. Clinical Relevance 65

66. Trigeminal neuralgia It is characterized by spontaneous, paroxysmal, lancinating pain in the trigeminal nerve distribution. C ause is not known. O ccasionally , tumor infiltration, vascular compression of nerve , & diseases such as multiple sclerosis may be the causative factors. Therefore these patients should undergo a complete neurologic evaluation 66

67. Indication Trigeminal nerve block is indicated: Treatment of trigeminal neuralgia Diagnostic testing Recurrent herpes zoster ophthalmicus Post herpetic neuralgia 67

68. Oral carbamazepine is the drug of choice. Trigeminal nerve block is reserved for patients who do not respond to medical treatment or patients in whom decompression of canal is not feasible or has failed. Before N eurolysis is carried out, the patient’s respond to diagnostic procedure with local anesthesia must be assessed 68

69. Contraindicated Pregnant women Antiplatelet medication Anticoagulant 69

70. Cluster Headaches 70

71. Sphenopalatine Neuralgia 71

72. Dry Eye Syndrome 72 Contact lenses Smoke or Wind or AC Ketatitis Lupus Allergies Menopause Vit . A deficiency

73. Sinusitis & Rhinitis 73

74. Thank You! Any Question? 74

75. 75 CN V (GS)

76. 76 C N V (GS) • C N V-1 • C N V-2 • C N V-3

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81. 81 •Paroti d gland •Facia l n . (BM) •Ex t caroti d a. • Retromand . v. •Massete r m. • Buccinato r m.

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