Injection of mandibular nerve and gasserian ganglion

INJECTION

OF MANDIBULAR NERVE AND GASSERIAN GANGLION AN ANATOMIC

STUDY

K. S. CHOUKB, M.D. Associate

Professor of Anatomy,

Graduate

SchooI of Medicine,

University

of PennsyIvania

Philadelphia, Pennsylvania

A

LCOHOL injection of the gasserian gangIion has been used for the reIief of trigemina1 neuraIgia since the beginning of this century. There are two principa1 methods: One is the ascending route first used by SchI8sser.l His method was foIIowed and modified by others.2-14 AI1 these authors have used the extrabucca1 ascending route except OstwaIt who started his injection through the mucous membrane of the mouth (intrabucca1 ascending route). The other method is the horizonta1 or transzygomatic route. This was first used by L&y and Baudouin.15 It was repeated with sIight variations by other operators.16-26 TECHNIC

OF

ZYGOMATIC

HORIZONTAL METHOD

TRANSOF

OR

the externa1 auditory meatus. After the needIe has pierced the skin the- bIunt styIet, when used, is pushed home and the deep tissues are penetrated with a bIuntended instrument without injuring the deep vesseIs. The needIe is directed sIightIy upward and a IittIe backward hugging the base of the skuI1 unti1 it reaches the mandibuIar nerve at its exit from the foramen ovaIe at a depth of about 4 cm. from the This depth varies sIightIy, dezygoma. pending upon the shape of the head and the thickness of soft parts, but it is never greater than 5.5 cm. from the surface. If diffIcuIty is encountered in passing through the sigmoid notch of the mandibIe, it may be overcome either by having the patient’s mouth wide open or by depressing the handie of the needIe sIightIy. The needIe passes through skin, subcutaneous tissue, masseter muscIe, posterior portion of the tempora1 tendon, superior border of the externa1 pterygoid muscIe and anterior to the temporomandibuIar joint. FrazierZ3 and Grantz4 used an instrument caIIed a zygometer. The use of this instrument, they thought, eIiminated the uncertainty of being abIe to fee1 the descending root of the zygoma, thus making the point of needIe puncture more accurate. Grant24a seIected the 2 cm. mark in the Iower bar of the zygometer in the standard position for the injection of the mandibuIar nerve. This corresponds approximateIy to the point of eIection described by LCvy and Baudouin. l5 In Grant’s 162 injections on eighty-one cadavers the horizonta1 angIe averaged 91 degrees and

SUB-

INJECTION

The aim is to inject the mandibuIar division of the trigemina1 nerve at the point of its exit from the foramen ovaIe. A straight needIe IO cm. Iong and 1.0 to 1.5 mm. in diameter is used. Some operators use it fitted with a bIunt styIet, others without a styIet. The needIe is marked in centimeters from the point up to five so that the operator may know what depth he has reached. The skin is prepared and anesthetized in the usua1 manner. The needIe is inserted through the cheek behind the Iast upper moIar at the Iower border of the zygoma 2 to 2.5 cm. in front of the descending root of the zygoma, which can aIways be feIt as a ridge cIose to the anterior bony border of 80

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the vertica1 angIe 108 degrees. The nerve was reached at a depth of 4.5 cm. De Froe and Wagenaar2” found the pterygospinous foramen of Civinini in 5 per cent of European skuIIs. They mention that Haertel erroneousIy thought that the presence of such a foramen couId prevent the injection of the semiIunar (gasserian) ganglion of the trigemina1 nerve through the foramen ovaIe. They point out that the presence of the partiaIIy or compIeteIy ossified pterygoalar Iigament (Iigamentum crotaphitico-buccinatorium of HyrtI) can really make the injection of the semiIunar ganglion impossibIe. My examination of 6,000 skuIIs2”2’” confirms their observation. The roentgenoIogic technic of De Froe and Wagenaar 25 has made it possibIe to exclude poor resuIts with certainty. They give credit to HaerteI for the first successfu1 visuaIization of the foramen ovaIe in the skiagraph of the base of the skuI1. According to them Giitze aIso used the roentgenoIogic examination of the foramen ovale successfuIIy. They describe HaerteI’s technic and an improvement of it by Briicke for the x-ray examination of the foramen ovaIe. deFroe and Wagenaar2j show roentgenograms of the foramen ovaIe with and without the presence of the ossilied pterygospinous and pterygoalar Iigaments. SunderIand2” describes a “pterygospinous bar,” but apparentIy he does not distinguish between the pterygospinous bar and the pterygoaIar bar which are two definitely separate and different entities. The former compIetes the pterygospinous foramen of Civinini whiIe the Iatter compIetes the pterygoaIar foramen (porus crotaphitico-buccinatorius of HyrtI). His ligures v and IX ihustrate the Iast mentioned bar which makes the introduction of the injection needIe into the foramen ovaIe by the horizontal transzygomatic route impossible. His figure IV represents the pterygospinous bar which, as he states, offers no obstacle for the passage of the needle into the foramen ovaIe.

July, 1949

TECHNIC

GangIion OF ASCENDING

BCCCAL

METHOD

81 INTRAOF

OR

EXTRA-

INJECTION

ApparentIy SchI6sser’ was the First to use this method. He did not describe his technic in detail. Hecht4 Iearned this method from KiIiani3 who in turn was personaIIy instructed by Schliisser. Hecht4 described deep injection of the mandibular nerve at the foramen ovaIe by SchIosser’s method as foIIows : “Having first introduced his fingers into the mouth back of the Iast moIar as a guide, he forces the Iongest one of his three especiaIIy devised needIes through the cheek, (extrabuccal) under the periosteum to the pterygoid plate and upward on it unti1 about 235 inches of the needIe are buried; Iowering the handle of the needIe admits of advancing the point about another one-fourth inch toward the base, where it is heId in pIace. Then deftly feeling the way backward, and keeping closely to the bone for about half an inch, one feels the needIe enter the foramen ovale and the injection is begun. Narcosis is hardly ever necessary, and should be omitted in order to get the benefit of the patient’s appreciation as to any sensory change following the injection.” 0stwaIt2 cIaims to have improved upon this method in some essentia1 points. He uses a bayonet-shaped needIe and introduces it directIy behind the upper third molar (intrabucca1). He pushes it through a rather thick submucous tissue and the externa1 pterygoid muscIe, or around its Iower border to the external pterygoid pIate. Then he moves the needle slowly and carefuIly upward until it reaches the infratempora1 surface of the great wing of the sphenoid bone. He then slides the point of the needIe backward between the infratemporal surface and the external pterygoid pIate as Iong as bony resistance is felt. As soon as this resistance ceases the needIe has entered the foramen ovale. HaerteI’s approachj to the gasserian gangIion through the foramen ovale is practica1 and usefu1. His method is an improvement over the method of Schlosser.

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HaerteI points the needIe to the pupi of the eye on the same side. The Iocation of the foramen ovaIe is at a point on the base of the skuI1 where a perpendicuIar pIane through the center of the pupi and a horizonta1 pIane through the articuIar eminence bisect. He takes roentgenograms of the patient’s skuI1 in a certain position to see the Iocation and shape of the foramen ovaIe and to find out if there are any bony anomaIies which might obstruct the passage of the needIe into the foramen ovaIe. Grinker” uses HaerteI’s method. He describes his own technic but his description is not very cIear. Under the ffuoroscope PoIIock and Potter’ introduce a catheter into the eustachian tube as a guide for the Iocation of the foramen ovaIe. They concIude that “empIoying the shadow cast by the anterior border of the petrous portion of the tempora1 bone, on a Auoroscope, as a Iine of orientation injection of the gasserian gangIion by HaerteI’s method is made more certain.” In Braun’s book, transIated by M. L. Harris,8 the technic of injection of the gasserian gangIion is essentiaIIy the same as that used by HaerteI. Irgergv2guses a needIe IO to 13 cm. Iong and 0.8 mm. thick. The needIe is furnished with a bar which couId be repIaced by a cork. He measures from the point of the needIe to the bar a distance equa1 to that from the angIe of the mandibIe (the mouth of the patient being cIosed) to the upper margin of the articuIar tubercIe. He introduces the needIe into the skin touching the media1 side of the angIe of the mandible. It is then sIowIy advanced to the bar fohowing the direction of the skuI1 base. It is to be noted that the articular tubercIes and the ova1 foramina are upon one Iine. The IongitudinaI direction of the needIe must coincide with the Iine uniting the puncture point withcthe upper margin of the articuIar tubercIe. According to Morris,lO HaerteI inserted the needIe at about the IeveI of the second upper moIar, guiding it with a finger in the

of Gasserian

Ganghon

mouth unti1 the point of the needIe reached the area of bone in front and IateraI to the foramen ovaIe. He considered this surface of the bone “so CharacteristicaIIy hard and smooth that it couId be used as a Iandmark to the foramen, which was the first depression or irreguiarity met with on it in working the point of the needIe backwards.” In this way he was abIe to Iocate the foramen ovaIe with accuracy. MorrislO states that “the (mandibuIar) nerve may run deep td the accessory ossifications in this region, and at a depth which makes its safe infiItration with aIcoho1 impossibIe.” MorrislO makes the skin puncture I to 2 cm. IateraI to the angIe of the mouth or 2 to 3 cm. above this point, the former being referred to as the “vertica1” type, the Iatter as the “horizonta1” type. He guides the point of the needIe between the buccinator muscIe and the mandibIe on the infratempora1 surface of the sphenoid bone, and with the aid of this surface and of the adjacent externa1 pterygoid pIate IocaIizes the foramen ovaIe. Souttarl’ inserts the needIe into the cheek I inch externa1 to the angIe of the mouth, directing it upward and inward toward the Iambda, the point on the skul1 where the Iambdoid and sagitta1 sutures meet. After passing through the cheek, the needIe enters the interna pterygoid muscIe on the inner side of the coronoid process. Leaving this, it enters the externa1 pterygoid and comes to rest at the root of the externa pterygoid pIate just in front of the foramen ovaIe and on the base of the skuI1. The needIe is now partIy withdrawn and directed sIightIy posteriorIy to its former Iine, when the point shouId pass through the foramen ovaIe into the gangIion. The Iambda, he cIaims, is his own Iandmark. It is easiIy felt as a depression on practicaIIy every skuI1; and if the indexfinger of the Ieft hand is pIaced on this point, it wiI1 be found a very easy matter to direct the needIe toward it. Horrax and Poppen12 use essentiaIIy the approaches to the foramen ovaIe described American

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by Haertel and by Harris. Their statement that “the foramen ovale lies just posterior and slightly medial to it (external pterygoid pIate) (Fig. 3)” is obviously in error, for a careful study of this figure in their articIe, as well as my examination of skuIls, shows that the foramen ovale lies just posterior and slightly lateral not medial to the external pterygoid pIate. Putnam and Hampton13 apply practicalIy the same technic employed by Haertel. W. Harris14 states, “ . . . the IateraI route through the sigmoid notch is often less satisfactory for injecting the gangIion than it is for the third division alone, owing to the dificulty in many cases of getting the needle to pass through the lips of the foramen.” He states further: “AIthough I used this route for a number of years, for the Iast three or four years I have adopted for preference the anterior route that was described many years ago by Haertel, which, although it is longer, has the advantage of being a much steeper approach, so that there is no difficulty in passing the needIe through the foramen. It is, however, in my opinion a route that required much more experience than the lateral route.” In genera1 the method is similar to the extrabuccal route of HaerteI. W. Harris30 in the last thirty years has cases of trigemina1 treated over 2,300 neuraIgias mostly by alcohol injections. Therefore, he believes and justIy so, that an analysis of his results “may be usefu1 in estabIishing the value and limitations of this method.” COMMENT

From the foregoing description it is obvious that there are two principal methods of injection used in the treatment of mandibular neuralgia. One is the horizonta1 or transzygomatic route, the other is the ascending method. The former method is comparativeIy easy to master, but the Iatter needs more experience and skil1. It is, however, anatomicalIy impossible to use the horizontal method in a certain per-

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FIG. I. Base of skuI1. I, pterygo-aIar bar; 2, one end of white paper is inserted into the petrygo-aIar foramen (porus crotaphitico-buccinatorius of Ilyrtl) under I ; 3, foramen ovale; 4. foramen Iacerum.

centage of cases due to the presence of a bony bar which completes the pterygo-alar foramen (porus crotaphitico-buccinatorius of HyrtI), Chouk&27~27a Both these methods were tried on IOO embalmed cadavers. It was very easy to reach the foramen ovale by the horizontal transzygomatic route, except when the pterygo-alar foramen was present. The foramen ovale was entered by the ascending method of Haertel only after many trials, but in no case was the presence of the pterygo-alar foramen responsible for failure of this method. Since the publication of my two papers on the subject, I have examined I ,7r I additional skulls bringing the total number of skulls observed to 6,000. In these 6,000 skuIIs the pterygo-aIar foramen was comper cent). It, was plete 463 times (7.72 incomplete in 659 (14.79 per cent) of 4,456 skulIs. The pterygo-alar foramen, when present, is formed by a bar of bone running from the root of the IateraI lamina of the pterygoid process of the sphenoid to the undersurface of the greater wing of the same bone. (Fig. I.) Its presence forms an obstruction in the path of the needle inserted by the horizontal transzygomatic route and intended to reach the foramen ovaIe for injecting the mandibuIar division of the

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trigemina1 nerve or the gasserian (semiIunar) gangIion. Quite often this bony bar is very strong and heavy. In dry skuIIs having the bar one cannot even see the foramen ovaIe from the IateraI side much Iess pass a needIe into it. In a Iiving person presence of the bar wouId precIude using the horizonta1 approach. In cases in which the aforementioned bony bar is thin, one can see the foramen ovaIe in a dry skuI1 but the passage of the needIe is stiI1 impossibIe. In the presence of such a bony bar the ascending route, originated by SchI6sser and improved upon by Haertel and others, affords a means for entering the foramen ovaIe without obstacIe. However, this method requires more experience and skiI1. It is apparentIy for this reason, aIthough he did not say so, that W. Harris30 after making injections into the foramen ovaIe in over 1,400 patients has now adopted the modified SchEsser’s ascending technic of injection in preference to his own horizontal transzygomatic method. RecentIy De Froe and Wagenaarz5 perfected a roentgenoIogic technic whereby they can visuaIize the foramen ovaIe and the presence or absence of the pterygo-aIar foramen. In this way they can reach the foramen ovaIe with certainty. It wouId seem possibIe that one couId inject the mandibuIar nerve or the gasserian gangIion under the ffuoroscope, thus avoiding a11 uncertainties about endangering other structures. SUMMARY

Two principal methods have been described for injecting the mandibuIar division of the trigemina1 nerve or the gasserian (semiIunar) gangIion; one is the horizonta1 transzygomatic route and the other is the ascending route started in the skin near the angIe of the mouth. In about 8 to IO per cent of individuals an anatomic anomaIy, pterygo-aIar foramen (porus crotaphitico-buccinatorius of HyrtI) is present. The presence of such an anomaIy makes the horizonta1 transzygomatic method of injection physically impossibIe.

of Gasserian

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The presence or absence of another anomaIy in the same region, nameIy, the foramen pterygospinosum of Civinini offers no barrier by either route to a needIe directed toward the foramen ovaIe, for the axis of the foramen of Civinini is vertica1 and at about right angIes to the horizontal axis of the pterygo-aIar foramen. The pterygo-aIar foramen is found in a higher percentage of negroes than in whites. For best cIinica1 resuIts in the treatment of trigemina1 neuraIgia by injection through the foramen ovaIe, it is suggested that the ascending approach be used, preferably under the ffuoroscope when practicable. REFERENCES I.

KARL. HeiIung peripherer Reizzustaende sensibler und motorischer Nerven. Ber. d. opbtb. Gesellscb. Heidelberg, 31: 84-89, 1903. 2. OSTWALT, F. Traitment des nCuralgies rebeIIes par Ies injections profondes d’aIcoho1. Presse mkd., 13: 812, 1905. 3. KILIANI, Oreo G. T. Schliisser’s alcohol injection into the foramen ovale for recurrent trigemina1 neuraIgia, after extirpation of the gasserian ganglion. J. New. ti Ment. Dis., 34: 777-779. SCHLOSSER,

,907.

4. HECHT, D’ORSAY. The method and technic of the deco alcohol injections for trifaciaI neurahzia. J. A. M. A., 4g:‘1574-1580, 1907. 5. HAERTEL, FRITZ. IntrakraniaIe Leitungsanlsthesie des Ganglion Gasseri. Zentralbl. j. Cbir., 39: 705-708, 1912. 5a. Idem. Die Leitungsanlsthesie und InjectionsbehandIung des GangIion Gasseri und der Trigeminusstlmme. Arch. f. klin. Cbir., 100: 193-292, 1912. 6. GRINKER, JULIUS. A new method of treating neuralgias of the trigeminus by the injection of aIcoho1 into the gasserian gangIion. J. A. M. A., 60: 1354-1357, 1913. 7. POLLOCK, L. J. and POTTER, H; E. Experimental studies of injection of the gasserian ganglion controIIed by ffuoroscopy. J. A. M. A., 67: 13571361, 1916. 8. BRAUN, HEINRICH. TransIated and edited by M. L. Harris. LocaI Anesthesia: Its Scientific Basis and PracticaI Use. PhiIadeIphia and New York, 1924. Lea 81 Febiger. g. IRGER, J. M. Penetrating to the gasserian gangIion. Ann. Surg., 92: 984-992, 1930. IO. MORRIS, LESLIE. Trigeminal neuralgia: the anatomy of the “H;irteI” technique for injection of gasserian ganglion. Lancet, I : I 22-126, 193 I. I I. SOUTTAR, H. S. Injection of the gasserian ganglion Lancet, 2:592-593, 1934. 12. HORRAX. GILBERT and POPPEN. J. L. What shall we do with the patient with trigemina1 neuralgia? New England J. Med., 212: 972-975, 1935.

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1211. Ibid. Trigeminal neuraIgia. Experience with, and treatment employed in 468 patients during the past IO years. Surg., Gynec. CYObst., 61: 394-402, ‘935. 13. PUTNAM, T. J. and HAMPTON, A. C. A technic

14.

IS.

16.

17.

18.

IO.

20.

2 I.

22.

of injection into the gasserian ganglion under roentgenographic control. Arch. Neurof. CT Psychiat., 35: 92-98, 1936. HARRIS, WILFRED. The FaciaI Neuralgias. Pp. 17, 48, 81, and 178. London, Humphrey Milford, I 937. Oxford University Press. LEVY, M. F. and BAUDOUIN, ALPHONSE. Les injections profondes dans le traitment de Ia nevralgie faciaIe rebelle. Presse m&d. 14: 108%109 (Feb. 17) I 906. BRISSAUD, EDOUARDand SICARD, J. A. Traitement des nevralgies du trijumeau dites “secondaires” par les injections profondes d’ alcoho1. Rev. neural., 15: I 157-1164, 1907. PATRICK, H. T. A new treatment of trifaciaI neuralgia, with report of cases; a preliminary report. Illinois M. J., I I : 385-388, 1907. PURVES-STEWART,J. Tic douloureux: the technique and results of SchIGsser’s method of treatment. &-it. M. J., II: 848-85 I, Igog. HARRIS, WILFRED. The alcohol injection treatment of neuralgia and spasm. Proc. Roy. Sot. Med., 2: 77-91; 1909. OFFERHAUS, H. K. Die Technik der Injectionen in die Trigeminusstamme und in das Ganglion Gasseri. Arch. J. klin. Cbir., 92: 47-78, ,910. MAY, OTTO. The functiona and histological effects of intraneura1 and intragangIionic injections of aIcoho1. &if. M. J., 2: 465-470, 1912. MAES, URBAN. The surgical treatment of tic douIoureux. Surg., Gynec. & Obst., 21: 34*35g, 19’S.

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23. FRAZIER, C. H. A cIinica1 Iecture on trigeminal neuraIgia. S. Chin. North America, I : 101-126, 1921. 24. GRANT, F, C. Anatomic study of injection of second and third divisions of trigemina1 nerve. J. A. M. A., 78: 794-797, 1922. 24a. Idem. AIcohol injections of second and third divisions of trigemina1 nerve. Clinical results with more exact technic. J. A. M. A., 78: 17801781, 1922. 25. DE FROE, A. and WAGENAAR, J. H. Die Bedeutung des Porus crotaphitico-buccinatorius und des Foramen pterygo-spinosum fiir NeuroIogie und Rantgenologie. Fortscbr. a. d. Gebiete d. Rb;ntgenstrablen, 52: 64-69, 1935. 26. SUNDERLAND,SYDNEY. A note on the variations of the foramen ovale. Australian C* New Zealand J. &Lrg., 8: 170-175, 1938. 27. CHOUI&, K. S. On the incidence of the foramen of Civinini and the porus crotaphitico-buccinatorius in American whites and negroes. I. Observations on 1544 skulls. Am. J. Pbys. Antbropof., ‘c: 203.. 225. 1946. 27a. Idem. On the incidence of the foramen of Civinini and the porus crotaphitico-buccinatorius in American whites and negroes. II. Observations on 2745 additional skuIIs. Am. J. Pbys. ,4ntbroPof., 5: 79-86, 1947. 28. H;~RTIIL, FRITZ F. Riintgenologische Dorstellung des Foramen ovale des Schldels und ihre Bedeutung fiir die Behandlung der Trigeminusneuralgic. Deutscbe med. Wcbnscbr., 61: 1069-1072, ‘935. 29. IRGER, J. M. AIcohoI injections of the gssserian gangIion for trigemina1 neuralgia. Ann. Surg., IOO: 61-67, 1934. 30. HARRIS, WILFRED. An analysis of 1433 cases of paroxysma trigemina1 neuralgia (trigeminal-tic) and the end-resuits of gasserian aIcoho1 injection. Brain, 63: 209-224, 1940.