TRIGEMINAL TRIGEMINAL NERVENERVE

Anatomy Anatomy Largest & one of most complex cranial Largest & one of most complex cranial

nervesnerves Mixed nerveMixed nerve Large sensory part (portio major) & much Large sensory part (portio major) & much

smaller motor part (portio minor)smaller motor part (portio minor) Sensory component has 3 divisions : Sensory component has 3 divisions :

ophthalmic, maxillary, mandibular.ophthalmic, maxillary, mandibular. Motor & prinicipal sensory nuclei – Motor & prinicipal sensory nuclei –

midponsmidpons Spinal tract & nucleus (pain, temp) – pons Spinal tract & nucleus (pain, temp) – pons

to upper cervical cordto upper cervical cord

Mesencephalic root receives Mesencephalic root receives proprioceptive fibres.proprioceptive fibres.

Trigeminal nuclear structures – Trigeminal nuclear structures – extend from rostral midbrain to extend from rostral midbrain to rostral spinal cordrostral spinal cord

Motor PortionMotor Portion

Motor nucleus – midpontine level Motor nucleus – midpontine level

medial to main sensory nucleus of Vth medial to main sensory nucleus of Vth nerve , near the floor of fourth ventricle.nerve , near the floor of fourth ventricle.

Supranuclear control - corticobulbar Supranuclear control - corticobulbar fibresfibres

from precentral gyrus.from precentral gyrus. Motor root : exits from motor nucleus , Motor root : exits from motor nucleus ,

passes thr substance of pons and emerges passes thr substance of pons and emerges from anterolateral aspect of pons anterior from anterolateral aspect of pons anterior and medial to the large sensory root.and medial to the large sensory root.

Motor root Motor root

Passes forward in posterior fossaPasses forward in posterior fossa Pierces the duramater beneath Pierces the duramater beneath

attachment of tentorium to tip of attachment of tentorium to tip of petrous part of temporal bone.petrous part of temporal bone.

Enters the meckel’s caveEnters the meckel’s cave leaves skull via Foramen Ovale. leaves skull via Foramen Ovale. It joins the mandibular div of Vth N It joins the mandibular div of Vth N

to form mandibular nerve – supplies to form mandibular nerve – supplies masticatory muscles .masticatory muscles .

Masseter : close the jaw , protrude it slightlyMasseter : close the jaw , protrude it slightly Temporalis : close the jaw , retract it slightlyTemporalis : close the jaw , retract it slightly Medial pterygoids : close the jaw & protrude Medial pterygoids : close the jaw & protrude

itit Lateral pterygoids : open the jaw & protrude Lateral pterygoids : open the jaw & protrude

itit

When pterygoids contract on one side- pull When pterygoids contract on one side- pull the mandible contralaterally -- Unilateral the mandible contralaterally -- Unilateral pterygoid weakness – jaw deviates towards pterygoid weakness – jaw deviates towards side of weak muscleside of weak muscle

Also suppliesAlso supplies

MylohyoidMylohyoid Ant.belly of digastricAnt.belly of digastric Tensor veli palatiniTensor veli palatini Tensor tympaniTensor tympani

Sensory portionSensory portion

Trigeminal / gasserian / semilunar ganglion Trigeminal / gasserian / semilunar ganglion Situated just beside pons in a shallow Situated just beside pons in a shallow

depression in petrous apex – meckel’s cavedepression in petrous apex – meckel’s cave Sensory root enters the pons course Sensory root enters the pons course

dorsomedially & terminate within dorsomedially & terminate within brainstem: Nucleus of spinal tract of Vth brainstem: Nucleus of spinal tract of Vth NN

Main/Principal sensory nucleusMain/Principal sensory nucleus

Mesencephalic nucleus Mesencephalic nucleus

Nucleus of spinal tract of Nucleus of spinal tract of Vth .NVth .N

Pars Oralis – mid pons to inferior Pars Oralis – mid pons to inferior oliveolive

Pars Interpolaris – rostal third of Pars Interpolaris – rostal third of inferior olive to obex of fourth inferior olive to obex of fourth ventricleventricle

Pars Caudalis – extends to & is Pars Caudalis – extends to & is continous with dorsal horn grey continous with dorsal horn grey matter of cervical spinal cordmatter of cervical spinal cord

Fibres – pain & temp – enter spinal tract Fibres – pain & temp – enter spinal tract of trigeminal & descend to various levels of trigeminal & descend to various levels depending on their somatotropic origin, depending on their somatotropic origin, then synapse in adjacent nucleus of then synapse in adjacent nucleus of spinal tract.spinal tract.

The axons of second order neurons cross The axons of second order neurons cross midline, aggregate as trigeminothalamic midline, aggregate as trigeminothalamic tract & ascend to VPM tract & ascend to VPM

From VPM , fibres project through From VPM , fibres project through thalamic radiations to sensory cortex in thalamic radiations to sensory cortex in post central gyruspost central gyrus

Onion skin somatotopic organization Onion skin somatotopic organization Described by DejerineDescribed by Dejerine Face is represented as concentric rings from Face is represented as concentric rings from

perioral to preauricular region.perioral to preauricular region. Fibers from foreface synapse most rostrally Fibers from foreface synapse most rostrally

in nucleus of spinal tract.in nucleus of spinal tract. Fibers from hindface synapse more caudally, Fibers from hindface synapse more caudally,

adjacent to sensory input from C2- C3adjacent to sensory input from C2- C3 Because of this organization – occasional Because of this organization – occasional

sparing , less freq selective inv of perioral sparing , less freq selective inv of perioral compared to posterior facecompared to posterior face

-- BALACAVA HELMET Distribution-- BALACAVA HELMET Distribution

Main sensory nucleus Main sensory nucleus

Lateral ponsLateral pons Posterolateral to motor nucleusPosterolateral to motor nucleus Tactile & proprioceptive sensationTactile & proprioceptive sensation Afferent fibers – light touch , Afferent fibers – light touch ,

pressure – enter this nucleus – pressure – enter this nucleus – synapse – second order neurons synapse – second order neurons which cross midline en route to VPM which cross midline en route to VPM Thalamic nucleus.Thalamic nucleus.

Mesencephalic nucleusMesencephalic nucleus

Extends cephalad from main sensory Extends cephalad from main sensory nucleus to sup.colliculus of nucleus to sup.colliculus of mesencephalon.mesencephalon.

Receives proprioceptive impulses Receives proprioceptive impulses from masticatory muscles, from masticatory muscles, extraocular & muscles of facial extraocular & muscles of facial expression.expression.

Gasserian ganglion lies lateral to Gasserian ganglion lies lateral to int.carotid.a & posterior part of int.carotid.a & posterior part of cavernous sinus cavernous sinus

Gives rise to 3 trunks : ophthalmic, Gives rise to 3 trunks : ophthalmic, maxillary & mandibular divisionsmaxillary & mandibular divisions

Ophthalmic divOphthalmic div

Skull foramenSkull foramen : superior orbital fissure : superior orbital fissure Terminal brTerminal br: : frontal , lacrimal, : : frontal , lacrimal,

nasociliary, meningeal nasociliary, meningeal Cutaneous innervation Cutaneous innervation : bridge & side : bridge & side

of nose, upper eyelid, forehead, scalp of nose, upper eyelid, forehead, scalp back to vertex, eyeball, lacrimal gland, back to vertex, eyeball, lacrimal gland, nasal septum, lat wall of nasal cavity, nasal septum, lat wall of nasal cavity, ethmoid sinus, tentorium cerebelliethmoid sinus, tentorium cerebelli

Maxillary divMaxillary div

Skull foramen Skull foramen : foramen rotundum : foramen rotundum Terminal brTerminal br : infraorbital, zygomatic, : infraorbital, zygomatic,

sup.alveolar, pterygopalatine, meningealsup.alveolar, pterygopalatine, meningeal Cutaneous innervationCutaneous innervation : cheek, : cheek,

lat.forehead, side of nose, upper lip, lat.forehead, side of nose, upper lip, upper teeth & gums, palate, upper teeth & gums, palate, nasopharynx, post.nasal cavity, nasopharynx, post.nasal cavity, meninges of ant & middle cranial fossaemeninges of ant & middle cranial fossae

Mandibular divMandibular div

Skull foramenSkull foramen : foramen ovale : foramen ovale Terminal br Terminal br : buccal, lingual, : buccal, lingual,

inf.alveolar, auriculotemporal, meningeal inf.alveolar, auriculotemporal, meningeal Cutaneous innervationCutaneous innervation : Inner cheek, : Inner cheek,

temple, lateral scalp, ext.aud.meatus, temple, lateral scalp, ext.aud.meatus, tympanic membrane, TMJ, mandible, tympanic membrane, TMJ, mandible, lower teeth & gums, ant.2/3 tongue, lower teeth & gums, ant.2/3 tongue, lower lip, meninges of ant & middle lower lip, meninges of ant & middle cranial fossaecranial fossae

Clinical examinationClinical examinationmotor functionsmotor functions

Bulk & power of masseters & pterygoids – Bulk & power of masseters & pterygoids – palpating as pt clinches the jawpalpating as pt clinches the jaw

Ask pt – to protrude & retract the jawAsk pt – to protrude & retract the jaw Pt bite on tongue depressors with molar teethPt bite on tongue depressors with molar teeth U/L Trigeminal motor weaknessU/L Trigeminal motor weakness – – deviation of jaw towards the weak side on deviation of jaw towards the weak side on

opening opening pt will be unable to move the jaw contralaterally.pt will be unable to move the jaw contralaterally. Lesion inv brainstem, gasserian ganglion, motor Lesion inv brainstem, gasserian ganglion, motor

rootroot

Clinical examinationClinical examinationmotor functionsmotor functions

B/L Weakness of B/L Weakness of muscles of muscles of mastication with mastication with inability to close the inability to close the mouth ( dangling mouth ( dangling jaw ) – motor jaw ) – motor neuron ds, neuron ds, neuromuscular neuromuscular transmission transmission disorder, myopathydisorder, myopathy

Trismus: acute dystonic reactions,Trismus: acute dystonic reactions, polymyositispolymyositis tetanustetanus trauma to muscles of masticationtrauma to muscles of mastication inf pterygomandibular spaceinf pterygomandibular space Flaccidity of floor of mouth : mylohyoid, Flaccidity of floor of mouth : mylohyoid,

digastric paralysisdigastric paralysis Difficulty in hearing high notes : paralysis Difficulty in hearing high notes : paralysis

of tensor tymapani of tensor tymapani

Clinical examination Clinical examination sensory functionssensory functions

Pain, touch, heat, cold – tested on Pain, touch, heat, cold – tested on face & mucous membranesface & mucous membranes

Each of the 3 divisions of Vth.N is Each of the 3 divisions of Vth.N is tested individually and compared tested individually and compared with the opposite side.with the opposite side.

Clinical examination Clinical examination sensory functionssensory functions

Determine whether sensory loss is Determine whether sensory loss is organic/nonorganicorganic/nonorganic

Determine which modalities are Determine which modalities are involvedinvolved

Define the distribution of sensory Define the distribution of sensory lossloss

Sensory evaluation Sensory evaluation lesionslesions

Individual divisions (distal to gasserian Individual divisions (distal to gasserian ganglion) : sensory loss confined to ganglion) : sensory loss confined to cut.supply of that division.cut.supply of that division.

At / proximal to gasserian ganglion : At / proximal to gasserian ganglion : sensory loss that affects whole ipsilateral sensory loss that affects whole ipsilateral face.face.

Within brainstem / upper cervical cord : Within brainstem / upper cervical cord : onion skin distribution of sensory lossonion skin distribution of sensory loss

Dissociation of sensation on face Dissociation of sensation on face ( pain,temp Vs touch sensation ) : ( pain,temp Vs touch sensation ) : differentiating b/w lesions affecting spinal differentiating b/w lesions affecting spinal tract, nucleus of trigeminal.n from lesions tract, nucleus of trigeminal.n from lesions affecting main sensory nucleus. affecting main sensory nucleus.

Clinical examinationClinical examinationreflexesreflexes

Jaw / Masseter / Mandibular Reflex :Jaw / Masseter / Mandibular Reflex :

Afferent arc : Ia motor fibers in mandibular Afferent arc : Ia motor fibers in mandibular div of Vth.N div of Vth.N

Efferent arc : mandibular fibers that Efferent arc : mandibular fibers that originate in motor nucleus of Vth.Noriginate in motor nucleus of Vth.N

Reflex centre : ponsReflex centre : pons Normally it is minimally active / absentNormally it is minimally active / absent Exaggerated : lesions of corticobulbar Exaggerated : lesions of corticobulbar

pathway above the motor nucleus esp if b/l : pathway above the motor nucleus esp if b/l : pseudobulbar palsy, ALSpseudobulbar palsy, ALS

Corneal ReflexCorneal Reflex

Afferent arc : ophthalmic div ( upper Afferent arc : ophthalmic div ( upper cornea ) & maxillary div ( lower cornea ) & maxillary div ( lower cornea ) of trigeminal.ncornea ) of trigeminal.n

Efferent arc : facial nerveEfferent arc : facial nerve

StimulateStimulate Direct Direct corneal corneal reflexreflex

Consensual Consensual corneal corneal reflexreflex

CompletComplete VthN e VthN lesionlesion

Involved eyeInvolved eye AbsentAbsent AbsentAbsent

Opposite eyeOpposite eye Normal Normal NormalNormal

CompletComplete VIIthN e VIIthN lesionlesion

Involved eyeInvolved eye AbsentAbsent NormalNormal

Opposite eyeOpposite eye NormalNormal AbsentAbsent

Sternutatory ( Nasal,Sneeze Sternutatory ( Nasal,Sneeze ) Reflex) Reflex

Afferent limb : Ophthalmic div of Vth Afferent limb : Ophthalmic div of Vth nervenerve

Efferent limb : CNs V, VII, IX, X & Efferent limb : CNs V, VII, IX, X & motor nerves of cervical & thoracic motor nerves of cervical & thoracic spinal cord.spinal cord.

Reflex center : brain stem & upper Reflex center : brain stem & upper spinal cordspinal cord

Trigeminal mediated Trigeminal mediated reflexesreflexes

Head retraction : b/l corticospinal Head retraction : b/l corticospinal lesions rostral to cervical spine – ALS lesions rostral to cervical spine – ALS

Zygomatic reflex : supranuclear lesionsZygomatic reflex : supranuclear lesions Corneomandibular reflex : supranuclear Corneomandibular reflex : supranuclear

interupption of ipsilat corticotrigeminal interupption of ipsilat corticotrigeminal tract. Only eye sign in ALStract. Only eye sign in ALS

Blink / glabellar / orbicularis oculi reflex Blink / glabellar / orbicularis oculi reflex

Localization of Localization of lesions affecting lesions affecting

VthCNVthCN

Supranuclear lesionsSupranuclear lesions

Lesions affecting corticobular pathway -Lesions affecting corticobular pathway -Contralateral trigeminal motor paresis Contralateral trigeminal motor paresis (deviation of jaw away from the lesion) (deviation of jaw away from the lesion)

B/L UMN lesions ( pseudobulbar palsy ) – B/L UMN lesions ( pseudobulbar palsy ) – trigeminal motor paresis , exaggerated trigeminal motor paresis , exaggerated jaw jerk.Mastication markedly impaired.jaw jerk.Mastication markedly impaired.

Thalamic lesions – anaesthesia of c/l faceThalamic lesions – anaesthesia of c/l face Parietal lesions – depression of c/l Parietal lesions – depression of c/l

corneal reflexcorneal reflex

Nuclear lesionsNuclear lesions

Motor , sensory nuclei – primary/met . Motor , sensory nuclei – primary/met . tumourstumours

AV malformationsAV malformations

demyelinating dsdemyelinating ds

infarction/h’ageinfarction/h’age

syringobulbia syringobulbia

that affect pons, medulla and upper cervical that affect pons, medulla and upper cervical cord.cord.

Nuclear lesionsNuclear lesions

Motor nucleus – lesions of dorsal Motor nucleus – lesions of dorsal midponsmidpons

Cong anomalies of motor component Cong anomalies of motor component rare , asso with CN VII /XIIrare , asso with CN VII /XII

--- I/P paresis, atrophy, fasiculations of --- I/P paresis, atrophy, fasiculations of muscles of mastication.muscles of mastication.

Nuclear lesionsNuclear lesions

Pontine lesions – with masticatory paresisPontine lesions – with masticatory paresis C/L hemiplegia ( basis pontis )C/L hemiplegia ( basis pontis ) I/P hemianaesthesia of face (main sensory nuc)I/P hemianaesthesia of face (main sensory nuc) C/L hemisensory loss of limbs & trunk C/L hemisensory loss of limbs & trunk

(spinothalamic tract)(spinothalamic tract) I/P tremor I/P tremor

Dorsal pontine lesions ( tumours ) : Dorsal pontine lesions ( tumours ) : u/l spasm & contracture of masseteru/l spasm & contracture of masseter Impairing pt to open jaw Impairing pt to open jaw Forcing to speak through ones teethForcing to speak through ones teeth

Nuclear lesionsNuclear lesions

Hemimasticatory spasm :Hemimasticatory spasm :

electrophysiologic studies – ectopic electrophysiologic studies – ectopic excitation of trigeminal motor root / excitation of trigeminal motor root / its nucleus .its nucleus .

Nucleus of spinal tract of VthCN : Nucleus of spinal tract of VthCN :

Lesions affecting caudal pons, Lesions affecting caudal pons, lat.medulla, upper cervical cord – I/P lat.medulla, upper cervical cord – I/P facial analgesia, hypesthesia, facial analgesia, hypesthesia, thermoanaesthesiathermoanaesthesia

Nuclear lesionsNuclear lesions

Rostral spinal trigeminal nuclei – caudal Rostral spinal trigeminal nuclei – caudal pontine lesions --- decreased intraoral pontine lesions --- decreased intraoral sensation but spared facial sensationsensation but spared facial sensation

Rostral medullary spinal nuclear lesions Rostral medullary spinal nuclear lesions – entire trigeminal cut distribution – entire trigeminal cut distribution involvementinvolvement

Lower medullary / upper cervical lesions Lower medullary / upper cervical lesions – sensory disturbance – forehead, cheek, – sensory disturbance – forehead, cheek, jaw (onion skin pattern of sensory loss)jaw (onion skin pattern of sensory loss)

Nuclear lesionsNuclear lesions Spinal nucleus of VthCN – lateral medullary Spinal nucleus of VthCN – lateral medullary

synsyn sec to brainstem infarction d/t IC vertebral sec to brainstem infarction d/t IC vertebral

artery occlusionartery occlusion Typical syn – pain, temp sensation lost over Typical syn – pain, temp sensation lost over

entire side of faceentire side of face Ventral syn – V1,V2 Ventral syn – V1,V2 Dorsolateral syn – V2,V3 Dorsolateral syn – V2,V3 Superficial syn – all portions of i/p face inv Superficial syn – all portions of i/p face inv

initially , but symptoms mild & improve initially , but symptoms mild & improve rapidlyrapidly

Nuclear lesionsNuclear lesions

Lesions affecting mesencephalic Lesions affecting mesencephalic nucleus – nucleus –

no apparent neurological signs, no apparent neurological signs, symptomssymptoms

except depression of i/p jaw jerkexcept depression of i/p jaw jerk

Lesions affecting Lesions affecting preganglionic trigeminal preganglionic trigeminal

nerve rootsnerve roots Tumour ( meningioma, schwannoma, Tumour ( meningioma, schwannoma,

metastasis, nasopharyngeal ca )metastasis, nasopharyngeal ca ) Infection ( granulomatous, infectious , Infection ( granulomatous, infectious ,

carcinomatous meningitis )carcinomatous meningitis ) TraumaTrauma AneurysmAneurysm Char i/p facial pain, parasthesias, Char i/p facial pain, parasthesias,

numbness, sensory loss, corneal reflex numbness, sensory loss, corneal reflex depressed, trigeminal motor paresis.depressed, trigeminal motor paresis.

Trigeminal neuralgiaTrigeminal neuralgia Tic douloureux / fothergill’s neuralgiaTic douloureux / fothergill’s neuralgia Paroxysms of fleeting ,excruciating u/l Paroxysms of fleeting ,excruciating u/l

facial pain, usually lasting less than a facial pain, usually lasting less than a minute.minute.

Usually V2/V3 , rarely V1Usually V2/V3 , rarely V1 MC – adv age, women , rt sideMC – adv age, women , rt side Stimulation of trigger zone – painStimulation of trigger zone – pain Pain – by activities like talking, chewing, Pain – by activities like talking, chewing,

brushing teeth, exposure to cold, by brushing teeth, exposure to cold, by wind on facewind on face

Trigeminal neuralgiaTrigeminal neuralgia

MC cause – compression of sensory MC cause – compression of sensory root by ectatic arterial loop .root by ectatic arterial loop .

MC CP angle tumour to cause TN- MC CP angle tumour to cause TN- like symptoms is acoustic neuromalike symptoms is acoustic neuroma

B/L TN – Multiple SclerosisB/L TN – Multiple Sclerosis

Herpes zoster Herpes zoster

Lesions affecting Gasserian Lesions affecting Gasserian ganglionganglion

Lesions of middle cranial fossa ( tumour, Lesions of middle cranial fossa ( tumour, herpes zoster, sarcoidosis, syphilis, herpes zoster, sarcoidosis, syphilis, tuberculosis, arachnoiditis, trauma, abscess tuberculosis, arachnoiditis, trauma, abscess ))

Pain – severe & paroxysmalPain – severe & paroxysmal Hemifacial / selective div of Vth CN Hemifacial / selective div of Vth CN

( esp V2,V3 )( esp V2,V3 ) Parasthesias , numbness may also occurParasthesias , numbness may also occur Sensory loss depends on div involvedSensory loss depends on div involved u/l pterygoid & masseter paresis may occur.u/l pterygoid & masseter paresis may occur.

Raeder’s paratrigeminal Raeder’s paratrigeminal syndromesyndrome

u/l oculosympathetic paresis – miosis u/l oculosympathetic paresis – miosis , ptosis (without facial anhydrosis), ptosis (without facial anhydrosis)

Evidence of trigeminal involvement Evidence of trigeminal involvement on same side.on same side.

d/t lesions in middle cranial fossa d/t lesions in middle cranial fossa ( b/w trigeminal ganglion & ( b/w trigeminal ganglion & int.carotid.a, near petrous apex) int.carotid.a, near petrous apex)

Lesions of gasserain ganglion – Lesions of gasserain ganglion – tumour, aneurysm, trauma, infectiontumour, aneurysm, trauma, infection

Gradinego syndrome - lesions at apex of Gradinego syndrome - lesions at apex of temporal bone- metastasis, osteitis, temporal bone- metastasis, osteitis, leptomeningitis d/t otitis media leptomeningitis d/t otitis media

Cavernous sinus syndrome – lesions within Cavernous sinus syndrome – lesions within sinus – tumour, carotid aneurysm, trauma, sinus – tumour, carotid aneurysm, trauma, carotid cavernous fistula, infection.carotid cavernous fistula, infection.

Superior orbital fissure syndrome – tumour, Superior orbital fissure syndrome – tumour, trauma, aneurysm, infection – complete trauma, aneurysm, infection – complete ophthalmoplegia with pain, parasthesias, ophthalmoplegia with pain, parasthesias, sensory loss in V1 cut. distributionsensory loss in V1 cut. distribution

Lesions affecting peripheral Lesions affecting peripheral branches of VthCN branches of VthCN

Ophthalmic div : in middle cranial Ophthalmic div : in middle cranial fossa , at temporal bone apex, lat fossa , at temporal bone apex, lat wall of cavernous sinus, sup.orbital wall of cavernous sinus, sup.orbital fissure, distally in facefissure, distally in face

Maxillary div : lower lateral wall of Maxillary div : lower lateral wall of cavernous sinus, at foramen cavernous sinus, at foramen rotundum, in pterygopalatine fossa, rotundum, in pterygopalatine fossa, in floor of orbit, at infraorbital in floor of orbit, at infraorbital foramen, in faceforamen, in face

Numbness & discomfort in maxillary Numbness & discomfort in maxillary distribution – initial presentation of distribution – initial presentation of nasopharyngeal canasopharyngeal ca

Lesions in infraorbital foramen – Lesions in infraorbital foramen – Numb cheek syndromeNumb cheek syndrome

Injury to ant.sup.alveolar nerve in Injury to ant.sup.alveolar nerve in trumpet players – upper lip trumpet players – upper lip numbness & pain – trumpet player’s numbness & pain – trumpet player’s neuropathyneuropathy

Mandibular div : in foramen ovale, Mandibular div : in foramen ovale, zygomatic fossa, in facezygomatic fossa, in face

The syndrome of numb chin / roger’s The syndrome of numb chin / roger’s sign : syn of isolated mental neuropathy sign : syn of isolated mental neuropathy – pain, swelling, numbness in jaw – pain, swelling, numbness in jaw ( lower lip, chin, mucous mem on inside ( lower lip, chin, mucous mem on inside of lip ) of lip )

Seen in systemic cancer – Seen in systemic cancer – lymphoreticular ca , ca breast, ca lung .lymphoreticular ca , ca breast, ca lung .

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