Surgical anatomy of the lingual nerve for palate surgery: where is located and how to avoid it

Abstract

Purpose To describe the anatomic relationship of the lingual nerve with the lateral oropharyngeal structures. Methods An anatomic dissection of the lateral oropharyngeal wall was conducted in eight sides from four fresh-frozen cadaveric heads. Small titanium clips were placed along the lingual nerve and the most anterior and medial border of the medial pterygoid muscle. Radiological reconstructions were employed for optimal visualization; the coronal view was preferred to resemble the surgical position. The distance between the lingual nerve and the medial pterygoid muscle at its upper and lower portion was measured radiologically. The trajectory angle of the lingual nerve with respect to the pterygomandibular raphe was obtained from the intersection between the vector generated between the clips connecting the upper and lower portion of the medial pterygoid muscle with the vector generated from the lingual nerve clips. Results The mean distance from the upper portion of the medial pterygoid muscle and superior lingual nerve clips was 10.16 ± 2.18 mm (mean ± standard deviation), and the lower area of the medial pterygoid muscle to the lingual nerve was separated 5.05 ± 1.49 mm. The trajectory angle of the lingual nerve concerning to the vector that describes the upper portion of the most anterior and medial border of the medial pterygoid muscle with its lower part was 43.73º ± 11.29. Conclusions The lingual nerve runs lateral to the lateral oropharyngeal wall, from superiorly–inferiorly and laterally–medially, and it is closer to it at its lower third.

The pterygomandibular raphe: a comprehensive review

“…The PMR forms the anterior wall of the pterygomandibular space, an important cavity containing the inferior alveolar nerve, artery and vein, the lingual nerve, the nerve to mylohyoid, and the sphenomandibular ligament [ 20 , 21 ]. Medial to the prestyloid compartment, the PMR’s medial surface is covered by oral mucosa [ 1 , 9 ]. The lateral surface, however, is disconnected from the ramus of the mandible by a layer of buccal fat pad-derived adipose tissue [ 1 ].…”

“…While some deny its existence, others support it ( Figs. 2 , 3 ) [ 3 , 8 , 9 , 22 - 24 ]. After studying 50 hemiheads, Gaughran [ 25 ] concluded that the PMR was an anatomical artifact, citing the continuous nature of the bucinator and the SPC in all specimens.…”

“…Magnetic resonance imaging (MRI) is generally considered the best way to visualize the PMR [ 8 , 9 , 13 , 31 ]. Contrast-enhanced computed tomography could be used, but dental amalgam artifacts seem to create far too much degradation of the image [ 13 ].…”

“…Contrast-enhanced computed tomography could be used, but dental amalgam artifacts seem to create far too much degradation of the image [ 13 ]. Many studies use a combination of tendon-identifying techniques and location inference based on the relationship of the PMR to the bucinator and the SPC [ 8 , 9 , 13 ]. However, reliably localizing the PMR using MRI can be challenging due to the limited resolution of the technique.…”

“…The PMR has proven to be useful in many different clinical practices. One of these is the treatment of OSA [ 8 - 11 , 34 ]. From mandibular advancement splint (MAS) to suspension palatoplasty to barbed reposition pharyngoplasty, the PMR plays an important role in various OSA procedures.…”