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The hypoglossal nerve is the twelfth paired cranial nerve.

Its name is derived from ancient greek,


hypo meaning under, and glossal meaning tongue. The nerve has a purely somatic motor
function, innervating the majority of the muscles of the tongue.
In this article, the anatomical course, motor functions and clinical relevance of the nerve will be
examined.

Anatomical Course

Fig 1.0 The extracranial anatomical course of the hypoglossal nerve

The hypoglossal nerve arises from the hypoglossal nucleus in the medulla oblongata of the
brain. It then passes laterally across the posterior cranial fossa, within the subarachnoid space.
The nerve exits the cranium via the hypoglossal canal.
Now extracranial, the nerve receives a branch of thecervical plexus that conducts fibres from
C1/C2 spinal nerve roots. These fibres do not combine with the hypoglossal nerve they merely
travel within its sheath.
It then passes inferiorly to the angle of the mandible, crossing the internal and external carotid
arteries, and moving in an anterior direction to enter the tongue.

Motor Function
The hypoglossal nerve is responsible for motor innervation of the vast majority of the muscles of
the tongue (except forpalatoglossus). These muscles can be subdivided into two groups:
i) Extrinsic muscles
Genioglossus (makes up the bulk of the tongue)
Hyoglossus
Styloglossus
Palatoglossus (innervated by vagus nerve)
ii) Intrinsic muscles
Superior longitudinal

Inferior longitudinal
Transverse
Vertical
Together, these muscles are responsible for all movements of the tongue.
Role of the C1/C2 Roots
The C1/C2 roots that travel with the hypoglossal nerve also have a motor function. They branch
off to innervate the geniohyoid (elevates the hyoid bone) and thryohyoid (depresses the hyoid
bone) muscles.
Another branch containing C1/C2 fibres descends to supply the ansa cervicalis a loop of
nerves that is part of the cervical plexus. From the ansa cervicalis, nerves arise to innervate the
omohyoid, sternohyoid and sternthyroid muscles. These muscles all act to depress the hyoid
bone.

Fig 1.1 Overview of the motor functions of the hypoglossal nerve

Clinical Relevance
Examination of the Hypoglossal Nerve

Fig 1.2 Right hypoglossal nerve palsy, characterised by deviation of the tongue to the right.

The hypoglossal nerve is examined by asking the patient to protrude their tongue. Other
movements such as asking the patient to push their tongue against their cheek and feeling for the
pressure on the opposite side of the cheek may also be used if damage is suspected.
Palsy of the Hypoglossal Nerve
Damage to the hypoglossal nerve is a relatively uncommon cranial nerve palsy. Possible causes
include tumours and penetrating traumatic injuries. If the symptoms are accompanied by acute
pain, a possible cause may be dissection of the internal carotid artery.
Patients will present with deviation of the tongue towards the damaged side on protrusion, as
well as possible muscle wasting and fasciculations (twitching of isolated groups of muscle
fibres) on the affected side.

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The vagus nerve is the 10th cranial nerve (CN X). It is a functionally diverse nerve, offering
many different modalities of innervation. Due to its widespread functions, pathology of the
vagus nerve is implicated in a vast variety of clinical cases.
In this article we shall look at its anatomical course, motor, sensory and autonomic functions.
The vagus nerve is associated with the derivatives of the fourth pharyngeal arch.
Sensory: Innervates the skin of the external acoustic meatus and the internal surfaces of the
laryngopharynx and larynx. Provides visceral sensation to the heart and abdominal viscera.
Special Sensory: Provides taste sensation to the epiglottis and root of the tongue.
Motor: Provides motor innervation to the majority of the muscles of the pharynx, soft palate and
larynx.
Parasympathetic: Innervates the smooth muscle of the trachea, bronchi and gastro-intestinal
tract and regulates heart rhythm.

Anatomical Course
The vagus nerve has the longest course of all the cranial nerves, extending from the head to the
abdomen. Its name is derived from the Latin vagary - meaning wandering. It is sometimes
referred to as the wandering nerve.
In the Head
The vagus nerve originates from the medulla of the brainstem. It exits the cranium via
the jugular foramen, with the glossopharyngeal and accessory nerves (CN IX and XI
respectively).
Within the cranium, the auricular branch arises. This supplies sensation to the posterior part of
the external auditory and canal external ear.
In the Neck
By Truth-seeker2004 [CC-BY-SA-3.0], via Wikimedia Commons

Fig 1.0 Overview of the major branches of the vagus nerve

In the neck, the vagus nerve passes into the carotid sheath, travelling inferiorly with the internal
jugular vein and common carotid artery. At the base of the neck, the right and left nerves have
differing pathways:

The right vagus nerve passes anterior to the subclavian artery and posterior to the sternoclavicular
joint, entering the thorax.

The left vagus nerve passes inferiorly between the left common carotid and left subclavian arteries,
posterior to the sternoclavicular joint, entering the thorax.

Several branches arise in the neck:

Pharyngeal branches Provides motor innervation to the majority of the muscles of the pharynx and
soft palate.
Superior laryngeal nerve - Splits into internal and external branches. The external laryngeal nerve
innervates the cricothyroid muscle of the larynx. The internal laryngeal provides sensory innervation
to the laryngopharynx and superior part of the larynx.
Recurrent laryngeal nerve (right side only) Hooks underneath the right subclavian artery, then
ascends towards to the larynx. It innervates the majority of the intrinsic muscles of the larynx.

In the Thorax

Fig 1.1 The origin of the recurrent laryngeal nerves

In the thorax, the right vagus nerve forms theposterior vagal trunk, and the left forms
theanterior vagal trunk. Branches from the vagal trunks contribute to the formation of the
oesophageal plexus, which innervates the smooth muscle of the oesophagus.
Two other branches arise in the thorax:

Left recurrent laryngeal nerve it hooks under the arch of the aorta, ascending to innervate the
majority of the intrinsic muscles of the larynx.
Cardiac branches these innervate regulate heart rate and provide visceral sensation to the organ.

The vagal trunks enter the abdomen via the oesophageal hiatus, an opening in the diaphragm.
In the Abdomen
In the abdomen, the vagal trunks terminate by dividing into branches that supply the oesophagus,
stomach and the small and large bowel (up to the splenic flexure).

Sensory Functions
There are somatic and visceral components to the sensory function of the vagus nerve.
Somatic refers to sensation from the skin and muscles. This is provided by the auricular nerve,
which innervates the skin of the posterior part of the external auditory canal and external ear.
Viscera sensation is that from the organs of the body. The vagus nerve innervates:

Laryngopharynx via the internal laryngeal nerve.


Superior aspect of larynx (above vocal folds) via the internal laryngeal nerve.
Heart via cardiac branches of the vagus nerve.
Gastro-intestinal tract (up to the splenic flexure) via the terminal branches of the vagus nerve.

Fig 1.2 The three parts of the pharynx, and their borders. The laryngopharynx is innervated by the vagus nerve.

Special Sensory Functions


The vagus nerve has a minor role in taste sensation. It carries afferent fibres from the root of the
tongue and epiglottis.
(This is not to be confused with the special sensation of the glossopharyngeal nerve, which
provides taste sensation for the posterior 1/3 of the tongue).

Motor Functions
The vagus nerve innervates the majority of the muscles associated with the pharynx and larynx.
These muscles are responsible for the initiation of swallowing and phonation.

Fig 1.2 Lateral view of the deep structures of the pharynx. Visible are the circular muscles of the pharynx, and the stylopharyngeus.

Muscles of the Pharynx


Most of the muscles of the pharynx are innervated by the pharyngeal branches of the vagus
nerve:

Superior, middle and inferior pharyngeal constrictor muscles


Palatopharyngeus
Salpingopharyngeus

An additional muscle of the pharynx, thestylopharyngeus, is innervated by the glossopharyngeal


nerve.
Muscles of the Larynx
Innervation to the intrinsic muscles of the larynx is achieved via the recurrent laryngeal
nerve and external branch of the superior laryngeal nerve.
Recurrent laryngeal nerve:

Thyro-arytenoid
Posterior crico-arytenoid
Lateral crico-arytenoid
Transverse and oblique arytenoids
Vocalis

External laryngeal nerve:

Cricothyroid

Other Muscles
In addition to the pharynx and larynx, the vagus nerve also innervates the palatoglossus of the
tongue, and the majority of the muscles of the soft palate.

Parasympathetic Functions

In the thorax and abdomen, the vagus nerve is the main parasympathetic outflow to the heart and
gastro-intestinal organs.
The Heart
Cardiac branches arise in the thorax, conveying parasympathetic innervation to the sino-atrial
and atrio-ventricular nodes of the heart (For more heart anatomy, see here).
These branches stimulate a reduction in the resting heart rate. They are constantly active,
producing a rhythm of 60 80 beats per minute. If the vagus nerve was lesioned, the resting
heart rate would be around 100 beats per minute.
Gastro-Intestinal System
The vagus nerve provides parasympathetic innervation to the majority of the abdominal organs.
It sends branches to the oesophagus, stomach and most of the intestinal tract up to the splenic
flexure of the large colon.
The function of the vagus nerve is to stimulate smooth muscle contraction and glandular
secretions in these organs. For example, in the stomach, the vagus nerve increases the rate of
gastric emptying, and stimulates acid production.

Clinical Relevance: Disorders of the Vagus Nerve


Cardiovascular

Many pharmacological agents can be used to potentiate vagal tone on the heart therefore slowing
the heart rate. Beta-blockers, muscarinic agonists and cardiac glycosides such as Digoxin are just
a few that can be used.
Vasovagal syncope can ensue during a period of emotional stress for example causing a sudden
drop in blood pressure and heart rate. Further to this a carotid massage can compress the carotid
sinus leading to the perception of a high blood pressure. This will cause CN X to increase its
firing leading to a decreased activity of the SA node and AV node. Overall a decreased rate and
strength of contraction will ensue and the person may experience syncope.
Many congenital heart defects such as a patent ductus arteriosus can irritate the left recurrent
laryngeal nerve, leading to dysphonia (hoarse voice).
Gastro-Intestinal

Lesions to the CN X are rare. A lesion to the pharyngeal branches can lead to dysphagia
(difficulty swallowing) due to the involvement with the muscles of the pharynx. As CN X
innervates the Palatopharyngeus and Salpingopharyngeus muscles a lesion here will cause the
Palatoglossal arch to drop leading to Uvula deviation away from the affected side. The CN IX is
sensory to the oropharynx and laryngopharynx with CN X being the motor efferents involved in
the Gag reflex therefore a lesion in this area will cause a loss of the Gag reflex.
Once upon a time a Vagotomy could be done to reduce excess stomach acid production.
However with advancements in pharmacological therapy this is no longer necessary.

Other

As stated above a lesion to one of the RLNs will cause dysphonia. A lesion to both RLNs will
cause aphonia (loss of voice) and a stridor (inspiratory wheeze). Paralysis of the RLNs usually
occur due to cancer of the larynx or thyroid gland or due to surgical complications.

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treatment purposes. This information is intended for medical education, and does not create any doctor-patient relationship, and should not
be used as a substitute for professional diagnosis and treatment.
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The glossopharyngeal nerve, CN IX, is the ninth paired cranial nerve. In this
article, we shall look at the anatomical course of the nerve, and the motor,
sensory and parasympathetic functions of its terminal branches.

Overview
Embryologically, the glossopharyngeal nerve is associated with the
derivatives of the third pharyngeal arch.
Sensory: Innervates the oropharynx, carotid body and sinus, posterior 1/3 of
the tongue, middle ear cavity and Eustachian tube.
Special Sensory: Provides taste sensation to the posterior 1/3 of the tongue.
Parasympathetic: Provides parasympathetic innervation to the parotid gland.
Motor: Innervates the stylopharyngeus muscle of the pharynx.

Anatomical Course
The glossopharyngeal nerve originates in the medulla oblongata of the brain.
It emerges from the anterior aspect of the medulla, moving laterally in the
posterior cranial fossa. The nerve leaves the cranium via the jugular
foramen. At this point, the tympanic nerve arises. It has a mixed sensory
and parasympathetic composition.

Fig 1.0 Lateral view of the neck, showing the innervation of the stylopharyngeus muscle.

Immediately outside the jugular foramen lie two ganglia (collections of nerve
cell bodies). They are known as the superiorand inferior (or petrous)
ganglia - they contain the cell bodies of the sensory fibres in the
glossopharyngeal nerve.
Now extracranial, the glossopharyngeal nerve descends down the neck,
anterolateral to the internal carotid artery. At the inferior margin of
thestylopharyngeus, several branches arise to provide motor innervation to
the muscle. It also gives rise to the carotid sinus nerve, which provides
sensation to the carotid sinus and body.
The nerve enters the pharynx by passing between the superior and middle
pharyngeal constrictors. Within the pharynx, it terminates by dividing into
several branches lingual, tonsil and pharyngeal.

Sensory Functions
The glossopharyngeal nerve provides sensory innervation a variety of
structures in the head and neck.

Fig 1.1 Overview of the branches of the glossopharyngeal nerve.

The tympanic nerve arises as the nerve traverses the jugular foramen. It
penetrates the temporal bone and enters the cavity of the middle ear. Here, it
forms the tympanic plexus a network of nerves that provide sensory
innervation to the middle ear,internal surface of the tympanic
membrane and Eustachian tube.
At the level of the stylopharyngeus, thecarotid sinus nerve arises. It
descends down the neck to innervates both the carotid sinus and carotid
body, providing information regarding blood pressure and oxygenation
respectively.
The glossopharyngeal nerve terminates by splitting into several sensory
branches:

Pharyngeal branch combines with fibres of the vagus nerve to form the
pharyngeal plexus. It innervates the mucosa of the oropharynx.
Lingual branch provides the posterior 1/3 of the tongue with general and
taste sensation

Tonsillar branch forms a network of nerves, known as the tonsillar


plexus, which innervates the palatine tonsils.

Special Sensory
The glossopharyngeal nerve provides taste sensation to the posterior 1/3 of
the tongue, via its lingual branch (Note: not to be confused with the lingual
nerve).

Motor Functions
The stylopharyngeus muscle of the pharynx is innervated by the
glossopharyngeal nerve. This muscle acts to shorten and widen the pharynx,
and elevate the larynx during swallowing.

Parasympathetic Functions

Fig 1.2 Path of the parasympathetic fibres to the parotid gland.

The glossopharyngeal nerve provides parasympathetic innervation to


the parotid gland. These fibres originate in the inferior salivatory nucleus of
CN IX. These fibres travel with the tympanic nerve to the middle ear. From
the ear, the fibres continue as the lesser petrosal nerve, before synapsing at
the otic ganglion.
The fibres then hitchhike on theauriculotemporal nerve to the parotid
gland, where they have a secretomotor effect.
Remember although the facial nerve splits into its five terminal branches in
the parotid gland, it is the glossopharyngeal nerve that actually supplies the
gland.

Clinical Relevance Gag Reflex

The glossopharyngeal nerve supplies sensory innervation to the oropharynx,


and thus carries the afferent information for the gag reflex. When a foreign
object touches the back of the mouth, this stimulates CNIX, beginning the
reflex. The efferent nerve in this process is the vagus nerve, CNX.
An absent gag reflex signifies damage to the glossopharyngeal nerve.

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The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or
treatment purposes. This information is intended for medical education, and does not create any doctor-patient relationship, and should not
be used as a substitute for professional diagnosis and treatment.
By visiting this site you agree to the foregoing terms and conditions. If you do not agree to the foregoing terms and conditions, you should not
enter this site.
Oliver Jones

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