SARAF KRANIAL

Cranial nerves are responsible for carrying information in and out of the brain. Ten of the
cranial nerves originate from the brain stem and mainly control the voluntary movement and
structures of the head with some exceptions. The nucleus of the olfactory and optic nerve
are located in the forebrain and thalamus, respectively, and are not considered true cranial
nerves. The others originating from the brainstem include oculomotor, trochlear, trigeminal,
abducens, facial, vestibulocochlear, glossopharyngeal, vagus, spinal accessory, and
hypoglossal. Of note, the accessory nerve innervates the sternocleidomastoid and trapezius
muscles, neither of which control muscles used exclusively in the head.

(neuroanatomi, somatic)

There are 12 pairs of cranial nerves, each of which is named according to its distribution or
function. Cranial nerves arise from the inferior surface of the brain and are numbered in the
order in which they connect with the brain from anterior to posterior (Patton and Thibodeau
2010). They may be sensory, motor or mixed nerves (Table 1).

TABLE 1

Classification and Gnction of the cranial nerves

Cranial nerve Classificatio Function

(number) n

Olfactory nerves (I) Sensory Provide the sense of smell. Impulses are conveyed to the
primary olfactory area in the temporal lobe of the
cerebral cortex.

Optic nerves (II) Sensory Send information from the eye to the diencephalon and
onward to the visual area of the occipital lobe providing
the sense of sight.

Oculomotor nerves Motor Supply the superior, medial and inferior recti and inferior
(III) oblique muscles; the ciliary muscles; the circular muscles
of the iris; and muscles that raise the upper eyelids, the
levator palpebrae muscles.

Trochlear nerves (IV) Motor Innervate the superior oblique muscles of the eye.

Trigeminal nerves (V) Mixed
The ophthalmic branch innervates the scalp and skin of
the forehead; the maxillary branch innervates the upper
lip and gums, teeth, cheeks, nose and lower eyelids; and
the mandibular branch innervates the muscles of
mastication.

Abducent nerves (VI) Motor Innervate the lateral rectus muscle of the eye.
Facial nerves (VII) Mixed Innervate the facial muscles (facial expression) and
control secretion of saliva and tears, as well as sensory
information from the taste buds along the anterior two
thirds of the tongue.

Vestibulocochlear Sensory The cochlear branch provides the sensation of hearing

nerves (VIII) and the vestibular branch provides the sensation of
equilibrium.

Glossopharyngeal Mixed Stimulate the posterior third of the tongue and the
nerves (IX) pharynx. Monitor blood pressure and respiratory gas
levels in the blood.

Vagus nerves (X) Mixed Supply visceral structures such as the pharynx, larynx,
trachea and heart and have diverse sensory functions
such as taste, touch, pain and temperature.

Accessory nerves (XI) Motor Innervate muscles that control movement of the head
and shoulders.

Hypoglossal nerves Motor Innervate the muscles of the tongue.

(XII)

(Tortora and Derrickson 2012)

(nervous system part 3)

Cranial nerves I and II cannot be regarded as peripheral nerves in terms of anatomy,

physiology, and develop- ment but are regarded as extensions of the CNS. We will thus
focus on cranial nerves (CN) III to XII, which are devoted to motor, sensory, and autonomous
function of the face and internal organs of the head and neck.

They are all paired structures. The Xth cranial nerve or vagus nerve is an exception as its
targets are outside the head and neck.

CN III (COMMON OCULOMOTOR NERVE), CN IV (TROCHLEAR NERVE), AND CN VI

(ABDUCENS MOTOR NERVE)

The CN III, IV, and VI innervate the extrinsic muscles of the eye. They are located in the
upper brainstem. CN III has parasympathetic and motor innervation. Its motor fibers
innervate the medial rectus, superior rectus, infe- rior rectus, and inferior oblique muscles.
It also innervates the levator palpebrae superioris muscle. Preganglionic parasympathetic
fibers come from the Edinger-Westphal nucleus and project to the ciliary ganglion from
which fibers innervate the pupil constrictor muscle allowing accommodation for near vision
(sympathetic postgangli- onic fibers from superior cervical ganglion innervate pupil dilator
and superior tarsal muscles). CN IV supplies the superior oblique muscle, allowing
downward and inward gaze, especially when climbing stairs or reading a book in bed. CN VI
innervates the lateral rectus muscle, resulting in the ipsilateral lateral gaze.

CN V (TRIGEMINAL NERVE)

The trigeminal nerve conveys sensation of the face, sinuses, teeth and the anterior part of
the oral cavity, and motor function during mastication. It is divided into:

(1) the ophthalmic branch – pure sensory innervation; (2) the maxillary branch – pure
sensory innervation; and (3) the mandibular branch – sensory and motor innervation of
masseter and tensor tympani muscles. The sensory part of the ophthalmic division of CN V
(V1) innervates the cornea and eyeball and forms the afferent limb of the corneal reflex. The
maxillary branch innervates the mid part of the face and the mandibular branch innervates
the lower face. Primary axons from the sensory semilu- nar and trigeminal Gasser ganglia,
responsible for fine discriminative sensitivity (epicritic), terminate on the main sensory and
the rostral descending nucleus of CN V. Axons that convey pain and temperature (proto-
pathic) terminate in the caudal descending nucleus (spinal) of CN V. The trigeminal nerve
also conveys pro- prioception arising from neuromuscular spindles lying in the masticatory
and extraocular muscles.

CN VII (FACIAL NERVE)

The CN VII has parasympathetic, motor, and sensory innervation. Motor fibers are
distributed to the muscles that contribute to facial expression (frontalis, orbicularis oculi,
and orbicularis oris), muscles of the scalp, auricle, buccinator, stapedius, stylo-hyoid, and
posterior belly of digastric muscles. Parasympathetic fibers from the superior salivary
nucleus project to the pterygopalatine ganglion, which innervates the lachrymal gland and
to the submandibular ganglion that innervates the subman- dibular and sublingual salivary
glands. Sensory taste fibers come from the anterior two-thirds of the tongue (via the chorda
tympani) and the soft palate (via the great petrosal nerve).

CN VIII (VESTIBULOCOCHLEAR NERVE)

CN VIII is made up of primary sensory neurons located in Scarpa’s ganglion (vestibular) and
in spiral ganglion (cochlear). Expansions of peripheral vestibular ganglion cells innervate the
utricle and saccule hair cells in response to linear acceleration (gravity) and in the ampullae
cells of the semicircular canals in response to angular acceleration (movement). The utricle,
saccule, and semicircular canals trigger signals necessary for coordination, balance, and
movement of the head and neck. Expansions of peripheral spiral ganglion innervate the hair
cells along the cochlear duct of Corti organ. They convey hearing information to the cochlear
nuclei.

CN IX (GLOSSOPHARYNGEAL NERVE)

CN IX has a parasympathetic, motor, and sensory inner- vation. Motor fibers from the
nucleus ambiguus inner- vate the stylopharyngeus muscle and participate in the innervation
of the pharyngeal muscles for swallowing. Preganglionic neurons from the inferior salivary
nucleus project to the otic ganglion, whose neurons target the parotid gland and mucous
glands. Neurons from the inferior (petrosal) ganglion convey taste sensitivity of the
posterior third of the tongue and posterior part of the soft palate and end in the rostral
portion of solitary nucleus. Other axons from the inferior ganglion convey the sensitivity of
the posterior third of the tongue, phar- ynx, tonsil, tympanic cavity, Eustachian tube, and
mas- toid cells. These fibers that convey the general sensibility of the pharynx form the
afferent gag reflex. Other pri- mary sensory neurons innervate the carotid body (CO2
chemoreception) and carotid sinus (baroreceptors), and end in the caudal solitary nucleus.
Other primary sensory neurons from the superior ganglion innervate a small area behind
the ear.

CN X (VAGUS NERVE)

CN X has parasympathetic, motor, and sensory inner- vation. The peripheral motor neurons,
located in the nucleus ambiguus in the medulla oblongata, innervate the muscles of the soft
palate, pharynx, and larynx, allowing speech and swallowing. Preganglionic para-
sympathetic axons, from the dorsal nucleus of the vagus located in the medulla oblongata
(medulla), project to the intramural ganglia of the thoracic and abdominal viscera and thus
ensure the autonomic innervation of the heart, lung, and gastrointestinal tract to the
descending colon. Primary sensory axons, from the inferior ganglion, ensure the sensitivity
of the larynx, pharynx, and tho- racic and abdominal viscera to end in the caudal nucleus
solitarius. Primary sensory axons from the superior (jug- ular) ganglion ensure the sensitivity
of the external audi- tory meatus and end on the descending (spinal) nucleus of CN V.

CN XI (ACCESSORY NERVE)

CN XI is a motor nerve with a cranial and a spinal part. The cranial part is formed of
peripheral motor neurons from the caudal end of the nucleus ambiguus. Axons pro- ject
with the laryngeal and pharyngeal branches of the vagus nerve and the nerves to the soft
palate. The spinal part is formed of spinal motor neurons from the lateral first 4 or 5
segments of the cervical spinal cord. Axons emerge as rootlets from the lateral edge of the
spinal cord, ascend behind the denticulate ligaments and then merge into a single nerve.
This nerve goes through the foramen magnum and joins the vagus nerve to exit through the
jug- ular foramen. The spinal accessory nerve innervates the sternocleidomastoid and the
upper two-thirds of the tra- pezius muscles, resulting in the rotation of the head and
shoulder elevation.

CN XII (HYPOGLOSSAL NERVE)

CN XII is a motor nerve. Motor neurons from the hypo- glossal nucleus of the medulla
oblongata emerge from the ventral surface of the medulla. They innervate the extrinsic
(hyoglossus, styloglossus, chondro- and genio- glossus) and intrinsic tongue muscles
(superior and infe- rior longitudinal, transverse, and vertical lingual tongue), resulting in
protrusion of the tongue.

(gross anatomy)

The brainstem is the source of all the cranial nerves and provides sensory, motor, and,
through the vagus nerve, parasympathetic preganglionic innervation to the face, head, thorax,
and most of the abdominal viscera. Distinct motor and sensory nuclei within the brainstem
project to the various structures of the head to provide (1) general sensory information from
the face, ears, and oropharynx and (2) motor innervations for facial movement and
expression, mastication, extraocular eye movements, and complex functions such as speech
and swallowing. The specialized olfactory, visual, auditory, and gustatory senses are
provided by highly specialized receptor cells and end organs, with ultimately wide cor- tical
projections.
Cranial nerve motor nuclei are located medially, whereas the sensory nuclei are found
generally more lateral. Three types of motor nuclei are present innervating voluntary striated
muscles (somatic), muscles of facial expressions and mastication (special motor derived
from embryonic branchial arch structures), and autonomic smooth muscles (visceral). Each
cranial nerve serves a regional skull area and may provide more than one function to that area
and therefore is not restricted to a single nucleus or nerve type. For example, the facial nerve
provides voluntary motor innervations to the face as well as taste special sensation to the
anterior tongue. The pure motor nerves (except for perhaps some proprioceptive function) are
the oculomotor III, trochlear IV, abducens VI, spinal accessory nerve XI, and hypoglossal XI.
The special sensory nerves are the olfactory, optic, and vestibulocochlear. Mixed cranial
nerves are the trigeminal V, facial VII, glossopharyngeal IX, and vagus X. A summary of the
origin, course, and distribution of each cranial nerve is outlined on the next plates.
Cranial neuropathies may manifest as a single cranial neuropathy or, less commonly,
as multiple cranial neuropathies. Single cranial neuropathies are discussed in their respective
sections. For example, Bell palsy is reviewed in the cranial nerve VII (facial nerve) section.
Multiple cranial neuropathies involve any combination of cranial nerves, although cranial
nerves III, V, VI, and VII are the most commonly affected in most clinical series. The
manifestations of multiple cranial neuropathies reflect the sites of injury and function of the
cranial nerves affected. The many different causes of multiple cranial neuropathies include
infectious, neoplastic, autoimmune disease, trauma, and vascular disease. Infections
associated with multiple cranial neuropathies include Lyme disease, tuberculous meningitis,
cryptococcus, histoplasmosis, botulism, mucormycosis, certain viruses (e.g., herpes simplex
virus, varicella-zoster virus) and bacterial meningitis. Guillain-Barré syndrome (GBS) and
the Miller Fisher variant of GBS are monophasic, autoimmune polyradiculoneuropathies that
can frequently involve multiple cranial nerves. Neoplasms cause multiple cranial
neuropathies either by direct compression and local extension, such as with meningiomas,
schwannomas, and nasopharyngeal tumors, or by diffuse dissemination and meningeal
infiltration, such as with lymphoma and various carcinomas. Myasthenia gravis (MG) mimics
multiple cranial neuropathies but the site of autoimmune attack in MG is directed against the
postsynaptic muscle end rather than the nerve
(netter collection volume 7)

The 12 pairs of cranial nerves are referred to by either name or Roman numeral (Fig 8-1 and
Table 8-1). Note that the olfactory peduncle (see Chapter 19) and the optic nerve (see Chapter
15) are not true nerves but rather fiber tracts of the brain, whereas nerve XI (the spinal
accessory nerve) is derived, in part, from the upper cervical segments of the spinal cord. The
remaining nine pairs relate to the brain stem

ORIGIN OF CRANIAL NERVE FIBERS

Cranial nerve fi bers with motor (efferent) fu nctions arise from collections of cells (motor
nuclei) that lie deep within the brain stem; they are homologous to the anterior horn cells of
the spinal cord. Cranial nerve fibers with sensory (afferent) functions have their cells of
origin (first-order nuclei) outside the brain stem, usually in ganglia that are homologous to
the dorsal root ganglia of the spinal nerves. Second order sensory nuclei lie within the brain
stem (see Chapter 7 and Fig 7-6). Table 8-1 presents an overview of the cranial nerves. This
table does not list the cranial nerves numerically; rather, it groups them functionally:
 Nerves I, II, and VIII are devoted to special sensory input.
 Nerves Ill, IV, and VI control eye movements and pupillary constriction.
 Nerves XI and XII are pure motor (XI: sternocleidomastoid and trapezius; XII:
muscles of tongue).
 • Nerves V, VII, IX, and X are mixed.
 Note that nerves III, VII, IX, and X carry parasympathetic fibers.

FUNCTIONAL COMPONENTS OF THE CRANIAL NERVES

A cranial nerve can have one or more functions (as shown in Table 8-1 ) . The functional
components are conveyed from or to the brain stem by six types of nerve fibers:
1. Somatic efferent fibers, also called general somatic efferent fibers, innervate striated
muscles that are derived from somites and are involved in eye (nerves III, IV, and VI)
and tongue (nerve XI I) movements.
2. Branchial efferent fibers , also known as special visceral efferent fibers , are special
somatic efferent components. They innervate muscles that are derived from the
branchial (gill) arches and are involved in chewing (nerve V), making fa cial
expressions (nerve VII), swallowing (nerves IX and X), producing vocal sounds
(nerve X), and turning the head (nerve XI).
3. Visceral efferent fibers are also called general visceral efferent fibers (preganglionic
parasympathetic components of the cranial division); they travel within nerves III
(smooth muscles of the inner eye), VII (salivatory and lacrimal glands) , IX (the
parotid gland), and X (the muscles of the heart, lung, and bowel that are involved in
 movement and secretion; see Chapter 20) .
4. Visceral afferent fibers, also called general visceral afferent fibers, convey sensation
from the alimentary tract, heart, vessels, and lungs by way of nerves IX and X. A
specialized visceral afferent component is involved with the sense of taste; fibers
carrying gustatory impulses are present in cranial nerves VII, IX, and X.
5. Somatic afferent fibers , often called general somatic afferent fibers, convey sensation
from the skin and the mucous membranes of the head. They are found mainly in the
trigeminal nerve (V) . A small number of afferent fibers travel with the fa cial (VII),
glossopharyngeal (IX), and vagus (X) nerves; these fibers terminate on trigeminal
nuclei in the brain stem.

(clinical neuroanatomy)
The 12 pairs of cranial nerves (see Fig. 3-13) leave the brain and pass through foramina in the skull. Some of
these nerves are composed entirely of afferent nerve fibers bringing sensations to the brain (olfactory, optic, and
vestlbulocochlear), others are composed entirely of efferent fibers ( oculomotor, trochlear, abducent, accessory,
and hypoglossal), while the remainder pos sess both afferent and efferent fibers (trtgeminal, facial,
glossopharyngeal, and vagus). The cranial nerves are described in detail in Chapter 11.