CRANIAL NERVES

III, IV, VI & VII

OLUWOLE AKINOLA
• Are 12 pairs of nerves
attached to the brain
• 31 pairs of spinal nerves
are associated with the
spinal cord
• Are surrounded by
variable extension of
the meninges as they
emerge from the brain
• Are either:
• motor (to muscles and
glands),
• sensory (conveying
impulses from
peripheral receptors); or
• mixed (containing both
motor and sensory
fibres)
Cranial nerves
include paired:
• Olfactory nerves
CRANIAL NERVES
• Optic nerves
• Oculomotor nerves
• Trochlear nerves
• Trigeminal nerves
• Abducent nerves
• Facial nerves
• Vestibulocochlear
nerves
• Glossopharyngeal
nerves
• Vagus nerves
• Accessory nerves, &
• Hypoglossal nerves
Cranial Nerve III: Oculomotor Nerve
• Innervates all extraocular muscles
• except lateral rectus and superior oblique;
• contains about 24,000 fibres
• Also supplies pupillary sphincter and ciliary
muscle
• Via ciliary ganglion and short ciliary nerves
• Sources of Fibres:
• Oculomotor nucleus
• a complex of nucleus in the ventral part of central
grey substance of midbrain at the level of superior
colliculus
• Source of general somatic efferent fibres
• Edinger-Wesphal nucleus
• Also called accessory oculomotor nucleus;
• source of preganglionic parasympathetic fibres
(special somatic efferent fibres) to ciliary ganglion
 Course of CN III
• CN III emerges from ventral aspect
of midbrain,
• passes forwards in interpeduncular
fossa (subarachnoid space)
• Here, it is covered by pia mater; then it
• Continues fwd btw posterior
cerebral artery above and superior
cerebellar artery below; and
• beyond these vessels, it lies
inferolateral to posterior
communicating artery; thereafter,
• it traverses lateral wall of cavernous
sinus
• Here, it lies above trochlear nerve and
lateral to internal carotid artery
 Division of CN III
• Divides into superior and inferior rami
• behind the superior orbital fissure
• These divisions traverse superior orbital
fissure
• within common tendinous ring (with the
nasociliary nerve between them)
• to enter the orbit
Distribution of Oculomotor Nerve
• the smaller superior ramus innervates
• superior rectus and
• levator palpebrae superioris
• inferior ramus innervates
• inferior rectus,
• inferior oblique &
• medial rectus
• ciliary ganglion also receives a branch
from infr ramus;
• this branch contains preganglionic
parasympathetic fibres
• from accessory oculomotor nucleus
Conjugate Horizontal Gaze
• Horizontal gaze twd the
right involved the right LR
and left MR
• and vice-versa
• Oculomotor nucleus and
abducent nucleus are
connected at the
brainstem
• Via medial longitudinal
fasciculus
Applied Anatomy of the Oculomotor Nerve
Lesion in the oculomotor nerve would
produce:
• Ptosis
• due to paralysis of levator palpebrae superioris
• Lateral strabismus
• owing to the unopposed action of lateral rectus
and superior oblique
• Pupillary dilatation
• owing to paralysis of pupillary sphincter
• Loss of accommodation and pupillary light
reflex,
• due to paralysis of ciliaris and sphincter
pupillae respectively, and
• Proptosis (prominence of the eyeball)
• due to muscular relaxation
• Irritation of CN III would produce spasm of
muscles supplied by it
 • the smallest cranial nerve
Trochlear Nerve • With the longest intracranial course
• innervates only one muscle
(Cranial Nerve IV) • superior oblique
• adult trochlear nerve about 3400 fibres;
• this number is however greater in foetus
• trochlear nucleus
• located in the lower part of the central grey
substance of the midbrain,
• at the level of inferior colliculus
• caudal to oculomotor nucleus
 Course of the • From its nucleus, fibres of trochlear nerve pass
backwards,
Trochlear Nerve • lateral to the central grey substance, and towards the dorsal
aspect of the midbrain
• These fibres decussate in the superior medullary velum,
and then
• emerge on the dorsal aspect of midbrain,
• below the inferior colliculus
• lateral to frenulum veli
• the only cranial nerve that emerges on the dorsal aspect of
brainstem
 Course of the • it then passes forwards
Trochlear Nerve • on the lateral aspect of cerebral peduncle
• just above the pons, and
• btw posterior cerebral and superior cerebellar
arteries; thereafter, it
• pierces dura and arachnoid mater to traverse
the lateral wall of cavernous sinus
• below oculomotor and above ophthalmic nerves;
• enters orbit via superior orbital fissure,
• above the tendinous ring, and
• medial to the frontal nerve
• In the orbit, trochlear nerve passes
medially,
• above levator palpebrae superioris,
• innervates superior oblique
• via the orbital aspect of this muscle
• the only muscle it supplies
 Trochlear Nerve:
Clinical Anatomy
• Lesion in trochlear nerve paralyzes
or weakens superior oblique;
• this abolishes inferolateral
(downward and outward) ocular
movement
• affected eye is directed upward and
outward,
• producing vertical diplopia
• when attempting to look downwards;
e.g.,
• descending a stair or reading
• To avoid diplopia,
• the subject tilts the head
to the normal side
• to adduct the eye, and
• pushes the chin downwards
• to elevate the eye
Abducent Nerve (CN VI)
• VIth cranial nerve;
• innervates lateral rectus only
• Its fibres arise from abducent
nucleus,
• in the lower part of pontine
tegmentum
• deep to the facial colliculus
• These fibres descend ventrally
through the pons, and
• Emerge from the brainstem through
the sulcus btw the lower pontine
border and the upper end of
medullary pyramid medulla
oblongata
Abducent nucleus
• contains large and small multipolar neurons
• about 22,000 neurons
• The large multipolar neurons are the source of
the fibres of CN VI
• The small multipolar neurons of abducent
nucleus are collectively known as nucleus para-
abducens;
• it is connected with oculomotor nucleus by medial
longitudinal fasciculus
• For conjugate horizontal eyes movement
Abducent nucleus receives fibres from
• Corticonuclear tract
• mainly the contralateral tract
• Medial longitudinal fasciculus (MLF);
• connects abducent nucleus with nuclei
of 3rd, 4th and 8th cranial nerves
• CN VIII carries fibres from vestibular
apparatus,
• and via vestibular nuclei connect with
nuclei of CN III, IV and VI
• This mediates movement of the eyes in a
direction opposite that in which the head
turns
• Tectobulbar tract;
• this links abducent nucleus with the
visual cortex and other centres,
• via the superior colliculus
 Course of the
Abducent Nerve
Abducent nerve
• Emerges from the brainstem anteriorly
• between the pons and medullary pyramid;
and
• ascends anterolaterally thro pontine
cistern
• dorsal to the anterior inferior cerebellar
artery
• Pierces dura matter lateral to dorsum
sellae,
• and traverses cavernous sinus at first lateral,
and then inferolateral to internal carotid
artery; then, it
Facial Nerve • 7th cranial nerve (CN VII)
CN VII • a mixed nerve
• Contains motor and sensory fibres; thus,
• has a motor root and a sensory root;
• Sensory root is the nervus intermedius
• Is the nerve of the 2nd branchial (pharyngeal)
arch;
• innervates all muscles derived from this arch
• muscles of facial expression
• takes a complex course thro pons and facial
canal
• genicular ganglion:
• located at the point where facial nerve turns
backwards within facial canal
• And above the promontory of middle ear
• Communicates with CN VIII, CN IX, and CN V
(including the auricular branch of CN X)
• Via MLF
• Motor nucleus
• located in the lower Nuclei associated with the
pontine tegmentum;
• source of motor fibres of facial nerve include:
facial nerve
• Superior salivatory
nucleus
• located at the
pontomedullary junction;
• source of (presynaptic)
parasympathetic fibres
of facial nerve
• Nucleus solitarius
• located in the medulla;
• receives taste fibres from
facial nerve
• Spinal nucleus of
trigeminal nerve
• located in the lower pons,
medulla and upper part
of spinal cord;
• receives general sensory
fibres from facial nerve
• from the external ear
Fibres contained in the facial nerve include:
• Motor fibres
• to facial muscles, scalp
muscles, auricular muscles,
buccinator, stylohyoid,
digastric (posterior belly),
platysma and stapedius
• Secretomotor fibres
• to sublingual, submandibular
and lacrimal glands, and
glands of the palate and
nasal cavity
• Special visceral afferent
(taste) fibres
• from the anterior 2/3 (oral
part) of the tongue (except
the vallate papillae) and soft
palate
• General sensory fibres
• from external ear
 • Emerges from brainstem
• as two roots
• motor and sensory
Course of • thro lateral part of
pontomedullary sulcus
Facial • medial to vestibulocochlear
Nerve nerve
• sensory root is lateral to
motor root
• Passes anterolaterally
• thro posterior cranial fossa,
to internal acoustic meatus
• In the fossa, nervus
intermedius lies btw
vestibulocochlear nerve
behind, and motor root of
facial nerve in front
 Course: Facial Nerve
• Traverses internal acoustic meatus,
• Here, it occupies a groove on the
anterosuperior aspect of CN VIII. Then, it
• Enters facial canal,
• Here, it first runs laterally (above the
vestibule of bony labyrinth); it then
• bends sharply backwards, to continue
posteriorly (above the promontory of
the middle ear), to the medial wall of the
aditus to the mastoid antrum (behind)
• The point at which the nerve turns sharply
backwards is the geniculum and
• the swelling presented here is the genicular
ganglion
Course: Facial Nerve
• The nerve then continues downwards (in its canal)
• on the posterior wall of the tympanic cavity.
• It emerges thro stylomastoid foramen
• btw mastoid process and styloid processes; then it
• Passes forwards to enter the parotid gland,
• Here, it lies superficial to retromandibular vein; and
• gives five terminal branches within this gland
Branches of the Facial Nerve In• Greater
the facial canal, the facial gives
petrosal nerve,
• arises from genicular ganglion;
• joins deep petrosal nerve to form nerve of the
pterygoid canal
• contains presynaptic parasympathetic fibres to
pterygopalatine ganglion and taste fibres from
palatal mucosa
• Nerve to stapedius;
• arises as facial nerve descends on the posterior
wall of middle ear
• innervates stapedius
• Chorda tympani;
• arises from facial nerve about 6 mm above
stylomastoid foramen
• enters infratemporal fossa
• Here, it joins lingual nerve at an acute angle;
• conveys taste fibres from anterior 2/3 of the
tongue and presynaptic parasympathetic fibres
to submandibular ganglion
• via lingual nerve
 Branches of the Facial Nerve
As it emerges from stylomastoid foramen, the facial
nerve gives
• Posterior auricular nerve; and
• Nerves to stylohyoid and posterior belly of
digastric
Posterior auricular nerve
• Arise from facial nerve
• as this nerve emerges from stylomastoid foramen;
• it then ascends btw mastoid process and external
acoustic meatus
• Divides into auricular and occipital branches
• Innervates auricularis posterior and intrinsic
auricular muscles of the cranial aspect of the
auricle
• through its auricular branch
• Also Innervates occipital belly of occipitofrontalis
• via its larger occipital branch
 • In the parotid gland, the facial
nerve gives 5 terminal branches
Terminal Branches of • these radiate to the face and neck;
and include:
Facial Nerve • Temporal branches
• Zygomatic branches
• Buccal branches
• Marginal mandibular branch, and
• Cervical branch;
• this descends to the neck deep to
platysma, which it innervates
Blood Supply to the Facial Nerve
Facial nerve receives blood from branches of
• anterior inferior cerebellar artery,
• in the cranial cavity
• superficial branch of middle meningeal and stylomastoid branch of
posterior auricular arteries,
• in the facial canal, and
• occipital, posterior auricular, stylomastoid, superficial temporal and
transverse facial arteries,
• in its extracranial part
• Veins of the facial nerve end in the accompanying veins of the
stylomastoid and superficial temporal arteries
Clinical Correlates of the Facial Nerve
 • Facial paralysis may arise from
Applied Anatomy of supranuclear, nuclear or infranuclear
Lesions
the Facial Nerve • Supranuclear lesions may be due to stroke;
• it thus involves upper motor neurons
(corticonuclear fibres) that supply facial nucleus
• In these lesions, voluntary movement of the
contralateral lower part of the face is weak or
absent; however,
• because the upper part of the face (forehead)
is not affected in this type of lesion,
movements such as wrinkling of the forehead,
etc, are not abolished
Lesions in the • Nuclear or infranuclear lesions
would produce paralysis of the
Facial Nerve ipsilateral half of the face
• Nuclear lesions involve central
injury to the motor nucleus or fibres
of facial nerve (in the lower pons)
• Infranuclear Lesions may occur in
the cranial cavity, internal
acoustic meatus or along the
extracranial course of the nerve
• Lesions in internal acoustic meatus
may involve CN VII (and CN VIII);
• producing hyperacusia, ipsilateral
facial palsy, etc
• When CN VII is injured in the facial
canal, the deficits depend on the
site of injury
• Lesion just proximal to the origin of
nerve to stapedius would result in
hyperacusia
• in addition to ipsilateral facial palsy, etc
• Lesion just proximal to the origin of
greater petrosal nerve may result in
reduced salivation in subm and subl
glands and reduced lacrimation in
lacrimal gland
• Aberrant repair of such injured
fibres (proximal to the origin of
greater petrosal nerve) may lead
to innervation of lacrimal gland
by fibres originally destined for
the submandibular ganglion
• resulting in crocodile tears
syndrome
• Injury to facial nerve near
stylomastoid foramen would not
paralyze stapedius,
• neither would lacrimation be
adversely affected
• because nerve to stapedius and greater
petrosal nerve are spared
• Bell’s palsy
• from inflammation of facial nerve in
the facial canal
• near stylomastoid foramen;
• may be idiopathic
• Ipsilateral facial palsy occurs
• Facial nerve is at risk during
parotidectomy
• When injured in this operation,
ipsilateral facial paralysis occurs
• When facial nerve injury is
limited to its extracranial part,
• secretory functions of subm, subl
and lacrimal glands are not
impaired,
• Nor is there loss of taste sensation
from anterior 2/3 of the tongue and
palate
• because chorda tympani and greater
petrosal nerves are spared
Extracranial facial nerve injury is xrized by
• Ipsilateral palsy of orbicularis orculi
• Deviation of angle of the mouth to the
unaffected side
• Ipsilateral absence of wrinkles in the
face
• Impaired corneal blinking reflex
• due to inability to close the eye
• Keratitis may result
Crocodile Tears
Syndrome
• Bell’s palsy is named after Charles Bell
• Due to inflammation of viral infection of CN VII in
facial canal
• Ipsilaral facial palsy occurs
• Bell’s phenomenon (Palpebral Oculogyric Reflex) is
also noted;
• This occurs when the subject attempt to close both eyes;
the affected eye rotates upwards and outward
• This is a normal defence mechanism of the eye
• seen in more than 75% of the popn