Cranial Nerves

Mr Christopher Simon
BSc (Neuroscience / Cognitive Psychology)
MSc (Human Anatomy)
 LEARNING OUTCOMES

Describe the nuclei , course, branches,

distribution & lesions of V cranial nerve.

Explain the nuclei , course, branches,

distribution & lesions of VII cranial nerve.

Discussthe nuclei , course, branches,

distribution & lesions of X cranial nerves.
 BRAIN
OVERVIEW OF THE NERVOUS SYSTEM
CRANIAL Head &
neck Skeletal
NERVES, including muscle,
S Plexuses & viscera
Ganglia Sensory
P
structures,
I
N SPINAL Head, neck, Smooth
thorax, muscle*,
A NERVES, abdomen,
L Plexuses & pelvis, Cardiac
C Ganglia including muscle*,
viscera,
O and limbs
PERIPHERAL Secretory
R
NERVOUS glands*
D
SYSTEM (PNS) TARGET
REGIONS
STRUCTURES
CENTRAL NERVOUS *Innervated by the ANS
SYSTEM (CNS)
 THE CRANIAL NERVES

Sensory information from the head & neck is

received and motor information is sent via 12 pairs
of cranial nerves.
Considered part of the Peripheral nervous system.

Convey messages to and from the body's muscles

and glands.
EACH CRANIAL NERVE.

Has at least a motor, sensory or parasympathetic

component.
Some have more than one component.

Most of the nuclei are situated in the brainstem.

CRANIAL NERVES
1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducent
7. Facial
8. Vestibulocochlear
9. Glossopharyngeal
10.Vagus
11.Accessory
12.Hypoglossal
CRANIAL NERVES - COMPONENTS
CRANIAL NERVES
Nerve Target Exit from cranial
cavity

I. Olfactory Olfactory epithelium- Cribriform plate

(Sensory) Smell (ethmoid)

II. Optic Retina - Vision Optic canal

(Sensory)
III. Oculomotor Eye ball muscles Superior orbital
(Motor + fissure
Parasympathetic)
IV. Trochlear Eye ball muscle Superior orbital
(Motor) fissure
CRANIAL NERVES
Nerve Target Exit from cranial
cavity
V. Trigeminal Head & Neck- 3 div. Superior orbital
(Mixed) Opthalmic- fissure, foramen
Mandibular, ovale, foramen
rotundum.
Maxillary.
VI. Abducens Eye ball muscle- Superior orbital
(Motor) Lateral rectus. fissure
VII. Facial Facial expression Internal auditory
(Mixed) muscles meatus

VIII. Vestibulo- Inner ear Internal auditory

cochlear meatus
(Sensory)
CRANIAL NERVES
Nerve Target Exit from cranial
cavity
IX.Glossopharyng Tongue(Post.1/3), ear & Jugular foramen
eal (Mixed) Parotid gland.

X. Vagus (Mixed) Tongue,.Pharynx, Jugular foramen

Larynx,Gut.
XI. Accessory Sternocleidomastoid,Tr Jugular foramen
(Motor) apezius.

XII. Hypoglossal Intrinsic & extrinsic Hypoglossal canal

(Motor) muscles of tongue.
Cranial nerves-Attachment
CRANIAL NERVE NUCLEI IN COLUMNS

Midbrain

Pons

Medulla
CRANIAL NERVE NUCLEI-BRAIN
CRANIAL NERVE V: TRIGEMINAL
CRANIAL NERVE V: TRIGEMINAL
Component #1: Sensory(impulses of
touch, pain, heat and cold)
Locations of nuclei: pons & medulla
Function: (1) sensations; (2) general
sensory from tongue; (3)
proprioception.
Structure(s) Innervated: (1) face, scalp, teeth, lips,
eyeballs, nose & throat
lining; (2) anterior 2/3 of
tonque; (3) muscles of
mastication.
CRANIAL NERVE V: TRIGEMINAL

Component #2: Motor

Function: chewing

Nucleus location: trigeminal motor nucleus

in pons
Structure(s) Innervated: muscles of mastication
 V: Trigeminal

Mixed nerve with both sensory and motor

functions

Has a motor root and a sensory root.

Because it has a sensory component, it has a

sensory ganglion, akin to the spinal ganglion.

Does NOT contain preganglionic parasympathetic

fibers as it leaves the brain stem.
 V: Trigeminal

Three branches:

V1 (OPHTHALMIC): SENSORY

V2 (MAXILLARY): SENSORY

V3 (MANDIBULAR): SENSORY and MOTOR

 Trigeminal:
Course And Features
V1 : Superior orbital fissure Orbit
Supraorbital notch
and foramen

V2 : Foramen rotundum Pterygopalatine fossa

Inferior orbital fissure
Infraorbital foramen

V3: Foramen ovale Infratemporal fossa

Mandibular canal
Mental foramen

Terminal branches in the face become cutaneous nerves in the head

including the face.
 V Trigeminal:
GIVES ATTACHMENT TO 4 PARASYMPATHETIC GANGLIA:
CILIARY GANGLION, ATTACHED TO V1

PTERYGOPALATINE GANGLION, ATTACHED TO V2

SUBMANDIBULAR GANGLION, ATTACHED TO V3

OTIC GANGLION ATTACHED TO V3

Preganglionic fibers for these ganglia come from other cranial
nerves and only the postganglionic fibers are conveyed by
trigeminal nerve to the target structures.

Trigeminal has no preganglionic parasympathetic components

arising from the brain stem.
Mandibular Division-Muscles of mastication

Temporalis
Masseter
Medial pterygoid
Lateral pterygoid
 V TRIGEMINAL
SENSORY FUNCTIONS
Conveys sensations (touch, pain, pressure etc.) from
skin of the head (face and scalp) and mucosa of cavities
in the head.

Responsible for consciously perceived pain

emanating from the head: toothache, headache and
sinus pain.

Provides sensory input for 2 reflexes often tested

during a neurologic examination: Corneal reflex & Jaw
jerk.
V TRIGEMINAL - SENSORY FUNCTION
 Trigeminal nerve
Parasympathetic Functions

Does not contain preganglionic parasympathetic axons.

Gives attachment to 3 parasympathetic ganglia.
Distribute postganglionic parasympathetic fibers to
lacrimal and two salivary glands.
TRIGEMINAL NERVE

Opthalmic division

Mandibular division

Maxillary division
TRIGEMINAL NERVE

Mandibular division
TRIGEMINAL NERVE
 V: TRIGEMINAL NERVE
V1. Ophthalmic
Exits superior orbital fissure,
Sensory to forehead, nasal cavity.
V2. Maxillary
Exits foramen rotundum through wall of maxillary sinus
to inferior orbital foramina)
Sensory to cheek, upper lip, teeth, nasal cavity.
V3. Mandibular
Exits foramen ovale to mandibular foramen to mental
foramen
Motor to jaw muscles--Masseter, temporalis, pterygoids&
digastric
Sensory to chin & tongue.
VII: FACIAL NERVE
 CRANIAL NERVE VII: FACIAL
Component #1: Sensory
Nucleus location: medulla
Function: (1) taste & (2)
proprioception
Structure(s) Innervated: (1) anterior 2/3 of tongue &
(2) face and scalp

Component #2: Motor

Nucleus location: facial motor nucleus in
pons
Function: facial expressions
Structure(s) Innervated: muscles of the face
CRANIAL NERVE VII: FACIAL
Component #3: Parasympathetic
Nucleus location: Superior salivatory nucleus
in medulla
Function: salivation and lacrimation
(drooling and tears)
Structure(s) Innervated: salivary and lacrimal glands
via submandibular and
pterygopalatine ganglia.
 VII: FACIAL NERVE

Exit through the Internal acoustic meatus &

stylomastoid foramen.
Innervates facial muscles (five branches fan out over
face from stylomastoid foramen)
Temporal
Zygomatic
Buccal
Mandibular
Cervical
Throughchorda tympani ( join V3 ) -
Taste to anterior 2/3 of tongue
Submandibular, sublingual salivary glands
Innervate lacrimal glands.
VII-FACIAL NERVE
VII-FACIAL NERVE
X NERVE- VAGUS
CRANIAL NERVE X: VAGUS
Component #1: Sensory
Nucleus location: medulla
Function: (1) chemoreceptors; (2) pain
receptors; (3) sensations; (4)
taste
Structure(s) Innervated: (1) blood oxygen concentration,
carotid bodies; (2) respiratory &
digestive tracts; (3) external ear,
larynx & pharynx (4) tongue.
CRANIAL NERVE X: VAGUS
Component #2: Motor
Nucleus location: medulla
Function(s): (1) heart rate & stroke volume;
(2) peristalsis; (3) air flow; (4)
speech & swallowing
Structure(s) Innervated: (1) pacemaker & ventricular
muscles; (2) smooth muscles of
the digestive tract (3) smooth
muscles in bronchial tubes (4)
muscles of larynx a & pharynx
Component #3: Parasympathetic
Structure(s) Innervated: smooth muscles and glands of the
same areas innervated by motor
component, as well as thoracic
and abdominal areas
 X Nerve- Vagus (Including Cranial XI)

Mixed nerve with sensory, motor and

parasympathetic components.

Cranial XI, which should be considered a part

of X, is purely motor and contributes to the
innervations of the skeletal muscles supplied by X.
X NERVE- VAGUS
 VAGUS NERVE IN THORAX

Right vagus
Left vagus
CRANIAL NERVE X: VAGUS
 X Vagus (Including Cranial XI)

Motor and sensory fibers are distributed in the

head and neck.

Sensory and parasympathetic fibers continue

into the thorax and abdomen to supply viscera.

Remember, it is the wandering cranial nerve!!

Course
Exits the skull from jugular foramen
Descends in the neck in carotid sheath between internal (or
common) carotid artery and internal jugular vein
Right vagus nerve
Enter thoracic inlet on right side of trachea

Travels downward posterior to right brachiocephalic

vein and superior vena cava

Passes posterior to right lung root

Forms posterior esophageal plexus

Forms posterior vagal trunk at esophageal hiatus

where it leaves thorax and passes into abdominal
cavity, then divides into posterior gastric and celiac
branches
Left vagus nerve
Enter thoracic inlet between left common carotid
and left subclavian arteries, posterior to left
brachiocephalic vein

Crosses aortic arch where left recurrent

laryngeal nerve branches off

Passes posterior to left lung root

Forms anterior esophageal plexus

Forms anterior vagal trunk at esophageal hiatus

where it leaves thorax and passes into abdominal
cavity , then divides into anterior gastric and
hepatic branches
Cranial Nerves-V,VII,X

Examination & Lesion

 Trigeminal Nerve
Neurological Exam-sensory
Test the touch and
pain sensation from
the skin territories
supplied by each
division.

compare the 2 sides

for equal / unequal
responses.
 Trigeminal Nerve
Neurological Exam-sensory-
CORNEAL REFLEX:

THE PATIENT LOOKS TO ONE SIDE.

THE OPPOSITE CORNEA IS GENTLY

STIMULATED BY A WISP OF COTTON.
THE NORMAL RESPONSE IS A
BILATERAL CLOSURE OF THE EYES.

V1 IS THE AFFERENT LIMB OF THE

REFLEX AND THE EFFERENT LIMB IS VII.
 Trigeminal Nerve
Neurological Exam - Motor
Have the patient clench the teeth and palpate the
contraction of the masseter & temporalis muscles.

Have the patient move mandible, look for normal

movements without any deviation to either side.

Jaw Jerk
- Keep the jaw relaxed and the mouth slightly open.

- Tap the chin to stretch the temporalis and masseter.

- Jaw closure in response. Normally weak or absent,

exaggerated in some motor neuron diseases.
 Trigeminal nerve : Dysfunctions

1. Loss of sensations in areas innervated.

2. Loss of corneal reflex when affected eye is stimulated.

Stimulation of the intact eye will result in a bilateral normal
response.

3. Paralysis of muscles of mastication, resulting in difficulty

in chewing, and a flattening of the side of the face.
 Trigeminal nerve : Dysfunctions
THE MORE COMMONLY MANIFESTED CONDITIONS ARE:

HERPES ZOSTER
AFFECTING TRIGEMINAL
GANGLION

TRIGEMINAL NEURALGIA
 Trigeminal neuralgia
Extremely painful condition that typically afflict
an older population.
Distinct clinical characteristics guide the
diagnosis.
Treatment involves medication first and then
surgical procedures if a patient is refractory to
medicinal therapy.
Antiepileptic medications are the most
effective agents .
FACIAL NERVE
 Facial Nerve injury- Bell's Palsy

Commonly, unilateral facial paralysis of sudden onset and

unknown cause.
Involves swelling of the nerve due to immune or viral
disease, with ischemia and compression of the facial nerve
in the temporal bone.
Pain behind the ear may precede facial weakness.
Weakness develops within hours, sometimes to complete
paralysis.
The affected side becomes flat and expressionless.
In severe cases, the palpebral fissure widens, and the eye
does not close. A numb or heavy feeling in the face, but no
sensory loss is demonstrable. A proximal lesion may affect
salivation, taste, and lacrimation and may cause
hyperacusis.
BELL'S PALSY
 BELL'S PALSY -DIAGNOSIS

Weakness of the entire half of the face distinguishes

Bell's palsy from supranuclear lesions (eg, stroke,
cerebral tumor), in which the weakness is partial,
affecting the frontalis and orbicularis oculi less than
the muscles in the lower part of the face.

Bell's palsy must be differentiated from unilateral

facial weakness due to other disorders of the facial
nerve or its nucleus, chiefly geniculate herpes (Ramsay
Hunt's syndrome), middle ear or mastoid infections.
VAGUS NERVE
 VAGUS NERVE
Tested clinically by comparing the palatal arches on
both sides. No arch on the paralysed side and uvula is
pulled to the normal side.

Injury to the vagus nerve produces-

- nasal regurgitation of swallowed liquid.
- nasal twang in voice.
- hoarseness of voice.
- cadaveric position of vocal cord.
- dysphagia (difficulty in swallowing)
 VAGUS NERVE
Irritation of the auricular branch of vagus in the
external ear (ear wax) may cause cough,vomiting
or even death due to cardiac inhibition.

Stimulation of auricular branch reflexly produces

increased appetite (gastric juice secretion).
VAGUS NERVE PARALYSIS
RECURRENT LARYNGEAL NERVE -INJURY
Summary
 Cranial Nerves: Principles of
organization
1. Cranial nerves are parts of the PNS.
2. Their nuclei are present in the brain stem (midbrain,
pons and medulla).
3. Exceptions are I and II which connect directly cerebrum.
4. Innervate:
Skeletal muscles
Sensory structures
Smooth muscles, cardiac muscles and secretory
glands (ANS)
CRANIAL NERVES V,VII,X

V3

VII

X
 CRANIAL NERVES
Cranial Nucleus name Nucleus Function Lesion
nerve location

Principal Pons Facial Facial

V aneasthesia
sensation
Spinal Medulla Loss of pain
Mastication sensation
Mesencephalic Pons/midbrain Weakness/loss of
mastication
Motor Pons
Motor Pons Facial Paralysis of facial
VII nerve muscles
Expresssion
Solitary Pons Taste
Loss of taste
(anterior 2/3rds of
Superior Pons Salivation, tongue)
salivatory Lacrimation Dry mouth, loss of
lacrimation
CRANIAL NERVES
Cranial Nucleus Nucleus Function Lesion
nerve name location
Nucleus Medulla Swallowing & Dysphagia &
X ambiguus talking hoarseness of voice

Insignificant
Dorsal motor Medulla Cardiac,
vagal GI tract,
respiration.

Solitary Loss of cough reflex

Medulla Taste (larynx/pharynx), loss
of taste (hard palate)