CRANIAL NERVES V,

IX, X & XI

Dr Onoja Peter Onyeholowo

 Anterior aspect
CN1 :Olfactory of midbrain
Dorsal aspect of
CN2 :Optic midbrain
CN3 :Oculomotor
midbrain
CN4 :Trochlear

CN5: Trigeminal

CN6 :Abducens
pons
CN7 :Facial

CN8: Vestibulocochlear

CN9: Glossoparyngeal

CN10: Vagus
medulla
CN11: Accessory

CN12: Hypoglossal
CRANIAL NERVES- INTRODUCTION
Like spinal nerves, cranial nerves are bundles of sensory or motor
fibers that innervate muscles or glands.

They carry impulses from sensory receptors, or show a

combination of these fiber types.

They are called cranial nerves because they emerge through

foramina or fissures in the cranium and are covered by tubular
sheaths derived from the cranial meninges.

There are twelve pairs of cranial nerves, which are numbered I to

XII, from rostral to caudal, according to their attachment to the
brain and penetration of the cranial dura.

Their names reflect their general distribution or function.

ORIGIN -
EXIT POINTS -
 The 12 pairs of cranial nerves are part of the
peripheral nervous system.
The Roman numeral is based on descending
order of the cranial nerve's attachment to the
CNS.
As a rule, cranial nerves do not cross in the brain.

Cranial nerves may be sensory, motor, both

somatic or parasympathetic, or have mixed
function.
 NORMAL ANATOMY
There are twelve cranial nerves and their
defining feature is that they exit the cranial
cavity through foramina or fissures.

All
cranial nerves innervate structures in the
head or neck.

In addition, the vagus nerve [X] descends

through the neck and into the thorax and
abdomen where it innervates viscera.
LOCATION OF THE CRANIAL NERVES
Anterior cranial fossa: C.N. 12
Middle cranial fossa: C.N. 3-6

Posterior cranial fossa: C.N. 7-12

IMAGING ANATOMY

Cranial nerves can be grouped based on area of

brainstem origin -

Diencephalon : CN2
Mesencephalon(mid-brain):CN3 & CN4
Pons:CN5,CN6,CN7 & CN8
Medulla:CN9,CN10,CN11 & CN12
 REMEMBER ME
SOME olfactory
SAY optic
MONEY occulomotor
MATTERS trochlear
BUT trigerminal
MY abducens
BROTHER facial
SAYS vestibulocochlear
BIG glossopharyngeal
BRAIN vagus
MATTERS spinal accessory
MOST hypoglossal

S-SENSORY
M- MOTOR
B- BOTH
Note that all of the above is in sequence
MNEMONIC

OLFACTORY OH
OPTIC ONCE
OCULOMOTOR ONE
TROCHLEAR TAKES
TRIGEMINAL THE
ABDUCENS ANATOMY
FACIAL FINAL
VESTIBULOCOCHLEAR VERY
GLOSSOPHARYNGEAL GOOD
VAGUS VACATION
ACCESSORY A-HEAD
HYPOGLOSSAL
 OLFACTORY OH
OPTIC ONCE
OCULOMOTOR
ONE
TROCHLEAR
TRIGEMINAL TAKES
ABDUCENS THE
FACIAL ANATOMY
VESTIBULOCOCHLEAR FINAL
GLOSSOPHARYNGEAL
VERY
VAGUS
ACCESSORY GOOD
HYPOGLOSSAL VACATIONS
ARE
HEAVENLY
 To remember at least part of the sequence of the first set
of cranial nerves that begin with the letter O, try this
You have I nose. You have II eyes.

I - Olfactory; II -- Optic
SUMMARY OF FUNCTION OF
CRANIAL NERVES
CRANIAL NERVES
Human Anatomy, Frolich, Head/Neck IV: Cranial Nerves
CRANIAL NERVES
CRANIAL NERVES
 SPECIAL SENSE NERVES

NERVE TARGET EXIT FROM

CRANIAL CAVITY
I. Olfactory Olfactory Cribiform plate
epithelium (ethmoid)
II. Optic Retina Optic canal
(sphenoid)
VIII. Auditory Inner ear Internal auditory
meatus (temporal)

Human Anatomy, Frolich, Head/Neck IV: Cranial Nerves

 SOMATIC MOTOR NERVES
(EYE MUSCLES AND TONGUE)
NERVE TARGET EXIT CR. CAVITY
IV. Trochlear Superior oblique m. Sup. Orbital fissure
(with trochlea) (sphenoid)
VI. Abducens Lateral rectus
III. Oculomotor Sup.,med.,inf.rectus
(Also parasympathetic Inferior Oblique
to ciliary mm, constrictor
pupillae) Levator palpebrae
superioris
XII. Hypoglossal Intrinsic, extrinsic Hypoglossal canal
mm. of tongue (occipital)

Human Anatomy, Frolich, Head/Neck IV: Cranial Nerves

 REST OF BODY NERVES
(ALL EXIT FROM JUGULAR FORAMEN)
NERVE TARGET

X: Vagus Somatic motor to larynx/pharynx

Parasympathetic to most of gut
Taste to back posterior pharynx
XI: (Spinal) Motor to traps,
Accesory sternocleidomastoid
IX: Glosso- Sensory to carotid body/sinus
pharyngeal Taste to posterior tongue
Sensory to ear opening/middle
ear
Parotid salivary gland

Human Anatomy, Frolich, Head/Neck IV: Cranial Nerves

CN V TRIGEMINAL NERVE

ORIGIN: Pons. The sensory nucleus extends from the pons to the
midbrain, and also to the medulla and spinal cord.
largest (thickest) cranial nerve
INNERVATION: Three branches of CN V: ophthalmic, maxillary,
& mandibular.
Fibers run from the face to the pons via the superior orbital
fissure (V1), the foramen rotundum (V2), and the foramen ovale
(V3)
Conveys sensory impulses from various areas of the face (V1) and
(V2), and supplies motor fibers (V3) for mastication
Motor innervation to masseter & temporal muscles.
Sensory innervation to skin & mucous membranes in head; teeth,
tongue, external auditory canal, and cornea
 TRIGEMINAL NERVE (CN V)
The trigeminal nerve (CN V) is the largest cranial nerve.
It emerges from the lateral aspect of the pons by a large sensory root and a small motor root. The large
sensory root runs medial to the small motor root. The roots of CN V are comparable to the posterior and
anterior roots of spinal nerves.
Enters middle cranial fossa by passing beneath tentorium at the apex of the petrous temporal bone & passes
through an opening in the dura called the porus trigeminus to enter the Meckels (trigeminal) cave.

Meckel (trigeminal) cave is a CSF-containing pouch in the middle cranial fossa which is continuous with
the pre-pontine sub-archnoid space.

Pia covers the CN 5 in Meckels cave.

CN V is the principal general sensory nerve for the head (face, teeth, mouth, nasal cavity, and dura of the
cranial cavity).

The large sensory root of CN V is composed mainly of the central processes of the pseudounipolar neurons
that make up the trigeminal ganglion.

The trigeminal ganglion is flattened and crescent shaped (hence its unofficial name, semilunar ganglion)
and is housed within a dural recess (trigeminal cave) lateral to the cavernous sinus. The peripheral
processes of the ganglionic neurons form three nerves or divisions:
ophthalmic nerve (CN V1), maxillary nerve (CN V2), and sensory component of the mandibular nerve (CN
V3).

Maps of the zones of cutaneous innervation by the three divisions resemble the dermatome maps for
cutaneous innervation by spinal nerves.
Unlike dermatomes, however, there is little overlap in innervation by the divisions;
lesions of a single nerve result in clearly demarcated areas of numbness.
The fibers of the motor root of CN V pass inferior to the trigeminal ganglion along the
floor of the trigeminal cave, bypassing the ganglion just as the anterior roots of
spinal nerves bypass the spinal sensory ganglia.
They are distributed exclusively via the mandibular nerve (CN V3), blending with the
sensory fibers as the nerve traverses the foramen ovale in the cranium; entering
branches pass to the muscles of mastication, mylohyoid, anterior belly of the
digastric, tensor veli palatini, and tensor tympani, which are derived from the 1st
pharyngeal arch.
Although CN V conveys no presynaptic parasympathetic (visceral efferent) fibers from
the CNS, all four parasympathetic ganglia are associated with the divisions of CN V.
Postsynaptic parasympathetic fibers from the ganglia join branches of CN V and are
carried to their destinations along with the CN V sensory and motor fibers.
Functions: General sensory (general somatic afferent) and branchial motor (special
visceral efferent) to derivatives of the 1st pharyngeal arch.
Nuclei: There are four trigeminal nuclei one motor and three sensory.
1. Main sensory nucleus
2. Nucleus of the spinal trigeminal:
receives information of pain and temperature
3. Mesencephalic nucleus
Central processes motor nuclei of trigeminal
Peripheral processes mandibular division
4. Trigeminal motor nucleus (SVE):
innervates muscles of mastication
CRANIAL NERVES
CN 5 Trigeminal Nerve
CN V

Sensory Ophthalmic (V1)

branch
Trigeminal Nerve

Maxillary (V2)

Mandibular (V3)

Temporalis
All involved in
Masseter
biting, chewing,
Motor Muscle of
Medial pterygoid swallowing except
mastication
Lateral pterygoid for tensor tympani
which acts to
Tensor veli palatini dampen sound
produced from
mylohyoid
chewing
Temporalis Others Anterior belly of digastric
Masseter Tensor tympani
Trigeminal nerve course and branches
 FUNCTION: Sensation of pain, touch, hot, &
cold; motor movement of masseter & temporal
muscles.
DYSFUNCTION: Loss of sensation - if affecting
all three branches, indicative of peripheral
injury.
Brainstem or upper cervical cord injury may
result in loss of sensation to one or more
branches of the trigeminal nerve.
Loss of corneal reflex.
Tic douloureux or trigeminal neuralgia
Paroxysmal attacks of severe, short, sharp,
stabbing pain affecting one or more branch of the
nerve in trigeminal area (near mouth or nose).
Most excruciating pain known (?)

Caused by inflammation of nerve

In severe cases, nerve is cut; relieves agony but

results in loss of sensation on that side of the face
 Paraesthesia and/or severe pain indicative of
nerve compression or irritation (Trigeminal
neuralgia)
Deviation of jaw towards the same side, loss of
sensation.
Inability to bite down and chew, inability to close
jaw.
Chewing, speaking, washing face, cold water,
may precipitate the attackTRIGGER POINT
TESTING TRIGEMINAL NERVE

Sensation-
Checked by extroceptive modalities like
superficial pain, thermal, light touch over jaw,
cheeks, and forehead.
Motor examination-
Muscle power of masticatory muscle namely the
masseter and temporalis.
Inability to raise, depress, protrude, retract and
deviate the mandible
Jaw deflected toward same side
TESTING TRIGEMINAL NERVE

Jaw jerk-
Ask the patient to relax jaw. Place finger on the
chin and tap it with hammer.
Closing of mouth is the response

Brisk is normal

Exaggerated is pathological

Corneal reflex-
Cornea is touched with wisp of wet cotton

Response is closing of both eyes

Afferent- ophthalmic div of VI nerve

Efferent- Facial nerve

CN 5 Trigeminal Nerve
CN V
Facial Sensory
Test for soft touch using cotton wool - sternum
first, close eyes
in the 3 divisions of the nerve
V1- ophthalmic- forehead up to the top of the
head
Say yes if you feel this
V2- maxillary
V3- mandibular (up to angle of the jaw)

The patient should be instructed to say yes each

time the touch of the cotton wool is felt. Do not
stroke the skin touch it.
Test for pain using sharp object.
Ask patient does it feel sharp or dull

Causes of sensory problems

- MS- MS plaque in the brainstem in young
people
- Sjogren- dry eyes, dry mouth
-Trigeminal neuralgia- older people
CN 5 Trigeminal Nerve
CN V
Corneal Reflex
Ask the pt to look up and away, touch the corneal.
Reflex blinking of both eyes is a normal response.

Im going to gently touch Pathology

your eye with a cotton bud. Bells palsy- unable to blink due to damage to the
efferent limb (CNVII)
CNV forms the afferent limb
CN 5 Trigeminal Nerve
CN V
Motor
Inspect for wasting of the temporal and masseter
muscles
Ask patient to clench their teeth and palpate for
contraction of the temporal and masseter muscles
Can you grit your teeth,
please?
CN 5 Trigeminal Nerve
CN V
Motor
Ask patient to open their mouth and hold it open
while the examiner attempts to force it shut
[pterygoid muscles].

Open up your mouth and A unilateral weakness of the motor division

hold it for me causes the jaw to deviate towards the weak side.If
weakness is suspected patients should be asked to
move the jaw laterally against resistance. The jaw
can be moved towards the affected muscle but
cannot move towards the normal side.
CN 5 Trigeminal Nerve
CN V
The Jaw Jerk
Ask the pt to open her mouth fully, and close
halfway, , place index finger on her chin and
tap with a patella hammer, if jaw jerk is highly
exaggerated.
Im going to gently tap
your jaw Help to distinguish btw pseudobulbar palsy
(UMN lesion of lower cranial nerve 9,
10,11,12) and a bulbar palsy (LMN lesion of
lower cranial nerve 9,10,11,12)
 Because the trigeminal nerve is large and its course
proceeds straight forward from the lateral pons, it is easy
to recognize on most MR images.
Trigeminal nerve.

FIESTA MR image shows the sensory (arrowhead) and motor (large arrow)
roots of the trigeminal nerve where they cross the prepontine cistern and
enter the Meckel cave (small arrows).
CRANIAL NERVES
BRANCHES
OF THE
TRIGEMINAL
NERVE
TRIGEMINAL NERVE SVE - FIRST BRANCHIAL ARCH MUSCLES
CN IX- GLOSSOPHARYNGEAL NERVE

ORIGIN-
Medulla

INNERVATION:
Mucous membranes of tonsils, pharynx, posterior
one-third of tongue, pharyngeal muscles, carotid
sinus and carotid body
FUNCTION:
Taste from posterior one-third of tongue -
Afferent limb of gag, swallow, and cardiac
reflexes.
DYSFUNCTION:
Loss of taste; Neuralgia
 CRANIAL NERVES
Glossopharyngeal Nerve (CN IX)
The glossopharyngeal nerve (CN IX) emerges from the lateral aspect of the medulla and passes
anterolaterally to leave the cranium through the anterior aspect of the jugular foramen and run to the
throat.

At this foramen are superior and inferior (sensory) ganglia, which contain the pseudounipolar cell
bodies for the afferent components of the nerve.

CN IX follows the stylopharyngeus, the only muscle the nerve supplies, and passes between the superior
and the middle constrictor muscles of the pharynx to reach the oropharynx and tongue.

It contributes sensory fibers to the pharyngeal plexus of nerves.

CN IX is afferent from the tongue and pharynx (hence its name) and efferent to the stylopharyngeus and
parotid gland.

Branchial Motor Motor fibers pass to one muscle, the stylopharyngeus, derived from the 3rd pharyngeal
arch.

Parasympathetic (Visceral Motor)

Following a circuitous route initially involving the tympanic nerve, presynaptic parasympathetic fibers
are provided to the otic ganglion for innervation of the parotid gland.

The otic ganglion is associated with the mandibular nerve (CN V3), branches of which convey the
postsynaptic parasympathetic fibers to the parotid gland .
Sensory (General Sensory)
The general sensory branches of CN IX are as follows : The tympanic nerve. The
carotid sinus nerve to the carotid sinus, a baro- (presso) receptor sensitive to
changes in blood pressure, and the carotid body, a chemoreceptor sensitive to blood
gas (oxygen and carbon dioxide levels).
The pharyngeal, tonsillar, and lingual nerves to the mucosa of the oropharynx and
isthmus of the fauces (L. throat), including palatine tonsil, soft palate, and posterior
third of the tongue. In addition to general sensation (touch, pain, temperature),
tactile (actual or threatened) stimuli determined to be unusual or unpleasant here
may evoke the gag reflex or even vomiting.
Taste (Special Sensory) Taste fibers are conveyed from the posterior third of the
tongue to the sensory ganglia.
Functions: Sensory (general somatic afferent, special visceral afferent, general
visceral afferent), motor (special visceral efferent), and parasympathetic (general
visceral efferent) for derivatives of the 3rd pharyngeal arch.
Nuclei: Four nuclei in the medulla send or receive fibers via CN IX: two motor and
two sensory. Three of these nuclei are shared with CN X.
1. Nucleus ambiguus (SVE)
Branchial motor to
stylopharyngeus
2. Inferior salivary nucleus
(GVE)
to parotid gland (via otic ganglion)
3. Spinaltrigeminal nucleus
Somatic sensory from outer ear
(superior ganglion of IX)
4. Nucleus of the solitary tract
Visceral sensory from carotid body and sinus, mucosa of
pharynx, posterior tongue, middle ear (inferior ganglion of
IX)
Visceral sensory from taste buds on posterior third of
tongue (inferior ganglion of IX)
CRANIAL NERVES
CN 9 Glossopharyngeal Nerve
CN IX
CN X VAGUS NERVE

ORIGIN-
Medulla
INNERVATION:
Muscles of larynx, pharynx, and soft palate.
Parasympathetic innervation of thoracic and abdominal viscera.
FUNCTION:
Muscles of larynx, pharynx, and soft palate
Sensation conveyed from the heart, lungs, digestive tract, carotid sinus, &
carotid body
Efferent limb of gag and swallow reflex
DYSFUNCTION:
Loss of gag & swallow reflex
Loss of carotid sinus
Oculocardiac reflex; Dysphagia
 CRANIAL NERVES
Vagus Nerve (CN X)
The vagus nerve (CN X) has the longest course and most extensive distribution of all the cranial nerves, most of
which is outside of (inferior to) the head.
It is the only cranial nerve that extends beyond the head and neck.
The term vagus is derived from the Latin word vagari meaning wandering.
CN X was so called because of its extensive distribution. It arises by a series of rootlets from the lateral aspect of
the medulla that merge and leave the cranium through the jugular foramen positioned between CN IX and CN
XI.

What was formerly called the cranial root of the accessory nerve is actually a part of CN X.
CN X has a superior ganglion in the jugular foramen that is mainly concerned with the general sensory
component of the nerve. Inferior to the foramen is an inferior ganglion (nodose ganglion) concerned with the
visceral sensory components of the nerve.

In the region of the superior ganglion are connections to CN IX and the superior cervical (sympathetic)
ganglion. CN X continues inferiorly in the carotid sheath to the root of the neck, supplying branches to the
palate, pharynx, and .
The course of CN X in the thorax differs on the two sides, a consequence of rotation of the midgut during
development.

CN X supplies branches to the heart, bronchi, and lungs.

The vagi join the esophageal plexus surrounding the esophagus, which is formed by branches of the vagi and
sympathetic trunks. This plexus follows the esophagus through the diaphragm into the abdomen, where the
anterior and posterior vagal trunks break up into branches that innervate the esophagus, stomach, and
intestinal tract as far as the left colic flexure.
Functions: Sensory (general somatic afferent, special visceral afferent, general visceral
afferent), motor (special visceral efferent), and parasympathetic (general visceral
efferent).
Sensory from the inferior pharynx, larynx, and thoracic and abdominal organs.
Sense of taste from the root of the tongue and taste buds on the epiglottis. Branches of
the internal laryngeal nerve (a branch of CN X) supply a small area, mostly general
but some special sensation; most general and special sensation to the root is supplied
by CN IX.
Motor to the soft palate; pharynx; intrinsic laryngeal muscles (phonation); and a
nominal extrinsic tongue muscle, the palatoglossus, which is actually a palatine
muscle based on its derivation and innervation.
Proprioceptive to the muscles listed above.
Parasympathetic to thoracic and abdominal viscera.
Nuclei: Four nuclei of CN X in the medulla send or receive fibers via CN IX two motor
and two sensory. Three of these nuclei are shared with CN IX.
1. Nucleus ambiguus (SVE)
A hybrid nucleus

Branchial motor to larynx and pharynx and autonomic

motor to thorax and abdomen
2. dorsal motor nucleus (GVE)
autonomic motor to thorax and abdomen
3. Spinal trigeminal nucleus
Somatic sensory from outer ear (superior ganglion of X)

4. Nucleus of the solitary tract

Visceral sensory from larynx , pharynx ,thorax and
abdomen (inferior ganglion of X)
CRANIAL NERVES
CRANIAL NERVES
Vagus nerve
course
CN 10 Vagus Nerve
CN X
CN 9, 10 Glossopharyngeal and Vagus Nerve
CN IX, X
CN IX- GLOSSOPHARYNGEAL AND CN X
- VAGUS

CN IX and X considered jointly, actions are

seldom compared separately; they are always
tested together.
POSITIVE FINDINGS-

Evaluate voice quality (hoarseness or dysarthria)

Ask patient to open mouth, say "ah", observe for

elevation of soft palate, midline position of uvula.
Gag reflex, bilaterally

Swallowing

Taste (bitter) posterior one-third tongue

CN IX- GLOSSOPHARYNGEAL AND CN X
- VAGUS

Negative Findings
Loss of voice quality, (dysarthria or hoarseness)

Deviation of uvula toward non-paralyzed side

Swallowing difficulty or nasal regurgitation

Vagal irritation (bradycardia)

CN 9, 10 Glossopharyngeal and Vagus Nerve
CN IX, X
Uvula + Gag Reflex
Uvula
Get the patient to open their mouth and
inspect the palate with a torch. Note any
displacement of the uvula.
Open your mouth and Ask the patient to say Ah. If the uvula is
say ah drawn to one side this indicates a unilateral
tenth nerve palsy. The uvula is pulled
towards the normal side.
Now test gently for the gag reflex
Ninth is the sensory component
Tenth is the motor component

Gag Reflex
Touch the back of the pharynx on each side
with a spatula. Ask the patient if the touch
of the spatula is felt each time. Normally
there is reflex contraction of the soft palate.

The ninth nerve supplies taste from the

posterior two-thirds of the tongue this is not
routinely tested for.
CN XI - SPINAL ACCESSORY NERVE

ORIGIN: Medulla
Formed from a cranial root emerging from the medulla and
a spinal root arising from the superior region of the spinal
cord
The spinal root passes upward into the cranium via the
foramen magnum
The accessory nerve leaves the cranium via the jugular
foramen
INNERVATION:
Supplies fibers to the larynx, pharynx, and soft palate
Sternocleidomastoid & trapezius muscles which move the
head and neck.
FUNCTION: Motor function Sternocleidomastoid &
trapezius
DYSFUNCTION: Muscle weakness.
CN XI - SPINAL ACCESSORY NERVE
CLINICAL EVALUATION
Palpate trapezius muscle as patient shrugs
shoulders against resistance; evaluate strength.
Ask patient to turn head to one side and push
against examiners hand or ask to flex head
against resistance, palpate and evaluate strength
of sternocleidomastoid muscle.
Evaluate both right and left side, compare for
symmetry.
SPINAL ACCESSORY NERVE (CN XI)

Functions: Motor to the striated sternocleidomastoid and trapezius

muscles.
Nuclei: The spinal accessory nerve arises from the nucleus of the
accessory nerve, a column of anterior horn motor neurons in the
superior five or six cervical segments of the spinal cord .
 Formed from a cranial root emerging from the medulla
and a spinal root arising from the superior region of the
spinal cord
1.Cranial root
Nucleus ambiguus (SVE)
2.Spinal root
Spinal accessory nuclei (GSE)
CRANIAL NERVES
CN 11 Accessory Nerve
CN XI Cranial Root Spinal Root

Receives corticonuclear fibers from both cerebral

hemispheres

It joins the spinal root Situated in the anterior grey

& leaves the skull column of the spinal cord in the
through jugular upper 5 cervical segments
foramen
Nerve fibers emerge from the
Then the roots spinal cord & form a nerve
separate again, cranial trunk that ascends into the
root joins the vagus skull through the foramen
magnum
Spinal part joins the cranial
part & pas through the jugular
foramen
Then they separate again

Supply the muscles of: Supplies the SCM muscle &

Soft palate (Except trapezius muscle
tensor veli palatini)
Pharynx (Except
stylopharyngeus)
Larynx (Except
cricothyroid)
CN 11 Accessory Nerve
CN XI
Trapezius
Ask the patient to shrug their shoulders
and feel the bulk of the trapezius muscles
and attempt to push the shoulders down.

Shrug your shoulder,

push up against my
hand
CN 11 Accessory Nerve
CN XI
Sternocleidomastoid
Ask the patient to turn their head against
resistance and feel the bulk of the
sternomastoids. Feel for the sternomastoid
Turn your head against on the side opposite to the turned head.
my hand There will be weakness on turning the
head away from the side of a muscle
whose strength is impaired.

(Optional)Test neck flexors if suspect

myasthenia gravis, MND-
put chin on chest, Ill put my hand onto
your forehead, push up against my hand
Thank
You