m

 

Prepared by Dr Mervat Hamed

Lecturer of Neuropsychiatry
Alexandria University
Ê m

  are nerves that emerge
directly from the brain, in contrast to spinal
nerves which emerge from segments of the
spinal cord.
Ê In humans, there are 12 pairs of cranial
nerves. Only the first and the second pair
emerge from the cerebrum; the remaining
10 pairs emerge from the brainstem.
J

  

Ê ©he 

  , or


 , is
the first of twelve cranial nerves. It is
instrumental in the sense of smell. It is the
shortest of the twelve cranial nerves.
Ê ©he specialized olfactory receptor neurons
of the olfactory nerve are located in the
olfactory mucosa of the upper parts of the
nasal cavity.
Ê ©he olfactory nerves do not form two trunks like
the remaining cranial nerves, but consist of a
collection of many sensory nerve fibers that
extend from the olfactory epithelium to the
olfactory bulb, passing through the many openings
of the Cribriform plate of the Ethmoid bone; a
sieve-like structure.
Ê Olfactory receptor neurons continue to be
born throughout life and extend new axons
to the olfactory bulb. Olfactory ensheathing
glia wrap bundles of these axons and are
thought to facilitate their passage into the
central nervous system.
! ©he sense of smell (olfaction) arises from the
stimulation of olfactory (or odorant) receptors
by small molecules of different spatial,
chemical, and electrical properties that pass
over the nasal epithelium in the nasal cavity
during inhalation. ©hese interactions are
transduced into electrical activity in the
olfactory bulb which then transmits the
electrical activity to other parts of the olfactory
system and the rest of the central nervous
system via the olfactory tract.
! ©o test the function of the olfactory nerve,
doctors block one of the patient's nostrils
and place a pungent odor (such as damp
coffee essence or orange seedle) under the
open nostril. ©he test is then repeated on the
other nostril.
! Lesions to the olfactory nerve can occur because of
blunt trauma, such a coup-contra-coup damage,
meningitis and tumors of the frontal lobe. ©hey often
lead to a reduced ability to taste and smell. However,
lesions of the olfactory nerve do not lead to a reduced
ability to sense pain from the nasal epithelium.
! ©his is because pain from the nasal epithelium is not
carried to the central nervous system by the olfactory
nerve; rather, it is carried to the central nervous system
by the trigeminal nerve (cranial nerve V).
J 
 
! ©he  
 , also called


 ,
transmits visual information from the retina to the
brain.
! ©he optic nerve is the second of twelve paired
cranial nerves but is considered to be part of the
central nervous system as it is derived from an
outpouching of the diencephalon during embryonic
development. Consequently, the fibres are covered
with myelin produced by oligodendrocytes rather
than the Schwann cells of the peripheral nervous
system and are encased within the meninges.
! ©he optic nerve is composed of retinal ganglion cell
axons and support cells. It leaves the orbit (eye) via the
optic canal, running postero-medially towards the optic
chiasm where there is a partial decussation (crossing) of
fibres from the temporal visual fields of both eyes. Most
of the axons of the optic nerve terminate in the lateral
geniculate nucleus from where information is relayed to
the visual cortex, while other axons terminate in the
pretectal nucleus and are involved in reflexive eye
movements and other axons terminate in the
suprachiasmatic nucleus and are involved in regulating
the sleep-wake cycle.
©est
! With patient wearing glasses, test each eye
separately on eye chart/ card using an eye cover.
! Examine visual fields by confrontation by
wiggling fingers 1 foot from pt's ears, asking
which they see move.
‡ Keep examiner's head level with patient's head.
! If poor visual acuity, map fields using fingers and
a quadrant-covering card.
! Look into fundi.
! Look at pupils: shape, relative size, ptosis.
! Shine light in from the side to gauge pupil's light reaction.
‡ Assess both direct and consensual responses.
‡ Assess afferent pupillary defect by moving light in arc
from pupil to pupil. unne). Optionally: as do arc test, have
pt place a flat hand extending vertically from his face,
between his eyes, to act as a blinder so light can only go
into one eye at a time.
! £ollow finger with eyes without moving head": test the 6
cardinal points in an H pattern.
‡ Look for failure of movement, nystagmus [pause to check
it during upward/ lateral gaze].
! Convergence by moving finger towards bridge of pt's nose.
! ©est accommodation by pt looking into distance, then a hat
pin 30cm from nose.
! If MG suspected: pt. gazes upward at Dr's finger to show
worsening pto
J
  
! ©he 
   is the third of
twelve paired cranial nerves. It controls
most of the eye's movement, constriction of
the pupil, and maintains an open eyelid.
(Note: cranial nerves IV and VI also
participate in control of eye movement.)
! ©he oculomotor nerve arises from the anterior
aspect of mesencephalon (midbrain). ©here are
two nuclei for the oculomotor nerve:
! ©he oculomotor nucleus originates at the level
of the superior colliculus. ©he muscles it
controls are the striated muscle in levator
palpebrae superioris and all extraocular
muscles except for the superior oblique muscle
and the lateral rectus muscle.
! ©he Edinger-Westphal nucleus supplies
parasympathetic fibres to the eye via the ciliary
ganglion, and thus controls the sphincter pupillae
muscle (affecting pupil constriction) and the
ciliary muscle (affecting accommodation).
! Sympathetic postganglionic fibres also join the
nerve from the plexus on the internal carotid artery
in the wall of the cavernous sinus and are
distributed through the nerve, e.g. to the smooth
muscle of levator palpebrae superioris.
! Cranial nerves III, IV and VI are usually tested
together. ©he examiner typically instructs the
patient to hold his head still and follow only
with the eyes a finger or penlight that
circumscribes a large "H" in front of the
patient. By observing the eye movement and
eyelids, the examiner is able to obtain more
information about the extraocular muscles, the
levator palpebrae superioris muscle, and
cranial nerves III, IV, and VI.
! Since the oculomotor nerve controls most of
the eye muscles, it may be easier to detect
damage to it. Damage to this nerve, termed

  
 is also known by
the  symptoms, because of the
position of the affected eye.
! ©he oculomotor nerve also controls the
constriction of the pupils and thickening of
the lens of the eye. ©his can be tested in two
main ways. By moving a finger towards a
person's face to induce accommodation, as
well as them going cross-eyed, their pupils
should constrict.
© 

 

! ©he  

  (the  



 , also called the   , ) is a
motor nerve (a ³somatic efferent´ nerve)
that innervates a single muscle: the
    muscle of the eye.
! ©he trochlear nerve is unique among the
cranial nerves in several respects. It is the
smallest nerve in terms of the number of
axons it contains. It has the greatest
intracranial length. Along with the optic
nerve (cranial nerve II), it is the only cranial
nerve that decussates (crosses to the other
side) before innervating its target. £inally, it
is the only cranial nerve that exits from the
dorsal aspect of the brainstem.
6
  

! ©he

  or

 
(the 


 , also called the
  or simply ) is a ³somatic
efferent´ nerve that controls the movement
of a single muscle, the lateral rectus muscle
of the eye.
© 
 

! ©he  
  (the  



 , also called the   , or simply
m or m) is responsible for sensation
in the face. Sensory information from the
face and body is processed by parallel
pathways in the central nervous system.
! ©he sensory function of the trigeminal
nerve is to provide the tactile,
proprioceptive, and nociceptive afference of
the face and mouth. ©he motor function
activates the muscles of mastication, the
tensor tympani, tensor veli palatini,
mylohyoid, and anterior belly of the
digastric.
Sensory branches
!  

  
 
! Dermatome distribution of the trigeminal nerve
! ©he ophthalmic, maxillary and mandibular
branches leave the skull through three separate
foramina: the superior orbital fissure, the foramen
rotundum and the foramen ovale. ©he mnemonic
`
 
 can be used to remember that
V1 passes through the superior orbital fissure, V2
through the foramen rotundum, and V3 through
the foramen ovale.
! ©he 

 carries sensory
information from the scalp and forehead,
the upper eyelid, the conjunctiva and cornea
of the eye, the nose (including the tip of the
nose, except alae nasi), the nasal mucosa,
the frontal sinuses, and parts of the
meninges (the dura and blood vessels).
! ©he


 carries sensory information from the lower eyelid

and cheek, the nares and upper lip, the upper teeth and gums, the nasal
mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and
sphenoid sinuses, and parts of the meninges.
! ©he


 carries sensory information from the lower lip,
the lower teeth and gums, the chin and jaw (except the angle of the
jaw, which is supplied by C2-C3), parts of the external ear, and parts
of the meninges.
± ©he mandibular nerve carries touch/position and pain/temperature
sensation from the mouth. It does not carry taste sensation (chorda
tympani is responsible for taste), but one of its branches, the
lingual nerve carries multiple types of nerve fibers that do not
originate in the mandibular nerve.
! Motor branches of the trigeminal nerve are
distributed in the mandibular nerve. ©hese fibers
originate in the motor nucleus of the fifth nerve,
which is located near the main trigeminal nucleus in
the pons.
! Muscles of mastication
! masseter
! temporalis
! medial pterygoid
! lateral pterygoid
! Corneal reflex: patient looks up and away.
‡ ©ouch cotton wool to other side.
‡ Look for blink in both eyes, ask if can sense it.
‡ Repeat other side [tests V sensory, VII motor].
! £acial sensation: sterile sharp item on forehead, cheek,
jaw.
‡ Repeat with dull object. Ask to report sharp or dull.
‡ If abnormal, then temperature [heated/ water-cooled
tuning fork], light touch [cotton].
! Motor: pt opens mouth, clenches teeth (pterygoids).
‡ Palpate temporal, masseter muscles as they clench.
! ©est jaw jerk:
± Dr's finger on tip of jaw.
± Grip patellar hammer halfway up shaft and tap Dr's
finger lightly.
± Usually nothing happens, or just a slight closure.
± If increased closure, think UMNL, esp pseudobulbar
palsy.
Pseudobulbar syndrome
! Bilateral pyramidal lesions above level of
pons.
! Characterized by:
! Exaggerated jaw jerk
! Emotional lability
! Bilateral pyramidal signs
! Bulbar symptoms
 £


 
! ©he


  is the seventh (VII) of
twelve paired cranial nerves. It emerges
from the brainstem between the pons and
the medulla, and controls the muscles of
facial expression, and functions in the
conveyance of taste sensations from the
anterior two-thirds of the tongue and oral
cavity. It also supplies preganglionic
parasympathetic fibers to several head and
neck ganglia.
! ©he motor part of the facial nerve arises from the facial nerve
nucleus in the pons while the sensory part of the facial nerve arises
from the nervus intermedius.
! ©he motor part and sensory part of the facial nerve enters the
petrous temporal bone into the internal auditory meatus (intimately
close to the inner ear) then runs a tortuous course (including two
tight turns) through the facial canal, emerges from the stylomastoid
foramen and passes through the parotid gland, where it divides into
five major branches. ©hough it passes through the parotid gland, it
does not innervate the gland (©his is the responsibility of cranial
nerve IX, the glossopharyngeal nerve).
! ©he facial nerve forms the geniculate ganglion prior to entering the
facial canal.
!
[


! Greater petrosal nerve - provides parasympathetic
innervation to lacrimal gland, sphenoid sinus, frontal sinus,
maxillary sinus, ethmoid sinus, nasal cavity, as well as
special sensory taste fibers to the palate via the Vidian
nerve.
! Nerve to stapedius - provides motor innervation for
stapedius muscle in middle ear
! Chorda tympani - provides parasympathetic innervation to
submandibular gland and sublingual gland and special
sensory taste fibers for the anterior 2/3 of the tongue.
! J
 
 

! Posterior auricular nerve - controls movements of some of the
scalp muscles around the ear
! Branch to Posterior belly of Digastric and Stylohyoid muscle
! £ive major facial branches (in parotid gland) - from top to
bottom:
± ©emporal (frontal) branch of the facial nerve
± Zygomatic branch of the facial nerve
± Buccal branch of the facial nerve
± Marginal mandibular branch of the facial nerve
± Cervical branch of the facial nerve
! Its main function is motor control of most of the muscles of
facial expression. It also innervates the posterior belly of the
digastric muscle, the stylohyoid muscle, and the stapedius
muscle of the middle ear. All of these muscles are striated
muscles of branchiomeric origin developing from the 2nd
pharyngeal arch.
! ©he facial also supplies parasympathetic fibers to the
submandibular gland and sublingual glands via chorda tympani.
Parasympathetic innervation serves to increase the flow of saliva
from these glands. It also supplies parasympathetic innervation
to the nasal mucosa and the lacrimal gland via the
pterygopalatine ganglion.
! ©he facial nerve also functions as the efferent limb of the
corneal reflex and the blink reflex.
£acial nerve lesion
! UMNL:
! Lesion in corticobulbar pathway till above
level of pons.
! Spared upper face, only lower face affected.
! Deviation of mouth toward healthy side.
! Emotion improve mouth deviation
! LMNL;
! Lesion from nucleus in the pons till the
facial muscles.
! Upper and lower face are affected.
! Emotion increase mouth deviation
©


 
! Voluntary facial movements, such as wrinkling the brow,
showing teeth, frowning, closing the eyes tightly (inability to do
so is called lagophthalmos)[1] , pursing the lips and puffing out
the cheeks, all test the facial nerve. ©here should be no
noticeable asymmetry.
! In an UMN lesion, called central seven, only the lower part of
the face on the contralateral side will be affected, due to the
bilateral control to the upper facial muscles (frontalis and
orbicularis oculi).
! Lower motor neuron lesions can result in a CNVII palsy (Bell's
palsy is the term used to describe the idiopathic form of facial
nerve palsy), manifested as both upper and lower facial
weakness on the same side of the lesion.
! ©aste can be tested on the anterior 2/3 of the tongue.
! Corneal reflex. ©he afferent arc is mediated by
the General Sensory afferents of the
©rigeminal Nerve. ©he efferent arc occurs via
the £acial Nerve. ©he reflex involves
consensual blinking of both eyes in response to
stimulation of one eye. ©his is due to the
£acial Nerve's innervation of the muscles of
facial expression, namely Orbicularis Oculi,
responsible for blinking. ©hus, the corneal
reflex effectively tests the proper functioning
of both Cranial Nerves V and VII.
! Inspect facial droop or asymmetry.
! £acial expression muscles: pt looks up and wrinkles
forehead.
‡ Examine wrinkling loss.
‡ £eel muscle strength by pushing down on each side
[

 preserved because of bilateral innervation].
! Pt shuts eyes tightly: compare each side.
! Pt grins: compare nasolabial grooves.
! Also: frown, show teeth, puff out cheeks.
! Corneal reflex already done.



 
! ©he 


  (also known as the
 or



 ) is the eighth of twelve cranial nerves, and is
responsible for transmitting sound and equilibrium (balance)
information from the inner ear to the brain. ©his is the nerve
along which the sensory cells (the hair cells) of the inner ear
transmit information to the brain.
! It consists of the cochlear nerve, carrying information about
hearing, and the vestibular nerve, carrying information about
balance. It emerges from the medulla oblongata and exits the
inner skull via the internal acoustic meatus (or internal auditory
meatus) in the temporal bone.
©est :
! Dr's hands arms length by each ear of pt.
‡ Rub one hand's fingers with noise on one side, other hand
noiselessly.
‡ Ask pt. which ear they hear you rubbing.
‡ Repeat with louder intensity, watching for abnormality.
! Weber's test: Lateralization
‡ 512/ 1024 Hz [256 if deaf] vibrating fork on top of
patients head/ forehead.
‡ "Where do you hear sound coming from?"
‡ Normal reply is midline.
! Rinne's test: Air vs. Bone Conduction
‡ 512/ 1024 Hz [256 if deaf] vibrating fork
on mastoid behind ear. Ask when stop
hearing it.
‡ When stop hearing it, move to the patients
ear so can hear it.
‡ Normal: air conduction [ear] better than
bone conduction [mastoid].
! If indicated, look at external auditory
canals, eardrums.
- 

  

! ©he  

  is the ninth

(IX) of twelve pairs of cranial nerves. It
exits the brainstem out from the sides of the
upper medulla, just rostral (closer to the
nose) to the vagus nerve.
! ©here are a number of functions of the glossopharyngeal nerve:
! It receives general sensory fibers (ventral trigeminothalamic tract)
from the tonsils, the pharynx, the middle ear and the posterior 1/3 of
the tongue.
! It receives special sensory fibers (taste) from the posterior one-third of
the tongue.
! It receives visceral sensory fibers from the carotid bodies.
! It supplies parasympathetic fibers to the parotid gland via the otic
ganglion.
! It supplies motor fibers to stylopharyngeus muscle, the only motor
component of this cranial nerve.
! It contributes to the pharyngeal plexus.
© 


 
! ©he integrity of the glossopharyngeal nerve
may be evaluated by testing the patient's
general sensation and that of taste on the
posterior third of the tongue. ©he gag reflex
can also be used to evaluate the
glossphyaryngeal nerve, but also tests the
vagus nerve, as only the afferent fibres
involved in the reflex are carried by the
glossopharyngeal nerve.
©est :
! Voice: hoarse or nasal.
! Pt. swallows, coughs (bovine cough: recurrent laryngeal).
! Examine palate for uvular displacement. (unilateral lesion:
uvula drawn to normal side).
! Pt says "Ah": symmetrical soft palate movement.
! Gag reflex [sensory IX, motor X]:
‡ Stimulate back of throat each side.
‡ Normal to gag each time.

 
! ©he 
 


 
! leaving the medulla between the olivary
nucleus and the inferior cerebellar peduncle,
it extends through the jugular foramen, then
passing into the carotid sheath between the
internal carotid artery and the internal
jugular vein down below the head, to the
neck, chest and abdomen, where it
contributes to the innervation of the viscera.
! ©he vagus nerve supplies motor
parasympathetic fibers to all the organs
except the suprarenal (adrenal) glands, from
the neck down to the second segment of the
transverse colon
 ©he vagus also controls a few skeletal
muscles, namely:
! Cricothyroid muscle
! Levator veli palatini muscle
! Salpingopharyngeus muscle
! Palatoglossus muscle
! Palatopharyngeus muscle
! Superior, middle and inferior pharyngeal
constrictors
! Muscles of the larynx (speech).
! Parasympathetic innervation of the heart is
mediated by the vagus nerve.
 


  
! ©he spinal accessory nerve provides motor
innervation from the central nervous system
to two muscles of the neck:
! the sternocleidomastoid muscle and the
trapezius muscle. ©he sternocleidomastoid
muscle tilts and rotates the head, while the
trapezius muscle has several actions on the
scapula, including shoulder elevation and
adduction of the scapula.
©est:
! £rom behind, examine for trapezius
atrophy, asymmetry.
! Pt. shrugs shoulders (trapezius).
! Pt. turns head against resistance: watch,
palpate SCM on opposite side
 
 
! ©he  
  is the twelfth
cranial nerve (XII), leading to the tongue.
©he nerve arises from the hypoglossal
nucleus and emerges from the medulla
oblongata in the preolivary sulcus
separating the 
 and the 
. It then
passes through the hypoglossal canal.
! It supplies motor fibres to all of the muscles
of the tongue, except the palatoglossus
muscle which is innervated by the vagus
nerve (cranial nerve X) or, according to
some classifications, by fibers from the
glossopharyngeal nerve
! ©o test the function of the nerve, a person is
asked to poke out their tongue. If there is a
loss of function on one side (unilateral
paralysis) the tongue will point towards the
affected side.
! ©he strength of the tongue can be tested by
getting the person to poke the inside of their
cheek, and feeling how strongly they can
push a finger pushed against their cheek - a
more elegant way of testing than directly
touching the tongue.
! ©he tongue can also be looked at for signs
of lower motor neuron disease, such as
fasciculation and atrophy.
! Paralysis/paresis of one side of the tongue
results in ipsilateral curvature of the tongue
(apex toward the impaired side of the
mouth) i.e., the tongue will move towards
the affected side.
! Listen to articulation.
! Inspect tongue in mouth for wasting,
fasciculations.
! Protrude tongue: unilateral deviates to
affected side.
©ounge examination