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VI I II III VII&VIII V XII XI IX X IX &X. Foramen: cribiform Foramen: cribiform plate of ethmoid plate of ethmoid Region Entered: Region Entered: nasal.

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Presentation on theme: "VI I II III VII&VIII V XII XI IX X IX &X. Foramen: cribiform Foramen: cribiform plate of ethmoid plate of ethmoid Region Entered: Region Entered: nasal."— Presentation transcript:

1 VI I II III VII&VIII V XII XI IX X IX &X

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3 Foramen: cribiform Foramen: cribiform plate of ethmoid plate of ethmoid Region Entered: Region Entered: nasal cavity nasal cavity Components: Components: special sensory special sensory Target: olfactory Target: olfactory epithelium epithelium Function: smell Function: smell Cranial Nerve I: Olfactory Bipolar cells cells Bulbus olfactorius 50 million primary sensory receptor cells in 2.5 cm2

4 The mucous lipids assist in transporting the odorant molecules as only volatile materials soluble in the mucous, can interact with the olfactory receptors & produce the signals that our brain interprets as odor 8-20 cilia of  in length 60  thick layer of mucous (lipid- rich secretion that bathes the surface of the receptors at the epithelium surface) First neurons: Unmyelinated Second neurons:

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6 anterior olfactory nucleus pyriform cortex olfactory tubercle transitional entorhinal cortex nucleus of horizontal limb of diagonal band Medial stria Lateral stria

7 Olfactory Tract Connections& Lesion  Lateral stria primary olfactory cortex (periamygdaloid & prepiriform areas) secondary olfactory cortex (entorhinal area (area 28))  Medial stria cross the anterior commisure to join contralateral olfactory bulb Unilateral anosmia : Compression due to abcess, glioma, meningioma of frontal lob or hypothalamus which may result in ipsilateral optic atropy & contralateral papilledema Foster-Kennedy syndrome

8 Cranial Nerve II: Opticus Foramen: optic canal of sphenoid Region Entered: orbit Components: special sensory Target, Function: retina-vision

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10 1st neurone: rod & cone cells of the retina 2nd neurone: bipolar neurones of the retina 3rd neurone: multipolar neurones of the retina Axons of the ganglion opticum run via the N. opticus to the chiasma

11 In the chiasma opticum, fibres of the nasal part of the retina cross to the contralateral side, and those of the temporal part continue ipsilaterally Each tractus opticus consists of fibres transporting the information from the contralateral halves of the visual field corpus geniculatum laterale&mediale (some fibres), hypothalamus go directly to the cortex of the brain 4th neurone: corpus geniculatum laterale areas 17&18 around the sulcus calcarinus (area striata)

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14 Acute right homonymous hemianopsia in a 59-year-old man due to embolus in the left PCA. (A) MRI shows infarction in the medial left occipital lobe (arrow). (B) Occlusion of the left PCA at its origin (arrow) by an embolus (DSA, left vertebral artery, AP view). (C) The capillary phase (arrow) is absent in the left occipital lobe due to the proximal embolus.

15 Causes of Papillitis&Retrobulbar Neuritis  Multiple sclerosis  Viral illness; Syphilis  Temporal arteritis & other kinds of inflammation of the arteries (vasculitis) inflammation of the arteries (vasculitis)  Poisoning by chemicals: lead, methanol...  Tumors that have spread to the optic n.  Allergic reactions to beestings  Meningitis  Uveitis  Arteriosclerosis

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17 preganglionic parasympathetic preganglionic parasympathetic to: ciliary ganglion (innervation of sphincter pupillae and ciliary muscle) to: ciliary ganglion (innervation of sphincter pupillae and ciliary muscle) Superior Orbital Fissure Syndrome VI IV III

18 Cranial Nerve III: Oculomotor Oculomotor Foramen: Superior orbital fissure Region Entered: Orbit Somatomotor Comp.: Target, Function: levator palpebrae sup. superior rectus medial rectus inferior rectus inferior oblique Visceromotor Comp.: preganglionic parasympathetic to: ciliary ganglion R eye

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21 THIRD CRANIAL NERVE PALSIES During primary gaze, weakness of During primary gaze, weakness of the muscles innervated by, result in:  Ptosis of the lid  Mydriasis  Outwardly turned eye Pupil is completely spared: MyopathyMyopathy but all other muscles innervated by the 3rd nerve are affected: diabetic 3rd nerve paresis (ischemic process)but all other muscles innervated by the 3rd nerve are affected: diabetic 3rd nerve paresis (ischemic process)

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23 Fixed dilated pupils: 3rd nerve compression Fixed dilated pupils: 3rd nerve compression - Aneurysm of the post. communicating art - Aneurysm of the post. communicating art - Trauma - Trauma - Intracranial mass lesion - Intracranial mass lesion - Increasingly unresponsive patient with - Increasingly unresponsive patient with 3rd n. palsy: transtentorial herniation 3rd n. palsy: transtentorial herniation Neurologic examination with CT or MRI When CT does not show blood: Lumbar puncture (suspected SAH)When CT does not show blood: Lumbar puncture (suspected SAH) Cerebral angiography: if aneurysm is suspectedCerebral angiography: if aneurysm is suspected

24 + Nuc. Ruber infarction in midbrain contralat. tremor + İpsilat. 3rd n. palsy & fixed pupilla Pupillary Reflex: Afferent: NII Edinger-Westpal nuc. Efferent: NIII parasympath. Argyll Robertson pupil  Accomodation Retained Light reflex absent

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26 Loss of sweating on the affected side of the face Loss of sweating on the affected side of the face From hypothalamus, sympathetic nn. descend ipsilat. through the brainstem & cervical cord & riches the sympathetic chain via the motor root of T1. From there, fibers pass along the outer sheath of the internal carotid artery&its opht.branch &to the pupilla. Fibers to the face travel with the ext. carotid artery From hypothalamus, sympathetic nn. descend ipsilat. through the brainstem & cervical cord & riches the sympathetic chain via the motor root of T1. From there, fibers pass along the outer sheath of the internal carotid artery&its opht.branch &to the pupilla. Fibers to the face travel with the ext. carotid artery Pancoast tm, mass compress. cervical symp. chain Ptosis Ptosis Myosis Myosis Enophthalmus Enophthalmus

27 Superior Orbital Fissure Syndrome VI IV III Foramen: Superior orbital fissure Region Entered: Orbit Components: somatomotor Target, Function: Superior oblique muscle Cranial Nerve IV: Trochlear Cranial Nerve IV: Trochlear

28 Cranial Nerve IV: Trochlear  Affect vertical eye position when the eye is turned inward when the eye is turned inward  The patient sees double images: one above & slightly to the one above & slightly to the side of the other side of the other  By tilting the head to the side opposite the palsied m., the pt opposite the palsied m., the pt may achieve full ocular motility without double vision may achieve full ocular motility without double vision  Causes: idiopathic, closed head trauma, aneurysms, tm, MS

29 Cranial Nerve VI: Abducens Foramen: Superior orbital fissure Region Entered: Orbit Region Entered: Orbit Components: Somatomotor Components: Somatomotor Target, Function: Target, Function: to lateral rectus (best abductor!) to lateral rectus (best abductor!)

30 Idiopathic: improvement within 2 mo Idiopathic: improvement within 2 mo Elderly or diabetic pts: small vessel disease Elderly or diabetic pts: small vessel disease Compression in cavernous sinus: severe Compression in cavernous sinus: severe headache & anesthesia in the area of n.V1 headache & anesthesia in the area of n.V1 Increased intracranial pressure: Increased intracranial pressure: shift in the brain stretch the 6th n. shift in the brain stretch the 6th n. Trauma (basilar skull fracture) Trauma (basilar skull fracture) Infections & tumors affecting the meninges Infections & tumors affecting the meninges Aneurysm, MS Aneurysm, MS Wernicke's encephalopathy Wernicke's encephalopathy

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32 ıv ıv ııı PPRF Lat. rectus Medial rectus VIIIN Pons Pons Mesensephalon MLF vı MLF MLF Nuc. Abducens Frontal eye field (FEF & SEF) (FEF & SEF) Saccadic Eye Movements VI Retina Optik nerve Corpus geniculatum lat. Area 17. & 19. FEF Mesencephalon Pons (VI. contral. III. & n. nuclei)

33 VIII Pons Mesencephalon VI VI MLF MLF MLF Nuc.VI PPRF ıv MLF ııı Lateral rektus Medial rektus vı Saccadic Eye Movements Frontal eye field (FEF & SEF)

34 VIII Pons Pons Mesencephalon VI VI MLF MLF Nuc. Abducens PPPPRRFF PPPPRRFFPPRF ıv MLF ııı Lateral rektus Medial rektus vı Saccadic Eye Movements Frontal eye field (FEF & SEF)

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37 Vertical Gaze Bilateral control Bilateral control Center: Dorsal rostral mesencephalon Center: Dorsal rostral mesencephalon 3 integral structures: 3 integral structures: - riMLF - riMLF - Cajal’s interstitial nuc. - Cajal’s interstitial nuc. - Posterior commisure - Posterior commisure Inputs from PPRF & vestibular nuclei Inputs from PPRF & vestibular nuclei Each riMLF projects ipsilaterally to III & IV n. nuclei Each riMLF projects ipsilaterally to III & IV n. nuclei Vestibulo-ocular Reflexe paths Rapid turn of the head to the left Ant. motion of the fluid in the labyrinth Eyes turn right in order to sustain forward gaze Ipsilat. IIIrd & contralat. VIth nerves are stimulated Cupula is stimulated

38 Cranial Nerve V: Trigeminal V1-Trigeminal ophthalmic Major branches: Lacrimal, Frontal, Nasociliary & Meningeal Foramen: superior orbital fissure Region Entered: orbit Components: general sensory Target, Function: general sensation from skin and mucosa in region at & above orbit at & above orbit

39 V. NERVUS TRİGEMİNUS Duysal  Yüz  Oral-nazal kavite  Dilin 2/3 ön kısmı: Ağrı-ısı- dokunma  Meninksler: Ağrı MotorÇiğneme kasları, tensor veli palatini RefleksKornea-Göz kırpma, çene SUPRANÜKLEER LEZYONLAR: Vasküler, demiyelinizan, tümör Bilateral-yaygın premotor nöron lezyonları  Çiğneme kasları paralizisi  Çene refleksi   Bilateral premotor nöron bulguları  Affekt kontrol bozukluğu, demans Talamik lezyonlarKarşı yüz yarımında his kusuru Parietal lezyonlar Karşı taraf kornea refleksi kaybı  hemifasiyal his kusuru

40 Cornea Reflex Afferent: Afferent: N V1 N V1 Efferent: Efferent: N VII N VII (blink) (blink) Ciliary ganglion

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44 Infraorbital, Zygomatic,Nasopalatine, Palatine V2-Trigeminal maxillary Infraorbital, Zygomatic,Nasopalatine, Palatine Foramen:rotundum Region Entered: pterygopalatine fossa Components: general sensory general sensory Target, Function: gen.sensation from gen.sensation from skin & mucosa skin & mucosa in region from in region from orbit to mouth orbit to mouth

45 V3-Trigeminal mandibular Buccal, Auriculotemporal, Lingual, Inf. alveolar & Meningeal V3-Trigeminal mandibular Buccal, Auriculotemporal, Lingual, Inf. alveolar & Meningeal Foramen: ovale with lesser petrosal with lesser petrosal from CN9 from CN9 Region Entered: infratemporal fossa infratemporal fossa Components: brachiomotor Target, Function: muscles of masticat. tensor tympani & veli palatini, mylohyoid ant. belly digastric

46  Lesion of spinal tract V IPSILATERAL deficits IPSILATERAL deficits in pain & temperature from the face etc. in pain & temperature from the face etc. (the pain information never gets to the (the pain information never gets to the caudal spinal nucleus) caudal spinal nucleus)  Interruption of the trigeminothalamic tract deficits in pain & temperature on the deficits in pain & temperature on the contralateral side of the face contralateral side of the face (comprised of axons that have crossed (comprised of axons that have crossed the midline) the midline)

47 Causes of Sensory Trigeminal Neuropathy Idiopathic Systemic inflammatory disease Sjögren's syndrome Progressive systemic sclerosis (scleroderma) Mixed connective tissue disease Systemic lupus erythematosus Dermatomyositis Rheumatoid arthritis Sarcoidosis Wegener's granulomatosis Undifferentiated connective tissue disease Giant cell arteritis Idiopathic hypertrophic cranial pachymeningitis Multiple sclerosis Tumor –Intracranial or extracranial –Metastatic –Primary: Meningioma, Schwannoma, Epidermoid, Chordoma Trauma Aneurysm Dural external carotid artery cavernous sinus fistula Sickle ceil disease Diabetes mellitus Syringobulbia Infections Sinusitis Herpes simplex Herpes zoster Hepatitis A infection Nonspecific viral infection Tuberculosis Whipple's disease Leprosy Arachnoiditis Tricloroethylene Hydroxystilbamidine Amyloidosis Spinal epidural anesthesia

48 Piramidal yol Kontralateral hemiparezi Spinotalamik demetKontralateral gövde ve ekstremitelerde his kusuru Orta serebellar pedünkülİpsilateral tremor Medial Longitudinal fasikülİnternükleer oftalmopleji İnen sempatik lifler İpsilateral Horner sendromu

49 Preganglionik sinir kökleri: Subaraknoid alan GASSER GANGLİONUNDA YERLEŞİK LEZYONLAR VaskülerAnevrizma, kollagen doku hastalıkları Tümör İnfeksiyonH. Zoster, abse, petrozitis + Sempatik pleksusOkülosempatik paralizi + IV - VIDiplopi + VIIIİşitme kaybı TRİGEMİNAL NEVRALJİ ?

50 PERİFERİK DALLARI ETKİLEYEN LEZYONLAR İnfeksiyonİnflamasyon; Bakteriyel-tbc-karsinomatöz- granülomatöz menenjit TravmaKafa kaidesi fraktürü Tümör Paget hastalığı VaskülerAnevrizma, infarkt (DM) Guillain-Barre sendromu KAVERNÖZ SİNÜSTE YERLEŞİK LEZYONLAR SUPERİOR ORBİTAL FİSSÜRDE YERLEŞİK LEZYONLAR

51 Brachiomotor: m. of facial expr.: stapedius,stylohyoid, mylohyoid, post.belly digastric Brachiomotor: m. of facial expr.: stapedius,stylohyoid, mylohyoid, post.belly digastric facial canal  middle ear  chorda tympani  petrotympanic fissure facial canal  middle ear  chorda tympani  petrotympanic fissure Special sensory: taste, ant. 2/3 tongue: facial canal  middle ear  chorda tympani  petrotympanic fissure Special sensory: taste, ant. 2/3 tongue: facial canal  middle ear  chorda tympani  petrotympanic fissure Visceromotor: preganglionic parasympathetic to submand. ganglia (innervates submand. &sublingual glands) Visceromotor: preganglionic parasympathetic to submand. ganglia (innervates submand. &sublingual glands) greater superficial petrosal  pterygoid canal greater superficial petrosal  pterygoid canal pterygopalatine ganglia to lacrimal, nasal & palatine gl. pterygopalatine ganglia to lacrimal, nasal & palatine gl. internal acoustic meatus  facial canal  stylomastoid foramen Facial Nerve Temporal, Zygomatic, Buccal, Mandibular, Cervical&Post. Auricular Facial Nerve Temporal, Zygomatic, Buccal, Mandibular, Cervical&Post. Auricular

52 Lesion at A: Ipsilateral  paralysis of all facial movements  corneal reflex is lost  sensory area to ear is lost Lesion at B: A(+) impaired  sublingual, submandi- bular glands’ secretions&  taste over ant. 2/3 of the tongue  hyperacusis Lesion at C: A&B(+) im- paired ipsilat.lacrimation C B A

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55 Causes of Peripheral Facial Nerve Palsy Idiopathic (Bell's palsy)Idiopathic (Bell's palsy) Infectious: Infectious: –Herpes simplex –Herpes zoster –Otitis media –Borrelia burgdorferi –Human immunodeficiency virus –Syphilis –Infectious mononucleosis –Mastoiditis –Poliomyelitis –Meningitis –Malaria –Leprosy –Rubella –Mumps –Osteomyelitis –Cat scratch disease InflammatoryInflammatory –Guillain-Barré syndrome –Sarcoidosis –Multiple sclerosis –Arteritis –Melkersson-Rosenthal syndrome –Behçet syndrome –Wegener's granulomatosis –Lymphomatoid granulomatosis –Kawasaki disease –Angioedema –Pseudotumor (Tolosa-Hunt syndrome) –Amyloidosis –Idiopathic hypertrophic cranial pachymeningitis NeoplasticNeoplastic –Schwannoma –Neurofibroma –Meningioma –Cholesteatoma –Parotid gland tumor –Metastasis –Carcinomatous meningitis –Leukemia MetabolicMetabolic –Diabetes mellitus –Hypothyroidism –Uremia –Porphyria Trauma: Surgical trauma to nerveTrauma: Surgical trauma to nerve Congenital, FamilialCongenital, Familial MiscellaneousMiscellaneous –Pregnancy –Paget's disease –Osteopetrosis –Hypertension –Diphtheria-pertussis-tetanus vaccination –Pontine infarction –Myasthenia gravis –Traumatic external carotid artery aneurysm –Lumbar extradural blood patch – Vascular malformation – Pseudotumor cerebri –Ethylene glycol poisoning

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59 Cranial Nerve VIII: Vestibulocochlear

60 1st neurone: bipolar cells of the gang. cochleare 2nd neurone: multipolar neurones of nuclei cochleares

61 Auditory path. 4th or 5th neurone:  Heschl's transverse gyrus & Wernicke's centre of the temporal lobe 2 nd neurones  corpus trapezoideum  opposite side  form lemniscus lat.  colliculus inferior  3 rd or 4 th neurone  colliculus superior  cerebellum & corpus geniculatum mediale 2 nd neurones  corpus trapezoideum  opposite side  form lemniscus lat.  colliculus inferior  3 rd or 4 th neurone  colliculus superior  cerebellum & corpus geniculatum mediale

62 2nd & following neurones: from nuc.vestibularis lat. (Deiter's) to: - formatio reticularis - motor nuclei of nerves III, IV & VI - nuc. ruber & as the tr. vestibulosp. into the ant. column of the sp. cord 2nd & following neurones: from nuc.vestibularis lat. (Deiter's) to: - formatio reticularis - motor nuclei of nerves III, IV & VI - nuc. ruber & as the tr. vestibulosp. into the ant. column of the sp. cord nuc. ruber FLM 1st neurone: bipolar cells of the ganglion vestibulare form the N. vestibularis on the floor of the internal acoustic meatus 1st neurone: bipolar cells of the ganglion vestibulare form the N. vestibularis on the floor of the internal acoustic meatus nuc. vestibularis sup. (Bechterew's) supplies some fibres to cerebellum Vestibular path

63 Disease affecting hearing Disease affecting hearing Acoustic neuroma (8th n) Presbyacusis (cochlea) Trauma“ Wax (ext.&middle ear) Otitis media“ Otosclerosis“ Disease affecting balance Disease affecting balance Vascular diseases(b.stem) Vascular diseases(b.stem) Demyelination “ Drugs (DPH, streptomycin) Viral, benign conditions Disease affecting hearing & balance (cochlea&labyrinth) Meniere Cranial Nerve VIII: Vestibulocochlear internal auditory meatus

64 Cochleo-vestibular Disease Main Symptoms Main Signs Cochleo-vestibular Disease Main Symptoms Main Signs DeafnessDeafness TinnitusTinnitus VertigoVertigo Loss of balanceLoss of balance Deafness Deafness Nystagmus Nystagmus Ataxia Ataxia Positional nystagmus Positional nystagmus

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66 Cranial Nerve IX: Foramen: jugular Foramen: jugular Special visceromotor: Function: elevates pharynx Special visceromotor: Function: elevates pharynx nucleus ambiguus  stylopharyngeus nucleus ambiguus  stylopharyngeus Gen. Sensory Components Function: general sensation of external, middle ear & auditory tube Gen. Sensory Components Function: general sensation of external, middle ear & auditory tube  geniculate ganglion  spinal trigeminal nucleus  geniculate ganglion  spinal trigeminal nucleus Special Viscerosensory Component: Special Viscerosensory Component: Function: taste, posterior 1/3 tongue=> Function: taste, posterior 1/3 tongue=> inferior petrosal ganglion  rostral tractus solitarius inferior petrosal ganglion  rostral tractus solitarius Region Entered: infratemporal fossa Region Entered: infratemporal fossa Gen. Viscerosensory: Sensory receptors of ant. surface epiglottis, root of tongue, border of soft palate, uvula, tonsil, pharynx, eustachian tube, carotid sinus & body  caudal tractus solitarius Gen. Viscerosensory: Sensory receptors of ant. surface epiglottis, root of tongue, border of soft palate, uvula, tonsil, pharynx, eustachian tube, carotid sinus & body  caudal tractus solitarius Gen.Visceromotor comp.: İnf.salivary nuc.  tympani n.  lesser petrosal n  otic ganglion  auriculotemporal n. Gen.Visceromotor comp.: İnf.salivary nuc.  tympani n.  lesser petrosal n  otic ganglion  auriculotemporal n. Function: parotid gland secretion Function: parotid gland secretion

67 These epithelial receptor cells make synaptic contact with distal processes of cranial nerves VII, IX, or X Microvilli of the taste receptor cells project into an opening in the epithelium, the taste pore, where they make contact with gustatory stimuli.

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69 Special Viscerosensory: taste in epiglottis  inf. Gang.  rostral tr. solitarius Special visceromotor: (deglutition phonation) n. Ambiguus  palatal, pharynx & larynx muscles General viscerosensory: post.epiglottis,larynx, trachea, bronchi, esopagus, stomach, s. İntestine, colon  inf. ganglion  caudal tr. solitarius General somatosensory: : auricle, ext. auditory meatus  sup. ganglion  spinal trigeminal nuc General Visceromotor: dorsal motor nucleus  preganglionic parasympathetic to abdomen & thorax cardiac depression, visc. mov., secretion Nervus Vagus

70 Primary afferents in the IX and X cranial nerves project to the NTS

71 vagal afferents

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73 Right & Left recurrent laryngeal nerves

74 Selected Causes of Vagus Nerve Dysfunction Lateral medullary syndrome Hyperextension injury of upper cervical spine Chronic lead poisoning Radiation therapy to head and neck Glomus vagale tumor Neuroma Schwannoma presenting as cerebellopontine angle mass Nasopharyngeal diphtheria Viral or postviral mononeuritis Herpes simplex Cytomegalovirus Herpes zoster Multiple system atrophy Superior laryngeal neuralgia

75 Brachiomotor Comp: Brachiomotor Comp: Foramen:  exits by jugular;  enters by foramen magnum  ant. horn cells C1-C5 Foramen:  exits by jugular;  enters by foramen magnum  ant. horn cells C1-C5 Target: trapezius, sternokleidomastoid Target: trapezius, sternokleidomastoid Function: head & shoulder movement Function: head & shoulder movement Spc.Visceromotor Comp.: Caudal nuc. ambiguus  vagus  muscles of larynx Function: phonation Spc.Visceromotor Comp.: Caudal nuc. ambiguus  vagus  muscles of larynx Function: phonation Cranial Nerve XI: Spinal Accessory

76 Symptoms of the 11th n. involvement Torticollis (dystonia) Asymmetric shoulders Impaired arm elevation

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78 Cranial Nerve XII: Hypoglossal Foramen: hypoglossal canal Foramen: hypoglossal canal Region Entered: neck Region Entered: neck Components: somatomotor Components: somatomotor Target, Function: all tongue muscles, except palatoglossus Target, Function: all tongue muscles, except palatoglossus

79 Infranuclear paralysis of the right trigeminal, facial, and hypoglossal nerves, showing deviation of the mandible and tongue to the right

80 12th n. palsy: AsymmetryDeviationAtrophyFasciculations 10th nerve 10th nerve

81 Common Condition Affecting 9th, 10th & 12th Nerve Function  Motor neuron disease  Cerebrovascular disease  Syringobulbia  Erosive tm of the skull base  Guillain-Barré syndrome  Recurrent laryngeal nerve palsy  Myastenia gravis Bulbar palsy Dysartria Dysartria Dysphagia Dysphagia Dysphonia Dysphonia Aspiration Aspiration

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