1. 1 Cranial Nerves

2. 2 Functional Classification of CN Spinal Nerve classification –General Efferent or Afferent: serve general motor, sensory. Cranial Nerves classification –Receptor type: General - just like spinal nerves Special –Use special receptors and neurons to serve additional specialized functions –Signal type Efferent – Sensory Afferent - Motoric –Voluntary or reflexive? Somatic. Innervate somatic muscles (muscles that arise from the soma in the embryological stage – voluntary muscle control) Visceral. Innervate visceral structures.

3. 3 7 Functional Types 1.General Somatic Efferent (GSE) Activates Muscles from Somites (Skeletal, Extraocular, Glossal) 2.General Visceral Efferent (GVE) Activates Visceral Organs 3.Special Visceral Efferent (SVE) Activates Muscles of face, palate, mouth, pharynx and larynx Excludes eye and tongue muscles 4.Special Visceral Afferent (SVA) Mediates visceral sensation of taste from tongue Olfaction from Nose 5.General Visceral Afferent (GVA) Mediates sensory innervation from visceral organs 6.General Somatic Afferent (GSA) Mediates information from muscles, skin, ligament and joints 7.Special Somatic Afferent (SSA) Mediates special sensations of vision from retina and audition and equilibrium from inner ear

4. Peripheral Nervous System (PNS) 12 pairs of cranial nerves- –Sensory, motor, or mixed “On Old Olympus Towering Top A Famous Vocal German Viewed Some Hops.”

5. Cranial Nerves (12 pair) I.Olfactory: smell II.Optic: vision III.Oculomotor: eyelid and eyeball movement IV.Trochlear: motor for vision (turns eye downward and laterally) V.Trigeminal: chewing, face and mouth touch and pain VI.Abducens: motor to lateral eye muscles VII.Facial: controls most facial expressions, taste, secretion of tears & saliva VIII.Vestibulocochlear: sensory for hearing and balance (aka Acoustic) IX.Glossopharyngeal: sensory to tongue, pharynx, and soft palate; motor to muscles of the the pharynx and stylopharyngeus X.Vagus Nerve: sensory to ear, pharynx, larynx, and viscera; motor to pharynx, larynx, tongue, and smooth muscles of the viscera, 2 parts: superior laryngeal branch and recurrent laryngeal branch XI.Spinal Accessory Nerve: motor to pharynx, larynx, soft palate and neck XII.Hypoglossal Nerve: motor to strap muscles of the neck, intrinsic and extrinsic muscles of the tongue

6. 6 I: Olfactory Special Sensory : smell -Injured by shearing (car accident) – unilateral loss of smell rad.usuhs.mil/cranial_nerves/timrad.html

7. 7 II: Optic Special Sensory: Sight Optic nerve nuclei are located in the lateral geniculate body Pupil constricts for light to contralateral eye, but not ipsilateral. Unilateral vision loss

8. 8 III: Oculomotor Somatic Motor: Superior, Medial, Inferior Rectus, Inferior Oblique Visceral Motor: Sphincter Pupillae Pupil asymmetry, no pupil reflex – regardless of which eye observes light. Difficulty with eye movments.

9. 9 IV: Trochlear Somatic Motor: Superior Oblique Injury leads to diplopia (due to extorsion), esp when looking down

10. 10 V: Trigeminal Somatic Sensory: Face Somatic Motor: Mastication, Tensor Tympani, Tensor Palati light touch and pain on the forehead (V1), cheeks (V2) and chin (V3).

11. 11 VI: Abducens Somatic Motor: Lateral Rectus Damage to the nerve is seen with decreased ability to abduct the eye. (diplopia: affected eye is pulled medially)

12. 12 VII: Facial Somatic sensory: Posterior External Ear Canal Special Sensory: Taste (Anterior 2/3 Tongue) Somatic Motor: Muscles Of Facial Expression Visceral Motor: Salivary Glands, Lacrimal Glands Drooping corner of mouth while at rest. Asymmetry of expressions (wrinkle forehead, raise eyebrows, etc)

13. 13 VIII: Vestibulocochlear Special Sensory: Auditory/Balance Can patient hear finger rubbing near ear.

14. 14 IX: Glossopharyngeal Somatic Sensory: Posterior 1/3 Tongue, Middle Ear Visceral Sensory: Carotid Body/Sinus Special Sensory: Taste (Posterior 1/3 Tongue) Somatic Motor: Stylopharyngeus Visceral Motor: Parotid Gland Asymmetric palate while saying ‘Aaah’, poor gag reflex (sensory = IX, motor = X)

15. 15 X: Vagus Somatic Sensory: External Ear Visceral Sensory: Aortic Arch/Body Special sensory: Taste Over Epiglottis Somatic Motor: Soft Palate, Pharynx, Larynx (Vocalization and Swallowing) Visceral Motor: Bronchoconstriction, Peristalsis, Bradycardia, Vomitting Asymmetric palate while saying ‘Aaah’, poor gag reflex

16. 16 XI: Spinal Accessory Somatic Motor: Trapezius, Sternocleidomastoid Drooping shoulder. Weakness turning head in one direction, difficult to shrug shoulders against resistance.

17. 17 XII: Hypoglossal Somatic Motor: Tongue Observe tongue while on florr of mouth. Twitching can suggest XII injury.

18. 18 Branchial Origin of Speech-Related Muscles Speech related muscles = visceral? Six branchial arches present in embryo One disappears during development Some cranial nerves originate from 5 brachial arches and are special visceral efferent nerves Speech related nerves Include –Trigeminal (V) –Facial (VII) –Glossopharyngeal (IX) –Superior laryngeal and recurrent laryngeal branches of Vagus (X)

19. 19 Cranial Nerve Nuclei Midbrain (3)- Control Eye Muscles –Two Motor N. of Oculomotor –One Motor N. of Trochlear Pons (6) –Three Sensory N. of Trigeminal Mesencephalic N. Primary Sensory N. Spinal Trigeminal N. –Motor N. of Trigeminal N. –Abducens N. –Facial Motor N.

20. 20 Cranial Nerve Nuclei: Medulla (9) 1.Cochlear N. (Hearing) 2.Vestibular N. (Equilibrium) 3.Salivary N. (Secretions) 4.Dorsal Motor N. of Vagus (Visceral Motor) 5.Hypoglossal N. (Tongue) 6.Nucleus Solitarius (Visceral Sensory) afferent swallowing 7.Spinal Trigeminal N. (Sensory) 8.Nucleus Ambiguus (Laryngeal & Pharyngeal Motor) efferent swallowing 9.Inferior Olivary N. (Info to Cerebellum)

21. 21 Pathways - Corticobulbar Motor Corticobulbar tract –Fibers between cortex and brain stem Cross midline at different levels –Upper and Lower Motor Neurons Clinical Signs: –Lower Motor Neuron Paralysis Absent Reflexes Flaccid Muscle Tone Fibrillation Fasciculations (twitching) Atrophy –Upper Motor Neuron Spasticity Increased Tendon Reflexes Contralateral Paresis

22. 22 Pathways - Sensory 3 Major types of sensory pathways –1st order - Outside brainstem –2nd order Cell bodies in gray matter of brainstem –3rd order - Cell bodies in ventral posterior medial N. of Thalamus projecting to cortex in parietal lobe Smell, hearing and vision are exceptions to rule three

23. 23 Olfactory Nerve (I) Special visceral afferent Parts –Olfactory Bulb –Olfactory Tract –Temporal Cortex

24. 24 Olfactory Nerve (I) Fibers pass through the foramina in the cribriform plate to olfactory bulb, olfactory tract to temporal cortex (uncus, amygdaloid N. and parahippocampal gyrus). Connects to limbic system and emotional brain. Olfactory ability decreases with age Anosmia: impaired smell (ask patient to identify odors)

25. 25 Optic Nerve (II) Special somatic afferent Retina to Optic Nerve to Optic Chiasm To Lateral Geniculate Body To Optic Radiations To Visual Cortex in Occipital Lobe Clinically: –Injury results in visual field loss –Common visual field losses in Chapter 8 (ask client to closes one eye and fix gaze straight ahead. Determine when patient can see objects in parts of visual field)

26. 26 Oculomotor Nerve (III) General somatic efferent –Innervate extrinsic muscles of eye General visceral efferent –Provides parasympathetic projections to constrictor fibers of iris and ciliary muscles –Provides motor innervation for iris to adjust to light and lens to focus –Edinger-Westphal Nucleus

27. 27 Oculomotor Nerve (III) Oculomotor Nerve Edinger- Westphal Nucleus Superior Colliculus Ciliary Ganglion

28. 28 Left Oculomotor (III) Nerve Paralysis Left eye is deviated laterally Does not move laterally Diplopia

29. 29 Diplopia

30. 30 Clinical Info: Oculomotor Nerve (III) Ptosis - eyelid droop Ophthalmoplegia –problems in adjusting to light –deviation of eye movements –diplopia (double vision)

31. 31 Trochlear IV General somatic efferent Only CN to exit brainstem dorsally Only CN that exits contralaterally Anterior oblique muscle for eye movement is only function Clinical –Difficulty looking downward and outward when Trochlear is injured –eye drifts upward relative to the normal eye

32. 32 Trochlear Nucleus Superior Oblique Muscle Trochlear (IV) Nerve Trochlear Nucleus

33. 33 Superior Oblique Muscle Function Right Superior Oblique Muscle Eye ball directed down and out

34. 34 Trigeminal (V) General somatic afferent Principal sensory nerve for head, face, orbit and oral cavity mediate sensations of pain, temperature, proprioception and fine discriminative touch Sensations from anterior 2/3 of tongue Three sensory branches –Ophthalmic –Maxillary –Mandibular

35. 35 Trigeminal (V)

36. 36 Trigeminal (V) Special visceral efferent Motor for mastication muscles for chewing and speaking –Internal and external pterygoid –Temporalis –Masseter –Mylohyoid –Anterior belly of digastric –Tensor veli palatini –Tensor tympani Reflex for jaw jerk reflex (mandibular)

37. 37 Trigeminal (V) Opthalmic Mandibular Maxillary

38. 38 Motor Branch of Trigeminal Nerve Pterygoid muscles Lateral (external) Medial (internal) Temporalis muscle Masseter muscle Mylohyoid Anterior belly Of digastric Tensor palatine Tensor tympani

39. 39 Clinical Info: Trigeminal (V) Sensory –Test for touch discrimination in different facial zones –Check for sneeze and corneal reflexes –Tic of douloureux (trigeminal neuralgia) which is excruciating pain Motor –Check for paralysis or paresis of ipsilateral muscles of mastication –Check for absent or exaggerated jaw reflex –Look for deviation of jaw toward side of injury –Unilateral lesion has mild effect on bite strength while bilateral has severe effect

40. 40 Abducens (VI) General somatic efferent Innervates only a single muscle: lateral rectus muscle which moves eye laterally Clinical Info: –When injured, medial rectus muscle is unopposed – eye shifts medially –Susceptible to disruption –Check for medial strabismus Turns in medially Double vision Left Abducens (VI) Nerve Paralysis Left eye is deviated medially

41. 41 Left Abducens (VI) Nerve Paralysis Diplopia Disappears on Eye Movement to the Right

42. 42 Abducens (VI) Nerve Lateral Rectus Muscle Abducens (VI) Nucleus

43. 43 Facial Nerve (VII) General visceral efferent –Parasympathetic innervation of lacrimal gland and palatal saliva –Innervation of mucous membrane secretions in mouth and pharynx Special visceral afferent –Gustatory sensations from anterior 2/3 of tongue

44. 44 Facial Nerve (VII) Special visceral efferent Primary motor nerve for facial muscles Extrinsic Muscles of ear –Cats can rotate outer ear Stapedius Muscle –Contraction attenuates sound Swallowing –Stylohyoid Muscle –Posterior Belly of Digastric Muscle Lacrimal secretion - Tears

45. 45 Clinical Info: Facial Nerve (VII) Upper Motor Neuron Disease –Why is it hard to only raise one eyebrow? –Unilateral paresis of muscles of lower half of face –Muscles above bilaterally innervated –Bilateral lesion can cause paralysis of upper and lower muscles bilaterally Lower Motor Neuron Disease –Injury near pons can cause lower motor neuron disease –Unilateral Paralysis of all facial muscles, stapedial muscle and taste in 2/3 of tongue

46. 46 Clinical Examples: Facial Nerve UMN LMN

47. 47 Clinical Examples: Facial Nerve

48. 48 Clinical Info: Facial Nerve (VII) Bell’s Palsy –LMN syndrome with sudden onset of paralysis of ipsilateral facial muscles –Inflammatory injury, infection or degenerative disease

49. 49 Vestibulo-acoustic Nerve (VIII) Special somatic afferent Vestibular Nerve –Gives feedback about position of head in space and balance Acoustic Nerve –Hearing Clinical Info –Tests for equilibrium, vertigo or dizziness, nystagmus and hearing loss

50. 50 Glosso-pharyngeal Nerve (IX) General visceral afferent –Mediates general visceral sensation from soft palate, palatal arch, posterior 1/3 of tongue and carotid sinus General visceral efferent –Secretion from parotid gland (salivary gland) Special visceral afferent –Taste sensation form posterior 1/3 of tongue Special visceral efferent –Contributes to swallowing through stylopharyngeus and upper pharyngeal constrictor fibers

51. 51 Clinical Info: Glosso-pharyngeal (IX) May be evident in dysphagia or loss of taste to posterior 1/3 of tongue Loss of gag reflex Excessive oral secretions Dry mouth Need bilateral damage of nerve to have strong clinical signs

52. 52 Vagus Nerve (X) General visceral afferent –Sensation from pharynx, larynx, thorax, abdomen –Regulates nausea, oxygen intake, lung inflation General visceral efferent –Innervates glands, cardiac muscles, trachea, bronchi, esophagus, stomach and intestine Special visceral afferent –Mediates taste sensation from posterior pharynx and epiglottis Special visceral efferent –Controls muscles of larynx, pharynx, soft palate for phonation, swallowing and resonance

53. 53 Clinical Info: Vagus Nerve (X) Bilateral lesion of the brainstem can be fatal due to respiratory involvement Unilateral lesion can result in ipsilateral paresis or paralysis of soft palate, pharynx and larynx Pharyngeal Branch –Pharynx and soft palate involvement –Uvula pulled to unaffected side, bilateral soft palate droops Recurrent Laryngeal Branch –Unilateral: Paralysis of vocal folds –Bilateral: Inspiratory stridor and aphonia

54. 54 Clinical Info: Vagus Nerve (X) Normal Soft PalateUnilateral ParalysisBilateral Paralysis

55. 55 Clinical Info: Vagus Nerve (X) Autonomic reflexes reduced Anesthesia of pharynx and larynx and loss of taste Superior Laryngeal Branch –Loss of ability to change pitch

56. 56 Spinal Accessory Nerve (XI) General visceral efferent –Controls head position by controlling trapezius and sternocleidomastoid muscles Clinical Information –Affects ability to control head movements –Ask patient to rotate head and note control

57. 57 Hypoglossal Nerve (XII) General somatic efferent –Controls tongue movement –Controls extrinsic and intrinsic muscles of tongue except palatoglossal (X) –Eating, sucking and chewing reflexes

58. 58 Clinical Info: Hypoglossal (XII) LMN unilateral lesion can cause wrinkling and flaccidity of tone with atrophy over time Dysarthria and Dysphagia Unilateral UMN lesions do not have much affect as tongue is bilaterally innervated Ask patient to complete oral motor movements

59. 59 Clinical Info: Hypoglossal (XII) Unilateral Tongue Paralysis Bilateral Tongue Paralysis

60. 60 Innervation of the tongue Glosso- pharyngeal (IX) Nerve Trigeminal (V) Nerve General (tactile, etc.) Special (taste) Glosso- pharyngeal (IX) Nerve Facial (VII) Nerve

61. 61 Cranial Nerve Combinations More than one nerve involved with some structures Eyes muscle control Sensory fibers to tongue –Anterior 2/3 special and general sensation: Facial and Trigeminal, –Posterior 1/3special and general sensation: Glossopharyngeal

62. 62 Cranial Nerve Combinations Motor Nerve Supply to Soft Palate and Pharynx –Vagus, Trigeminal and Glossopharyngeal Sensory Nerve Supply to Soft Palate and Pharynx –Glossopharyngeal, Vagus and Trigeminal

63. 63 Nerve Classifications This division give rise to a classification based on whether a nerve is: Afferent, efferent, or both Somatic or visceral, or both Special, general, or both The only combination that does not exist is: Special, somatic, efferent.

64. 64 Case # 1 Setting: Neonatal intensive care unit (NICU) Patient: Pt. is a two-day old male. Delivery was complex but completed with cesarean section, neurological exam suggests a right facial paralysis /s other prominent symptoms. 1.What cranial nerve(s) is/are involved? 2.Discuss the probable cause of the right facial paralysis 3.In what cases will the symptoms resolve? 4.What are some possible current functional problems that may be present? 5.What are some possible future functional problems?

65. 65 Case # 2 Setting: Out-patient clinic Patient: 64 y.o. male. Pt. is 18 months post-stroke. Neurological exam revealed: aphasia, dilated left pupil, left eye deviated downwards and lateral. Left eyelid droop. 1.What cranial nerve is involved? 2.What kind of a visual problem would this patient have? 3.What can the patient do to compensate for the visual problem? 4.Will this condition persist? 5.In the long run, how will the brain compensate for this problem? 6.Is it probable that the same lesion resulted in the visual problem and the aphasia?

66. 66 Case #3 Setting: Nursing home Patient: Pt. is a 78 y.o. female who has been residing at the nursing home for the last 3 years. She was originally admitted to the nursing home following amputation of both legs below the knee. This was necessary secondary to diabetes that results in gradual neuropathy and loss of vascular circulation in the extremities. A recent visit by the primary care physician revealed loss of sensation in the face secondary to progressive neuropathy. Her jaw is slightly deviated to the left. 1.What cranial nerve is involved? 2.How can you determine which afferent part of this cranial nerve is affected? 3.What would cause the jaw to deviate to one side? 4.Is this an upper or lower motor neuron problem? 5.Will she improve? Why/why not?

67. 67 Case #4 Setting: ICU Patient: 42 y.o. female. Patient was brought to the ER following a motor vehicle accident. She was comatose for 4 days but is now alert but not oriented. Pt. has multiple fractures including the: left tibia, left humerus and clavicle. Extensive facial bruising. MRI showed scattered bruising of the cortex and possible brain stem involvement. The neuro exam revealed severe aphonia, stridor, absent swallow reflex, drooping soft palate, no gag reflex. 1.What cranial nerve is most likely affected? 2.Is this an upper or lower motor problem? 3.What are some other neurological symptoms that could be present? 4.Would you recommend an oral diet for this patient? Why/why not?

68. 68 Case #5 Setting: Nursing home (SNF) Patient: Pt. is a 71 y.o. male who was admitted to the SNF following hospitalization for stroke. The MRI revealed multiple infarctions at the level of the basal ganglia and perhaps the brain stem. The neuro report from the hospital suggested that the patient has right lower facial droop, poor movement of most facial muscles, exaggerated smile, and excessive laughter or crying. 1.Does this clinical picture agree with cranial nerve involvement? Why/why not? 2.Is this an upper or lower motor neuron problem? 3.Poor movement of most facial muscles would implicate what cranial nerve?

69. 69 VIII Injury : www.dizziness-and- hearing.com/testing/acoustic_reflexes.htm Central case example: A 40 year old man was well until he was involved in an auto accident. Two days later he developed diplopia and a rotatory type vertigo. On physical examination he had clear spontaneous nystagmus, a fourth nerve palsy, and mildly decreased hearing on the left side. Audiometry documented mildly impaired hearing on the left, but acoustic reflexes were abnormal with very rapid decay on the left side. BAER responses were also very abnormal on the left. An MRI scan documented a lesion resembling an MS placque in his left cerebellar peduncle area, just behind the 8th nerve (see figure to right). His symptoms resolved spontaneously and he has had not further neurological complaints in 5 years of followup. COMMENT: This was most likely a demyelinative lesion resembling transverse myelitis. The abnormal reflex decay pointed towards a central lesion.