Ammar Alnajjar

Cranial Nerves
Number Nerves Mnemonic Function Mnemonic
I Olfactory Oh Sensory Some
II Optic Oh Sensory Say
III Oculomotor Oh Motor Marry
IV Trochlear To Motor Money
V Trigeminal Touch Both But
VI Abducens And Motor My
VII Facial Feel Both Brother
VIII Vestibulocochlear Very Sensory Says
IX Glossopharyngeal Good Both Big
X Vagus Violin Both Brains
XI Accessory Ah Motor Matters
XII Hypoglossal Heaven Motor More

All 12 pairs of cranial nerves emerge from brainstem,

except CN I & CN II which emerge directly from the brain.

The other 10 CN arises as follows:

Cranial Nerves Brainstem

III Mid Brain
IV
V (4 nuclei) Pons
VI
VII
VIII (ponto-medullary junction)
IX Medulla Oblongata
X
XI
XII
 CN I : Olfactory Nerve Anosmia = The complete loss of smell.

Special Sense Hyposmia = decreased sense of smell, or a decreased

ability to detect odors through your nose.
Arise from frontal lobe
Parosmia = a distortion of the sense of smell
Function: Sensory → Responsible for Smell (malpresentation)

How to Examine CN I ?

1- Make sure the nasal passages are patent (clear, both) by asking the patient to close
one nostril with finger and blow air against small piece of paper. If the paper moves
it’s clear and repeat process with the other nostril.

2- Bring 3 test tubes, each one with different odor (one of them is water for control,
no odor) and cover them with blaster (or you can ask the patient to close his eyes)
the odors should be non-irritant materials like coffee, chocolate, soap, orange, mint
(common substance)

Q/Why do we use non irritant substances ?

A/ to prevent
1- destruction of nasal epithelium
2- destruction of smell receptors
3- to avoid false results → because there is irritant receptors in the trigeminal n.

3- Ask the patient to close eyes and one of the nostrils, put the test tube near the
open nostril and ask weather the patient can smell anything or not.

4- Repeat with the other nostril.

Causes of Anosmia

1- Bilateral Anosmia: Mostly are ENT disorders (Flu, Sinusitis, Because the olfactory nerve is
nasal obstruction, nasal polyps) poorly localized, it may be
effected by trauma or systemic
disease.
2- Unilateral Anosmia: Mostly Neurological origins
A- Parkinson’s disease
B- Trauma (fracture) in the cribriform plate of the ethmoid bone.
C- Tumor in the olfactory groove (olfactory groove meningioma)

Causes of Parosmia
1- Head trauma (post-traumatic head injury)
2- Sinus infection
3- Side effect of drugs

Sometimes temporal lobe disorder can cause olfactory hallucinations and simple focal
seizures that spread causing generalized seizures.

Part of CN I course is beneath the frontal lobe in direct contact with the meninges, so
frontal lobe meningitis can cause hyposmia and anosmia
CN II : Optic Nerve
Special Sense
Function: Sensory → Responsible for Vision

Sequence of CN II examination

1- Visual Acuity 2- Visual Field 3- Color Vision 4- Fundoscopy

Visual Acuity
There are more than one way to test this:

1- Snellen’s chart : put the chart at 6m distance from the patient (or at
3m and a mirror). Close one eye and descend from above downward
on the chart until the patient can’t correctly identify the letter. Repeat
with the second eye.

2- Finger – Counting (bed side test):

At 6m distance, ask the patient to close one eye and try to identify
how many fingers I am holding. If the patient could correctly identify
the number, that is good.
If not, step 1m closer to him and ask again.
If he still can’t identify, keep proceeding 1m at a time.
When you reach 1m distance from the patient and he still do not know, do not move 1m
but start waving your hand and ask him if he sees.
If no response then switch to a torch and shine light towards his eye, if still can not see
and the pupil is dilating then the patient is blind.
Repeat with the other eye.

d/D
‫م و المقام متغير حسب حدة النظر‬6 ‫البسط يكون ثابت‬
6/6 = normal = the object can be seen along 6m distance.
 Visual Field
A- Peripheral Visual Field B- Central Visual Field C- Blind Spots

Position:
1- Same level as patient (both sitting or both standing same level)
2- Eye on same level as patient eye
3- Closing the opposite eye of the patient’s closed eye
4- Focus his eye on my eye
and vice versa.

Peripheral Visual Field

(Confrontation method)
1- Sit in front of the patient at
1m distance
2- Ask him to look directly
into your eye and cover
one eye.
3- Cover your eye that is in
front of the patient’s
covered eye (the opposite).
4- Extend your arm from each
corner and wiggle your
finger as you move your
arm diagonally toward the
center and ask the patient
to say “yes” when he sees
your finger each time.
5- Repeat with the other eye.

1- Right Monocular Blindness

2- Bitemporal Homonymous Hemianopia
3- Left Homonymous Hemianopia
4- Left Superior Homonymous
Quadrantanopia
5- Left Homonymous Hemianopia
6- Left Inferior Homonymous Hemianopia
7- Left Homonymous Hemianopia with
Macular Sparing
Central Visual Field (Red ball pin test)
1- Repeat the first 3 steps
2- Using the red shiny hat pen, place it in the middle between yours & the patient’s open
eyes
3- Ask weather he sees the red color of the pen as pink or pale which means color
desaturation.
4- Compare what you saw with that of the patient and repeat for the other eye.
Normally → he will see it as clearly (the same) as you see it
If he has a defect → he will say when you put in the center it becomes blurred.

For blind spots (area that the optic nerve enters the optic disc)
Scotoma (area in the visual field that lacks photoreceptors ‘rods & cons’)
1- Same as before
2- Start moving the pin horizontally then vertically and with each movement, ask the
patient if he sees the red ball or not.
Normally → it should disappear and appear for me and the patient at the same time.
If → it disappears and stayed not visible for him while I can see it
It means → enlargement of the blind spots → increased intracranial pressure.

Physiological (exit of the optic nerve) Pathological

Normally, the physiological scotoma is formed Increased intracranial pressure causes

15 degree on the temporal part of each eye. papilledema which increase the diameters of the
blindspots

The Retina composed of

Cones Rods

Responsible for color vision Responsible for white and black vision

Tested by (red pin test) Tested by (white pin test)

For central vision because retina rich in For peripheral vision because retina
cones in central part rich in rods in peripheral part

For detection of blind spot

Red pin test is useful in 2 conditions:

1- Papilledema
Its sign of increased intracranial pressure →causing enlargement in blind spot
Causes:
A- Inflammatory process
B- Brain tumor
C- Subarachnoid hemorrhage Congestive optic disc could be
D- Idiopathic intracranial hypertension due to papilledema and optic
neuritis (both cause
2- Optic neuritis enlargement of optic disc)
Its inflammation of optic nerve, divided into:
A- Papillitis: inflammation of head of optic nerve.
B- Retro-bulbar neuritis: inflammation of optic nerve.
Causes:
1- Demyelination in optic nerve as in multiple sclerosis → central scotoma
2- Post-viral infection (most common cause)

Papilledema Optic neuritis

1- signs & symptoms of increase ICP 1- usually unilateral not bilateral
a- Headache (pain usually)
b- Projectile vomiting
c- Nausea
d- Bilateral not unilateral

Headache is the prominent

presenting feature
2- predominant on affected eye →
On examination: especially on eye movement
a- Enlargement of blind spot
b- Constriction of visual field

Visual acuity relative to papilledema

3- visual acuity will be affected
If not treated will lead to secondary
optic atrophy
Color Vision
It can be tested by using Ishihara test (chart)
If this chart isn’t present → we use normal colors (red,
blue, green) and this is called color desaturation test

If the patient is unable to identify real color, this

condition is called red desaturation due to optic nerve damage

Most common cause of chromatopsia (a visual defect in which colored objects appear unnaturally
colored and colorless objects appear tinged with color) is:
a- night blindness
b- color desaturation
c- congenital red green blindness (x-linked congenital disease affecting 7% of males)

Fundoscopic examination by ophthalmoscope

• We check optic disc →normally )‫(لونه برتقالي اصفر حوافه كلش واضحة‬

• Optic disc swelling  disrupted margins ‫(اذا كان لونه احمر فاقع) و‬

‫اذا بالجهتين‬

‫ اسمه‬papilledema (bilateral optic disc swelling)

In increased ICP (brain tumor)

• Primary optic atrophy  )‫ (اذا كان لونه ابيض و صغير و الحواف موجودة‬chalky

In increased pressure on Optic nerve (tumor) ex. Optic glioma or untreated papillitis

NB:

secondary optic atrophy occur when papilledema is left untreated. (sequalae)

Primary optic atrophy occur when papillitis & optic neuritis is left untreated.
(sequalae)
 CN III: Oculomotor CN IV: Trochlear CN VI: Abducens
Nerve Nerve Nerve

Motor → Responsible for Eye Movement (Ocular Motility)

All the muscles of the eye are

1- Superior Oblique by 2- Lateral Rectus by Abducens
supplied by Oculomotor nerve
Trochlear nerve nerve
Except:

The Oculomotor nerve also

have parasympathetic
innervation that enable
pupillary constriction (Pupil
constriction) and
accommodation

Muscles of the eye

1- Recti Muscles
A- Superior Rectus → Upward
B- Inferior Rectus → Downward
C- Lateral Rectus → Outward (away from nose)
D- Medial Rectus → Inward (towards nose)

2- Oblique Muscles
A- Superior Oblique → Inward – Downward
‫مع اتجاه الخشم و عكس اتجاه االسم‬
B- Inferior Oblique → Outward – Upward
‫عكس اتجاه الخشم و عكس اتجاه االسم‬
How to examine these Nerves?

1- Inspection (4 Ps)

It could be:
A- (complete or partial)
B- (unilateral or bilateral)

It is examined from behind above the patient, any abnormal bulging of one or both eyes is
considered proptosis. We also can examine each eye separately from the side.

1- Allergic eye disease

2- Thyroid eye disease
3- Orbital Cellulitis
4- Angioedema
5- Cavernous sinus disease
 C- : we ask the patient to look at
distant point and we check to see weather
both pupils are symmetrical or asymmetrical
If they are asymmetrical:
a- Miosis (constriction)
b- Mydriasis (Dilatation)
(3-5) normal size

1- Drugs (Morphine) 1- 3RD nerve palsy

2- Horner Syndrome 2- Trauma
3- Aging 3- Anticholinergic
4- Organophosphorus poisoning

D- we see are they symmetrical or asymmetric

Check for squint and if it is intortion or extortion. ‫حول‬
NB: Asymptomatic, no symptoms of diplopia.

Notes:
1- Partial ptosis + fluctuation in symptoms (normal in morning & abnormal in evening)
Ddx = myasthenia gravies

2- Partial ptosis + small size eye ball + anhidrosis → ddx = horner syndrome
(mnemonic: horner is a guy, who’s forehead is dry, who has a small eye and can’t see the sky)

3- Bilateral ptosis → in young age as in 5 year old → congenital cause

The rest of it → usually asymptomatic

4- Partial ptosis + eyeball deviation downward and inward + pupil dilated → 3rd nerve injury
2- Ocular Motility (Movement of the eye)
Check for:
A- Eye movement
B- Nystagmus
C- Diplopia

To check for A & B (H-shape test)

At 30cm from the patient, use a pen or your index finger and ask the patient to follow it
with only his eyes (without moving his head, you can fix his head in place by other hand)
as you draw H-shape from the center

Nystagmus (Involuntary oscillatory

jerky movement of the eye)
Direction of nystagmus:

1- Vertical
2- Horizontal
3- Rotational

Nystagmus has 2 phases: Causes:

A- Slow phase 1- Brainstem
B- Rapid phase 2- Cerebellum
3- Vestibular nerve

• Cerebellar lesion that cause nystagmus are found in same side of fast phase.
• Vestibular lesion that cause nystagmus are found away from the fast phase.

right ‫ جانت باتجاه العي‬rapid phase‫يعن اذا ال‬

‫ي‬
either the patient has:
Right cerebellar lesion
Or Left vestibular lesion
 The most common cause is Vestibular Nystagmus

Peripheral Central
Horizontal, Vertical or Rotational One direction only
Accompanied with vertigo Less accompanied
Common causes: Common causes:
a- Vestibular a- Multiple sclerosis
b- Neuritis b- Cerebrovascular disease
c- Meniere disease

Diplopia (Double vision)

Cover & Uncover test: ask the patient to close one eye and check for double vision
to localize the defected eye.

3- Reflexes (Light & Accommodation)

Light reflex:
A- Direct: refers to constriction of the pupil on ipsilateral side (same eye)
B- Indirect: refers to constriction of the pupil on contralateral side (other eye)

Optic nerve → ‫يجيب من العين االيعاز مال ضوة‬

Oculomotor nerve →‫يودي للعين االيعاز مال ضوة‬

oculomotor 2 ‫ يروح لل‬optic tract ‫و بما انو كل‬

nuclei

Oculomotor nerve both pupils will constrict = light reflex ‫فاذا اسوي‬

‫ اثنينها‬optic tract ‫ تنطي لل‬nuclei ‫الن‬

Accommodation Reflex
Ask the patient to look for a distance and then look to a close object or my
finger as I move it closer to his nose.
We should notice:
A- Bilateral Ptosis
B- Bilateral Miosis
C- Eyes convergence (conversion)

3rd Nerve Palsy Horner’s syndrome (small eye)

Upper eye lid Upper + lower eye lid
Mostly Complete Partial only
Large pupil Small pupil

If surgical cause is what effecting the oculomotor

nerve → pupil usually effected

If medical cause is what effecting the oculomotor

nerve → pupil usually not effected
CN V: Trigeminal Nerve
The Trigeminal nerve is divided into:
A- Ophthalmic branch (V1)
B- Maxillary branch (V2)
C- Mandibular branch (V3)

The Trigeminal nerve have 3 functions to

look for:
A- Sensory
1- Ophthalmic = Upper border of the upper
eye lid and above
2- Maxillary = Upper lip and above
3- Mandibular = Upper lip and below
NB: Angle of the mandible supplied directly
by C2.

B- Motor
Mandibular branch only supplies the following muscles: (mastication)
1- Temporalis muscle (Elevates and retracts mandible at temporomandibular joint to
close jaw)
2- Masseter muscle (action of mastication)
3- Pterygoid muscle (Medial & lateral)
a- Lateral (Protrude mandible, side to side movement of mandible)
b- Medial (elevates mandible, closes jaw, helps lateral pterygoids in moving the jaw
from side to side)

C- Reflexes
a- Jaw jerk reflex
b- Corneal reflex
1- Sensory Examination
‫الزم نجيب دبوس و قطنة‬
To examine touch:
• Ask the patient to close both eyes
• Touch the face by coton in each area from each branch and on both sides
• Ask him where he feels the touch

To examine pain:
• Same but with a fine needle but only one touch each time

If there is loss of sensation → Trigeminal Neuropathy

Causes of Trigeminal Neuropathy

1- Tumor in cerebellopontine angle region (tumor between cerebellum &
pons) → lead to loss sensation in trigeminal sensory suppling area of
face.
2- Multiple Sclerosis
3- Cavernous sinus thrombosis (syndrome)

2- Motor Examination
a- Temporalis muscle & masseter muscle: ask to firmly close the mouth (clinging)
‫ صك سنونك‬and feel the muscle bilaterally .

b- Lateral pterygoid muscle: put my hand along the lower jaw and ask the patient to
stabilize his head and try to push my hand by the jaw only ‫(بهاي الطريقة نفحص العضلة‬
)‫بالجهة المعاكسة لاليد‬

c- Medial pterygoid muscle: (crt & lt) by asking the patient to push my hand (which
I put below his lower jaw) downward without moving the head.
3- Reflexes Examination
Corneal Reflex
• patient should be in sitting position
‫نكوله باع ليكدام و اجيب قطعة قطن نظيفة صغية‬
And we ask him to look to the other side
‫و أحاول اطخ منطقة البي‬
Cornea and sclera called → Corneal scleral junction of limbus

Ophthalmic (V1)

So according to the picture → normally there should be bilateral

blinking.

Causes of loss of Corneal Reflexes: (‫كشمولة‬.‫)د‬

1- cerebellopontine tumor
2- Multiple Sclerosis
Jaw Jerk Reflex
‫نضب بالهمر عىل اصبع‬ ‫الزم نكول للمريض افتح حلكك شوية و من ر‬ Finger over the mentum (midline
‫مو دايركتىل ر‬
‫تضب الزم من فوك لجوة ويه الجاذبية‬ of mandible)
‫ي‬
Normally → either absent or just present minimally

Abnormal → Brisk (exaggerated) jaw jerk → sudden clinging → ‫يطلع صوت‬

‫مسموع مال طكة السنون‬

‫ اليمنى و اليسرى‬nuclei‫ يعني الكورتكس اليمنى تنطي لل‬nuclei ‫ تنطي لكل‬cortex (rt,lf) ‫الن كل‬
‫ اليسرى راح يعوض اليمنى و كذا‬cortex‫فاذا مضروب ال‬

bilateral cortical lesion (UMNL) <-- brisk jaw jerk ‫فاذا صاير‬

NB: In quadriparesis Afferent → Mandibular

To see weather the cause is bilateral UMNL
(exaggerated reflex) or LMNL (absent or just Efferent → Mandibular
present reflex which is normal)

Bulbar Palsy Pseudo-Bulbar Palsy

LMNL of lower cranial nerves UMNL of lower cranial nerves
(9,10,11,12) (9,10,11,12)
No jaw jerk Brisk Jaw Jerk
Dysphagia Dysphagia
Dysphonia ((Nasal, breathy) Dysphonia (Heavy, Spastic)
Dysarthria (‫بالحج‬
‫ي‬ ‫)يتلعثم‬ Dysarthria
No Emotional Liability Emotional Liability
Absent Gag Reflex Exaggerated Gag Reflex
Causes: Causes: (UMNL)
A- Motor neuron disease A- Multiple trauma
B- Myasthenia Gravis B- Multiple stroke
C- Gillian barre syndrome C- Motor neuron disease
D- Multiple Sclerosis
CN VII: Facial Nerve
Motor and Special Sense

Steps of Examination:
1- Inspection: look for symmetry in the face in the following:
a- Forehead Wrinkles
b- Palpebral Fissure (opening of the eyes)
c- Naso-labial fold
d- Angle of the mouth

2- Motor: examine the following:

a- Frontalis: ask the patient to look upward without moving the
head (wrinkles) ‫يرفع حواجبه‬

b- Orbicularis oculi: ask the patient to strongly close your eyes,

normally, the eye lashes will be buried deep, if you see that
one side of the eye lashes easily visible this means weakness in
the muscle,
Also ask the patient to prevent us from opening his eyes by my
fingers.

c- Buccinator: ask the patient to puff out his cheeks, then gently
push against his cheeks.
Normally the patient should be able to maintain air inside the
cheeks.

d- Orbicularis oris: (& buccinator) ask the patient to either blow

air or whistle.‫اخىل يضحك‬ ‫ر‬
‫و همي ي‬

e- Mentalis & Platysma: ‫عادة ما ينفحصون بس اذا نريد نفحصه نكوله باوع‬
!! ‫ليفوك كانو دتبوس السكف‬
 f- ‫عال اكو خلل‬
‫واحج (اهمس) إذا سمع ي‬
‫ي‬ ‫اج من وراه‬
‫ي‬
(Hyperacusis) → because stapedius muscle is supplied by
facial nerve)

3- Special Sense
The facial nerve supplies the taste of the anterior The posterior 1/3 is supplied by
glossopharyngeal CN IX
2/3 of the tongue. (4 tube method sweet, salty,
sour, bitter).

Facial nerve palsy

Upper Motor Neuron Lesion Lower Motor Neuron Lesion

Only lip (only lower ½ of face) Lip + eye (whole side of the face)

The lesion is contralateral to the The lesion is ipsilateral to the effected

effected side side

Causes: Causes
1- Brain tumor 1- Facial palsy (bell’s palsy)
2- Stroke 2- Herpes Zoster virus (HZV)
Bilateral: Gullian barre, 3- Ramsey Hunt syndrome
sarcoidosis, CP tumor

Facial nerve has

Upper nucleus → upper ½ → Bilateral nerve innervation from both cortex

Lower nucleus → Lower ½ → Unilateral contralateral nerve innervation

If UMNL ‫بجهة‬
Upper ½ of the face ‫راح تعوضه الجهة الخ‬
Lower ½ of the face ‫ مراح يتعوض الن‬unilateral contralateral
and there is no ipsilateral supply

NB: contralateral
‫ هو المضوب‬left facial nerve ‫من تنضب الجهة اليمن معناها ال‬
CN VIII: Vestibulocochlear Nerve
Sensory
The Vestibulocochlear nerve has 2 branches:

1- Cochlear branch → Responsible for hearing

A- Whispering test
B- Webber’s test
C- Rinne’s test

2- Vestibular branch → Responsible for equilibrium

A- Oculo-cephalic reflex (Doll’s eye maneuver)
The patient must be in lying position
‫و ندور راسه عىل اليمن و اليرسى‬
Normally
‫من اقلب راسه عىل اليمن = عيونه تقلب عىل اليسار‬
‫من اقلب راسه عىل اليسار = عيونه تقلب عىل اليمن‬

But abnormally (1)

‫اذا اقلب راسه عىل اليمن = عيونه تقلب يمن‬
‫و اذا اقلب راسه عىل اليسار = عيونه تقلب يسار‬

This indicate Nuclear lesion of vestibular branch of CN VIII

in pons of brainstem

Abnormally (2)
‫اذا ما تحركت العي نهائيا‬

This indicate Deep coma + Lesion appear in cerebral

hemisphere

B- Caloric Test
a- ‫ ماي بارد‬+ ‫داف‬
‫نجيب ماء ي‬
b- :‫ درجة و نحقن شوية يف االذن راح نالحظ‬45 ‫المريض يكون متمدد‬

Abnormal jerky oscillatory rhythmic movement (involuntary) of eye

ball which is called (Nystagmus)
 Normally
‫ئ‬
‫الداف‬ ‫يف حالة حقن الماء‬ ‫يف حالة حقن الماء البارد‬
Nystagmus ‫راح يصي‬ Nystagmus ‫راح يصي‬
‫ يف نفس جهة الحقن‬Rapid phase ‫ عكس جهة الحقن‬Rapid phase
(R=R,L=L) (R=L,L=R)
Warm water → Nystagmus with Cold water → Nystagmus on
same site of inoculation opposite site of inoculation

But if there is no Nystagmus at all

Indicate Vestibulocochlear nerve injury

CN IX: Glossopharyngeal CN X: Vagus Nerve
Nerve
Motor + Sensory + Autonomic Sensory + Motor + Autonomic

Dysphonia → ‫خلل بالصوت‬

How to examine those both disease?
Dysarthria → ‫خلل بالكالم‬

1- Speech: talk with the patient to notice Dysphonia or Dysarthria.

Dysarthria: A- Nasal speech → LMNL → Bulbar palsy.
C- Spastic speech (hot potato speech) → UMNL → Pseudo-bulbar palsy.

2- Swallowing Water: ask him to drink cup of water Dysphagia

Nasal Reaggregation
Check if he )‫(يغص او يطلع يم من خشمه‬ Reaggregation

3- Cough: ask the patient to cough and assess the cough

A- Bovine cough: occur due to Recurrent laryngeal nerve injury (branch of Vagus n.)
B- Weak (non-powerful) cough: occur due to both nerves injury

4- Uvula & Palate: ask him to open his eye and say ahhhh and with tongue depressor
check uvula & palate.
Uvula: Palate:
A- Centrally located (normal) A- Move up & down (normal)
B- Deviated to either side B- Or abnormal (weak)
(abnormal)

When uvula deviates to the right

side, it means the lesion is on the
left side

Uvula deviate to the normal side

5- Gag Reflex: by tongue depressor ‫نفوته جوة عىل‬ Afferent → Glossopharyngeal nerve. ‫يستلم‬
‫ اليمن وراها عىل اليرسى‬post pharyngeal wall Efferent → Vagus nerve ‫يسوي الرفلكس‬

Glossopharyngeal nerve responsible for

sensation of posterior pharyngeal wall
a- Normal ‫يريد يزوع‬
b- Absent gag reflex → LMNL → Bulbar palsy
c- Exaggerated gag reflex → UMNL → Pseudo-bulbar palsy

6- Sensation of posterior pharyngeal wall: by pointed edge of tongue depressor

A- Intact sensation
B- No sensation → Glossopharyngeal nerve injury

CN IX injury
Absent gag
CN X injury
reflex
both

If sensation of (ppw) is normal → normal intact CN IX (so with this) → it’s a vagus nerve injury (CN X)

But if sensation is absent

CN IX injury
CN X injury
both

‫ بس‬absent gag reflex → vagus

‫ بس‬sensation ‫ → ماكو‬glossopharyngeal
Absent gag reflex & sensation ‫ → ماكو‬glossopharyngeal or both

Causes of CN IX, CN X injury Causes of tongue Causes of tongue

1- UMNL wasting& atrophy in LMNL spasticity in UMNL
2- Stroke 1- Motor neuron disease 1- Stroke
3- Tumor 2- Tumor in nerve & its
4- LMNL nucleus
5- Myasthenia Gravis Causes of LMNL Causes of UMNL
6- Gillian barre syndrome 1- Motor disease 1- Stroke
7- Motor neuron disease causing 2- Myasthenia Gravis 2- Tumor
L&UMNL
CN XI: Accessory Nerve
Motor
The accessory nerve has two parts:
A- Spinal part → supplying Trapezius & Sternocleidomastoid.
B- Cranial part → supplying intrinsic muscles of larynx (involuntary)

How to examine: (only spinal part)

1- Trapezius Stand behind the patient
a- Inspect for muscle wasting or asymmetry
b- Ask to shrug/elevate the shoulder while you apply downward
pressure on them

2- Sternocleidomastoid stand in front of patient

c- Inspect both muscles for wasting or hypertrophy
d- Palpate the muscles
e- Assess the power of each one by placing hand on the right side of his
face and ask to push your hand with his head (testing the left muscle)
f- Repeat with the other side to assess the right one (just like lateral
pterygoid)
NB: contraction of both SCM at the same time will cause the head to tilt
downward

Damage to the CN XI occur in:

1- Surgery in posterior triangle of the neck
2- Local invasion by tumor
3- Penetrating injuries
CN XII: Hypoglossal Nerve Fasciculation = it’s abnormal
Motor involuntary contraction of a group
Examination: of muscles fibers → lead to
1- Inspection: ‫يفتح حلكه بدون ميطلع لسانه و‬ involuntary movement → can be
seen by naked eye → indicates
‫نشوف باستخدام التورج اللسان‬
LMNL )‫(حركة دودية‬
a- Wasting
b- Wrinkles (atrophy) (LMNL) It’s always pathological in the
c- Fasciculation (LMNL) tongue but can be normal in other
d- Spasticity (UMNL) parts

2- Movement: ‫طلع لسانك‬

a- Normal (straight forward).
b- Deviated to one side.
• In LMNL → it deviates to the affected side (same side of lesion)
• In UMNL → it deviated to the contralateral side (opposite side of lesion)

3- Assess power (by putting hand against cheek and ask him to push it by tongue)

UMNL LMNL
1- Spasticity 1- Wasting (atrophy) + Fasciculation
2- Tongue deviate to opposite side 2- Tongue deviate to same side of lesion
of lesion (contralateral) (R=L , L=R) (Ipsilateral) (R=R , L=L)
3- A- Stroke above nucleus 3- A- Tumor in nucleus or nerve
B- Tumor above nucleus B- Motor neuron disease (ALS)

wrinkles

fasciculation
wasting

Deviation