Chris Evans

Describe the origin, course, function, relevant pathology and integrity tests of cranial nerves 7-12

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Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal

Olfactory Optic Occulomotor Trochlear Trigeminal Abducent

Begins as 2 roots leaving brainstem laterally between the pons and medulla oblongata

Large motor root small sensory root

(intermediate nerve)

Facial nerve leaves brainstem between pons and medulla oblongata on lateral sides
Pons

Medulla oblongata

1. 2.

Crosses posterior cranial fossa Enters internal acoustic meatus

Internal acoustic meatus

Passes through facial canal in temporal bone 4. Exits through stylomastoid foramen
3.

Mastoid process

Stylomastoid foramen

Gives off greater petrosal nerve at the geniculate ganglion

Carries parasympathetic fibres to lacrimal gland

Gives nerve to stapedius

Stapedius dampens excessive movement of stapes protects against excessive noise

Gives chorda tympani

joins with lingual nerve (from mandibular nerve), provides parasympathetic input to submandibular and sublingual salivary glands carries taste sensation from anterior 2/3 of tongue

Posterior auricular branch supplies posterior auricular muscle and occipital belly of occipitofrontalis

Facial Canal Motor root Greater petrosal nerve Nerve to stapedius Sensory root Facial Nerve Geniculate Ganglion Stylomastoid Foramen Chorda tympani

Posterior auricular branch

Facial Nerve

5.

Enters parotid gland, splits into 5 terminal motor branches

Temporal Zygomatic Buccal Marginal mandibular Cervical

Innervates all muscles of facial expression and anterior+posterior auricular muscles Innervates stylohyoid, posterior belly of digastric and stapedius muscles

Facial nerve is restricted inside bony facial canal, and is vulnerable to compression if infection causes inflammation of the nerve Damage to facial nerve may cause loss of taste, inability to salivate and paralysis of facial muscles
Peripheral damage to facial nerve causes ipsilateral (same side) paralysis, damage to facial nerve in CNS casuses contralateral (opposite side) paralysis

Ask patient to make a series of different facial expressions

Make sure all muscles are used and function correctly

Enquire about sense of taste, mouth dryness and lacrimation

Wrinkle forehead
Blow out cheeks

Close eyes against resistance

Bear teeth

Consists of vestibular and cochlear nerves that leave the brainstem laterally between the pons and medulla oblongata The vestibular and cochlear join very soon after leaving brainstem and enter the internal acoustic meatus

Vestibulocochlear nerve leaves brainstem between pons and medulla oblongata on lateral sides, just below facial nerve

Pons

Medulla oblongata

1. 2.

Crosses posterior cranial fossa Enters internal acoustic meatus

Internal acoustic meatus

3.

Splits into vestibular and cochlear nerves

Cochlear nerve carries auditory information

Forms spiral ganglion which connects to parts of the cochlear Forms vestibular ganglion which connects to parts of the vestibule

Vestibular nerve carries balance information

Internal acoustic meatus Cochlear nerve Vestibulocochlear nerve

Cochlear nerve

Vestibular nerve

Vestibular nerve

Internal acoustic meatus Cochlear nerve Vestibulocochlear nerve

Cochlear nerve

Vestibular nerve Facial Canal Motor root

Vestibular nerve

Greater petrosal nerve Nerve to stapedius

Chorda tympani

Sensory root Facial Nerve Geniculate Ganglion

Posterior auricular branch Facial Nerve

Stylomastoid Foramen

Damage to the cochlear nerve can produce ringing in the ears (tinnitus) or impairment of hearing Damage to vestibular nerve can produce dizziness and balance loss (vertigo) Central damage to CNVIII can produce a combination of symptoms

Conductive deafness problem with ear prevents sound reaching cochlear (often middle ear inflammation) Sensorineural deafness problem with cochlea/cochlear nerve prevents nerve signals to brain

Rinne test place a tuning fork on the mastoid process, and then next to ear
Second position should be louder identifies conductive hearing loss Failure to hear either position shows sensorineural hearing loss

Weber test place a tuning fork in middle of forehead

Should be heard equally in both ears Detects unilateral hearing loss

Begins on lateral aspect of medulla oblongata as several rootlets, join in jugular foramen

1. 2.

Crosses posterior cranial fossa Enters jugular foramen

Jugular foramen

3.

Forms the superior and inferior ganglia around jugular foramen

Follows stylopharyngeus, terminates in oropharynx

4.

Supplies stylopharyngeus muscle Supplies parasympathetic fibres to parotid gland

Conveys taste sensation from posterior 1/3 of tongue

Recieves information from carotid body (chemoreceptor) and carotid sinus (baroreceptor)

Recieves sensory information from posterior 1/3 of tongue Sensory from oropharynx (tonsils, soft palate, back of throat) Sensory from tympanic cavity, pharyngotympanic tube and internal surface of tympanic membrane

Isolated lesions of CNXI are uncommon

Instead damage usually around jugular foramen and affect multiple nerves (jugular foramen syndrome)

Lesions produce loss of taste and some problems swallowing

Gag reflex often lost

Absent in 1/3 of healthy people

Touch arches of pharynx, test sensation

Inquire about swallowing ability

Check gag reflex
Stimulate back of tongue and oropharynx with tongue depressor

Begins on lateral aspect of medulla oblongata below CNXI as several rootlets, join in jugular foramen

1. 2.

Crosses posterior cranial fossa Enters jugular foramen

Jugular foramen

3.

Forms a superior and inferior ganglion below jugular foramen Continues inferiorly in carotid sheath

4.

5.

Give left and right recurrent laryngeal branches Right loops around right subclavian artery

Left loops around aortic arch

Receives sensory input from:

external auditory canal skin posterior to ear dura mater of posterior cranial fossa

Supplies all muscles of larynx Supplies pharyngeal muscles

Except stylopharyngeus

Supplies muscles of soft palate

Except tensor velli pallatini

Supplies parasympathetic motor fibres to many thoracic and abdominal viscera Receives sensory input from viscera including chemoreceptors and baroreceptors in aortic arch

Lesion causes deviation of palate towards unaffected sided

Muscles on healthy side have no opposition

Recurrent laryngeal branch lesions can cause hoarseness of the voice and difficulty speaking

Can cause tachycardia and cardiac arrhythmias

Check for palatal deviation Check ability to swallow

Have you had anything to drink today?

Listen to patients voice, inquire as to any change

Listen for hoarseness, weakness, loss

Begins as rootlets from motor neurones of upper 5 segments of spinal cord

1. 2.

Ascends into cranial cavity, crosses posterior cranial fossa Enters jugular foramen

Jugular foramen

3.

Descends along carotid artery Receives sensory input from cervical plexus C2-4 Reaches sternocleidomastoid and trapezius

4.

5.

Provides motor input to sternocleidomastoid and trapezius

Trapezius elevates and depresses shoulders, and retracts scapula Sternocleidomastoid rotates head and flexes neck

Carries sensory information from SCM and trapezius

Relative superficial position near jugular vessels means it is susceptible to injury during surgical procedures Damage produces weakness of SCM and trapezius

Ask patient to shrug shoulders and turn head against resistance

Begins on lateral aspect of medulla oblongata as several rootlets

1. 2.

Crosses posterior cranial fossa Enters hypoglossal canal Hypoglossal canal

3.

Receives motor and sensory fibres from C1-2 Passes medial to angle of mandible, turns to reach tongue

4.

Innervates all intrinsic muscles of tongue, and all extrinsic muscles excluding palatoglossus Supplies infrahyoid muscles
Sternohyoid Sthernothyroid Omohyoid

Meningeal branch returns to cranium through hypoglossal canal and innervates dura in posterior cranial fossa

Injury to hypoglossal nerve paralyses the ipsilateral half of the tongue

Causes atrophy on damaged side

Unopposed action of genioglossus causes deviation towards damaged side

Genioglossus protrudes tongue

Examine tongue for wasting and fasiculations

Small involuntary twitches

Damage causes deviation towards damaged side Deviation always caused by unopposed muscle action!!