CRANIAL NERVES

dr. Ika Marlia, M.Sc, Sp.S

Bagian Neurologi FK UNSYIAH/RSUD
Dr Zainoel Abidin Banda Aceh
 Introduction

 There are 12 cranial nerves which pass to and from the

brain through foramina and fissures in the skull.

 All cranial nerves are distributed in head and neck except

the Vagus (10th) which extends down to supply other
structures in the thorax and the abdomen.

 Cranial nerves are either sensory, motor or mixed and they

have central nuclei situated in the brain stem.
THE FOLLOWING IS A SUMMARY OF THE CRANIAL NERVES
& THEIR RESPECTIVE FUNCTIONING
 I - Smell
 II - Visual acuity, visual fields and ocular fundi
 II,III - Pupillary reactions
 III,IV,VI - Extra-ocular movements, including
opening of the eyes
 V - Facial sensation, movements of the jaw, and
corneal reflexes
 VII - Facial movements and gustation
 VIII - Hearing and balance
 IX,X - Swallowing, elevation of the palate, gag reflex
and gustation
 V,VII,X,XII - Voice and speech
 XI - Shrugging the shoulders and turning the head
 XII - Movement and protrusion of tongue
MOTOR NUCLEI
 Receive impulses from cerebral cortex
through the corticobulbar fibers.
 Originate from the precentral
gyrusdescend through the corona
radiatagenu of internal capsule 
motor nuclei.
 The majority cross to the other side before
reaching the motor nuclei.
 Bilateral connections are presents for all
nuclei except for part of facial nucleus.
SENSORY NUCLEI
 1storder neuron cells found in special
ganglia or in sensory organs (nose, eye, or
ear).
 Cells in sensory nuclei are considered 2nd
order neurons.
 Axons from sensory nuclei cross the
midline and synapse with other sensory
nuclei and the thalamus.
 Axons from these other sensory nuclei
ascend to reach the cerebral cortex
forming the 3rd order neurons.
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OLFACTORY NERVE (I)
 Origin: starts from the olfactory receptor
cells in the mucous membrane of the upper
part of nasal cavity.

 Pathway: olfactory receptor cells 

cribriform plate of ethmiod bone  olfactory
bulb olfactory tract  divide to Medial and
Lateral olfactory striae. Medial striae cross to
the other bulb while Lateral continues to
reach the cortex.
Note: Unlike other sensations, only 2 order
neurons and no synapse with the thalamus.
 HOW TO EXAMINE?

 Nasal passages are patent.

 Patient is given different substances put in
similar bottles and asked if he smells
anything. If yes then what.
 Each nostril should be examined separately.
 Irritant substances and ammonia should not
be used, WHY?
DYSFUNCTION
 Loss of smell sensation is called ANOSMIA.

What causes anosmia?

Bilateral (most cases):
Basal skull fracture, congenital (Kallmann’s
syndrome), smoking, aging, Parkinson’s disease
and tumors.

Unilateral:
Head trauma without a fracture, early
meningioma of the olfactory groove.
OPTIC NERVE (II)
 Origin: starts at the retina by the axons of
ganglion cells. These receive impulses from
the photoreceptors (rods and cones).
 Pathway: Optic verve > chiasma > optic
tract > lateral geniculate body > optic
radiation > primary visual cortex.

 Notes:
 Optic radiation fibers pass through the
posterior part of the internal capsule.
HOW TO EXAMINE?
 Things to be examined are:
1. Visual Acuity and color.
2. Visual field.
3. Fundi.
4. Pupils.

1) Visual acuity:
By Snellen’s chart or hand-held eye chart. A defect in
acuity can be caused by any lesion from the eyeball till
the cortex.

Note: acuity must be examined with the corrected

vision (glasses!).
2) Visual Fields:
By confrontation. Glasses should be removed.
Ask the patient to look in your eyes.
Visual Inattention?

Nasal fields, each eye should be examined separately.

Patient right eye to the examiner left eye and vice versa.
More accurate test is the Goldmann Perimeter.
 Possible field defects:
Field defect Common causes
Tunnel vision Glucoma, papilledema, syphilis
Central scotoma Demyelination, toxicity, nutritional
Bitemporal hemianopia Chiasma lesion (pituitary tumor)
Homonymous hemianopia Optic tract or radiation (vascular)
Upper quadrant HH Temporal lobe lesion
Lower quadrant HH Parietal lobe lesion
3) FUNDUS EXAMINATION:
 Examine the right eye with your right eye
and vice versa.
 Start from 30 cm away and approach
gradually till 2 cm from the patient eye.
 Examine the optic disc for: color, edge, and
central cup.
4) Pupil examination:
 Look for: size, shape, equality, and reflexes.
 Senile miosis and anisocoria are normal
findings.
 Reflexes abnormalities could be due to
optic or oculomotor defects.
OCULOMOTOR NERVE (III)
 It has 2 motor nuclei:

1) The main oculomotor nucleus:

 Present in midbrain – superior
colliculus level.
 From both hemispheres.
 In connection with the nuclei of 4th, 6th,
and 8th nerves.
 Outgoing fibers pass through red
nucleus and supply extraocular all
muscles except 2 muscles. Also supplies
eyelid openers (ptosis)!
OCULOMOTOR (III) CONT’D:

2) Edinger-Westphal nucleus:
 Parasympathetic nucleus.
 Receive fibers from corticobulbar for
accommodation reflex and from
pretectal nucleus for the direct and
consensual light reflex.
 Afferents join other fibers from the
main nucleus and reach the ciliary
ganglion (presynaptic).
TROCHLEAR NERVE (IV)
 Its nucleus is situated in the midbrain –
inferior colliculus level.
 Corticobulbar fibers from both hemispheres.

 Connected with 3rd, 6th, and 8th cranial

nuclei.
 Enters the orbit through superior orbital
fissure.
 Supplies the superior oblique muscle.
ABDUCENT NERVE (VI)
 Its nucleus is situated in the pons.
 Corticobulbar fibers from both hemispheres.

 Connected to 3th, 4th and 8th cranial nuclei.

 Efferent fibers pass through the cavernous

sinus.
 Enters the eyeball through superior orbital
fissure.
 Supplies lateral rectus muscle.
EYE REFLEXES AND MOVEMENTS
 Light Reflex:
 Direct and consensual.
 Afferent: optic nerve  chiasma tract
pretectal nucleus  Edinger-Westphal
nuclei of both sides.
 Efferent: Edinger-Westphal nucleus 
oculomotor fibers  ciliary ganglion 
short ciliary nerve  constrictor papillae.
 Abnormalities:
 1- Holmes-Adie pupil? ciliary ganglion.
 2- Marcus Gunn pupil? due to RAPD.
 Accommodation Reflex:
 A.k.a near response.
 3 components: convergence of the ocular
axis, lens thickness increases, and pupil
constriction.
 Afferent: optic nerve  visual cortex.
 Efferent: visual cortex  frontal eye field 
Main 3rd nerve nucleus and Edinger-
Westphal nuclei of both sides.
 Abnormalities:
 Argyll Robertson pupil?
 pretectal nucleus lesion.
 Mainly due to Syphilis and DM. Rarely multiple
sclerosis.
 Eye movements:
 Controlled by extraocular muscles as
follow:
 Abducent (VI): lateral rectus  lateral movement.
 Trochlear (IV): superior oblique  downward
medially.
 Oculomotor (III): All other muscles.

 Note: Abducted eye  recti muscles.

Adducted eye  oblique muscles.

- Testing:
- H pattern moving finger.

- Diplopia.

- Nystagmus.
 CRANIAL NERVES III, IV AND VI

 Instruct the patient to follow

the penlight or opthalmoscope
with their eyes without
moving their head.
 Move the penlight slowly at
eye level, first to the left and
then to the right.
 Then repeat this horizontal
sweep with the penlight at the
level of the patient's forehead
and then chin.
 Note extra-ocular muscle
palsies and horizontal or
vertical nystagmus.
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TRIGEMINAL NERVE (V)
 It’s the largest cranial nerve.
 It has 4 nuclei:
 Main sensory: posterior part of pons.
 Mesencephalic: In the midbrain. Extends down
to MS.
 Spinal: continuation of MS, extends from the
pons till C2.
 Motor: In the pons medial to MS.

Note: 1  Touch and pressure.

2  Propioception.
3  Pain and temperature.
4  receives corticobulbar fibers from
both sides.
TRIGEMINAL DIVISIONS
 Starts from the pons  run over temporal
lobe.
 It forms the Trigeminal (Gasserian) ganglion
that gives the 3 divisions:

 Ophthalmic: runs in cavernous sinus with the 3rd nerve.

Supplies the skin of forehead, cornea and conjunctiva.

 Maxillary: Emerges from the infraorbital fissure. Supplies

skin in maxillary area, mucous membranes of the upper
mouth, palate and nasopharynx.

 Mandibular: Runs along with the motor part emerging

through foramen ovale. Supplies skin over the jaw and
mucous membranes of lower mouth.
 Motor fibers supply muscles of mastication.
TRIGEMINAL EXAMINATION:
 Corneal reflex: touch cornea with a cotton
wool from the side  blinking of both eyes.
Efferent fibers  facial (7th ) nerve.

 Facial sensation: examine for : light touch,

temperature, dull and sharp pain.

 Motor examination: examine the masseter

and temporal muscles when clinching.
Examine the jaw jerk.
 CRANIAL NERVE V

 First,palpate the masseter muscles while you

instruct the patient to bite down hard.
 Also note masseter wasting on observation.
 Next, ask the patient to open their mouth
against resistance applied by the instructor at
the base of the patient's chin

32
 Next, test gross sensation of the trigeminal
nerve. Tell the patient to close their eyes
and say "sharp" or "dull" when they feel an
object touch their face.
 Allowing them to see the needle before this
examination may alleviate any fear of
being hurt.
 Using the needle and brush from your
reflex hammer or the pin from a safety pin,
randomly touch the patient's face with
either the needle or the brush.
 Touch the patient above each temple, next
to the nose and on each side of the chin, all
bilaterally.
 Ask the patient to also compare the
strength of the sensation of both sides. If
the patient has difficulty distinguishing
pinprick and light touch, then proceed to
check temperature and vibration sensation
using the vibration fork.
 One may warm it or cool it under a
running faucet.

33
  Finally, test the
corneal reflex
using a large Q-
tip with the
cotton extended
into a wisp.
 Ask the patient to
look at a distant
object and then
approaching
laterally, touch
the cornea (not
the sclera) and
look for the eye to
blink.
 Repeat this on
the other eye.
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 Special clinical presentations:
 Cavernous sinus aneurysm: tumor or thrombosis
causing ophthalmic division palsy + 3rd, 4th, and 6th.

 Dissociated sensory loss: loss of pain but touch is

preserved.

 Trigeminal neuralgia: paroxysmal attacks, severe

stabbing pain, more in 2nd & 3rd divisions, trigger spot,
more in females, over 50 yrs.
FACIAL NERVE (VII)
 It has 3 nuclei:
 Main motor nucleus:
 In the reticular formation of lower pons.

 Upper face muscles  both hemispheres.

 Lower face  contralateral corticonuclear fibers.

 Parasympathetic nuclei:
 Superior salivatory and lacrimal nuclei.

 SS receives from hypothalamus and solitary tract

nucleus.
 Lacrimal receives from hypothalamus & 5
th nerve

nucleus.
 Sensory Nucleus:
 Afferents from Geniculate ganglion, taste
fibers.
 Efferents cross to reach thalamus &
hypothalamus.
 Thalamus  internal capsule corona
radiata  cortex (lower part of post-central
gyrus.

 Facial Nerve pathway:

 2 roots: Sensory root (direct) and motor root ( hooks
around 6th nucleus).
 The nerve emerges anteriorly between pons and
medulla.
 Travels with 8th nerve and enters the internal
acoustic meatus.
 Then through the facial canalinner ear forms the
geniculate ganglion  emerges through stylomastoid
foramen.
 Functions:
 Motor: muscles of facial expression and
stapedius.
 Parasympathetic: nasal, lacrimal,
submandibular and sublingual salivatory
glands.
 Sensory: taste from ant. 2\3 of the tongue.

 Examination:
 Symmetry: forehead, nasolabial, mouth
corner.
 Look up, Close your eye, show your teeth
and whistle.
 Taste examination.
 Bell’s phenomenon!
  Initially, inspect the face during
CRANIAL NERVE VII conversation and rest noting any
facial asymmetry including
drooping, sagging or smoothing of
normal facial creases.
 Next, ask the patient to raise their
eyebrows, smile showing their teeth,
frown and puff out both cheeks.
 Note asymmetry and difficulty
performing these maneuvers.
 Ask the patient to close their eyes
strongly and not let the examiner
pull them open.
 When the patient closes their eyes,
simultaneously attempt to pull
them open with your fingertips.
 Normally the patient's eyes cannot
be opened by the examiner. Once
again, note asymmetry and
weakness.
40
  When the whole side of the
face is paralyzed the lesion
CRANIAL NERVE VII is peripheral.
 When the forehead is
spared on the side of the
paralysis, the lesion is
central (e.g., stroke).
 This is because a portion of
the VII cranial nerve
nucleus innervating the
forehead receives input
from both cerebral
hemispheres.
 The portion of the VII
cranial nerve nucleus
innervating the mid and
lower face does not have
this dual cortical input.
41
Triple W Sign - Wrinkle, Wink, Whistle
facial motor nucleus neurons
supplying forehead muscle
Bilateral Corticobulbar Tract
 Clinical presentations:

 UMNL: preservation of the upper part of the

face. Due to vascular lesion or tumor,
supranuclear.

 LMNL: complete half of the face.

Causes include: Bell’s palsy, Ramsay Hunt
syndrome, otitis media, acoustic neuroma,
vascular lesion, multiple sclerosis.

 Bilateral facial weakness: Guillain Barre`

syndrome.

 Unilateral loss of taste: middle ear lesion

involving chorda tympani.
VESTIBULOCOCHLEAR NERVE (VIII)
A. Vestibular Nerve:
Pathway:
• Starts from: utricle and saccule  head
position.
• Semicircular canal  head movement.
• Vestibular fibers  V. ganglion  join
the auditory fibers in facial canal 
reach V. Nuclear complex.
 Vestibular Nuclear complex:
• (lat., med., sup. and inf.).
 Afferents: Vestibular nerve and
cerebellum.
Efferents

Ascend Descend Cerebellum C.Nuclei

Vest. Area in Vestibulo- Through 3rd, 4th

post-central gyrus Spinal tract ICP and 6th
(uncrossed)
VESTIBULAR EXAMINATION:

1) Nystagmus:
 Uncontrollable rhythmic oscillations of the eyes.
The fast phase away from lesion.
2) Romberg’s test:

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 If unable to stand even with open eyes, may be
due to vestibular dysfunction.
3) Caloric test:
 Induces convection in the endolymph. Findings
can be:
 Canal paresis or Directional preponderance
4) Hallpike’s maneuver:
 Differentiates between peripheral (b.p.v) and
central vestibular syndromes.
HALLPIKE’S MANEUVER
B. COCHLEAR NERVE:

Pathways:
• Starts from organ of Corti in cochlea.
• Cochlear fibers  spiral ganglion  C.
fibers run in facial canal  Cochlear
nuclei.

Cochlear Nuclei:
• 2 nuclei, post. and Ant.
• Afferents: from trochlear nerve.
• Efferents: Cross to trapezoid body &
olivary nucleus  lateral lemniscus 
inferior colliculus or medial geniculate
body  auditory cortex.
COCHLEAR EXAMINATION:
1) Whispering:
 Each ear separately. High and low Frequency.
 If reduced hearing, proceed.
2) Rinne’s test:
 256 Hz tuning fork on mastoid then in front of
ear.
3) Weber’s test:
 256 Hz fork on the vertex of head. Which side is
louder?

Type of deafness Rinne’s test Weber’s test

Conductive BC > AC Better of deaf ear
Sensory-neural AC > BC Better on good ear
CRANIAL NERVE
 Assess hearing by instructing
VIII the patient to close their eyes
and to say "left" or "right"
when a sound is heard in the
respective ear.
 Vigorously rub your fingers
together very near to, yet not
touching, each ear and wait
for the patient to respond.
After this test, ask the
patient if the sound was the
same in both ears, or louder
in a specific ear.
 If there is lateralization or
hearing abnormalities
perform the Rinne and Weber
tests using the 256 Hz tuning
fork.

52
 The Weber test is a test for

lateralization. Wrap the
tuning fork strongly on your
palm and then press the
CRANIAL NERVE VIII butt of the instrument on
the top of the patient's head
in the midline and ask the
patient where they hear the
sound.
 Normally, the sound is
heard in the center of the
head or equally in both ears.
If their is a conductive
hearing loss present, the
vibration will be louder on
the side with the conductive
hearing loss. If the patient
doesn't hear the vibration at
all, attempt again, but press
the butt harder on the
patient's head.

53
CRANIAL NERVE VIII  The Rinne test compares
air conduction to bone
conduction.
 Wrap the tuning fork
firmly on your palm and
place the butt on the
mastoid eminence firmly.
 Tell the patient to say
"now" when they can no
longer hear the vibration.
 When the patient says
"now", remove the butt
from the mastoid process
and place the U of the
tuning fork near the ear
without touching it.

54
  Tell the patient to say "now" when they
can no longer hear anything. Normally,
one will have greater air conduction than
CRANIAL NERVE VIII bone conduction and therefore hear the
vibration longer with the fork in the air.
If the bone conduction is the same or
greater than the air conduction, there is
a conductive hearing impairment on that
side. If there is a sensineuronal hearing
loss, then the vibration is heard
substantially longer than usual in the air.
Make certain that you perform both the
Weber and Rinne tests on both ears. It
would also be prudent to perform an
otoscopic examination of both eardrums
to rule out a severe otitis media,
perforation of the tympanic membrane or
even occlusion of the external auditory
meatus, which all may confuse the
results of these tests. Furthermore, if
hearing loss is noted an audiogram is
indicated to provide a baseline of hearing
for future reference.
Because of the extensive bilateral
connections of the auditory system, the
only way to have an ipsilateral hearing
loss is to have a peripheral lesion, i.e. at
the cranial nerve nucleus or more
peripherally. Bilateral hearing loss from
a single lesion is invariably due to one
55 located centrally.
GLOSSOPHARYNGEAL NERVE (IX)
Origin and pathway:
 It has 3 nuclei:
 1- Main motor: receives from both hemispheres and
supplies the stylopharyngeus muscle.
 2- Parasympathetic: a.k.a inferior salivatory nucleus.
In connection with the olfactory and solitary tracts.
Supplies the parotid gland.
 3- Sensory: Receive from the mucous membranes of
pharynx, , middle and inner ear and post. 1\3 of
tongue.
 (Carotid sinus, leaves through jugular foramen,
lesser petrosal and otic ganglion.).
VAGUS NERVE (X)
Origin and pathway:
 It has also 3 nuclei:
 Main motor: Receives from both hemispheres.
Supplies constrictors of the pharynx and intrinsic
muscles of larynx ( via recurrent).
 Parasympathetic: Receives from the hypothalamus
and Glossopharyngeal. Supplies involuntary muscles
of internal organs. (distal 1\3 of colon).
 Sensory: receives sensation from mucous
membranes of larynx, pharynx, tympanic membrane
and external ear. (postcentral gyrus, vagus descends
within carotid sheath, with IJV and carotid).
IX & X NERVE EXAMINATION:
1) Uvula examination:
 Uvula position, deviates towards the normal side.
 Say “ah”, normal moves upward and backward.
2) The Gag reflex:
 Afferent: IX nerve, Efferent: X nerve.
 Done on both side.
 Inspect for contraction. Also the uvula!
 Most common cause of reduced gag ref. is old age.
3) Coughing and swallowing:
 Delay in swallowing.
 Bovine cough.
 Hoarseness of voice.
ACCESSORY NERVE (XI)
 The central portion of this nerve arises
in the medulla.
 The spinal portion arises from the upper
five cervical segments.
 It leaves the skull with the 9th and 10th
nerves through jugular foramen.
 Its central division gives motor fibers to
vagus nerve.
 The spinal division innervates the
trapezius & sternomastoid muscles.
ACCESSORY NERVE EXAMINATION:

 Shrug his/her shoulder.

 Feel the bulk of trapezius
muscle.
 Then ask the patient to turn
his/her head against
resistance (examiner’s hand).
 Also feel the muscle bulk of
the sternomastoids.
HYPOGLOSSAL NERVE (XII)

 The nerve arises from the medulla.

 It leaves the skull via the hypoglossal foramen.

 It’s the motor nerve for the tongue.

 HYPOGLOSSAL NERVE EXAMINATION:

 Inspect the tongue.

 Look for wasting &
fasciculations.
 Ask patient to poke out
his/her tongue.
HYPOGLOSSAL NERVE EXAMINATION
CONT’D:
 It has bilateral upper motor neurone
innervation.

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 Combination of bilateral upper motor
neuron lesions of the ninth IX, tenth X
and twelfth XII nerves called
pseudobulbar palsy.
 A LMN lesion of the twelfth XII nerve
causes fasciculation, wasting and
weakness, as well as dysarthria if the
lesion is bilateral.
CAUSES OF TWELFTH NERVE PALSY:
 Bilateral UMN lesions:
may be due to
-vascular lesions
-motor neurone disease
-tumours
 Unilateral UMN lesion:
may be due to
-vascular lesions such as thrombosis
-motor neurone disease
-aneurysm
-tumours
-trauma
-congenital malformation
-chronic meningitis
 Bilateral LMN lesions:
may be due to
-motor neurone disease
-Gullian-Barre syndrom
-poliomyelitis
????
TERIMA KASIH
SEMOGA BERMANFAAT