SEMINR ON CRANIAL NERVES

(ANATOMY AND PHYSIOLOGY)

LIYA SOLOMON
APRIL,14,2014
OUTLINE
• Anatomy & physiology of :
- Olfactory nerve
- Oculomotor nerve
- Trochlear nerve
- Trigeminal nerve
- Abducens nerve
- Facial nerve
• Clinical evaluation
• Nerve lesions
Introduction
• paired sets of nerves whose constituent fibers
enter (or exit)the central nervous system above
the level of the foramen magnum.
• of the 12 pairs of cranial nerves, all but two—the
olfactory and optic, have their nuclei in the
brainstem.
• Oculomotor and trochlear exit from the
midbrain
• The trigeminal enters and leaves at the pontine level.
• the abducens , facial , and vestibulocochlear are
found at the pontomedullary junction
• glossopharyngeal , vagus , and hypoglossal are
located farther down the medulla.
• accessory nerve has cells of origin both in the
medulla and cervical cord
Cranial Nerve I (Olfactory N)
• Originates from small olfactory receptors in the
mucous membrane of the nose
• Unmyelinated CN I fibers pass through the
cribriform plate of the ethmoidal bone and enter
the ventral surface of the olfactory bulb
• The olfactory tract runs posteriorly from the
bulb, beneath the frontal lobe of the brain in a
groove and lateral to the gyrus rectus to the
primary olfactory cortex
Cranial Nerve III (Oculomotor)

• Arises from a complex group of cells in the

rostral midbrain
• Largest of the ocular motor nerves (24,000
axons)
• Motor supply to all the extraocular muscles
except the superior oblique and the lateral
rectus.
• Carries cholinergic innervation to the pupillary
sphincter and the ciliary muscle.
• Four paired subnuclei supplying innervation to
the inferior, medial, and superior rectus muscles
and to the inferior oblique muscle.
• Single caudal, dorsal midline nucleus providing
innervation to the levator muscle.
• Edinger-Westphal nuclei supply the
parasympathetic preganglionic neurons that
project to the ciliary ganglion.
• Except for superior rectus muscle, Innervation of
the extraocular muscles from the paired nuclei is
ipsilateral.
•  The fascicles pass through the medial
longitudinal fasciculus, the red nucleus, and the
medial portion of the cerebral peduncle and
through the corticospinal fibers.
• passes below the posterior cerebral artery and
above the superior cerebellar artery in the
subarchinoid space.
• Aneurysms commonly occur at the junction of
the PCA and ICA.
• pierces the dura, runs along the lateral wall of
the cavernous sinus and above CN IV to enter
the orbit through the superior orbital fissure in
the annulus of Zinn
• divides into superior division(SR, LP) and larger
inferior division(MR,IR,IO)
• parasympathetic fibers enter the inferior
division, join the ciliary ganglion
• postganglionic fibers emerge as many short
ciliary nerves to innervate the pupillary
sphincter and the ciliary muscle
• superficial location of these fibers makes them
more vulnerable to compression than to
ischemia.
Lesions of the Oculomotor Nerve
• classic symptoms include diplopia with
strabismus, failure of adduction, inability to
elevate the eye, ptosis, dilated pupil, and
difficulty focusing on near objects.
• affected eye will be shifted slightly laterally
downward at rest
• a nuclear lesion may result in bilateral weakness
of the superior rectus muscles
Cranial Nerve IV (Trochlear)
• The only cranial nerve to exit dorsally from the
brainstem
• The only cranial nerve that fully crosses the
midline (decussates) after leaving its nucleus
• The longest of the ocular motor nerves(75cm),
fewest nerve fibers (frequently injured in closed
head trauma)
• The only ocular motor nerve that does not pass
through the annulus of Zinn
• The nerve nucleus is located in the caudal
mesencephalon
• continuous with the caudal end of the CN III
nucleus and differs histologically
• decussate completely in the superior medullary
velum and exit the brainstem just beneath the
inferior colliculus
• Swings around the midbrain, paralleling the
tentorium just under the tentorial edge ,(injured in
neurosurgical procedures involving tentorium)
• Passes around the cerebral peduncles, penetrating
the dura to reach the cavernous sinus.
• Enters the posteriolateral aspect of the
cavernous sinus just underneath CN III and run
forward within the lateral wall
• Crosses over CN III to enter the superior orbital
fissure runs superiorly to innervate the superior
oblique muscle.
 Lesions of the Trochlear Nerve

• Patient complains of double vision in situations

requiring movements to adduct the eye and at the
same time to look down
• The involved eye is higher (hypertropic) when pt looks
straight ahead which worsens when looking in the
direction of uninvolved eye or tilting the head toward
the ipsilateral shoulder
• Head tilt toward the unaffected side in order to
compensate for the diplopia
 Cranial Nerve V (Trigeminal)
• The largest cranial nerve
• Contains both a sensory and a motor root.
• Nuclear complex extends from the midbrain to
the upper cervical segments and consists of 4
nuclei
Mesencephalic Nucleus
• Cell bodies lie within the central nervous system
• Mediates proprioception and deep sensation
from the masticatory, facial, and extraocular
muscles
Main Sensory Nucleus
• Lies in the pons, lateral to the motor nucleus.
• Serves light touch from the skin and mucous
membranes.
• The sensory root of CN V, upon entering the
pons, divides into ascending tract(MSN) and a
descending tract (SN)
Spinal Nucleus and Tract

• Extend through the medulla to C4.

• The nucleus receives pain and temperature
afferents from the descending spinal tract,
• also carries cutaneous components of CN VII. CN
IX, and CN X that serve sensations from the ear
and external auditory meatus.
• sensory fibers from the
 ophthalmic division of CN V (V,) terminate in the
most ventral portion
 maxillary division (V,) end in the midportion
 mandibular division (V,) end in the dorsal parts
• The cutaneous territory of each of the CN V
divisions ("onionskin" pattern)
Fibers of perioral region rostrally
Fibers of midfacial region central
peripheral face and scalp caudal
Axons from the main sensory. spinal, and
portions of the mesencephalic nuclei

cross the midline in the pons

(trigeminothalamic tracts)
thalamus
(internal capsule)
postcentral gyrus
Motor Nucleus
• Medial to the main sensory nucleus in the pons.
• Receives fibers from both cerebral hemispheres,
the reticular formation, red nucleus, tectum,
MLF, and MSN.
• Monosynaptic reflex arc is formed by cells from
the mesencephalic nucleus and the motor
nucleus.
• Axons that form the motor root eventually
supply the muscles of mastication, tensor
tympani, tensor veli palatini, mylohyoid,
anterior belly of the digastric.
• The cell bodies of the sensory portion lie in the
gasserian, semilunar ganglion, with the
exception of those for muscle spindle
information.
• The gasserian ganglion is located in Meckel's
cave near the petrous tip of the temporal bone
just behind internal carotid and posterior
portion of the cavernous sinus.
•  The three sensory divisions of the trigeminal
nerve are the ophthalmic (V1), maxillary (V2),
and mandibular (V3).
• Parasympathetic fibers from CNIII, CN VII, CN IX,
and sympathetic fibers from cervical ganglia
CNV1,
• Within cavernous sinus it gives off a tentorial-
dural branch.
• CN V1 passes into the orbit through the superior
orbital fissure and divides into 3 branches.
 The frontal nerve
• divides into the supraorbital and supratrochlear
nerves, which innervate the medial portion of
the upper eyelid, forehead, scalp, frontal sinus,
and bridge of the nose.
The lacrimal nerve
• supplies the conjunctiva and the skin of the
lateral portion of the upper lid and lacrimal
gland.
 The nasociliary nerve
• Long ciliary nerves and short ciliary nerves
Transmit somatic sensation from iris, cornea, and
ciliary muscle.
Carry sympathetic fibers to iris dilators and ciliary
muscle
parasympathetic fibers to iris constrictors and ciliary
muscle
 Hutchinson's sign
Anterior and posterior ethmoidal nerves
Infratrochlear nerve innervate
-Sphenoid and posterior ethmoid sinuses
- Upper eyelid, caruncle
- Canaliculi and lacrimal sac
- Mucosa of nasal septum
-Inferior and middle turbinates
- Tip and side of nose and
Carry Sympathetic fibers to Müller's ms
CNV2
• exit the skull through the foramen rotundum
• courses through the pterygopalatine fossa into
the inferior orbital fissure,
• then runs through the infraorbital canal as the
infraorbital nerve.
• After exiting the infraorbital foramen, it divides
into
• an inferior palpebral, nasal and a superior labial
branch .
• The teeth, maxillary sinus, roof of the mouth,
and soft palate
CNV3
• exits the skull through the foramen ovale.
• provides motor input for the masticatory
muscles.
• Sensation is supplied to the mucosa and skin of
the mandible, lower lip, tongue, external ear,
and tympanum.
CLINICAL ASSESSMENT
SENSORY FUNCTIONS
 corneal reflex
 cutaneous sensation
MOTOR FUNCTIONS
 palpating the temporal and masseter muscles
as the patient clenches his or her jaw
  jaw opening and lateral movement against
resistance
electromyography
TRIGEMINAL NERVE DYSFUNCTION
• present with loss of function or abnormal
sensation
 brain stem lesion
 dissociation of light touch and pain and
thermal sensation
 other cranial nerves, tracts connecting the
spinal cord will be affected.8
Supranuclear lesions
most often have a wider distribution of
dysfunction than just the face
LOSS OF CORNEAL SENSATION
• cornea is supplied by 60 to 80 nerves that
course radially from the limbus and branch into
over 1000 small axons that terminate as free
nerve endings in the stroma and epithelium.
  compressive lesion of the trigeminal root 
 surgery
 corneal dystrophy
 infection 
Complication Neuroparalytic keratitis 
OCULAR PAIN
• Ocular diseases (Corneal foreign bodies,
epithelial defects or inflammation, iridocyclitis, acute
angle-closure glaucoma, optic neuritis, myositis, and
orbital inflammations )
•  Referred (cervical disease or posterior fossa
masses, Meningeal irritation )
• Disorder of the trigeminal nerves, ganglion, or
root 
• Sjögren's syndrome
• Giant cell arteritis
THE PAINFUL BLIND EYE
•  end-stage glaucoma
• long-standing retinal detachment
• chronic hypoxia
• severe infection or inflammation
• previous trauma
Cranial Nerve VI (Abducens)
• originates in the dorsal caudal pons just beneath
the fourth ventricle.
• surrounded by the looping fibers (genu) of the
facial nerve and is adjacent to the PPRF and the
MLF
• The nucleus contains both primary motor
neurons and interneurons that cross to the
contra lateral MLF to reach the CN III nucleus.
• The fascicle courses ventrally, laterally, and
caudally to emerge at the junction of the pons
and medulla just lateral to the pyramid
•  ascends in the subarachnoid space along the
clivus, passing near the inferior petrosal venous
sinus and then passing beneath petrosphenoid
ligament (Dorello's canal)
• penetrates the dura to enter the cavernous
sinus, located just lateral to the carotid artery
within the substance of the sinus
• In the cavernous sinus, the abducens nerve
combines briefly with the ocular sympathetics
before exiting through the superior ophthalmic
fissure.
• Passes through the annulus of Zinn, positioned
lateral to the optic nerve and medial to the
lateral rectus innervating the muscle.
ABDUCENCE NERVE DYSFUNCTION
• Binocular horizontal diplopia , most pronounced
in the direction of paretic lateral rectus musle
• Involved eye does not turn outward(temporally)
• Etiology
▫ vasculopathic (DM, HTN, atherosclerosis),
traumatic, idiopathic
▫ raised ICP, cavernous sinus mass, multiple
sclerosis, sarcoidosis/ vasculitis
▫ Postviral, Gradenigo’s syndrome
Cranial Nerve VII (Facial)
• Mixed sensory and motor nerve
• The motor root contains special visceral efferent
fibers that innervate the muscles of facial
expression.
• sensory root of (nervus intermedius) which
contains special visceral afferent,general somatic
afferent, and general visceral efferent fibers
• SVA sense of taste from the anterior two
thirds of the tongue to the nucleus of the tractus
solitarius
• GSA sensation from the external auditory
meatus and the retro auricular skin to the spinal
nucleus of CN V.
• GVE preganglionic parasympathetic
innervations by the sphenopalatine and
submandibular ganglia to the lacrimal,
submaxillary, and sublingual glands.
SUPRANUCLEAR SEGMENT
• Input from both pyramidal and extrapyramidal
areas
• Extrapyramidal circuits explain the tight
association of facial movement with emotions
• The cortical area that subserves volitional facial
movement is located in the lower third of the
precentral gyrus
• Crossed and uncrossed fibers descend to the
upper face, whereas only crossed fibers descend
to the lower face
NUCLEAR SEGMENT
• 4 mm long, located in the caudal third of the
pons.
• Ventrolateral to the CN VI nucleus, ventromedial
to the spinal nucleus of CN V, and dorsal to the
superior olive
• Running rostromedially and dorsally, fibers
sweep around CN VI nucleus to form the
internal genu,
• The nerve passes by the superior salivatory
nucleus pick up motor fibers destined for the
submandibular and sphenopalatine ganglia
• The parasympathetic outflow originates in the
superior salivatory nucleus and the lacrimal
nucleus.
• both lie posterolateral to the motor nucleus and
receive afferent fibers from the hypothalamus
and olfactory system.
• The hypothalamic fibers reaching the lacrimal
nucleus mediate emotional tearing and there is
supranuclear input from the cortex and the
limbic system
INFRANUCLEAR SEGMENT
• Cranial nerve VII, the nervus intermedius, and
CN VIII (acoustic) pass together through the
lateral pontine cistern in the cerebellopontine
angle
• enter the internal auditory meatus in a common
meningeal sheath.
• CN VII and the intermedius nerve then enter the
fallopian canal (the longest bony canal traversed
by any cranial nerve, 30 mm).
• divided into 3 segments in its course through
this canal
labyrinthine segment
tympanic segment
mastoid segment.
• preganglionic parasympathetic fibers pass
peripherally as part of the nervus intermedius
divide into 2 groups near the external genu
The lacrimal group of fibers passes to the
pterygopalatine ganglion in the greater
superficial petrosal nerve.
 The salivatory group of fibers projects through
the chorda tympani nerve to the submandibular
ganglion to innervate the submandibular and
sublingual salivary glands
• The CN VII trunk then exits the skull at the
stylomastoid foramen and separates into a large
temporofacial and a small cervicofacial division
between the superficial and deep lobes of the
parotid gland.
• The temporofacial division gives rise to the
temporal. zygomatic. and buccal branches,
• The cervicofacial division is the origin of the
marginal mandibular and colli branches,
• The temporal branch supplies the upper half of
the orbicularis oculi, frontalis. corrugator
supercilii. and pyramidalis muscles
• The zygomatic branch supplies the lower half.
CLINICAL EVALUATION OF FACIAL NERVE
FUNCTION
MOTOR FUNCTION
• View the patient at rest, during emotionally
derived movements, and during volitional facial
movements (drooping of the angle of the mouth
and lower lid, asymmetry of blink)
• Inspect forced closure of the eyes
(lagophthalmos and Bell's phenomenon)
• Look for involuntary facial movements during
volitional movements and with the patient at
rest
SENSORY FUNCTION
Taste- electrogustometry

AUTONOMIC FUNCTION
salivary flow test and Schirmer's test 
Seventh Nerve Disorders
• Supranuclear facial palsy: contralateral
weakness of lower two thirds of the face
• Nuclear facial palsy: facial monoplegia, sixth
nerve nucleus involvement (ipsilateral gaze
palsy) and frequent ataxia, occasional Horner
syndrome
• Cerebellopontine angle: decreased tearing,
dysgeusia, loss of salivary secretion, loss of
taste from anterior 2/3 of tongue, hearing
impairment, nystagmus, vertigo, ataxia, adjacent
CN findings IV, VI)
• Geniculate ganglionitis (Ramsay Hunt
syndrome, zoster oticus): same findings except
without involvement of brainstem and other
cranial nerves
• Fallopian canal: involvement of nerve to
stapedius muscle, dysacusis, involvement of
chorda tympani, loss of taste to anterior 2/3 of
the tongue, impaired salivary secretion
• Distal to chorda tympani: isolated paralysis of
facial muscles
• Distal to branching of seventh nerve after it
leaves stylomastoid foramen: only certain
branches of seventh nerve are affected
Disorders of Underactivity of the Seventh Nerve

Etiologies of Facial Paralysis

• Idiopathic Bell's palsy
• Infections (Herpes zoster,Lyme disease,Acute or
chronic otitis media, syphilis, meningitis,
leprosy, tuberculosis, HIV)
• Pontine infarct or hemorrhage
• Pontine demyelination
• Neoplasms
• Trauma
• Miscellaneous (Congenital,GBS, Sarcoidosis
DM, Vasculitis)
Bell's palsy
• Sudden onset of facial paresis
• Facial numbness, Decreased tearing, diminished
taste, and dysacusis
• etiology is unknown (may be caused by
autoimmune or viral-induced inflammatory or
ischemic injury with swelling of the peripheral
nerve)
• Incidence is higher in pregnant and in patients
with DM or a family history of Bell's palsy
• 85% of patients experience a satisfactory
spontaneous recovery within 3 weeks of onset of
the deficit and is complete by 2-3 months
Poor prognostic signs
 Complete facial palsy at presentation
 Impairment of lacrimation,
 Dysacusis
 Advanced age
  Complications
 Contracture
 Synkinesis
“crocodile tears,”
 hemifacial spasm
Tretment
 close ophthalmologic observation for corneal
exposure and the use of ocular emollients in
patients with a poor or absent blink
Avoid a dusty or Windy environment.
patching or closing the eye with tape at night
Steroids
• Loss of corneal sensation combined with a facial
nerve palsy is a particularly difficult clinical
problem.
• The risk of neurotrophic combined with
neuroparalytic keratitis demands an aggressive
approach that possibly includes early
tarsorrhaphy or gold weight implant.
Disorders of Overactivity of the Seventh
Nerve
• Disorders of the seventh nerve, its nucleus, or
the pyramidal or extrapyramidal pathways may
produce hyperexcitable states.
• Essential blepharospasm, hemi facial spasm, and
facial myokymia are the 3 most common
disorders of overactivity
References
• BCSC Section 2 ,5
• DUANES
• Netter’s Atlas Of Human Anatomy
THANK YOU