CRANIAL NERVE

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CRANIAL NERVES ANATOMY&EXAMINATION: 

CRANIAL NERVES ANATOMY&EXAMINATION DR.TAMIL MANI V JUNIOR RESIDENT MEDICAL UNIT-5 GNDH ASR DR.TAMIL MANI V JUNIOR RESIDENT MEDICAL UNIT-5 GNDH ASR CRANIAL NERVES ANATOMY&EXAMINATION

The cranial nerves: 

The cranial nerves 12 in number Are part of the peripheral nervous system All exit the cranial cavity through foramina or fissures All originate from the brain except cranial nerve 11( Accessory nerve) Contain sensory, motor or both components

Slide 3: 

-special sensory components are associated with hearing, seeing, smelling, balancing and tasting -special motor components include those that innervate muscles derived from the pharyngeal arches

Slide 5: 

Functional Component Abbreviation General function Cranial nerve General Somatic Afferent GSA Touch, Pain and Temperature 5,7 &10 General Visceral Afferent GVA Sensory from Viscera 9 & 10 Special Afferent SA Smell, Taste, Vision, Hearing and Balance 1,2,7,8,9 & 10

Slide 6: 

Functional component Abbreviation General function Cranial nerves General Somatic Efferent GSE Motor Innervations to skeletal (voluntary) muscles 3,4 6 & 12 General Visceral Efferents GVE Motor innervations to smooth muscle, heart muscle and glands 3,7,9 &10 Brachial Efferent (SVE) BE Motor innervation to skeletal muscles from pharyngeal arch 5,7,9,10 &11

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In utero, 6 pharyngeal arches are designated but the 5 th never develops Each pharyngeal arch is associated with a developing cranial nerve or its branches

Slide 8: 

1 st arch- CN 5 (V 3 ) 2 nd arch- CN 7 3 rd arch- CN 9 4 th arch- Superior Laryngeal Branch of CN 10 6 th arch- Recurrent Laryngeal Branch of CN 10

Slide 9: 

Olfactory nerve-CN I Carries special afferents (SA) for smell Peripheral processes act as receptors in the nasal mucosa Receptors are located in the roof and upper parts of the nasal cavity Central processes return information to the brain Central processes enter cranial cavity through the Cribiform plate of ethmoid Terminate by synapsing with neurons in the olfactory bulb Lesions result in ANOSMIA

EXAMINATION OF CN-1: 

EXAMINATION OF CN-1 See the nasal passage Avoid ammonia-it stimulates trigeminal N Bed side soap,coffee. Each nostril tested seperately,compare it Perception is important than idenification Perception-indicates intact olfactory pathway Identification-pathway+cortical function b/l innervation-lesion in olfactory cortex does not produce anosmia

DISORDER OF SMELL: 

DISORDER OF SMELL ANOSMIA HYPOSMIA HYPEROSMIA DYSOSMIA PAROSMIA CACOSMIA

Causes of anosmia: 

Causes of anosmia Common-URI,Trauma,nasal& sinus Menigioma in sphenoidal ridge Menigioma in olfactory groove cause foster kennady syndrome. Pseudo foster-ant optic nerve ischemia Cacaine use,smoking Vit –B6,B12,A Head injury Degenerative –alzhemier,parkinsons

Cont….: 

Cont…. Depression Hysterical-use ammonia Kallman syn-hypo gonad,anosmia

Hyper osmia: 

Hyper osmia Functional Substance abuse Migrane Olfactory hallucinations UNCINATE FITS-focus in medial temp lobe

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Optic nerve-CN II Special afferents for vision Returns information from photoreceptors in the retina to the brain Optic nerve enter the cranial cavity through the optic canals Lesion leads to anopsia and loss of light reflex

Examination of CN-2 : 

Examination of CN-2 Visual acuity distant – snellen’s chart near – Jaegar Pin hole

Cont…: 

Cont… Visual field temp – 100 nasal – 60 sup – 60 inf – 70 Confrontation method Perimetry – goldmann – most accurate Automated perimetry

Cont…. : 

Cont…. Colour vision – ishihara chart [pseudo isochromatic plates] Swinging light reflex FUNDUS EXAMINATION

Oculomotor nerve- CN III : 

Oculomotor nerve- CN III

Oculomotor nerve- CN III : 

Oculomotor nerve- CN III Moves the eyeball in all directions Adduction is the most important action Constricts pupil (sphincter papillae) Accomodates (ciliary muscle) Raises eyelids (LPS)

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Oculomotor nerve- CN III Carries 2 types of fibers GSE innervating most of the extra ocular muscles (LPS,SR,IR,MR,IO) GVE part of the parasympathetic part of Autonomic Nervous System -synapse in the ciliary ganglion (pupillary constriction and accommodation) Exits the cranial cavity via the lateral wall of the cavernous sinus through the superior orbital fissure Lesion involves ptosis, external strabismus etc

Examination of CN - 3: 

Examination of CN - 3 Ptosis Size of pupils Light reflex direct consensal Accomodation reflex argyll robertson pupil reverse Ocular movements intra nuclar – ipsi 3, contro 6

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Trochlear nerve CN IV GSE to Superior Oblique muscle Enters the orbit via the lateral wall of the cavernous sinus Abducent nerve-CN VI GSE –Lateral Rectus in orbit Crosses the cavernous sinus as it enters the orbit through the superior orbital fissure Lesion- internal strabismus

VI NERVE PALSY: 

VI NERVE PALSY

Trigeminal nerve CN V : 

Trigeminal nerve CN V

Trigeminal nerve CN V : 

Trigeminal nerve CN V General sensory of the head, motor innervation to muscles that move the lower jaw GSA-sensory input from the face, the scalp, mucous membrane of oral and nasal cavity ,PNS, part of the TM, eye and conjunctiva, dura mater in the anterior and middle cranial fossa

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2 roots- Large sensory - small motor Expands into a Trigeminal ganglion in the middle cranial fossa 3 divisions -V 1 -V 2 -V 3

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Ophthalmic nerve (V 1 ) exits the cranial cavity into the orbit via the lateral wall of the cavernous sinus and superior orbital fissure Sensory from the eyes, conjunctiva and orbital contents including the lacrimal gland

Slide 43: 

Maxillary nerve Exits the cranial through foramen rotundum Sensory branches from anterior and middle cranial fossa, nasopharynx, palate, nasal cavity, teeth of the upper jaw, maxillary sinus, skin of the side of the nose, lower eyelid, cheek, upper lip

Slide 44: 

Mandibular nerve Exits skull through foramen ovale Motor root of CNS also exits through foramen ovale and unites with the sensory component of V 3 outside the skull Only division that contains a motor component Motor fibers innervate muscles of mastication, tensor tympani, anterior belly of digastric

Slide 45: 

Sensory fibres from the skin of the lower face, cheek lower lip, ear, external auditory meatus and temporal region, anterior two thirds of the tongue , teeth of the lower jaw, teeth of the lower jaw, mastoid air cells, mucus membrane and dura in the middle cranial fossa Lesion involves loss of sensation, weakness in chewing, Jaw deviation towards the affected side, Trigeminal neuralgia

Examination of CN-5: 

Examination of CN-5 Sensory v1,v2,v3 Motor masseter,temporal jaw deviates to same side reflex corneal jaw jerk

SENSORY: 

SENSORY

R L palsy: 

R L palsy

Slide 51: 

Complete Trigeminal Nerve Lesion Stimulate involved eye Direct- Absent Consensual- Absent Stimulate opposite eye Direct- Normal Consensual- Normal Complete Facial Nerve Lesion Stimulate involved eye D- Absent C- Normal Stimulate opposite eye D- Normal C- Absent

Slide 53: 

Facial nerve- CN VII Carries GSA,SA,GVE and BE GSA-sensory input from ext auditory meatus and small skin posterior to the ear SA- taste from anterior two thirds of the tongue

Slide 57: 

GVE-parasympathetic part of Autonomic Nervous System -stimulate secretomotor activity in the lacrimal gland, submandibular and sublingual glands, mucus membranes of the nasal cavity, hard and soft palates BE-muscles of the face, scalp, stapedius, posterior belly of the digastric and stylohyoid muscles 2 roots- Large motor - Smaller sensory (the intermediate nerve)

Slide 58: 

Intermediate nerve contains SA (taste), GVE (parasympathetic) and GSA Large motor root contains the BE fibres Both roots exit the posterior cranial fossa through the internal auditory meatus and fuse within the facial canal (petrous part of the temporal bone) →facial nerve Expands into the geniculate ganglion Greater petrosal nerve →preganglionic parasympathetic Nerve to stapedius and chorda tympani in the facial canal

Slide 59: 

Exits the skulls through the stylomastoid foramen Chorda tympani carries taste (SA) fibres from the anterior two thirds of the tongue and preganglionic parasympathetic (GVE) to the submandibular ganglion.

Examination of CN -7: 

Examination of CN -7 MOTOR SENSORY Taste sweet,salt sour, bitter SECRETORY Schirmer’s test Nasolacrimal reflex Salivation REFLEX C orneal Stapedial

Vestibulocochlear nerve-CN VIII: 

Vestibulocochlear nerve-CN VIII SA for hearing and balance 2 divisions -vestibular component for balance -cochlear component for hearing

Examination of CN- VIII: 

Examination of CN- VIII Auditory by use of human voice conversational voice 20 ft whispering 10 ft Watch test Tuning fork test Rinne’s – AC>BC –Normal, sensorineural BC>AC – Conductive Weber – normal- no lateralisation lat to normal ear – sensory ABC[Schwabach test]

Cont….: 

Cont…. Audiometric tests 1] Pure tone audiometry high tone loss- sensory low tone loss – conductive 2]speech discrimination audio VIII nerve tumor 3]Loudness recruitment cochlear 4]Tone decay <15 – normal >20 - sensory

Objective hearing test: 

Objective hearing test Impedence measurement amount of sound reflected from tympanic membrane BRAINSTEM EVOKED RESPONSE AUDIOMETRY

Vestibular function: 

Vestibular function Fistula sign Oculocephalic reflex Positional vertigo CALORIC TEST Head elevated to 30 lat cc to vertical fix central gaze 30 and 44 c 30-40 sec normal – cold – opp warm – same[COWS]

Slide 68: 

Glossopharyngeal nerve CN (IX) carries GVA, SA, GVE, and BE fibers: GVA fibers provide sensory input from the carotid body and sinus, posterior one-third of the tongue, palatine tonsils, upper pharynx, and mucosa of the middle ear and pharyngotympanic tube; SA fibers are for taste from the posterior one-third of the tongue; GVE fibers are part of the parasympathetic part of the autonomic division of the PNS and stimulate secretomotor activity in the parotid salivary gland BE fibers innervate the muscle derived from the third pharyngeal arch (the stylopharyngeus muscle)

Slide 69: 

Tympanic nerve: branch from CN IX within the jugular foramen Forms part of the tympanic plexus within the middle ear cavity Contributes GVE which leaves tympanic plexus in the lesser petrosal nerve carrying preganlionic parasympathetic fibres to the otic ganglion → parotid

Slide 71: 

Ganglion Input CN origin of preganglionic fibers Function Ciliary CN III CNIII sphincter papillae and ciliary muscles Pterygopalatine Greater petrosal n CN VII Lacrimal gland and mucus glands of nasal cavity PARASYMPATHETIC GANGLIA OF THE HEAD

Slide 72: 

Ganglion Input CN origin of preganglionic fibres Function Otic Lesser petrosal n CN IX Parotid gland innervation Submandibular Chorda tympani to lingual n to submandibular ganglion CN VII Submandibular and sublingual glands

CRANIAL NERVE-X: 

CRANIAL NERVE-X

Slide 75: 

Vagus nerve- CN X carries GSA, GVA, SA, GVE, and BE fibers: GSA fibers provide sensory input from the skin posterior to the ear and the external acoustic meatus; GVA fibers provide sensory input from the aortic body chemoreceptors and aortic arch baroreceptors, and the mucous membranes of the pharynx, larynx, esophagus, bronchi, lungs, heart, and abdominal viscera in the foregut and midgut; SA fibers are for taste around the epiglottis

Slide 76: 

GVE fibers are part of the parasympathetic part of the autonomic division of the PNS and stimulate smooth muscle and glands in the pharynx, larynx, thoracic viscera, and abdominal viscera of the foregut and midgut; BE fibers innervate one muscle of the tongue (palatoglossus), the muscles of the soft palate (except tensor veli palatini), pharynx (except stylopharyngeus), and larynx. Lesion- dysphagia, hoarseness, uvula points away from the affected side, loss of gag and cough reflex, Horner's syndrome

Slide 78: 

Accessory nerve-CN XI BE fibres to the sternocleidomastoid and trapezius muscles Roots arise from the motor neurons in the upper 5 segments of the cervical spinal cord Turns head to opposite side/elevates and rotates scapula Lesion- shoulder droop, weakness turning head to opposite side

Slide 81: 

Hypoglossal nerve- CN XII GSE- Intrinsic and most extrinsic muscles of the tongue Exits the cranial cavity through the hypoglossal canal Supplies the hyoglossus, styloglossus, genioglossus and all the intrinsic muscles of the tongue Lesion causes tongue to point towards affected side See the bulk , fibri,strength

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THANK YOU