‫‪12 cranial nerves‬‬

‫‪Weaam Saif‬‬ ‫ﻣﻦ ﻣﺤﺎﺿﺎرات اﻟﺪﻛ )ٮور ٮ ‪%‬ﺎﺳﺮ‪،‬‬

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 Olfactory Nerve (1) (I)

• Special Somatic Afferent (Sensory) SSA, for small.

• The first-order neuron is bipolar with its cell body in olfactory mucosa, and the
peripheral process of the nerve is ciliated, arising from olfactory receptors.

• The central process of bipolar cells forms 20 non-myelinated bundles (fila

olfactoria) that pass through cribriform plate, dura mater, and arachnoid to
relay in the olfactory bulb.

• The bulbs receive fibers from corresponding half of the nasal cavity .

• Second order cell (mitral cell) originates in lower part of bulb, and Its axon goes
in the olfactory tract which lies in the olfactory sulcus at the inferior surface of
frontal lobe.

• Axon of mitral cells form olfactory stria.

• Olfactory trigone formed from the tract at the

anterior edge of anterior perforated
substance. Trigone divides into medial and
lateral olfactory striae.

• The medial stria passes to the contralateral

side through the anterior commissure.

• The lateral stria passes anterolateral to the

anterior perforated substance and terminates
in gyrus semilunaris (prepyriform cortex).

• Olfaction is a two neuron pathway (others are 3 neurons).

• Olfactory impulses are transmitted directly to cerebral cortex without relay in

thalamus.

• Receptor cell is in itself the first order neuron.

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 Optic Nerve (2) (II)
• Special Somatic Afferent (sensory) SSA

• The sense of vision comes from rods and cones through bipolar cells to ganglion cells of the
retina.

• The axons in the retinal ganglion cells pierce the sclera deep to the optic disk (blind spot).

• Then pass posteromedially in the orbit and exit the orbit through the optic canal
(accompanied with ophthalmic artery).

• Enter the middle cranial fossa, forming the optic chiasma, front of the tubreculum sellae,
anterior to the pituitary stalk.
•
• where the medial fibers of optic chiasma cross and lateral fibers remain uncrossed.

• The meninges and subarachnoid space, filled with CSF, surround the optic nerve, and walk
with the central vein and artery of retina.

• At the optic chiasma, the nasal fibers decussate, and the

nasal fibers from the opposite side join the temporal fibers
of the same side.

• The optic tract contains the fibers from the opposite nasal
field and the same temporal field, extending toward the
lateral geniculate body of the thalamus.

• The optic radiation from the lateral geniculate body carries

the fourth-order neurons, extending to the calcarine sulcus
in the occipital cortex, carrying visual information.

Lesions:

bitemporal
hemianopia homonymous
hemianopia
 Oculomotor Nerve (3) (III)
• General Somatic Efferent (motor) GSE For superior Rectus + Inferior Rectus + Medial Rectus
+ Inferior Oblique + Levator Palpebrae Superioris (LPS).

• General Visceral Efferent (motor) GVE For constrictor Pupillae (sphincter Pupillae) + ciliary
muscles ( parasympathetic).

• Oculomotor nuclear complex: is located in the midbrain Ventral to Aqueduct at level of

Superior Colliculus.

• Parasympathetic fibers : originate in the visceral oculomotor nucleus ( Edinger-Westphal

nucleus) .

• The (III) nerve pierce the dura mater pass through the lateral wall of cavernous sinus then
pass through the Superior Orbital fissure between two heads of lateral Rectus, where divides
into superior & inferior division.

• Superior division supply Levator Palpebrae Superioris + Superior Rectus.

• Inferior division supply MR, IR, IO + carries Parasympathetic fibers to Ciliary ganglion which
Post-ganglionic supply sphincter Pupillae & Ciliary muscles.

• Post-ganglionic symptomatic originated in the superior cervical ganglion to the superior

tarsal muscles.

• Then traveled via the internal carotid plexus, where small branches communicate with
oculomotor nerve as it pass through cavernous sinus.

• Then sympathetic continue with superior division of oculomotor nerve where they inter the
tarsal muscles.

Damage of (III) over the eye by other division of (III) leads to:
1. Eyes looks laterally ( by lateral Rectus), downward ( by superior
oblique), cannot move the eye upward and medially.
2. Ptosis due to Paralysis of LPS (drooping upper lid)
3. Dilated Pupil due to Paralysis of Sphincter Pupillae.
4. Loss of Accommodation ( Paralysis ciliary muscles).
5. Double Vision ( Diapolpia).

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Optic and oculomotor nerve:

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 Trochlear Nerve (4) (IV)
• General Somatic Efferent (motor) to Superior Oblique (SO4).

• Front of the cerebral aqueduct at the level of inferior colliculi.

• The nerve runs dorsally medially to encircle the aqueduct and emerges
below inferior colliculus.

• The nerve decussates and crosses Ventral to Cerebral Peduncles.

Trochlear nerve Palsy:

• Diplopia Inability to rotate the eye infero-laterally.

• eye deviate upward and medially (Slightly).
• Difficultly walking downstairs.
• Asks the patient to look downwards to test nerve.

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 Trigeminal Nerve (5) (V)
• arise from the pons by two roots and has a ganglion (Trigeminal or Gasserian) that lies in the
anterior surface of petrous bone in the trigeminal depression.

• Divided into 3 divisions:

1- Ophthalmic
2- Maxillary
3- Mandibular

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 Abducent Nerve (6) (VI)
• General Somatic Efferent (GSE
motor): Supplies lateral rectus.

• Nucleus lies in the pons, front of the floor of the 4th ventricle.

• Nerve fibers pass emerges in pontomedullary junction.

• enter the cavernous sinus below the internal carotid artery superior orbital
fissure lateral rectus.

• Then: Pierces the dura, lateral to the dorsum sellae.

• Pass inside the cavernous sinus lattice to internal carotid artery.

• Enters the orbit, passing through the superior orbital fissure, between the two
heads of lateral rectus.

• Nerve damage:

• Medial (convergent )strabismus.

• Diplopia, which increases on looking towards the paralyzed side.

• very little abduction by oblique muscles.

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 Fecial Nerve (7) (VIl)

• The facial nerve arises from the pons by two roots: Motor root, Nervus
intermedius which carries sensory and parasympathetic fibers.

• The roots join each others and the facial nerve passes through the internal
auditory meatus on the posterior surface of the petrous bone to reach the
internal ear .where it has a ganglion called the geniculate ganglion.

• Then it passes through the facial canal that extends backwards inside the
middle ear.

• then leave the skull through the stylomastoid foramen.

Branches of the facial nerve during its intrapetrous part:

1 . Greater superficial petrosal nerve (parasympathetic)
2 . Nerve to stapedius muscle in the middle ear.
3. Chorda tympani

Chorda tympani:
• It arises from the facial nerve while lying in the facial canal of the middle ear.
• It enters the cavity of the middle ear through the posterior canaliculus.
• It runs forwards on the inner surface of the drum
• then it emerges the anterior canaliculus.
• Then it leaves the skull through the Petrotympanic fissure. It passes forwards
to reach the infratemporal fossa where it joins the lingual
• It supplies taste sensation to the anterior 2/3 of the tongue and preganglionic
parasympathetic fibers to the submandibular ganglion
1.Supranclear Lesions (UMNL):
• The part of the facial nucleus that controls the muscles
of the upper part of the face receives corticonuclear
fibers from both cerebral hemispheres.
• The lower half of the nucleus is controlled by the
contralateral cortex only.
• So in the upper motor neurons lesion, only the muscles
of the lower part of the face will be paralyzed.

2. (Infranuclear lesions (LMNL):) :

• Inability to close the eye all half of the face. (due to
paralysis of orbicularis oculi).
• Inability to raise the eye brows (due to paralysis of
occipitofrontalis).
• Drooping of the angle of the mouth (due to paralysis
oflevator anguli oris).
• Lesion proximal to or at the internal auditory meatus affects all components.

• Nerve to stapedius and chorda tympani leave the facial canal after the ganglion,
a lesion beyond the geniculate ganglion leads to loss of taste and hyper- acousis.

• Lesion within or just outside facial canal leads to Bells Palsy.

(motor fibers) which could be due to inflammatory,Vascular or
narrowing of the facial canal.

• Accumulation of the food between the gums and cheek and dribbling of saliva
(due to paralysis of buccinator).
• Hyperacusis (due to paralysis of stapedius).
• Loss of sensation over the anterior 2/3 of the tongue.
• Loss of lacrimation (due to injury of greater superficial petrosal nerve)
• Loss of corneal and lacrimation reflexes.
 Vestibulo-Cochlear (8) (VIII)
• It is classified as special somatic afferent SSA

• It is a composite nerve formed of : 1. Cochlear (for hearing) 2. Vestibular (for

equilibrium)

COCHLEAR NERVE:
• It conveys auditory impulses from organ of Corti (in Scala media) .
• Its ganglion (spiral ganglion) lies in the spiral canal of the modiolus
• Its peripheral fibres reach hair cells in organ of Corti.
• Central fibres pass from spiral ganglion, at base of modiolus, with the vestibular
division through internal acoustic meatus to posterior cranial fossa.

• Cochlear division enters pontomedullary junction and is separated from

vestibular division by inferior cerebellar peduncle.
• Nerve enters cochlear nuclei (ventral and dorsal) ( 2nd order neuron).
• Ventral nucleus lies in the ventral side of inferior cerebellar peduncle and dorsal
nucleus on dorsal aspect of the peduncle.
• All cochlear nerve fibres enter the ventral nucleus and divide into fibres that end
in ventral nucleus and fibres that end in dorsal nucleus.
• Axon of cells in cochlear nuclei decussate transversely at potomedullary level to
form trapezoid body .
• Crossing fibres relay in contralateral trapezoid nucleus ( 3rd order neuron) and
ascend in lateral lemniscus.
• Lateral lemniscus is found on both sides of brainstem as compact bundle of
fibres. It is from the 3rd order auditory neurons which go to the inferior
colliculus .
• Majority of L. lemniscus fibres pass through inferior brachium to the
corresponding medial geniculat body.
• Remaining fibres of L. lemniscus terminate in the nucleus of inferior colliculus.
• Axons of cells of medial geniculate body ascend in the internal capsule and
form auditory radiation which ends in the cortical auditory area in the middle and
superior temporal gyri.

LESIONS:

Cochlear lesions present with tinnitus and deafness.

Tinnitus: Different noises
Deafness : 2 types: • (1) Conductive Deafness, (2) Sensory Neural Deafness:
 Weaam Saif
VESTIBULAR NERVE :

• It transmits afferent impulses for equilibrium .

• Receptors are crista ampullaris of the Semicircular ducts .
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Semicircular ducts:
• They lie inside the semicircular canals
• their ampullae contain specialized receptors (crista ampullaris) sensitive to the
orientation of the head to the gravity.
• They receive terminals of the vestibular nerve.

COURSE & CONNNECTIONS :

• peripheral processes of bipolar cells are formed from nerve fibres
in macula of utricle and saccule and from neuroepithelium of the ampullae of the
semicircular canal.
• Fibres join the vestibular ganglion in the internal meatus.
• Central processes of bipolar cells enter cranial cavity to cerebellopontine angle
to the pons + medulla
• Fibres terminate in the four main vestibular nuclei (superior, inferior, medial
and lateral) of Dieters in the pontomedullary region.
• Some fibres pass uninterrupted to flocculus and nodule of cerebellum.
• Vestibular nuclei are found in the floor of 4th ventricle.

• Fibres from medial nucleus descend to cervical spinal cord to form medial
vestibulospinal tract.
• The tract facilitates extensor activity which prevents body collapse by pull of
gravity.
• Vestibulocerebellar connections contribute to coordination of muscle
contraction in maintenance of upright posture.

LESIONS:

Lesions of nerve or disorders of labyrinth produce vertigo and

nystagmus.

VERTIGO: Defined as feeling of

rotation either of the patient himself or
the environment.
NYSTAGMUS :It is a side to side movement of eyes composed of a slow
component and a rapid return jerk, can be horizontal, vertical or rotatory depending on
the plane of rotation.
 Glossopharyngeal nerve (9) (lX)

• It emerges by many rootlets through the posterolateral fissure of the medulla,

• It carries :
• Somatic Motor to muscles of pharynx
• Parasympathetic (motor) to salivary glands
• Sensory to pharynx and taste to posterior tongue

• GVE fibers: arise from: inferior salivatory nucleus, relay in otic ganglion, the
postganglionic fibers supply parotid gland.

• SVE fibers: originate from nucleus ambiguus, and supply stylopharygeus.

MCQ: All pharynx muscles are supplied by vagus EXEPT?

• SVA fibers: arise from the cells NST of inferior ganglion, their central processes
terminate in:
• nucleus of solitary tract the peripheral processes supply the taste buds on
posterior third .

Branches:

Symptoms of nerve damage:

Loss of gag reflex
Difficulty swallowing
Loss of taste
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 Vagus nerve (10) (X)

• It emerges through the posterolateral fissure of the medulla.

• It carries parasympathetic, motor and sensory fibers.
• It leaves the skull through the jugular foramen.
• Just below the foramen it has two sensory ganglia: superior and inferior and it
receives the cranial accessory nerve.

Branches:
From the superior ganglion:
1. Meningeal branch (sensory) to the dura mater
2. Auricular branch (sensoryto the ear)

From the inferior ganglio:

1. Pharyngeal branch : gives the motor root of the pharyngeal plexus that
supplies all the muscles of the pharynx except the stylopharyngeus
and all muscles of the palate except the tensor palati.

• The pharyngeal plexus is formed of:

a. Pharyngeal branch of vagus (motor).
b. Pharyngeal branch of glossopharyngeal (sensory).
c. Pharyngeal branch of superior cervical sympathetic ganglion (sympathetic)

Superior laryngeal (mixed: sensory and motor ) : divides into internal and external
laryngeal branches that pass deep to the external carotid artery.

• The internal laryngeal nerve (sensory) accompanies the superior laryngeal

artery and both pierce the thyrohyoid membrane to enter the larynx .
• It supplies the the mucous membrane of the larynx above the vocal cords.

• The external laryngeal nerve (motor) accompanies the superior thyroid artery
and ends by supplying the cricothyroid muscle .

the left recurrent laryngeal nerve arises from the left vagus in the thorax as it
hooks around arch of aorta .
The right vagus gives the right recurrent laryngeal nerve as it hooks around the
first part of right subclavian artery.
They supply:
•All muscles of the larynx except the cricothyroid. • The lower part of the mucous
membrane of the larynx.
•Cardiac branches to share in the formation of the cardiac plexuses.
•Branches to the trachea, oesophagus and the inferior constrictor of the pharynx.
LESIONS:

• Injury of the vagus nerve can be

detected by:
unilateral palatal and pharyngeal
paralysis .
Loss of gag reflex.
uvula is pulled to normal side
hoarseness of voice, anaesthesia
of larynx.
Dysphonea
dysphagia.
 Accessory nerve (11) (XI)

• Purely motor fibres of cranial root + spinal root, S V E from nucleus ambiguus
distributed via N. X , G S E from cervical spinal cord to trapezius and
sternomastoid muscle.

• 2 parts:
• Cranial part; Emerges from the anterior surface of the medulla.
• Spinal part: Arises from the anterior horn cells of the upper 5 cervical segments
of the spinal cord.

• The spinal part enters the skull through the foramen magnum to join the
cranial part.
• The two parts unite and descend through the jugular foramen.
• Just below the foramen the two parts separate.
• The cranial accessory joins the vagus nerve and is distributed through its
pharyngeal and superior and recurrent laryngeal branches.

Weaam Saif

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 Hypoglossal nerve (12) (Xll)

• It is motor to skeletal muscle of tongue (G S E) take origin in hypoglossal

nucleus in the medulla.

• It is a motor nerve that emerges from the the medulla.

• It leaves the skull through the hypoglossal canal.

• It descends between the internal carotid artery and the internal jugular vein
accompanying 9, 10,11 nerve within the upper part of the carotid sheath.

• It supplies all muscles of the tongue except the palatoglossus.

UMNL Hypoglossal Nerve:

• Supranuclear lesions lead to weakness of
opposite half of tongue (UMNL).
• On protrusion, the tongue deviates to side
opposite to that of lesion.
• No marked atrophy of tongue but tongue
smaller than normal due to spasticity.

LMNL Hypoglossal Nerve

• Test: • Ask patient to stick out tongue

• Symptoms of nerve damage:

When paralyzed, the tongue will point to the damaged
side
atrophy of the ipsilateral half of tongue