Olfactory Nerve: It is a type of sensory nerve,

Supply : It supplies to the Olfactory Epithelium

(cells)

Function : Perception of smell from the nasal

cavity.

2. Optic Nerve: It is a type of sensory nerve,

Supply : Retina (ganglion cells)

Function : Vision of retina.

3. Oculomotor Nerve: It i a type of motor nerve,

Supply : Midbrain, presynaptic midbrain,

postsynaptic ciliary ganglion

Function : Motor function to superior rectus

and inferior rectus, medial rectus, inferior

oblique, and levator palpebrae superioris

muscles, raises superior eyelid and also turns

eyeball superiorly, inferiorly and medially,

constricts pupil and accomidates lens of eye.

4. Trochlear Nerve: It is a type of motor nerve,

Supply : Midbrain

Function : to the superior oblique muscle that

assists in turning of the eye inferio laterally.

5. Trigeminal Nerve: It has 3 branches:

i) Opthalmic nerve: It is the sensory nerve.

Supply : Trigeminal ganglion.

Function : Sensation from cornea, skin of scalp,

eyelids, nose and mucosa of nasal cavity.

ii) Maxillary nerve: It is also a type of sensory nerve.

Supply : Trigeminal Ganglion.

Function : Sensation from skin face of face

over maxilla, upper lip, maxillary teeth, mucosa

of nose, maxillary sinuses and palate.

iii) Mandibular nerve: It is a type of motor nerve.

Supply : Pons, to the muscles of mastication.

Function : Motor supply to the muscles of

mastication, mylohyoid, anterior belly of

digastric, tensor villi palatini and tensor tympani.

6. Abducent: It is a type of motor nerve.

Supply : Pons, to the lateral rectus

Function : To turn the eye laterally.

7. Facial: It is of a mixed type with both sensory and

motor functions.

Supply : Pons, Geniculate ganglion, Sub

mandibular ganglion, pterygopalatine ganglion,

muscles of facial expression in scalp, stapedius

of middle ear, stylohyoid and posterior belly of

digastric, anterior two thirds of the tongue, to

submandibular salivary glands, lacrimal glands

and glands of nose and palate.

Function : Taste from anterior two thirds of the

tongue, motor function to the muscles of facial

expression and scalp.

8. Vestibulocochlear : It is a type of sensory nerve.

Supply : Vestibular ganglion and spiral ganglion.

Function : Vestibular sensation from the

semicircular ducts, utricle and saccule related to

position and movement of head, hearing from

spinal organ.

9. Glossopharyngeal: It is a mixed type with both

sensory and motor functions.

Supply : Stylopharyngeus, parotid gland, acotid

body, pharynx and middle ear, external ear.

Function : Assists in swallowing, taste

perception from the posterior third of the tongue,

cutaneous sensation from the external ear.

10. Vagus: It is also a type of mixed nerve with both

motor and sensory functions.

Supply : Superior ganglion, inferior ganglion,

medulla, constrictor muscles of pharynx, intrinsic

muscles of larynx, muscles of palate, striated

muscles in two thirds of esophagus, smoot

muscles of trachea, bronchi, cardiac muscles of

heart, base of tongue, epiglottis, palate.

Function : Motor function in the constrictor

muscles of pharynx, intrinsic muscles of larynx,

muscles of palate, striated muscles in two thirds

of esophagus, taste perception from the

epiglottis and palate, semsation from the auricle,

external acoustic meatus, dura matter of cranial

fossa.

11. Spinal accessory nerve: It is type of motor nerve.

Supply : Spinal cord, sternocleidomastoid and

trapezius muscle.

Function : Motor supply to the

sternocleidomastoid and trapezius muscle.

12. Hypoglossal: It is a type of motor nerve.

Supply : Medulla, and to the intrinsic and

extrinsic muscles of tongue.

Function : Motor supply to intrinsic and

extrinsic muscles of the tongue.

Important facts and points about Cranial Nerves:

1. Trigeminal nerve is the Largest Cranial Nerve

2. Olfactory is the smallest cranial nerve

3. Vagus Nerve is with Vague or Extensive

Distribution

4. Trochlear nerve shows largest intracranial

course
5. Smallest branch of Trigeminal nerve is the

Opthalmic branch

6. Largest branch of Trigeminal nerve is

Mandibular branch

7. Buccal nerve is the only Sensory branch of

anterior division of the Mandibular Nerve

8. Smallest of 3 terminal branches of opthalmic

nerve is lacrimal nerve and frontal nerve is the

largest terminal branch of opthalmic nerve

9. Posterior Ethmoidal is the branch of Nasociliary

which is frequently absent.

10. Posterior Superior alveolar nerve is the branch of

maxillary nerve in Pterygopalatine fossa

11. Middle superior alveolar nerve is present in only

28% of the individuals

12. Greater palatine nerve = Anterior palatine nerve

13. Lesser Palatine Nerve = Middle and Posterior

palatine branches

14. Nervus Intermedius is Sensory branch of facial

nerve

The cranial nerves are 12 pairs of nerves that

emerge from the brain and are responsible for

providing motor and sensory functions. They are

among the most delicate nerves in the human

nervous system and require experts who specialize

in their normal and abnormal presentations.

Cranial nerve issues can affect a motor nerve, called

cranial nerve palsy, or affect a sensory nerve,

causing pain or diminished sensation. Individuals

with a cranial nerve disorder may suffer from

symptoms that include intense pain, vertigo, hearing

loss, weakness or paralysis. These disorders can

also affect smell, taste, facial expression, speech,

swallowing, and muscles of the neck.

Cranial Nerve Conditions

Trigeminal Neuralgia

Trigeminal neuralgia , or Tic Douloureux, is a

disorder of the fifth cranial nerve, the trigeminal

nerve, a large nerve that carries sensation from the

face to the brain. Pain associated with the

trigeminal nerve can be severe and intense, usually

only on one side of the face, often around the eye,

cheek, and lower part of the face. Pain may be

triggered by touch or sounds and can occur while a

person is brushing their teeth, eating, drinking, or

shaving.

This disorder can be caused by a tumor, or multiple

sclerosis, or when blood vessels press on the root

of the trigeminal nerve. Trigeminal neuralgia is

initially treated the same as atypical facial pain (e.g.

medications). If medications fail, however, then it

can be treated with neurosurgical intervention.

Trigeminal neuralgia is diagnosed based on clinical

presentation. Ancillary tests such as blood tests,

dental examinations, and magnetic resonance

imaging (MRI) scans are used primarily to rule out

other possible diagnosis.

Hemifacial Spasm

A hemifacial spasm is a neurological disorder in

which blood vessels constrict the seventh cranial

nerve, causing muscles on one side of the face to

twitch or 'tic' involuntarily. Hemifacial spasm can be

caused by several factors: facial nerve injury, a

blood vessel touching a facial nerve, or a tumor.

Although these twitches are uncomfortable, they are

usually not life-threatening.

As the disorder progresses, you may experience

spasms in the muscles of the lower face which may

affect your mouth to be slightly pulled to the side.

You may start to experience discomfort and pain. If

left untreated, a hemifacial spasm can cause all

muscles of the face to twitch and spasm.

Hemifacial spasm is diagnosed based on clinical

presentation--the characteristic twitch or tic is the

best evidence of the condition. However, additional

tests including the detection of a brain tumor, will

need to be performed to confirm a hemifacial

spasm.

Glossopharyngeal Neuralgia

Glossopharyngeal neuralgia is a compression of the

ninth cranial nerve and causes brief but excruciating

pain at the base of the tongue which can radiate to

the ear and neck. The pain can last for a few

seconds to a few minutes and may return multiple

times in a day or once every few weeks. Typical

triggers often include eating, drinking, swallowing,

speaking, sneezing, or coughing. Glossopharyngeal

can also occur in people with throat or neck cancer.

If left untreated, glossopharyngeal neuralgia can

worsen, causing longer, frequent attacks of

excruciating pain.

Diagnosis is based on clinical presentation. If

glossopharyngeal neuralgia is suspected, the doctor

may request an MRI, MRA, or CT scan. The doctor

may also attempt to trigger an episode by touching

the back of the mouth or tonsils. If that causes pain,

a topical anesthetic is applied to the back of the

mouth and the test repeated. If pain is not triggered

after topical anesthetic is applied, glossopharyngeal

neuralgia is diagnosed.

Skull Base Tumors

Many skull base tumors, also know as cranial base

tumors . These tumors involve cranial nerves and

cause double vision, vision loss, hearing loss, and/

or dizziness. Examples of tumors that affect cranial

nerves and are tackled by skull base surgery include:

acoustic neuroma , pituitary adenoma, meningioma,

craniopharyngioma, hemangiopericytoma,

chordoma, and chondrosarcoma. Patients may have

subtle symptoms for a long period of time before

the tumor is diagnosed.

A diagnosis is made with advanced imaging such

as a CT scan or an MRI scan. We work closely with

our colleagues in ENT to craft the appropriate

surgical procedure to remove the tumor and restore

cranial nerve function.

Ophthalmic nerve

The ophthalmic nerve passes through the wall

of the cavernous sinus and enters the orbit via

the superior orbital fissure. Branches in the

orbit are (1) the lacrimal nerve, serving the

lacrimal gland, part of the upper eyelid, and

the conjunctiva, (2) the nasociliary nerve,

serving the mucosal lining of part of the nasal

cavity, the tentorium cerebelli and some of the

dura mater of the anterior cranial fossa, and

skin on the dorsum and tip of the nose, and

(3) the frontal nerve, serving the skin on the

upper eyelid, the forehead, and the scalp

above the eyes up to the vertex of the head.

Maxillary nerve

The maxillary nerve courses through the

cavernous sinus below the ophthalmic nerve

and passes through the foramen rotundum

into the orbital cavity. Branches of the

maxillary nerve are (1) the meningeal

branches, which serve the dura mater of the

middle cranial fossa, (2) the alveolar nerves,

serving the upper teeth and gingiva and the

lining of the maxillary sinus, (3) the nasal and

palatine nerves, which serve portions of the

nasal cavity and the mucosa of the hard and

soft palate, and (4) the infraorbital,

zygomaticotemporal, and zygomaticofacial

nerves, serving the upper lip, the lateral

surfaces of the nose, the lower eyelid and

conjunctiva, and the skin on the cheek and the

side of the head behind the eye.

Mandibular nerve

The mandibular nerve exits the cranial cavity

via the foramen ovale and serves (1) the

meninges and parts of the anterior cranial

fossae (meningeal branches), (2) the

temporomandibular joint, skin over part of the

ear, and skin over the sides of the head above

the ears (auriculotemporal nerve), (3) oral

mucosa, the anterior two-thirds of the tongue,

gingiva adjacent to the tongue, and the floor

of the mouth ( lingual nerve ), and (4) the

mandibular teeth (inferior alveolar nerve). Skin

over the lateral and anterior surfaces of the

mandible and the lower lip is served by

cutaneous branches of the mandibular nerve.

Trigeminal motor fibres exit the cranial cavity

via the foramen ovale along with the

mandibular nerve. They serve the muscles of

mastication (temporalis, masseter, medial

and lateral pterygoid), three muscles involved

in swallowing (anterior portions of the

digastric muscle, the mylohyoid muscle, and

the tensor veli palatini), and the tensor

tympani, a muscle that has a damping effect

on loud noises by stabilizing the tympanic

membrane .

Abducens nerve (CN VI or 6)

From its nucleus in the caudal pons , the

abducens nerve exits the brainstem at the

pons-medulla junction, pierces the dura mater,

passes through the cavernous sinus close to

the internal carotid artery , and exits the cranial

vault via the superior orbital fissure. In the

orbit the abducens nerve innervates the lateral

rectus muscle, which turns the eye outward.

Damage to the abducens nerve results in a

tendency for the eye to deviate medially, or

cross. Double vision may result on attempted

lateral gaze. The nerve often is affected by

increased intracranial pressure.

Facial nerve (CN VII or 7)

The facial nerve is composed of a large root

that innervates facial muscles and a small root

(known as the intermediate nerve) that

contains sensory and autonomic fibres.

From the facial nucleus in the pons , facial

motor fibres enter the internal auditory

meatus, pass through the temporal bone, exit

the skull via the stylomastoid foramen, and

fan out over each side of the face in front of

the ear. Fibres of the facial nerve are special

visceral efferent; they innervate the small

muscles of the external ear, the superficial

muscles of the face, neck, and scalp, and the

muscles of facial expression.

The intermediate nerve contains autonomic

(parasympathetic) as well as general and

special sensory fibres. Preganglionic

autonomic fibres, classified as general

visceral efferent, project from the superior

salivatory nucleus in the pons. Exiting with the

facial nerve, they pass to the pterygopalatine

ganglion via the greater petrosal nerve (a

branch of the facial nerve) and to the

submandibular ganglion by way of the chorda

tympani nerve (another branch of the facial

nerve, which joins the lingual branch of the

mandibular nerve). Postganglionic fibres from

the pterygopalatine ganglion innervate the

nasal and palatine glands and the lacrimal

gland, while those from the submandibular

ganglion serve the submandibular and

sublingual salivary glands. Among the sensory

components of the intermediate nerve,

general somatic afferent fibres relay sensation

from the caudal surface of the ear, while

special visceral afferent fibres originate from

taste buds in the anterior two-thirds of the

tongue, course in the lingual branch of the

mandibular nerve, and then join the facial

nerve via the chorda tympani branch. Both

somatic and visceral afferent fibres have cell

bodies in the geniculate ganglion, which is

located on the facial nerve as it passes

through the facial canal in the temporal bone.

Injury to the facial nerve at the brainstem

produces a paralysis of facial muscles known

as Bell palsy as well as a loss of taste

sensation from the anterior two-thirds of the

tongue. If damage occurs at the stylomastoid

foramen, facial muscles will be paralyzed but

taste will be intact.

Vestibulocochlear nerve (CN VIII or 8)

This cranial nerve has a vestibular part, which

functions in balance, equilibrium, and

orientation in three-dimensional space, and a

cochlear part, which functions in hearing . The

functional component of these fibres is

special somatic afferent; they originate from

receptors located in the temporal bone.

Vestibular receptors are located in the

semicircular canals of the ear, which provide

input on rotatory movements (angular

acceleration), and in the utricle and saccule,

which generate information on linear

acceleration and the influence of gravitational

pull. This information is relayed by the

vestibular fibres, whose bipolar cell bodies are

located in the vestibular (Scarpa) ganglion.

The central processes of these neurons exit

the temporal bone via the internal acoustic

meatus and enter the brainstem alongside the

facial nerve .

Auditory receptors of the cochlear division are

located in the organ of Corti and follow the

spiral shape (about 2.5 turns) of the cochlea .

Air movement against the eardrum initiates

action of the ossicles of the ear, which, in

turn, causes movement of fluid in the spiral

cochlea. This fluid movement is converted by

the organ of Corti into nerve impulses that are

interpreted as auditory information. The

bipolar cells of the spiral, or Corti, ganglion

branch into central processes that course with

the vestibular nerve. At the brainstem,

cochlear fibres separate from vestibular fibres

to end in the dorsal and ventral cochlear

nuclei.

Lesions of the vestibular root result in eye

movement disorders ( nystagmus ), unsteady

gait with a tendency to fall toward the side of

the lesion, nausea, and vertigo. Damage to the

cochlea or cochlear nerve results in complete

deafness, ringing in the ear ( tinnitus), or both.

Glossopharyngeal nerve (CN IX or 9)

The ninth cranial nerve, which exits the skull

through the jugular foramen, has both motor

and sensory components. Cell bodies of

motor neurons, located in the nucleus

ambiguus in the medulla oblongata , project as

special visceral efferent fibres to the

stylopharyngeal muscle. The action of the

stylopharyngeus is to elevate the pharynx , as

in gagging or swallowing. In addition, the

inferior salivatory nucleus of the medulla

sends general visceral efferent fibres to the

otic ganglion via the lesser petrosal branch of

the ninth nerve; postganglionic otic fibres

innervate the parotid salivary gland .

Among the sensory components of the

glossopharyngeal nerve, special visceral

afferent fibres convey taste sensation from

the back third of the tongue via lingual

branches of the nerve. General visceral

afferent fibres from the pharynx, the back of

the tongue, parts of the soft palate and

eustachian tube , and the carotid body and

carotid sinus have their cell bodies in the

superior and inferior ganglia, which are

situated, respectively, within the jugular

foramen and just outside the cranium.

Sensory fibres in the carotid branch detect

increased blood pressure in the carotid sinus

and send impulses into the medulla that

ultimately reduce heart rate and arterial

pressure; this is known as the carotid sinus

reflex .

Vagus nerve (CN X or 10)

The vagus nerve has the most extensive

distribution in the body of all the cranial

nerves, innervating structures as diverse as

the external surface of the eardrum and

internal abdominal organs. The root of the

nerve exits the cranial cavity via the jugular

foramen. Within the foramen is the superior

ganglion, containing cell bodies of general

somatic afferent fibres, and just external to

the foramen is the inferior ganglion,

containing visceral afferent cells.

Pain and temperature sensations from the

eardrum and external auditory canal and pain

fibres from the dura mater of the posterior

cranial fossa are conveyed on general somatic

afferent fibres in the auricular and meningeal

branches of the nerve. Taste buds on the root

of the tongue and on the epiglottis contribute

special visceral afferent fibres to the superior

laryngeal branch. General visceral afferent

fibres conveying sensation from the lower

pharynx , larynx , trachea , esophagus , and

organs of the thorax and abdomen to the left

(splenic) flexure of the colon converge to

form the posterior (right) and anterior (left)

vagal nerves. Right and left vagal nerves are

joined in the thorax by cardiac, pulmonary, and

esophageal branches. In addition, general

visceral afferent fibres from the larynx below

the vocal folds join the vagus via the recurrent

laryngeal nerves, while comparable input from

the upper larynx and pharynx is relayed by the

superior laryngeal nerves and by pharyngeal

branches of the vagus. A vagal branch to the

carotid body usually arises from the inferior

ganglion.

Motor fibres of the vagus nerve include

special visceral efferent fibres arising from

the nucleus ambiguus of the medulla

oblongata and innervating pharyngeal

constrictor muscles and palatine muscles via

pharyngeal branches of the vagus as well as

the superior laryngeal nerve. All laryngeal

musculature (excluding the cricothyroid but

including the muscles of the vocal folds) are

innervated by fibres arising in the nucleus

ambiguus. Cells of the dorsal motor nucleus

in the medulla distribute general visceral

efferent fibres to plexuses or ganglia serving

the pharynx, larynx, esophagus, and lungs. In

addition, cardiac branches arise from plexuses

in the lower neck and upper thorax, and, once

in the abdomen, the vagus gives rise to

gastric, celiac, hepatic, renal, intestinal, and

splenic branches or plexuses.

Damage to one vagus nerve results in

hoarseness and difficulty in swallowing or

speaking. Injury to both nerves results in

increased heart rate, paralysis of pharyngeal

and laryngeal musculature, atonia of the

esophagus and intestinal musculature,

vomiting, and loss of visceral reflexes. Such a

lesion is usually life-threatening, as paralysis

of laryngeal muscles may result in

asphyxiation.

Accessory nerve (CN XI or 11)

The accessory nerve is formed by fibres from

the medulla oblongata (known as the cranial

root) and by fibres from cervical levels C –C

(known as the spinal root ). The cranial root

originates from the nucleus ambiguus and

exits the medulla below the vagus nerve. Its

fibres join the vagus and distribute to some

muscles of the pharynx and larynx via

pharyngeal and recurrent laryngeal branches

of that nerve. For this reason, the cranial part

of the accessory nerve is, for all practical

purposes, part of the vagus nerve.

Fibres that arise from spinal levels exit the

cord, coalesce and ascend as the spinal root

of the accessory nerve, enter the cranial cavity

through the foramen magnum, and then

immediately leave through the jugular

foramen. The accessory nerve then branches

into the sternocleidomastoid muscle, which

tilts the head toward one shoulder with an

upward rotation of the face to the opposite

side, and the trapezius muscle, which

stabilizes and shrugs the shoulder.

Hypoglossal nerve (CN XII or 12)

The hypoglossal nerve innervates certain

muscles that control movement of the tongue .

From the hypoglossal nucleus in the medulla

oblongata, general somatic efferent fibres exit

the cranial cavity through the hypoglossal

canal and enter the neck in close proximity to

the accessory and vagus nerves and the

internal carotid artery . The nerve then loops

down and forward into the floor of the mouth

and branches into the tongue musculature

from underneath. Hypoglossal fibres end in

intrinsic tongue muscles, which modify the

shape of the tongue (as in rolling the edges),

as well as in extrinsic muscles that are

responsible for changing its position in the

mouth.

A lesion of the hypoglossal nerve on the same

side of the head results in paralysis of the

intrinsic and extrinsic musculature on the

same side. The tongue atrophies and, on

attempted protrusion, deviates toward the

side of the lesion.

Cranial nerve , in vertebrates, any of the paired

nerves of the peripheral nervous system that

connect the muscles and sense organs of the

head and thoracic region directly to the brain .

In higher vertebrates (reptiles, birds,

mammals) there are 12 pairs of cranial

nerves: olfactory (CN I), optic (CN II),

oculomotor (CN III), trochlear (CN IV),

trigeminal (CN V), abducent (or abducens; CN

VI), facial (CN VII), vestibulocochlear (CN VIII),

glossopharyngeal (CN IX), vagus (CN X),

accessory (CN XI), and hypoglossal (CN XII).

Lower vertebrates (fishes, amphibians) have

10 pairs. A 13th pair, a plexus (branching

network) known as the terminal nerve (CN 0),

is sometimes also recognized in humans,

though whether it is a vestigial structure or a

functioning nerve is unclear.

Cranial nerves are made up of motor neurons ,

sensory neurons, or both. They are named for

their function or structure; for example, the

trigeminal nerve consists of three primary

branches, while the vestibulocochlear nerve

serves the organs of equilibrium and hearing.

The vagus nerve is one of the most important;

it extends to many of the organs in the chest

and upper abdomen .

The cranial

nerves are

12 pairs of

nerves that

can be

seen on

the ventral

(bottom)

surface of

the brain.

Some of

these

nerves

bring

information

from the

sense

organs to

the brain;
other

cranial

nerves

control

muscles;

other

cranial

nerves are

connected

to glands

or internal

organs

such as

the heart

and lungs.

Test Your Cranial Nerves

Now that you know the names and functions of the

cranial nerves, let's test them. These tests will help

you understand how the cranial nerves work. These

tests are not meant to be a "clinical examination" of

the cranial nerves.

You will need to get a partner to help...both of you

can serve as the experimenter (tester) and the

subject. Record your observations of what your

partner does and says.

Olfactory Nerve (I)

Gather some items with distinctive smells (for

example, cloves, lemon, chocolate or coffee). Have

your partner smell the items one at a time with each

nostril. Have your partner record what the item is and

the strength of the odor. Now you be the one who

smells the items...have your partner use different

smells for you.

Optic Nerve (II)

Make an eye chart (a "Snellen Chart") like the one on

the right. It doesn't have to be perfect. Have your

partner try to read the lines at various distances away

from the chart.

Oculomotor Nerve (III), Trochlear Nerve (IV) and

Abducens Nerve (VI)

These three nerves control eye movement and pupil

diameter. Hold up a finger in front of your partner. Tell

your partner to hold his or her head still and to follow

your finger, then move your finger up and down, right

and left. Do your partner's eyes follow your fingers?

Check the pupillary response (oculomotor nerve): look

at the diameter of your partner's eyes in dim light and

also in bright light. Check for differences in the sizes

of the right and left pupils.

Trigeminal Nerve (V)

The trigeminal nerve has both sensory and motor

functions. To test the motor part of the nerve, tell your

partner to close his or her jaws as if he or she was

biting down on a piece of gum.

To test the sensory part of the trigeminal nerve, lightly

touch various parts of your partner's face with piece

of cotton or a blunt object. Be careful not to touch

your partner's eyes. Although much of the mouth and

teeth are innervated by the trigeminal nerve, don't put

anything into your subject's mouth.

Facial Nerve (VII)

The motor part of the facial nerve can be tested by

asking your partner to smile or frown or make funny

faces. The sensory part of the facial nerve is

responsible for taste on the front part of the tongue.

You could try a few drops of sweet or salty water on

this part of the tongue and see if your partner can

taste it.

Vestibulocochlear Nerve (VIII)

Although the vestibulocochlear nerve is responsible

for hearing and balance, we will only test the hearing

portion of the nerve here. Have your partner close his

or her eyes and determine the distance at which he or

she can hear the ticking of a clock or stopwatch.

Glossopharyngeal Nerve (IX) and Vagus Nerve (X)

Have your partner drink some water and observe the

swallowing reflex. Also the glossopharyngeal nerve is

responsible for taste on the back part of the tongue.

You could try a few drops of salty (or sugar) water on

this part of the tongue and see if your partner can

taste it.

Spinal Accessory Nerve (XI)

To test the strength of the muscles used in head

movement, put you hands on the sides of your

partner's head. Tell your partner to move his or her

head from side to side. Apply only light pressure when

the head is moved.

Hypoglossal Nerve (XII)

Have your partner stick out his or her tongue and

move it side to side.

The cranial nerves are a set of 12 paired

nerves that arise directly from the brain.

The first two nerves ( olfactory and optic )

arise from the cerebrum, whereas the

remaining ten emerge from the brain

stem.

The names of the cranial nerves relate to

their function and they are also

numerically identified in roman numerals

(I-XII).

In this article, we shall summarise the

anatomy of the cranial nerves.

There are twelve cranial nerves in total.

The olfactory nerve (CN I) and optic nerve

(CN II) originate from the cerebrum .

Cranial nerves III – XII arise from the

brain stem (Figure 1). They can arise

from a specific part of the brain stem

(midbrain, pons or medulla), or from a

junction between two parts:

Midbrain – the trochlear nerve (IV)

comes from the posterior side of the

midbrain. It has the longest

intracranial length of all the cranial

nerves.

Midbrain-pontine junction –

oculomotor (III).

Pons – trigeminal (V).

Pontine-medulla junction –

abducens, facial, vestibulocochlear

(VI-VIII).

Medulla oblongata – posterior to the

olive: glossopharyngeal, vagus,

accessory (IX-XI). Anterior to the

olive: hypoglossal (XII).

The cranial nerves are numbered by their

location on the brain stem (superior to

inferior, then medial to lateral) and the

order of their exit from the cranium

(anterior to posterior) (Figures 1 & 2).

Simplistically, each cranial nerve can be

described as being sensory, motor or

both. They can more specifically transmit

seven types of information; three are

unique to cranial nerves (SSS, SVS and

SVM). See table 1 for a summary of the

cranial nerves, their modalities and

functions.

General somatic sensory (GSS) –

general sensation from skin.

General visceral sensory (GVS) –

general sensation from viscera.

Special somatic sensory (SSS) –

senses derived from ectoderm (e.g.

sight, sound, balance).

Special visceral sensory (SVS) –

senses derived from endoderm (e.g.

taste, smell).

General somatic motor (GSM) –

skeletal muscles.

General visceral motor (GVM) –

smooth muscles of gut and

autonomic motor.

Special visceral motor (SVM) –

muscles derived from pharyngeal

arches.
Cranial nerves are the nerves that emerge directly

from the brain (including the brainstem ), in

contrast to spinal nerves (which emerge from

segments of the spinal cord ). [1] 10 of the cranial

nerves originate in the brainstem. Cranial nerves

relay information between the brain and parts of

the body, primarily to and from regions of the head

and neck. [2]

Spinal nerves emerge sequentially from the spinal

cord with the spinal nerve closest to the head ( C1 )

emerging in the space above the first cervical

vertebra. The cranial nerves, however, emerge from

the central nervous system above this level. [3]

Each cranial nerve is paired and is present on both

sides. Depending on definition in humans there are

twelve or thirteen cranial nerves pairs, which are

assigned Roman numerals I–XII, sometimes also

including cranial nerve zero . The numbering of the

cranial nerves is based on the order in which they

emerge from the brain, front to back

( brainstem ). [1]

The terminal nerves (0), olfactory nerves (I) and

optic nerves (II) emerge from the cerebrum or

forebrain, and the remaining ten pairs arise from

the brainstem, which is the lower part of the

brain. [1]

The cranial nerves are considered components of

the peripheral nervous system (PNS), [1] although

on a structural level the olfactory (I), optic (II), and

trigeminal (V) nerves are more accurately

considered part of the central nervous system

(CNS). [4]
Anatomy

Most typically, humans are considered to have

twelve pairs of cranial nerves (I–XII), with the

terminal nerve (0) more recently canonized [1][3][5]

. They are: the olfactory nerve (I), the optic nerve

(II), oculomotor nerve (III), trochlear nerve (IV),

trigeminal nerve (V), abducens nerve (VI), facial

nerve (VII), vestibulocochlear nerve (VIII),

glossopharyngeal nerve (IX), vagus nerve (X),

accessory nerve (XI), and hypoglossal nerve (XII).

Terminology

Cranial nerves are generally named according to

their structure or function. For example, the

olfactory nerve (I) supplies smell, and the facial

nerve (VII) supplies motor innervation to the face.

Because Latin was the lingua franca (common

language) of the study of anatomy when the

nerves were first documented, recorded, and

discussed, many nerves maintain Latin or Greek

names, including the trochlear nerve (IV), named

according to its structure, as it supplies a muscle

that attaches to a pulley ( Greek : trochlea). The

trigeminal nerve (V) is named in accordance with

its three components ( Latin : trigeminus meaning

triplets ), [6] and the vagus nerve (X) is named for

its wandering course ( Latin : vagus ). [7]

Cranial nerves are numbered based on their rostral-

caudal (front-back) position, [1] when viewing the

brain. If the brain is carefully removed from the

skull the nerves are typically visible in their numeric

order, with the exception of the last, CN XII, which

appears to emerge rostrally to (above) CN XI. [8]

Cranial nerves have paths within and outside the

skull. The paths within the skull are called

"intracranial" and the paths outside the skull are

called "extracranial". There are many holes in the

skull called "foramina" by which the nerves can exit

the skull. All cranial nerves are paired , which means

that they occur on both the right and left sides of

the body. The muscle, skin, or additional function

supplied by a nerve on the same side of the body

as the side it originates from, is referred to an

ipsilateral function. If the function is on the

opposite side to the origin of the nerve, this is

known as a contralateral function. [9]

Intracranial course

Intracranial course of cranial nerves is important

regarding diagnosis of various intracranial lesions

like brain tumors and intracranial arterial

aneurysms . Dysfunction of one or more cranial

nerves indicates compression or stimulation by

some lesion. For example an acoustic schwanoma

may initially cause disturbance in hearing but with

further growth of tumor it may involve other cranial

nerves and the patient may present with pain

resembling trigeminal neuralgia when the tumor

involves trigeminal nerve or diplopia due to

abducent nerve involvement similarly facial palsy

with facial nerve compression. These findings

along with cerebellar signs will suggest the

diagnosis of a cerebellopontine angle lesion . A

patient presenting with ptosis may have a posterior

communicating artery aneurysm compressing the

oculomotor nerve during its intracranial course.

Facial pain in the distribution of any one or all

divisions of trigeminal nerve suggests stimulation

of trigeminal nerve roots by a near by

vessel. [ medical citation needed ]

Nuclei

Main article: Cranial nerve nucleus

The cell bodies of many of the neurons of most of

the cranial nerves are contained in one or more

nuclei in the brainstem . These nuclei are important

relative to cranial nerve dysfunction because

damage to these nuclei such as from a stroke or

trauma can mimic damage to one or more

branches of a cranial nerve. In terms of specific

cranial nerve nuclei, the midbrain of the brainstem

has the nuclei of the oculomotor nerve (III) and

trochlear nerve (IV); the pons has the nuclei of the

trigeminal nerve (V), abducens nerve (VI), facial

nerve (VII) and vestibulocochlear nerve (VIII); and

the medulla has the nuclei of the glossopharyngeal

nerve (IX), vagus nerve (X), accessory nerve (XI)

and hypoglossal nerve (XII). The fibers of these

cranial nerves exit the brainstem from these

nuclei. [1]

Ganglia

Main article: Cranial nerve ganglia

Some of the cranial nerves have sensory or

parasympathetic ganglia (collections of cell

bodies ) of neurons, which are located outside the

brain (but can be inside or outside the skull). [1]

The sensory ganglia are directly correspondent to

dorsal root ganglia of spinal nerves and are known

as cranial sensory ganglia . [8] Sensory ganglia

exist for nerves with sensory function: V, VII, VIII,

IX, X. [3] There are also parasympathetic ganglia,

which are part of the autonomic nervous system

for cranial nerves III, VII, IX and X.

The trigeminal ganglia of the trigeminal nerve

(V) occupies a space in the dura mater called

Trigeminal cave . This ganglion contains the cell

bodies of the sensory fibers of the three

branches of the trigeminal nerve.

The geniculate ganglion of the facial nerve (VII)

is found just after the nerve enters the facial

canal ; it contains the cell bodies of the sensory

fibers of the facial nerve.

Superior and inferior ganglia of the

glossopharyngeal nerve (IX) , are located just

after the nerve passes through the jugular

foramen and contain the cell bodies of the

sensory fibers of this nerve.

inferior ganglion of vagus nerve (nodose

ganglion) is located below the jugular foramen

and contains the cell bodies of the sensory

fibers of the vagus nerve (X).

After emerging from the brain, the cranial nerves

travel within the skull , and some must leave this

bony compartment in order to reach their

destinations. Often the nerves pass through holes

in the skull, called foramina , as they travel to their

destinations. Other nerves pass through bony

canals, longer pathways enclosed by bone. These

foramina and canals may contain more than one

cranial nerve and may also contain blood

vessels. [10]
The Terminal nerve (0), is a thin plexus of fibers

associated with the dura and lamina terminalis

running rostral to the olfactory nerve, with

projections through the cribriform plate.

The olfactory nerve (I), actually composed of

many small separate nerve fibers, passes

through perforations in the cribriform plate part

of the ethmoid bone . These fibers terminate in

the upper part of the nasal cavity and function

to convey impulses containing information about

odors to the brain.

The optic nerve (II) passes through the optic

foramen in the sphenoid bone as it travels to the

eye. It conveys visual information to the brain.

The oculomotor nerve (III), trochlear nerve (IV),

abducens nerve (VI) and the ophthalmic branch

of the trigeminal nerve (V1) travel through the

cavernous sinus into the superior orbital fissure ,

passing out of the skull into the orbit . These

nerves control the small muscles that move the

eye and also provide sensory innervation to the

eye and orbit.

The maxillary division of the trigeminal nerve

(V2) passes through foramen rotundum in the

sphenoid bone to supply the skin of the middle

of the face.

The mandibular division of the trigeminal nerve

(V3) passes through foramen ovale of the

sphenoid bone to supply the lower face with

sensory innervation. This nerve also sends

branches to almost all of the muscles that

control chewing.
The facial nerve (VII) and vestibulocochlear

nerve (VIII) both enter the internal auditory canal

in the temporal bone . The facial nerve then

reaches the side of the face by using the

stylomastoid foramen, also in the temporal

bone. Its fibers then spread out to reach and

control all of the muscles of facial expression.

The vestibulocochlear nerve reaches the organs

that control balance and hearing in the temporal

bone and therefore does not reach the external

surface of the skull.

The glossopharyngeal (IX), vagus (X) and

accessory nerve (XI) all leave the skull via the

jugular foramen to enter the neck. The

glossopharyngeal nerve provides innervation to

the upper throat and the back of the tongue, the

vagus provides innervation to the muscles in the

voicebox and continues downward to supply

parasympathetic innervation to the chest and

abdomen. The accessory nerve controls the

trapezius and sternocleidomastoid muscles in

the neck and shoulder.

The hypoglossal nerve (XII) exits the skull using

the hypoglossal canal in the occipital bone and

reaches the tongue to control almost all of the

muscles involved in movements of this organ. [1]

Function

The cranial nerves provide motor and sensory

innervation mainly to the structures within the head

and neck. The sensory innervation includes both

"general" sensation such as temperature and touch,

and "special" innervation such as taste , vision ,

smell , balance and hearing[1][11]

The vagus nerve (X) provides sensory and

autonomic (parasympathetic) motor innervation to

structures in the neck and also to most of the

organs in the chest and abdomen. [1][3]

Pheromonal Response (0)

The terminal nerve (0) is involved in hormonal

responses to smell, and has been implicated in

sexual response and mate selection. [5]

Smell (I)

The olfactory nerve (I) conveys the sense of smell.

Damage to the olfactory nerve (I) can cause an

inability to smell ( anosmia ), a distortion in the

sense of smell ( parosmia ), or a distortion or lack

of taste. If there is suspicion of a change in the

sense of smell, each nostril is tested with

substances of known odors such as coffee or

soap. Intensely smelling substances, for example

ammonia, may lead to the activation of pain

receptors ( nociceptors) of the trigeminal nerve that

are located in the nasal cavity and this can

confound olfactory testing. [1][12]

Vision (II)

The optic nerve (II) transmits visual information. [3]

[11]

Damage to the optic nerve (II) affects specific

aspects of vision that depend on the location of the

lesion. A person may not be able to see objects on

their left or right sides ( homonymous

hemianopsia), or may have difficulty seeing objects

on their outer visual fields ( bitemporal

hemianopsia) if the optic chiasm is involved. [13]

Vision may be tested by examining the visual field ,

or by examining the retina with an

ophthalmoscope, using a process known as

funduscopy . Visual field testing may be used to

pin-point structural lesions in the optic nerve, or

further along the visual pathways. [12]

Eye movement (III, IV, VI)

Various deviations of the

eyes due to abnormal

function of the targets of

the cranial nerves

The oculomotor nerve (III), trochlear nerve (IV) and

abducens nerve (VI) coordinate eye movement.

Damage to nerves III, IV, or VI may affect the

movement of the eyeball (globe). Both or one eye

may be affected; in either case double vision

( diplopia ) will likely occur because the movements

of the eyes are no longer synchronized. Nerves III,

IV and VI are tested by observing how the eye

follows an object in different directions. This object

may be a finger or a pin, and may be moved at

different directions to test for pursuit velocity. [12]

If the eyes do not work together, the most likely

cause is damage to a specific cranial nerve or its

nuclei. [12]

Damage to the oculomotor nerve (III) can cause

double vision ( diplopia) and inability to coordinate

the movements of both eyes ( strabismus ), also

eyelid drooping ( ptosis ) and pupil dilation

( mydriasis ). [13] Lesions may also lead to inability

to open the eye due to paralysis of the levator

palpebrae muscle. Individuals suffering from a

lesion to the oculomotor nerve may compensate by

tilting their heads to alleviate symptoms due to

paralysis of one or more of the eye muscles it

controls. [12]

Damage to the trochlear nerve (IV) can also cause

diplopia with the eye adducted and elevated. [13]

The result will be an eye which can not move

downwards properly (especially downwards when

in an inward position). This is due to impairment in

the superior oblique muscle, which is innervated by

the trochlear nerve. [12]

Damage to the abducens nerve (VI) can also result

in diplopia. [13] This is due to impairment in the

lateral rectus muscle, which is innervated by the

abducens nerve. [12]

Trigeminal nerve (V)

The trigeminal nerve (V) comprises three distinct

parts: The Ophthalmic (V1), the Maxillary (V2), and

the Mandibular (V3) nerves. Combined, these

nerves provide sensation to the skin of the face

and also controls the muscles of mastication

(chewing). [1] Conditions affecting the trigeminal

nerve (V) include trigeminal neuralgia , [1] cluster

headache , [14] and trigeminal zoster . [1] Trigeminal

neuralgia occurs later in life, from middle age

onwards, most often after age 60, and is a

condition typically associated with very strong pain

distributed over the area innervated by the

maxillary or mandibular nerve divisions of the

trigeminal nerve (V 2 and V3 ). [15]

The facial nerve passes

through the petrous temporal

bone , internal auditory meatus ,

facial canal , stylomastoid

foramen , and then the parotid

gland .

Facial expression (VII)

Lesions of the facial nerve (VII) may manifest as

facial palsy . This is where a person is unable to

move the muscles on one or both sides of their

face. In blunt trauma , the facial nerve is the most

commonly injured cranial nerve . [16] A very

common and generally temporary facial palsy is

known as Bell's palsy . Bell's Palsy is the result of

an idiopathic (unknown cause), unilateral lower

motor neuron lesion of the facial nerve and is

characterized by an inability to move the ipsilateral

muscles of facial expression, including elevation of

the eyebrow and furrowing of the forehead.

Patients with Bell's palsy often have a drooping

mouth on the affected side and often have trouble

chewing because the buccinator muscle is

affected. [1] Bell's palsy occurs very rarely,

affecting around 40,000 Americans annually. There

are studies in mice and humans suggesting

members of the family Herpesviridae are capable

of producing Bell's palsy. Facial paralysis may be

caused by other conditions including stroke, and

similar conditions to Bell's Palsy are occasionally

misdiagnosed as Bell's Palsy. [17] Bell's Palsy is a

temporary condition usually lasting 2-6 months,

but can have life-changing effects and can reoccur.

Strokes typically also affect the seventh cranial

nerve by cutting off blood supply to nerves in the

brain that signal this nerve and so can present with

similar symptoms.

Hearing and balance (VIII)

The vestibulocochlear nerve (VIII) splits into the

vestibular and cochlear nerve . The vestibular part is

responsible for innervating the vestibules and

semicircular canal of the inner ear ; this structure

transmits information about balance , and is an

important component of the vestibuloocular reflex ,

which keeps the head stable and allows the eyes to

track moving objects. The cochlear nerve transmits

information from the cochlea, allowing sound to be

heard. [3]

When damaged, the vestibular nerve may give rise

to the sensation of spinning and dizziness.

Function of the vestibular nerve may be tested by

putting cold and warm water in the ears and

watching eye movements caloric stimulation. [1]

[12] Damage to the vestibulocochlear nerve can

also present as repetitive and involuntary eye

movements ( nystagmus ), particularly when looking

in a horizontal plane. [12] Damage to the cochlear

nerve will cause partial or complete deafness in the

affected ear. [12]

Oral sensation, taste, and

salivation (IX)

Deviating uvula

due to cranial

nerve IX lesion

The glossopharyngeal nerve (IX) innervates the

stylopharyngeus muscle and provides sensory

innervation to the oropharynx and back of the

tongue. [1][18] The glossopharyngeal nerve also

provides parasympathetic innervation to the

parotid gland . [1] Unilateral absence of a gag reflex

suggests a lesion of the glossopharyngeal nerve

(IX), and perhaps the vagus nerve (X). [19]

Vagus nerve (X)

Loss of function of the vagus nerve (X) will lead to

a loss of parasympathetic innervation to a very

large number of structures. Major effects of

damage to the vagus nerve may include a rise in

blood pressure and heart rate. Isolated dysfunction

of only the vagus nerve is rare, but - if the conflict

or lesion is located above the point at which the

vagus first branches off - can be diagnosed by a

hoarse voice, due to dysfunction of one of its

branches, the recurrent laryngeal nerve . [1]

Damage to this nerve may result in difficulties

swallowing. [12]

Shoulder elevation and head-

turning (XI)

Winged scapula may

occur due to lesion of

the spinal accessory.

Damage to the accessory nerve (XI) will lead to

ipsilateral weakness in the trapezius muscle. This

can be tested by asking the subject to raise their

shoulders or shrug, upon which the shoulder blade

( scapula ) will protrude into a winged position. [1]

Additionally, if the nerve is damaged, weakness or

an inability to elevate the scapula may be present

because the levator scapulae muscle is now solely

able to provide this function. [15] Depending on the

location of the lesion there may also be weakness

present in the sternocleidomastoid muscle, which

acts to turn the head so that the face points to the

opposite side. [1]

Tongue movement (XII)

A damaged hypoglossal nerve will

result in an inability to stick the

tongue out straight.

A case with unilateral hypoglossal

nerve injury in branchial cyst

surgery. [20]

The hypoglossal nerve (XII) is unique in that it is

innervated from the motor cortices of both

hemispheres of the brain. Damage to the nerve at

lower motor neuron level may lead to fasciculations

or atrophy of the muscles of the tongue. The

fasciculations of the tongue are sometimes said to

look like a "bag of worms". Upper motor neuron

damage will not lead to atrophy or fasciculations,

but only weakness of the innervated muscles. [12]

When the nerve is damaged, it will lead to

weakness of tongue movement on one side. When

damaged and extended, the tongue will move

towards the weaker or damaged side, as shown in

the image. [12]

Clinical significance

Examination

Main article: Cranial nerve examination

Physicians, neurologists , and other medical

professionals may conduct a cranial nerve

examination as part of a neurological examination

to examine the functionality of the cranial nerves.

This is a highly formalized series of tests that

assess the status of each nerve. [21] A cranial

nerve exam begins with observation of the patient

because some cranial nerve lesions may affect the

symmetry of the eyes or face. The visual fields are

tested for nerve lesions or nystagmus via an

analysis of specific eye movements. The sensation

of the face is tested, and patients are asked to

perform different facial movements, such as

puffing out of the cheeks. Hearing is checked by

voice and tuning forks. The position of the patient's

uvula is examined because asymmetry in the

position could indicate a lesion of the

glossopharyngeal nerve. After the ability of the

patient to use their shoulder to assess the

accessory nerve (XI), and the patient's tongue

function is assessed by observing various tongue

movements. [1][21]

Damage

Compression

Nerves may be compressed because of increased

intracranial pressure, a mass effect of an

intracerebral haemorrhage , or tumour that presses

against the nerves and interferes with the

transmission of impulses along the nerve. [22] A

loss of functionality of a single cranial nerve may

sometimes be the first symptom of an intracranial

or skull base cancer. [23]

An increase in intracranial pressure may lead to

impairment of the optic nerves (II) due to

compression of the surrounding veins and

capillaries, causing swelling of the eyeball

( papilloedema ). [24] A cancer, such as an optic

glioma , may also impact the optic nerve (II). A

pituitary tumour may compress the optic tracts or

the optic chiasm of the optic nerve (II), leading to

visual field loss. A pituitary tumour may also extend

into the cavernous sinus, compressing the

oculuomotor nerve (III), trochlear nerve (IV) and

abducens nerve (VI), leading to double-vision and

strabismus . These nerves may also be affected by

herniation of the temporal lobes of the brain

through the falx cerebri . [22]

The cause of trigeminal neuralgia , in which one side

of the face is exquisitely painful, is thought to be

compression of the nerve by an artery as the nerve

emerges from the brain stem. [22] An acoustic

neuroma , particularly at the junction between the

pons and medulla, may compress the facial nerve

(VII) and vestibulocochlear nerve (VIII), leading to

hearing and sensory loss on the affected side. [22]

[25]

Stroke

Occlusion of blood vessels that supply the nerves

or their nuclei, an ischemic stroke , may cause

specific signs and symptoms that can localise

where the occlusion occurred. A clot in a blood

vessel draining the cavernous sinus ( cavernous

sinus thrombosis) affects the oculomotor (III),

trochlear (IV), opthalamic branch of the trigeminal

nerve (V1) and the abducens nerve (VI). [25]

Inflammation

Inflammation resulting from infection may impair

the function of any of the cranial nerves.

Inflammation of the facial nerve (VII) may result in

Bell's palsy . [26]

Multiple sclerosis , an inflammatory process that

may produce a loss of the myelin sheathes which

surround the cranial nerves, may cause a variety of

shifting symptoms affecting multiple cranial

nerves. [26]

Other

Trauma to the skull, disease of bone such as

Paget's disease , and injury to nerves during

neurosurgery (such as tumor removal) are other

possible causes of cranial nerve damage.

Cranial Nerves and their functions

The cranial nerves are the 12 pairs of nerves that

leave the brain via their own individual apertures in

the skull .

List of the Cranial Nerves

1. I Olfactory (Smell)

2. II Optic (Sight)

3. III Oculomotor (Moves eyelid and eyeball and

adjusts the pupil and lens of the eye)

4. IV Trochlear (Moves eyeballs)

5. V Trigeminal (Facial muscles incl. chewing; Facial

sensations)

6. VI Abducens (Moves eyeballs)

7. VII Facial (Taste, tears, saliva, facial expressions)

8. VIII Vestibulocochlear (Auditory)

9. IX Glossopharyngeal (Swallowing, saliva, taste)

0. X Vagus (Control of PNS e.g. smooth muscles of GI

tract)

1. XI Accessory (Moving head & shoulders,

swallowing)

2. XII Hypoglossal (Tongue muscles - speech &

swallowing)

More information about the names, numbers and

functions of each of the 12 cranial nerves is follows

below.

I olfactory

Type: Sensory

Functions: Smell

II optic

Type: Sensory

Functions: Vision, also called eyesight .

Each optic nerve contains approx. a

million nerve fibres that receive

information from the rod and cone cells

of the retina.

III oculomotor

Type: Mixed, mainly motor

Functions: Moves the eyeball & eyelid, adjusts the

lens of the eye for near vision and

constricts the pupil of the eye via

motor fibres distributed to muscles

located in and around the eye.

Parasympathetic fibres

adjust the size of the pupil and the

shape of the lens of the eye.

Fibres outside the eye

extend to the upper eye-lid and the

extrinsic muscles that turn the eyeball

in different directions, (incl. the superior

rectus, medial rectus, inferior rectus

and inferior oblique muscles).

IV trochlear

Type: Mixed, mainly motor

Functions: Moves the eyeballs by sending nerve

impulses to the superior oblique

muscles which are among the group of

muscles that rotate the eyeballs in their

sockets. (The action of this nerve is

coordinated with those of the

oculomotor and abducens nerves i.e.

cranial nerves III and VI.)

V trigeminal

Type: Mixed

Functions: This is largest cranial nerve and splits

into the following 3 divisions, each of

which includes both motor and sensory

fibres.

1. Ophthalmic nerve

2. Maxillary nerve

3. Mandibular nerve

The motor fibres of all 3 divisions

control the facial muscles involved in

chewing. The sensory fibres convey

sensations of touch, pain and

temperature from the front of the head

including the mouth and also from the

meninges.

VI abducens

Type: Mixed, mainly motor

Functions: Moves the eyeballs outwards by

sending nerve impulses to the lateral

rectus muscles.

VII facial
Type: Mixed

Functions: Sensory fibres are concerned with

taste via the taste buds at the front of

the tongue.

Motor fibres control secretion of tears

via the lacrimal glands and saliva via

the sublingual salivary glandsas well

as facial expressions via some of the

muscles of facial expression.

A branch of the facial nerve regulates

the tension on the ear ossicles.

VIII vestibulocochlear

Type: Mixed, mainly sensory

Functions: Two branches: Vestibular nerve

(senses equilibrium) and Cochlear

nerve (hearing)

Vestibular nerve :

Aids equilibrium by carrying impulses

from the semicircular canals - providing

info about posture, movement and

balance

Cochlear nerve :

Carries impulses from the cochlea, so is

known as the nerve of hearing .

IX glossopharyngeal

Type: Mixed

Functions: Motor Fibres

Modulate swallowing via supply to

muscles of the throat (pharynx) area

Parasympathetic control of secretion

of saliva (via supply to the parotid

salivary glands)
Sensory Fibres

Monitors blood pressure

Monitors levels of oxygen and carbon

dioxide in blood

Coordination of some muscle activity

e.g. in some swallowing muscles

Sensations of taste, touch, pain and

temperature from posterior third of

the tongue and tissues of the soft

palate

X vagus

Type: Mixed

Functions: Motor Fibres :

Under conscious control

Stimulates voluntary muscles that

effect swallowing, coughing and

speech .

Under unconscious control

Stimulates the contraction and

relaxation of smooth muscle in

the gastrointestinal tract (GI, also

called the alimentary canal )

Can trigger reduction (slowing) of

heart-rate

Stimulates secretion of digestive

fluids

Sensory Fibres :

Monitors blood pressure

Monitors levels of oxygen and carbon

dioxide in blood

Sensations of touch, pain and

temperature from thoat area

Sensations from visceral organs in

thorax and abdomen

XI accessory

Type: Mixed, mainly motor

Functions: Arises from two roots, cranial and

spinal .

Cranial parts : Controls swallowing

movements because nerve fibres (from

the cranial root of cranial nerve XI) join

the vagus nerve to form the recurrent

laryngeal nerve which supplies the

internal laryngeal muscles.

Spinal Parts : Governs movement of the

head and shoulders by supplying the

sternocleidomastoid and trapezius

muscles in the (anterior and posterior)

regions of the neck.

XII hypoglossal

Type: Mixed, mainly motor

Functions: Supplies the muscles of the tongue -

responsible for the tongue movements

involved in speech and swallowing

Cranial Nerves

Brief Overview of Cranial Nerves

The peripheral nervous system has 12 pairs of

cranial nerves that control much of the motor

and sensory functions of the head and neck.

Key Points

The cranial nerves serve

functions such as smell,

sight, eye movement, and

feeling in the face. The

cranial nerves also control

balance, hearing, and

swallowing.

The twelve cranial nerves, in

order from I to XII are:

olfactory nerve, optic nerve,

oculomotor nerve, trochlear

nerve, trigeminal nerve,

abducens nerve, facial

nerve, vestibulocochlear

nerve, glossopharengeal

nerve, vagus nerve, spinal

accessory nerve, and

hypoglossal nerve.

The vagus nerve (X) has

many branches and is

responsible for tasks

including heart rate,

gastrointestinal peristalsis,

sweating, and muscle

movements in the mouth,

including speech and

keeping the larynx open for

breathing.

Cranial nerves are the nerves that emerge

directly from the brain (including the

brainstem). In contrast, spinal nerves emerge

from segments of the spinal cord. Cranial

nerves relay information between the brain and

parts of the body, primarily to and from

regions of the head and neck.

Cranial Nerve Anatomy and Terminology

Spinal nerves emerge sequentially from the

spinal cord with the spinal nerve closest to the

head (C1) emerging in the space above the

first cervical vertebra. The cranial nerves

emerge from the central nervous system above

this level.

Each cranial nerve is paired and is present on

both sides. The numbering of the cranial

nerves is based on the order in which they

emerge from the brain, front to back

(brainstem).

The terminal nerves, olfactory nerves (I) and

optic nerves (II) emerge from the cerebrum or

forebrain, and the remaining ten pairs arise

from the brainstem, which is the lower part of

the brain. The cranial nerves are considered

components of the peripheral nervous system.

However, on a structural level, the olfactory,

optic, and terminal nerves are more accurately

considered part of the central nervous system.

The twelve cranial nerves are shown in the

figure below followed by brief descriptions.

The cranial nerves : The locations of the

cranial nerves within the brain.

The olfactory nerve (I): This is

instrumental for the sense of smell, it is

one of the few nerves that are capable

of regeneration.

The optic nerve (II): This nerve carries

visual information from the retina of the

eye to the brain.

The oculomotor nerve (III): This controls

most of the eye’s movements, the

constriction of the pupil, and maintains

an open eyelid.

The trochlear nerve (IV): A motor nerve

that innervates the superior oblique

muscle of the eye, which controls

rotational movement.

The trigeminal nerve (V): This is

responsible for sensation and motor

function in the face and mouth.

The abducens nerve (VI): A motor nerve

that innervates the lateral rectus muscle

of the eye, which controls lateral

movement.

The facial nerve (VII): This controls the

muscles of facial expression, and

functions in the conveyance of taste

sensations from the anterior two-thirds

of the tongue and oral cavity.

The vestibulocochlear nerve (VIII): This

is responsible for transmitting sound

and equilibrium (balance) information

from the inner ear to the brain.

The glossopharyngeal nerve (IX):

This nerve receives sensory information

from the tonsils, the pharynx, the

middle ear, and the rest of the tongue.

The vagus nerve (X): This is responsible

for many tasks, including heart rate,

gastrointestinal peristalsis, sweating,

and muscle movements in the mouth,

including speech and keeping the larynx

open for breathing.

The spinal accessory (XI): This nerve

controls specific muscles of the

shoulder and neck.

The hypoglossal nerve (XII): This nerve

controls the tongue movements of

speech, food manipulation, and

swallowing.

Olfactory (I) Nerve

The olfactory nerve, or cranial nerve I, is the

first of 12 cranial nerves and is responsible for

the sense of smell.

Key Points

The olfactory nerve consists

of a collection of many

sensory nerve fibers that

extend from the olfactory

epithelium to the olfactory

bulb.

Olfactory receptors within

the olfactory mucosa in the

nasal cavity receive

information about smells

that travel to the brain

through the cranial nerve

that extends from the

olfactory epithelium to the

olfactory bulb.

Olfactory receptor neurons

continue to emerge

throughout life and extend

new axons to the olfactory

bulb.

The olfactory nerve is the

shortest of the 12 cranial

nerves and only one of two

cranial nerves (the other

being the optic nerve) that

do not join with the

brainstem.

The olfactory nerve,

or cranial nerve I, is

the first of the 12

cranial nerves. It is

instrumental in the

sense of smell. The

olfactory nerve is

the shortest of the

12 cranial nerves

and only one of two

cranial nerves (the

other being the optic

nerve) that do not

join with the

brainstem.

The specialized olfactory receptor neurons of

the olfactory nerve are located in the olfactory

mucosa of the upper parts of the nasal cavity.

The olfactory nerves consist of a collection of

many sensory nerve fibers that extend from

the olfactory epithelium to the olfactory bulb,

passing through the many openings of the

cribriform plate of the ethmoid bone.

Olfactory receptor neurons continue to emerge

throughout life and extend new axons to the

olfactory bulb. Olfactory-ensheathing glia wrap

bundles of these axons and are thought to

facilitate their passage into the central nervous

system.

The sense of smell (olfaction) arises from the

stimulation of olfactory (or odorant) receptors

by small molecules of different spatial,

chemical, and electrical properties that pass

over the nasal epithelium in the nasal cavity

during inhalation. These interactions are

transduced into electrical activity in the

olfactory bulb, which then transmits the

electrical activity to other parts of the olfactory

system and the rest of the central nervous

system via the olfactory tract.

Optic (II) Nerve

The optic nerve (cranial nerve II) receives visual

information from photoreceptors in the retina

and transmits it to the brain.

Key Points

The optic nerve is

considered part of the

central nervous system.

The myelin on the optic

nerve is produced by

oligodendrocytes rather

than Schwann cells and it is

encased in the meningeal

layers instead of the

standard endoneurium,
perineurium, and

epineurium of the peripheral

nervous system.

The optic nerve travels

through the optic canal,

partially decussates in the

optic chiasm, and

terminates in the lateral

geniculate nucleus where

information is transmitted

to the visual cortex.

The axons responsible for

reflexive eye movements

terminate in the pretectal

nucleus.

The optic nerve is also known as cranial nerve

II. It transmits visual information from the

retina to the brain.

Each human optic nerve contains between

770,000 and 1.7 million nerve fibers. The eye’s

blind spot is a result of the absence of

photoreceptors in the area of the retina where

the optic nerve leaves the eye.

The optic nerve is the second of twelve paired

cranial nerves. It is considered by physiologists

to be part of the central nervous system, as it

is derived from an outpouching of the

diencephalon during embryonic development.

As a consequence, the fibers are covered with

myelin produced by oligodendrocytes, rather

than Schwann cells that are found in the

peripheral nervous system. The optic nerve is

ensheathed in all three meningeal layers (dura,

arachnoid, and pia mater) rather than the

epineurium, perineurium, and endoneurium

found in the peripheral nerves.

The fiber tracks of the mammalian central

nervous system are incapable of regeneration.

As a consequence, optic nerve damage

produces irreversible blindness.

The optic nerve leaves the orbit, which is also

known as an eye socket, via the optic canal,

running posteromedially toward the optic

chiasm, where there is a partial decussation

(crossing) of fibers from the nasal visual fields

of both eyes.

Most of the axons of the optic nerve terminate

in the lateral geniculate nucleus (where

information is relayed to the visual cortex),

while other axons terminate in the pretectal

nucleus and are involved in reflexive eye

movements.

The optic nerve transmits all visual information

including brightness perception, color

perception, and contrast. It also conducts the

visual impulses that are responsible for two

important neurological reflexes: the light reflex

and the accommodation reflex.

The light reflex refers to the constriction of

both pupils that occurs when light is shone into

either eye; the accommodation reflex refers to

the swelling of the lens of the eye that occurs

when one looks at a near object, as in reading.

Oculomotor (III) Nerve

The oculomoter nerve (cranial nerve III)

controls eye movement, such as constriction

of the pupil and open eyelids.

Key Points

The oculomotor nerve is the

third paired cranial nerve.

The oculomotor nerve

contains two nuclei,

including the Edinger-

Westphal nucleus that

supplies parasympathetic

nerve fibers to the eye to

control pupil constriction

and accommodation.

The oculomotor nerve

originates at the superior

colliculus and enters

through the superior orbital

fissure to control the

levator palpebrae superioris

muscles that hold the

eyelids open.

The oculomotor nerve is the third paired cranial

nerve. It enters the orbit via the superior orbital

fissure and controls most of the eye’s

movements, including constriction of the pupil

and maintaining an open eyelid by innervating

the levator palpebrae superiors muscle.

The occulomotor nerve is derived from the

basal plate of the embryonic midbrain. Cranial

nerves IV and VI also participate in control of

eye movement.
There are two nuclei for the oculomotor nerve:

1. The oculomotor nucleus originates at

the level of the superior colliculus. The

muscles it controls are the striated

muscle in the levator palpebrae

superioris and all extraocular muscles,

except for the superior oblique muscle

and the lateral rectus muscle.

2. The Edinger-Westphal nucleus supplies

parasympathetic fibers to the eye via

the ciliary ganglion, and controls the

pupillae muscle (affecting pupil

constriction) and the ciliary muscle

(affecting accommodation).

Sympathetic postganglionic fibers also join the

nerve from the plexus on the internal carotid

artery in the wall of the cavernous sinus and

are distributed through the nerve, for example,

to the smooth muscle of levator palpebrae

superioris.

Emergence from Brain

On emerging from the brain, the oculomotor

nerve is invested with a sheath of pia mater

and enclosed in a prolongation from the

arachnoid mater. It passes between the

superior cerebellar and posterior cerebral

arteries, and then pierces the dura mater

anterior and lateral to the posterior clinoid

process (to give attachment to the tectorium

cerebella), passing between the free and

attached borders of the tentorium cerebelli.

It then runs along the lateral wall of the

cavernous sinus, above the other orbital

nerves, receiving in its course one or two

filaments from the cavernous plexus of the

sympathetic nervous system, and a

communicating branch from the ophthalmic

division of the trigeminal nerve.

It then divides into two branches that enter the

orbit through the superior orbital fissure,

between the two heads of the lateral rectus (a

muscle on the lateral side of the eyeball in the

orbit). Here the nerve is placed below the

trochlear nerve and the frontal and lacrimal

branches of the ophthalmic nerve, while the

nasociliary nerve is placed between its two

rami (the superior and inferior branch of

oculomotor nerve).

Trochlear (IV) Nerve

The trochlear nerve (cranial nerve IV) is a

motor nerve that innervates a single muscle:

the superior oblique muscle of the eye.

Key Points

The trochlear nerve

innervates the superior

oblique muscle of the eye.

The trochlear nerve

contains the smallest

number of axons of all the

cranial nerves and has the

greatest intracranial length.

The two major clinical

syndromes that can arise

from damage to the

trochlear nerve are vertical

and torsional diplopia.

The trochlear nerve (cranial nerve IV) is a

motor nerve that innervates a single muscle:

the superior oblique muscle of the eye.

The trochlear nerve

is unique among the

cranial nerves in

several respects.

It is the

smallest

nerve in

terms of the

number of

axons it

contains and

it has the

greatest

intracranial

length.

Other than

the optic

nerve (cranial

nerve II), it is

the only cranial nerve that decussates

(crosses to the other side) before

innervating its target.

It is the only cranial nerve that exits

from the dorsal aspect of the

brainstem.

The nucleus of the trochlear nerve is located in

the caudal mesencephalon beneath the

cerebral aqueduct. It is immediately below the

nucleus of the oculomotor nerve (III) in the

rostral mesencephalon.

The trochlear nucleus is unique in that its

axons run dorsally and cross the midline

before emerging from the brainstem—so a

lesion of the trochlear nucleus affects the

contralateral eye. Lesions of all other cranial

nuclei affect the ipsilateral side (except of

course the optic nerve, cranial nerve II, which

innervates both eyes).

Homologous trochlear nerves are found in all

jawed vertebrates. The unique features of the

trochlear nerve, including its dorsal exit from

the brainstem and its contralateral innervation,

are seen in the primitive brains of sharks.

The human trochlear nerve is derived from the

basal plate of the embryonic midbrain.

Clinical Syndromes

There are two major clinical syndromes that

can manifest through damage to the trochlear

nerve:

Vertical diplopia: Injury to the trochlear

nerve causes weakness of downward

eye movement with consequent vertical

diplopia (double vision).

Torsional diplopia: Weakness of

intorsion results in torsional diplopia, in

which two different visual fields, tilted

with respect to each other, are seen at

the same time. To compensate for this,

patients with trochlear nerve palsies tilt

their heads to the opposite side, in

order to fuse the two images into a

single visual field.

The clinical syndromes can originate from both

peripheral and central lesions. A peripheral

lesion is damage to the bundle of nerves, in

contrast to a central lesion, which is damage

to the trochlear nucleus.

Trigeminal (V) Nerve

The trigeminal nerve is the fifth cranial nerve

and it is responsible for sensation and motor

function in the face and mouth.

Key Points

The sensory function of the

trigeminal nerve is to

provide tactile, motion,

position, and pain

sensations for the face and

mouth; its motor function

activates the muscles of

the jaw, mouth, and inner

ear.

The trigeminal nerve has

three major branches on

each side—the opthalmic

nerve, maxillary nerve, and

mandibular nerve—that

converge on the trigeminal

ganglion.

The trigeminal ganglion is

analogous to the dorsal

root ganglia of the spinal

cord, which contain the cell

bodies of incoming sensory

fibers from the rest of the

body.

The trigeminal nerve (cranial nerve V), and it

contains both sensory and motor fibers. It is

responsible for sensation in the face and

certain motor functions such as biting,

chewing, and swallowing.

The sensory

function of the

trigeminal nerve is

to provide the

tactile, motion,

position, and pain

sensations of the

face and mouth. The

motor function

activates the

muscles of the jaw,

mouth, and inner

ear.

Structure

The trigeminal nerve

is the largest of the

cranial nerves. Its

name, trigeminal,

means three twins. It is derived from the fact

that each nerve, one on each side of the pons,

has three major branches: the ophthalmic nerve

(V1 in the illustration below), the maxillary

nerve (V2), and the mandibular nerve (V3).

The ophthalmic and maxillary nerves are purely

sensory. The mandibular nerve has both

sensory and motor functions.

The three branches converge on the trigeminal

ganglion that is located within the trigeminal

cave in the brain; it contains the cell bodies of

incoming sensory nerve fibers. The trigeminal

ganglion is analogous to the dorsal root

ganglia of the spinal cord, which contain the

cell bodies of incoming sensory fibers from the

rest of the body.

From the trigeminal

ganglion, a single

large sensory root

enters the brainstem

at the level of the

pons. Immediately

adjacent to the

sensory root, a

smaller motor root

emerges from the

pons at the same

level.

Motor fibers pass

through the

trigeminal ganglion

on their way to

peripheral muscles,

but their cell bodies

are located in the

nucleus of the

trigeminal nerve,
deep within the

pons.

Function

The sensory function of the trigeminal nerve is

to provide tactile, proprioceptive, and

nociceptive afferents to the face and mouth.

The motor component of the mandibular

division (V3) of the trigeminal nerve controls

the movement of eight muscles, including the

four muscles of mastication: the masseter, the

temporal, and the medial and lateral

pterygoids.

The other four muscles are the tensor veli

palatini, the mylohyoid, the anterior belly of the

digastric, and the tensor tympani. With the

exception of the tensor tympani, all of these

muscles are involved in biting, chewing and

swallowing, and all have bilateral cortical

representation.

Abducens (VI) Nerve

The abducens nerve (cranial nerve VI) controls

the lateral movement of the eye through

innervation of the lateral rectus muscle.

Key Points

The abducens nerve exits

the brainstem at the

junction of the pons and the

medulla and runs upward to

reach the eye, traveling

between the dura and the

skull.

The long course of the

abducens nerve between

the brainstem and the eye

makes it vulnerable to injury

at many levels.

In most mammals besides

humans, it also innervates

the musculus retractor

bulbi, which can retract the

eye for protection.

The abducens nerve (cranial nerve VI) is a

somatic efferent nerve that, in humans,

controls the movement of a single muscle: the

lateral rectus muscle of the eye that moves the

eye horizontally. In most other mammals it

also innervates the musculus retractor bulbi,

which can retract the eye for protection.

Homologous abducens nerves are found in all

vertebrates except lampreys and hagfishes.

The abducens nerve

leaves the brainstem

at the junction of the

pons and the

medulla, medial to

the facial nerve. In

order to reach the

eye, it runs upward

(superiorly) and

then bends forward

(anteriorly).

The nerve enters the

subarachnoid space

when it emerges
from the brainstem.

It runs upward

between the pons

and the clivus, and

then pierces the

dura mater to run between the dura and the

skull.

At the tip of the petrous temporal bone, it

makes a sharp turn forward to enter the

cavernous sinus. In the cavernous sinus it runs

alongside the internal carotid artery. It then

enters the orbit through the superior orbital

fissure and innervates the lateral rectus muscle

of the eye.

The long course of the abducens nerve

between the brainstem and the eye makes it

vulnerable to injury at many levels. For

example, fractures of the petrous temporal

bone can selectively damage the nerve, as can

aneurysms of the intracavernous carotid

artery.

Mass lesions that push the brainstem

downward can damage the nerve by stretching

it between the point where it emerges from the

pons and the point where it hooks over the

petrous temporal bone.

Facial (VII) Nerve

The facial nerve (cranial nerve VII) determines

facial expressions and the taste sensations of

the tongue.

Key Points

The facial nerve (cranial

nerve VII) is responsible for

the muscles that determine

facial expression, as well as

the sensation of taste in the

front of the tongue and oral

cavity.

The facial nerve’s motor

component begins in the

facial nerve nucleus in the

pons, and the sensory

component begins in the

nervus intermedius. The

nerve then runs through the

facial canal, passes through

the parotid gland, and

divides into five branches.

Voluntary facial

movements, such as

wrinkling the brow, showing

teeth, frowning, closing the

eyes tightly (inability to do

so is called

lagophthalmos), pursing

the lips, and puffing out the

cheeks, all test the facial

nerve.

The facial nerve is

the seventh (cranial

nerve VII) of the 12,

paired cranial

nerves. It emerges

from the brainstem

between the pons

and the medulla and

controls the

muscles of facial

expression.

It also functions in

the conveyance of

taste sensations

from the anterior

two-thirds of the tongue and oral cavity, and it

supplies preganglionic parasympathetic fibers

to several head and neck ganglia.

Location

The motor part of the facial nerve arises from

the facial nerve nucleus in the pons, while the

sensory part of the facial nerve arises from the

nervus intermedius. The motor and sensory

parts of the facial nerve enter the petrous

temporal bone into the internal auditory

meatus (intimately close to the inner ear), then

runs a tortuous course (including two tight

turns) through the facial canal, emerges from

the stylomastoid foramen, and passes through

the parotid gland, where it divides into five

major branches.

Although it passes through the parotid gland, it

does not innervate the gland (this is the

responsibility of cranial nerve IX, the

glossopharyngeal nerve). The facial nerve

forms the geniculate ganglion prior to entering

the facial canal.

The path of the facial nerve can be divided into

six segments.

1. The intracranial (cisternal) segment.

2. The meatal segment (brainstem to

internal auditory canal).

3. The labyrinthine segment (internal

auditory canal to geniculate ganglion),

4. The tympanic segment (from

geniculate ganglion to pyramidal

eminence).

5. The mastoid segment (from pyramidal

eminence to stylomastoid foramen).

6. The extratemporal segment (from

stylomastoid foramen to post parotid

branches).

Function

Voluntary facial

movements, such as

wrinkling the brow,

showing teeth,

frowning, closing

the eyes tightly

(inability to do so is

called

lagophthalmos),

pursing the lips, and

puffing out the

cheeks, all test the

facial nerve. There

should be no

noticeable

asymmetry.

In an upper motor
neuron lesion, called

central seven

(central facial

palsy ), only the

lower part of the face on the contralateral side

will be affected due to the bilateral control to

the upper facial muscles (frontalis and

orbicularis oculi).

Lower motor neuron lesions can result in a

cranial nerve VII palsy (Bell’s palsy is the

idiopathic form of facial nerve palsy),

manifested as both upper and lower facial

weakness on the same side of the lesion.

Taste can be tested on the anterior 2/3 of the

tongue. This can be tested with a swab dipped

in a flavored solution, or with electronic

stimulation (similar to putting your tongue on a

battery).

In regards to the corneal reflex, the afferent arc

is mediated by the general sensory afferents of

the trigeminal nerve. The efferent arc occurs

via the facial nerve.

The reflex involves the consensual blinking of

both eyes in response to stimulation of one

eye. This is due to the facial nerve’s

innervation of the muscles of facial expression,

namely the orbicularis oculi, responsible for

blinking. Thus, the corneal reflex effectively

tests the proper functioning of both cranial

nerves V and VII.

Vestibulocochlear (VIII) Nerve

The vestibulocochlear nerve (cranial nerve VIII)

carries information about hearing and balance.

Key Points

The vestibulocochlear nerve

comprises the cochlear

nerve that transmits hearing

information, and the

vestibular nerve that

transmits balance

information.

The cochlear nerve travels

away from the cochlea of

the inner ear where it starts

as the spiral ganglia.

The vestibular nerve travels

from the vestibular system

of the inner ear.

The vestibulocochlear nerve (also known as

the auditory vestibular nerve and cranial nerve

VIII) has axons that carry the modalities of

hearing and equilibrium.

It consists of the cochlear nerve that carries

information about hearing, and the vestibular

nerve that carries information about balance.

This is the nerve along which the sensory cells

(the hair cells) of the inner ear transmit

information to the brain. It emerges from the

pons and exits the inner skull via the internal

acoustic meatus (or internal auditory meatus)

in the temporal bone.

The

vestibulocochlear

nerve consists
mostly of bipolar

neurons and splits

into two large

divisions: the

cochlear nerve and

the vestibular nerve.

The cochlear nerve

travels away from

the cochlea of the

inner ear where it

starts as the spiral

ganglia.

Processes from the

organ of Corti (the

receptor organ for

hearing) conduct afferent transmission to the

spiral ganglia. It is the inner hair cells of the

organ of Corti that are responsible for

activating the afferent receptors in response to

pressure waves reaching the basilar membrane

through the transduction of sound.

The vestibular nerve travels from the vestibular

system of the inner ear. The vestibular

ganglion houses the cell bodies of the bipolar

neurons and extends processes to five sensory

organs.

Three of these are the cristae, located in the

ampullae of the semicircular canals. Hair cells

of the cristae activate afferent receptors in

response to rotational acceleration.

The other two sensory organs supplied by the

vestibular neurons are the maculae of the

saccule and utricle. Hair cells of the maculae

activate afferent receptors in response to linear

acceleration.

The vestibulocochlear nerve has axons that

carry the modalities of hearing and equilibrium.

Damage to the vestibulocochlear nerve may

cause hearing loss, vertigo, a false sense of

motion, loss of equilibrium in dark places,

nystagmus, motion sickness, and gaze-evoked

tinnitus.

A benign primary intracranial tumor of

vestibulocochlear nerve is called a vestibular

schwannoma (also called acoustic neuroma).

Glossopharyngeal (IX) Nerve

The glossopharyngeal nerve (cranial nerve IX)

serves many distinct functions,

including providing sensory innervation to

various head and neck structures.

Key Points

The glossopharyngeal nerve

(cranial nerve IX) is

responsible for swallowing

and the gag reflex, along

with other functions.

The glossopharyngeal nerve

receives input from the

general and special sensory

fibers in the back of the

throat.

The glossopharyngeal nerve

has five components:

branchial motor, visceral

motor, visceral sensory,

general sensory, and

special sensory

components.

Structure

The glossopharyngeal nerve is the ninth of 12

pairs of cranial nerves. It exits the brainstem

out from the sides of the upper medulla, just

rostral (closer to the nose) to the vagus nerve.

The motor division

of the

glossopharyngeal

nerve is derived

from the basal plate

of the embryonic

medulla oblongata,

while the sensory

division originates

from the cranial

neural crest.

Function

There are a number

of functions of the

glossopharyngeal

nerve. It controls muscles in the oral cavity and

upper throat, as well as part of the sense of

taste and the production of saliva.

Along with taste, the glossopharyngeal nerve

relays general sensations from the pharyngeal

walls. The various functions of the

glossopharyngeal nerve are that:

It receives general sensory fibers

(ventral trigeminothalamic tract) from

the tonsils, the pharynx, the middle ear,

and the posterior 1/3 of the tongue.

It receives special sensory fibers

(taste) from the posterior 1/3 of the

tongue.

It receives visceral sensory fibers from

the carotid bodies, carotid sinus.

It supplies parasympathetic fibers to

the parotid gland via the otic ganglion.

It supplies motor fibers to the

stylopharyngeus muscle.

It contributes to the pharyngeal plexus.

Five Functional Components

The glossopharyngeal nerve consists of five

components with distinct functions:

1. Branchial motor (special visceral

efferent): Supplies the stylopharyngeus

muscle.

2. Visceral motor (general visceral

efferent): Provides parasympathetic

innervation of the parotid gland.

3. Visceral sensory (general visceral

afferent): Carries visceral sensory

information from the carotid sinus and

body.

4. General sensory (general somatic

afferent): Provides general sensory

information from the skin of the

external ear, internal surface of the

tympanic membrane, upper pharynx,

and the posterior 1/3 of the tongue.

5. Special sensory (special afferent):

Provides taste sensation from the

posterior 1/3 of the tongue.

Vagus (X) Nerve

The vagus nerve (cranial nerve X) is

responsible for parasympathetic output to the

heart and visceral organs.

Key Points

The vagus nerve (cranial

nerve X) sends information

about the body’s organs to

the brain and carries some

motor information back to

the organs.

The vagus nerve has axons

that originate from or enter

the dorsal nucleus of the

vagus nerve, the nucleus

ambiguus, the solitary

nucleus in the medulla, and

the spinal trigeminal

nucleus.

The vagus nerve is

responsible for heart rate,

gastrointestinal peristalsis,

and sweating, to name a

few.

Vagus Nerve Anatomy

The vagus nerve, also known as the

pneumogastric nerve or cranial nerve X, is the

tenth of twelve paired cranial nerves. Upon

leaving the medulla between the medullary

pyramid and the inferior cerebellar peduncle, it

extends through the jugular foramen, then

passes into the carotid sheath between the

internal carotid artery and the internal jugular

vein below the head, to the neck, chest and

abdomen, where it contributes to the

innervation of the viscera.

Besides output to

the various organs

in the body, the

vagus nerve conveys

sensory information

about the state of

the body’s organs

to the central

nervous system.

Eighty to 90% of the

nerve fibers in the

vagus nerve are

afferent (sensory)

nerves that

communicate the

state of the viscera

to the brain.

The vagus nerve includes axons that emerge

from or converge onto four nuclei of the

medulla.

The dorsal nucleus of vagus nerve:

Sends parasympathetic output to the

viscera, especially the intestines.

The nucleus ambiguus: Sends

parasympathetic output to the heart

(slowing it down).

The solitary nucleus: Receives afferent

taste information and primary afferents

from visceral organs.

The spinal trigeminal nucleus: Receives

information about deep/crude touch,

pain, and temperature of the outer ear,

the dura of the posterior cranial fossa,

and the mucosa of the larynx.

Function

The vagus nerve supplies motor

parasympathetic fibers to all the organs,

except the suprarenal (adrenal) glands, from

the neck down to the second segment of the

transverse colon. The vagus also controls a

few skeletal muscles, most notably:

Cricothyroid muscle.

Levator veli palatini muscle.

Salpingopharyngeus muscle.

Palatoglossus muscle.

Palatopharyngeus muscle.

Superior, middle, and inferior

pharyngeal constrictors.

Muscles of the larynx (speech).

This means that the vagus nerve is responsible

for such varied tasks as heart rate,

gastrointestinal peristalsis, sweating, and quite

a few muscle movements in the mouth,

including speech (via the recurrent laryngeal

nerve), swallowing, and keeping the larynx

open for breathing (via action of the posterior

cricoarytenoid muscle, the only abductor of the

vocal folds).

It also has some afferent fibers that innervate

the inner (canal) portion of the outer ear, via

the auricular branch (also known as

Alderman’s nerve) and part of the meninges.

This explains why a person may cough when

tickled on the ear (such as when trying to

remove ear wax with a cotton swab).

Afferent vagus nerve fibers that innervate the

pharynx and back of the throat are responsible

for the gag reflex. In addition, 5-HT3 receptor-

mediated afferent vagus stimulation in the gut

due to gastroenteritis and other insults is a

cause of vomiting.

Cardiovascular Influence

Parasympathetic innervation of the heart is

partially controlled by the vagus nerve and is

shared by the thoracic ganglia. Activation of

the vagus nerve typically leads to a reduction in

heart rate and/or blood pressure.

This occurs commonly in cases of viral

gastroenteritis, acute cholecystitis, or in

response to stimuli such as the Valsalva

maneuver or pain. Excessive activation of the

vagal nerve during emotional stress can also

cause vasovagal syncope due to a sudden

drop in cardiac output, causing cerebral

hypoperfusion.

Accessory (XI) Nerve

The accessory nerve (cranial nerve XI) controls

the muscles of the shoulder and neck.

Key Points
Cranial nerve XI is

responsible for tilting and

rotating the head, elevating

the shoulders, and

adducting the scapula.

Most of the fibers of the

accessory nerve originate in

neurons situated in the

upper spinal cord. The

fibers that make up the

accessory nerve enter the

skull through the foramen

magnum and proceed to

exit the jugular foramen

with cranial nerves IX and

X.

Due to its unusual course,

the accessory nerve is the

only nerve that enters and

exits the skull.

Anatomic Description

The accessory nerve (cranial nerve XI) controls

the sternocleidomastoid and trapezius

muscles of the shoulder and neck. It begins in

the central nervous system (CNS) and exits

the cranium through a foramen.

Unlike the other 11 cranial nerves, the

accessory nerve begins outside the skull. In

fact, most of the fibers of the nerve originate in

neurons situated in the upper spinal cord.

The fibers that make

up the accessory
nerve enter the skull

through the foramen

magnum and

proceed to exit the

jugular foramen with

cranial nerves IX and

X. Due to its

unusual course, the

accessory nerve is

the only nerve that

enters and exits the

skull.

Traditional

descriptions of the

accessory nerve

divide it into two

components: a

spinal component

and a cranial

component.

However, more

modern

characterizations of

the nerve regard the

cranial component

as separate and

part of the vagus

nerve.

Therefore, in contemporary discussions of the

accessory nerve, it is common to disregard the

cranial component when referencing the

accessory nerve and assume reference to the

spinal accessory nerve.

Accessory Nerve Function

The accessory nerve provides motor

innervation from the CNS to the

sternocleidomastoid and trapezius muscles of

the neck. The sternocleidomastoid muscle tilts

and rotates the head, while the trapezius

muscle has several actions on the scapula,

including shoulder elevation and adduction of

the scapula.

During neurological examinations, the function

of the spinal accessory nerve is often

measured by testing the range of motion and

strength of the aforementioned muscles.

Limited range of motion or diminished muscle

strength often indicates injury of the accessory

nerve.

Patients with spinal accessory nerve palsy may

exhibit signs of lower motor neuron disease,

such as atrophy and fasciculations of both the

sternocleidomastoid and trapezius muscles.

Hypoglossal (XII) Nerve

The hypoglossal nerve (cranial nerve XII)

controls the muscles of the tongue.

Key Points

It controls tongue

movements of speech, food

manipulation, and

swallowing.

While the hypoglossal nerve

controls the tongue’s

involuntary activities of
swallowing to clear the

mouth of saliva, most of

the functions it controls are

voluntary, meaning that the

execution of these activities

requires conscious thought.

Proper function of the

hypoglossal nerve is

important for executing

tongue movements

associated with speech.

Many languages require

specific uses of the nerve

to create unique speech

sounds, which may

contribute to the difficulties

some adults encounter

when learning a new

language.

Structure and Location

The hypoglossal nerve is the twelfth cranial

nerve (XII) and innervates all extrinsic and

intrinsic muscles of the tongue, except for the

palatoglossus. The hypoglossal nerve emerges

from the medulla oblongata in the preolivary

sulcus where it separates the olive (olivary

body) and the pyramid (medullary pyramid).

It goes on to traverse the hypoglossal canal

and, upon emerging, it branches and merges

with a branch from the anterior ramus of C1. It

passes behind the vagus nerve and between

the internal carotid artery and internal jugular

vein which lies on the carotid sheath. After

passing deep to the posterior belly of the

digastric muscle it proceeds to the

submandibular region to enter the tongue.

Hypoglossal nerve : Schematic image of

the hypoglossal nerve and the structures it

innervates.

Function

The hypoglossal nerve controls tongue

movements of speech, food manipulation, and

swallowing. It supplies motor fibers to all of

the muscles of the tongue, with the exception

of the palatoglossus muscle, which is

innervated by the vagus nerve (cranial nerve X)

or, according to some classifications, by fibers

from the glossopharyngeal nerve (cranial nerve

IX) that hitchhike within the vagus.

While the hypoglossal nerve controls the

tongue’s involuntary activities of swallowing to

clear the mouth of saliva, most of the

functions it controls are voluntary, meaning

that the execution of these activities requires

conscious thought.

Proper function of the hypoglossal nerve is

important for executing the tongue movements

associated with speech. Many languages

require specific and sometimes unusual uses

of the nerve to create unique speech sounds,

which may contribute to the difficulties some

adults encounter when learning a new

language. Several corticonuclear-originating

fibers supply innervation and aid in the

unconscious movements required upon

engaging in speech and articulation.

Progressive bulbar palsy is a neuromuscular

atrophy associated with the combined lesions

of the hypoglossal nucleus and the nucleus

ambiguous, upon atrophy of the motor nerves

of the pons and medulla. This condition

causes dysfunctional tongue movements that

lead to speech and chewing impairments and

swallowing difficulties. Tongue muscle atrophy

may also occur.

In this four-part series of articles, we look at how

and why to assess a patient who has suffered an

insult to the head or spine. This first article

focuses on the importance of the cranial nerve

exam. In subsequent articles we will consider the

neurologic exam, talk about what selective spinal

immobilization protocols actually assess, and

review what dermatomes are and how to use

them to our advantage. In a follow-up article, we

will review what happens to our patients in the

months and years that follow a severe spinal

injury.

Cranial nerves begin and, for the most part, end in

the head, which makes them very useful in

detecting brain injury, sometimes long before a

patient becomes severely ill. They innervate, and

thereby give movement and sensation to, the eyes,

ears, nose, mouth and face in the same way

peripheral nerves give motion and sensation to our

torso, arms, legs, hands and feet. Anatomically,

the cranial nerves travel through distinct locations

in the brain, and because of this assessing them

can sometimes give us early and detailed

information about brain injury.

Brain Injury Detectors

Brain injury stemming from stroke, trauma and

even a combination of both is commonly

encountered in the prehospital environment.

Perhaps because of this frequency, most

providers are adept at diagnosing “classic” brain

injury. We all know to be vigilant for obvious signs,

particularly in at-risk patients such as children,

alcoholics, the elderly and persons on

anticoagulant medications. In all patient groups,

we listen carefully for slurred speech and look for

one-sided weakness, changes in mental status,

alterations in pupillary reaction and pronator drift.

But the patients who present with these obvious

signs or had an impressive mechanism of injury

are the easy cases. We know these patients are

significantly injured and need immediate in-

hospital neurologic care. These are not the

patients a cranial nerve exam will likely benefit.

When considering the importance of learning the

cranial nerve exam, don’t think of your experiences

with grossly brain-injured patients; instead, ask

yourself how many times you’ve seen patients

who suffered seemingly minor head trauma and

wished you had a few more tools at your disposal

to more thoroughly evaluate them. These are the

patients who have fallen from a standing position

and bumped their head or been hit on the head by

a stray baseball or walked into some unexpectedly

hard object and developed a large scalp

hematoma. And how many times have you

evaluated a patient who has vague complaints

that might resemble stroke and wanted to have

another tool to add to your usual stroke exam?

These are the times when the cranial nerve exam

can be very helpful.

These minor-injury and low-suspicion patients are

sometimes reluctant to be transported, and we,

being good medical providers, often respond by

coaching them to be transported anyway, or at

least be seen on their own at a facility where

emergency care and a CT scanner are available.

Should they happen to be taking warfarin, be

elderly or alcoholic, or have a history of prior brain

injury or some other risk factor for intracranial

bleeding, our alarm bells start ringing and we balk

hard at taking “no” for a transport answer. This is

good standard practice; it is how good providers

ensure a minor head injury yielding a small

amount of intracranial hemorrhage doesn’t evolve

into a larger, problematic hemorrhage without

someone detecting it in time.

The problem is that when brain-injured patients

don’t yet appear to be acutely ill or have risk

factors that put them on our radar, they are

notoriously hard to assess. We know this

intuitively because most of us have seen, or at

least heard stories about, patients who originally

exhibited few symptoms from a brain injury but

later became very ill and were found to have

intracranial hemorrhage. The case of Natasha

Richardson, an actress who died in 2009 from

traumatic brain injury after falling on a ski slope

and initially refusing care, brought this type of

injury to the forefront of national awareness as

well. We need to have some strategies to

anticipate this kind of change.

Assessing a cranial nerve exam can be one of

these strategies. Although it cannot be used to

rule out brain injury, this exam can occasionally

pick up subtle signs of brain injury we otherwise

might miss and help us get our patients to the

most appropriate hospital care. As prehospital

providers it is our job to perform the initial triage

of every one of our patients. Not only do we

decide which patients get transported to the ED,

but in many cases we recommend the appropriate

destination hospital for their care. Positive

findings in the cranial nerve exam can help us by

providing an early clue that a major injury may

have followed minor trauma. This is important in

our effort to advocate appropriately for patient

transport, and can also aid in deciding whether a

patient needs a hospital with a neurosurgery

service or whether one without will, at least

initially, suffice. On arrival, it is our presentation to

the ED staff that largely determines which patients

get seen immediately in an acute room (and get

an immediate CT) and which may wait for

assessment and treatment. In the case of patients

with minor-appearing head injuries or vague

symptoms of stroke, positive cranial nerve exam

findings can sometimes help determine correct

emergency department triage.

Subtle Signs

Cranial nerve exams are quick and easy.

Particularly when they are done serially (every 5 or

10 minutes throughout the time we spend with our

patient) and analyzed for any change, they can

help us pick up subtle signs of worsening injury.

One of the easiest ways to learn the exam is to

memorize a simple pattern of tests the patient

should be able to complete. Keep the pattern in

order. Be consistent when you use it and don’t

skip steps. Don’t bother learning the nerve names

until you have gotten lots of practice with the

exam pattern and know it cold. To be normal, the

findings of all tests should be bilateral and

symmetrical.

There are lots of renditions of the cranial nerve

exam, some more exhaustive than others, so don’t

worry if someone else’s exam is slightly different

from yours, but do always take the opportunity to

learn from them. An example of one good cranial

nerve exam pattern for the emergency care setting

follows. The mnemonic for this particular exam is

PEEE FFUTSS (sounds like peanuts ):

Pupils— Dim the dome lights and perform a pupil

exam with your penlight. Pupils should be equal,

round and reactive when you apply your light

directly, and when you flash your light in one eye,

both pupils should constrict.

Eyes— Test for eye motion. The patient should be

able to follow your finger as you trace a large H-

shaped pattern about one arm’s length away from

their face (using the approximate length of the

patient’s arm is most appropriate). This allows

you to see whether they can move both of their

eyes up, sideways and down in both the lateral

and medial fields. Also, ask whether the patient is

having any differences from their usual vision

(new blurriness, double vision, etc.).

Eyelids— Instruct the patient to keep their eyelids

squeezed tightly shut, then place your fingertips

lightly upon the lids and gently see if you can open

them. You should not be able to do so.

Ears— Rub your fingers together next to each of

the patient’s ears and see if they can hear them to

their usual (self-reported) ability.

Facial Sensation and Mastication— Lightly brush

the patient’s skin at the forehead, cheeks and chin

with your fingertips. Record whether they have

sensation bilaterally, then hold your fingers on the

sides of their mandible and have them squeeze

their teeth together as if chewing. Make sure their

chewing muscles tense beneath your fingers.

Facial Movement— Have the patient smile widely,

showing their teeth, and raise their eyebrows.

Their facial expression should be symmetrical.

Uvula— Have the patient open their mouth wide

and say ‘A-a-ah.’ Look in the back of their throat

as they do this. Their uvula should stay in a

midline position.

Tongue— Have the patient stick out their tongue

as if they are angry at you and see whether it

sticks out straight (normal) or to one side

(abnormal).
Swallow— Have the patient swallow. They should

do so without distress or difficulty.

Shrug— Have the patient shrug their shoulders

against resistance from your hands. The shrug

should be strong and symmetrical.

You can learn the cranial nerve assessment

pattern and use it without knowing exactly what

the names of the cranial nerves are. If you are

interested, however, you can go on to memorize

which actual cranial nerves go with which

assessment maneuvers. Again, the time to do this

is usually after you’ve gotten really good at using

the assessment pattern. This may keep your

frustration to a minimum.

Good paramedic students learn (correctly) that

there 12 cranial nerves. You can remember them

with the “clean” rhyme below ( On old Olympus’

towering top, a French and German viewed a hop )

or with assorted more entertaining ones (Google

can help you find those).

Conclusion

The cranial nerve exam is not a perfect

assessment tool. Brain injury, especially when it

involves intracranial hemorrhage, can be an

evolving process. Therefore, a patient with a

cranial nerve exam that shows no abnormal

findings can certainly still go on to manifest later

with life-threatening stroke or traumatic brain

injury. Any abnormality that is found, however,

should always be taken as a serious warning of

worsening bleed. This is particularly true when the

cranial nerve findings worsen over the course of

two or more exams.

Consider these findings when deciding upon an

appropriate destination hospital, and report them

directly to a physician as well as the nursing staff

as soon as possible upon arrival. Report of a

cranial nerve abnormality, particularly if it is

evolving, will usually prompt a more rapid

evaluation and decision about the need for CT by

ED staff. Evaluation of the cranial nerve exam is

one more strategy to help prehospital providers

find and treat brain injuries sooner, and for some

of our brain-injured patients, time most certainly

counts.