CRANIAL NERVES

Dr Dyan Roshinta Laksmi Dewi,Sp.S

SMF SARAF
RSUD DR SOEDARSO PONTIANAK
 CRANIAL NERVES

General Characteristics:
 The 12 pairs of cranial nerves are part of the
peripheral nervous system.

 The Roman numeral is based on descending order

of the cranial nerve's attachment to the CNS.

 As a rule, cranial nerves do not cross in the brain.

 Cranial nerves may be sensory, motor both

somatic or parasympathetic, or have mixed
function.
 CN I - OLFACTORY
ORIGIN: Cerebral hemisphere
INNERVATION: Nasal mucous membranes.
FUNCTION: Sense of smell
DYSFUNCTION: Anosmia

CLINICAL EVALUATION
 Use aromatic substances,
i.e. coffee, lemon, garlic,
etc.
 Test each nostril separately.
 CN II - OPTIC
CLINICAL EVALUATION
VISUAL ACUITY: Snellen chart for distant
vision, newspaper or fingers for near vision.
VISUAL FIELDS: Confrontation.
FUNDI AND OPTIC DISCS:
Visualization of the termination of
the optic nerve by looking through
pupil with ophthalmoscope.

SPECIFIC DYSFUNCTIONS
 Blurred vision or complete blindness.
 Ipsilateral vision loss - Optic atrophy, retinal/optic nerve lesions, trauma.
 Visual loss (one or both eyes) - Optic chiasm or occipital lobe lesions.
 Cortical blindness - Lesion of occipital cortex bilaterally, pupil reflexes intact.
 Papilledema - Optic nerve tumor, venous obstruction, chronic increased ICP.
 Optic atrophy - MS, optic neuritis, increased ICP.
 Scotomas- (Abnormal blind spots on visual fields) - optic neuritis or atrophy.
 Hemianopia - (loss of half of visual field in one or both eyes) - Lesions of optic
chiasm, tracts, or radiations.
 CN III - OCULOMOTOR
ORIGIN: Midbrain
INNERVATION: EOM's; eyelid; ciliary; and sphincter of iris.
FUNCTION: Eye movement inward (medially), upward, downward, and outward; pupil
constriction, shape and equality; elevates upper eyelid; accommodation
reflex.
DYSFUNCTION:Unable to look up, down, or medial (dysconjugate gaze); ptosis, pupil
dilatation - bilateral or ipsilateral, and loss of accommodation reflex.
CLINICAL EVALUATION
 Observe for eye opening and symmetry.

 Direct light response - brisk, sluggish, or non-reactive.

 Consensual response - present or absent.

 Pupil size and shape.

 Accommodation.

 Extraocular movement (EOM's) (Abducens).

CRANIAL NERVE FUNCTION & MUSCLE INNERVATION
RELATIVE TO EYE MOVEMENT

Superior rectus Inferior oblique

CN III CN III

Lateral rectus Medial rectus

CN VI CN III

Inferior rectus Superior oblique

CN III CN IV
CN IV - TROCHLEAR CN VI - ABDUCENS

ORIGIN: Midbrain ORIGIN: Pons

INNERVATION: Superior oblique muscle.
FUNCTION: Down and inward movement of
the eye.
DYSFUNCTION: Loss of downward, inner
movement of eye, dysconjugate gaze.
INNERVATION: Lateral rectus muscle.
FUNCTION: Outward, lateral movement of
eye.
DYSFUNCTION: Loss of lateral eye
movement, dysconjugate gaze.

CLINICAL EVALUATION

 Extraocular movements (EOM's)

 CN IV (Trochlear) and CN VI tested with CN III (Oculomotor)
 CN V - TRIGEMINAL
ORIGIN: Pons. The sensory nucleus extends from the pons to the midbrain, and
also to the medulla and spinal cord.
INNERVATION: Three branches of CN V:
Ophthalmic, maxillary, & mandibular. Motor
innervation to masseter & temporal muscles.
Sensory innervation to skin & mucous
membranes in head; teeth, tongue, external
auditory canal, and cornea.
FUNCTION: Sensation of pain, touch, hot, &
Nerve Root Patterns
cold; motor movement of masseter & temporal
muscles.
DYSFUNCTION: Loss of sensation - if affecting all three branches, indicative of peripheral
injury. Brainstem or upper cervical cord injury may result in loss of sensation to one or more
branches of the trigeminal nerve.
- Loss of corneal reflex.
- Paresthesia and/or severe pain indicative
of nerve compression or irritation (Trigeminal neuralgia)
-Deviation of jaw, loss of sensation. Brain Stem = Onion skin
Inability to bite down and chew, inability to close jaw. sensory deficit
 CN V - TRIGEMINAL
CLINICAL EVALUATION
 SENSATION: Test with patients eye closed. Evaluate pain, temperature, & light
touch to jaw, cheeks, and forehead. Observe response and symmetry.

 MOTOR: Open jaw, check for deviation. Have patient bite down, palpate masseter
and temporal muscles. Move jaw laterally against resistance to evaluate weakness
or paralysis.

CORNEAL REFLEX: Cotton wisp across cornea, observe for

blink (function of CN III)

JAW JERK: Tap lower jaw with mouth open - check for slight
elevation of mandible.
 CN VII- FACIAL
ORIGIN: Pons & medulla.
INNERVATION: Anterior two-thirds of tongue; facial muscles, scalp, ear, and neck.
FUNCTION: - Control of facial muscles (expressions)
- Motor limb of blink & corneal reflexes
- Secretion of salivary & lacrimal glands
- Sensation of taste, anterior two-thirds tongue.

DYSFUNCTION:
Motor = Facial asymmetry - Ipsilateral weakness/paralysis, right or left, indicative of
damage to motor nucleus or peripheral component (lower motor neuron lesion) EX:
Bell's palsy
Contralateral weakness/paralysis of lower face indicative of contralateral motor
cortex damage (upper motor neuron lesion) or hemispheric lesion, i.e. massive CVA.
Bilateral weakness or paralysis , E.g. myasthenia gravis or Guillian Barre.

Parasympathetic -Loss or excessive tearing or salivation

Sensory= Loss of taste
Combined problem = speech difficulty and drooling/difficulty handling food
 CN VII - FACIAL
CLINICAL EVALUATION

MOTOR FUNCTION:
 Observe for facial symmetry
 Ask patient to wrinkle forehead, puff cheeks,
smile, show teeth, open eyes against
resistance, and whistle.
SENSORY FUNCTION:
 Test each side of tongue separately.
 Test for sweet (tip of tongue); sour (sides of
tongue); salty (over most of tongue, but
concentrated on sides).
 Give sip of water between tastes.
 CN VIII - ACOUSTIC
ORIGIN: Pons and medulla
INNERVATION: Cochlear - ear
Vestibular - ear
FUNCTION: Cochlear - Hearing
Vestibular - Balance, maintenance of body position, and proprioception.
DYSFUNCTION (Cochlear)
- Unilateral deafness
- Loss of sound appreciation
- Tinnitis
- (Rinne Test) AC >BC or both diminished indicative of nerve damage,
BC> AC middle ear disease.
- (Weber Test) Lateralization to good ear is nerve damage, lateralization to
bad ear is, middle ear disease.

DYSFUNCTION (VESTIBULAR)
- Vertigo
- Balance disturbances

Vestibular branch normally not tested unless patient gives history of vertigo or balance
Disturbance history is positive, caloric testing is done by physician.
 CN VIII - ACOUSTIC
CLINICAL EVALUATION
 HEARING: Test bilaterally, whisper or watch tick

 CONDUCTION: Weber and Rinne tests (Differentiate between conduction

deafness and nerve deafness)

Weber Test: Evaluates lateralization. Use

vibrating tuning fork on top of patient's head,
ask patient where he hears it (one or both
sides).
Rinne Test: Evaluates air (AC) and bone
conduction (BC). Place the base of a vibrating
tuning fork on the mastoid process until patient
can no longer hear sound; then quickly move
tuning fork near ear canal. Ask the patient if he
hears it, compare hearing times.
Rinne test: AC > BC normal result.
 CN IX- GLOSSOPHARYNGEAL
and CN X - VAGUS
Glossopharyngeal (IX) Vagus (X)

ORIGIN: Medulla Medulla

Mucous membranes of tonsils, Muscles of larynx, pharynx, and

pharynx, posterior one-third of soft palate. Parasympathetic
INNERVATION:
tongue, pharyngeal muscles, innervation of thoracic and
carotid sinus and carotid body abdominal viscera.

Muscles of larynx, pharynx, and

soft palate;- Sensation conveyed
Taste from posterior one-third of
from the heart, lungs, digestive
FUNCTION: tongue - Afferent limb of gag,
tract, carotid sinus, & carotid
swallow, and cardiac reflexes.
body; Efferent limb of gag and
swallow

Loss of gag & swallow reflex;

DYSFUNCTION: Loss of taste; Neuralgia Loss of carotid sinus &
oculocardiac reflex; Dysphagia
 CN IX- GLOSSOPHARYNGEAL
and CN X - VAGUS
CLINICAL EVALUATION

CN IX and X considered jointly, actions are seldom compared separately; they are
always tested together.

- Evaluate voice quality (hoarseness or dysarthria)

- Ask patient to open mouth, say "ah", observe for
elevation of soft palate, midline position of uvula.
- Gag reflex, bilaterally
- Swallowing
- Taste (bitter) posterior one-third tongue*
*usually not tested
Negative Findings
- Loss of voice quality, (dysarthria or hoarseness)
- Deviation of uvula toward non-paralyzed side
- Swallowing difficulty or nasal regurgitation
- Vagal irritation (bradycardia)
 CN XI - SPINAL ACCESSORY
ORIGIN: Medulla
INNERVATION: Sternocleidomastoid & trapezius muscles
FUNCTION: Motor function sternocleidomastoid & trapezius
DYSFUNCTION: Muscle weakness.

CLINICAL EVALUATION

 Palpate trapezius muscle as patient shrugs

shoulders against resistance; evaluate strength.

 Ask patient to turn head to one side and push

against examiners hand, palpate and evaluate
strength of sternocleidomastoid muscle.

 Evaluate both right and left side, compare for

symmetry.
 CN XII -Hypoglossal
ORIGIN: Medulla
INNERVATION: Muscles of the tongue
FUNCTION: Movement of the tongue
DYSFUNCTION:
Unilateral
Flaccid paralysis (peripheral lesion)
- Tongue deviates to side of lesion.
- Isilateral atrophy
- Fasciculation
Spastic paralysis (cortical pathways)
- Tongue deviates to opposite side of lesion
- No atrophy
- Dysarthria and ataxia of tongue
Bilateral
Flaccid paralysis (medullary lesion, MG)
- Dysphagia
- Dysarthria
- Difficulty chewing food
CRANIAL NERVES I Olfactory CEREBRAL
II Optic HEMISPHERE
III Oculomotor
IV Trochlear MIDBRAIN

V Trigeminal
VI Abducens
PONS
VII Facial
VIII Acoustic

MEDULLA
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal