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Ê ©he
, or
, is
the first of twelve cranial nerves. It is
instrumental in the sense of smell. It is the
shortest of the twelve cranial nerves.
Ê ©he specialized olfactory receptor neurons
of the olfactory nerve are located in the
olfactory mucosa of the upper parts of the
nasal cavity.
Ê ©he olfactory nerves do not form two trunks like
the remaining cranial nerves, but 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; a
sieve-like structure.
Ê Olfactory receptor neurons continue to be
born 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.
! ©he 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. ©hese 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.
! ©o test the function of the olfactory nerve,
doctors block one of the patient's nostrils
and place a pungent odor (such as damp
coffee essence or orange seedle) under the
open nostril. ©he test is then repeated on the
other nostril.
! Lesions to the olfactory nerve can occur because of
blunt trauma, such a coup-contra-coup damage,
meningitis and tumors of the frontal lobe. ©hey often
lead to a reduced ability to taste and smell. However,
lesions of the olfactory nerve do not lead to a reduced
ability to sense pain from the nasal epithelium.
! ©his is because pain from the nasal epithelium is not
carried to the central nervous system by the olfactory
nerve; rather, it is carried to the central nervous system
by the trigeminal nerve (cranial nerve V).
J
! ©he
, also called
,
transmits visual information from the retina to the
brain.
! ©he optic nerve is the second of twelve paired
cranial nerves but is considered to be part of the
central nervous system as it is derived from an
outpouching of the diencephalon during embryonic
development. Consequently, the fibres are covered
with myelin produced by oligodendrocytes rather
than the Schwann cells of the peripheral nervous
system and are encased within the meninges.
! ©he optic nerve is composed of retinal ganglion cell
axons and support cells. It leaves the orbit (eye) via the
optic canal, running postero-medially towards the optic
chiasm where there is a partial decussation (crossing) of
fibres from the temporal visual fields of both eyes. Most
of the axons of the optic nerve terminate in the lateral
geniculate nucleus from where information is relayed to
the visual cortex, while other axons terminate in the
pretectal nucleus and are involved in reflexive eye
movements and other axons terminate in the
suprachiasmatic nucleus and are involved in regulating
the sleep-wake cycle.
©est
! With patient wearing glasses, test each eye
separately on eye chart/ card using an eye cover.
! Examine visual fields by confrontation by
wiggling fingers 1 foot from pt's ears, asking
which they see move.
Keep examiner's head level with patient's head.
! If poor visual acuity, map fields using fingers and
a quadrant-covering card.
! Look into fundi.
! Look at pupils: shape, relative size, ptosis.
! Shine light in from the side to gauge pupil's light reaction.
Assess both direct and consensual responses.
Assess afferent pupillary defect by moving light in arc
from pupil to pupil. unne). Optionally: as do arc test, have
pt place a flat hand extending vertically from his face,
between his eyes, to act as a blinder so light can only go
into one eye at a time.
! £ollow finger with eyes without moving head": test the 6
cardinal points in an H pattern.
Look for failure of movement, nystagmus [pause to check
it during upward/ lateral gaze].
! Convergence by moving finger towards bridge of pt's nose.
! ©est accommodation by pt looking into distance, then a hat
pin 30cm from nose.
! If MG suspected: pt. gazes upward at Dr's finger to show
worsening pto
J
! ©he
is the third of
twelve paired cranial nerves. It controls
most of the eye's movement, constriction of
the pupil, and maintains an open eyelid.
(Note: cranial nerves IV and VI also
participate in control of eye movement.)
! ©he oculomotor nerve arises from the anterior
aspect of mesencephalon (midbrain). ©here are
two nuclei for the oculomotor nerve:
! ©he oculomotor nucleus originates at the level
of the superior colliculus. ©he muscles it
controls are the striated muscle in levator
palpebrae superioris and all extraocular
muscles except for the superior oblique muscle
and the lateral rectus muscle.
! ©he Edinger-Westphal nucleus supplies
parasympathetic fibres to the eye via the ciliary
ganglion, and thus controls the sphincter pupillae
muscle (affecting pupil constriction) and the
ciliary muscle (affecting accommodation).
! Sympathetic postganglionic fibres 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, e.g. to the smooth
muscle of levator palpebrae superioris.
! Cranial nerves III, IV and VI are usually tested
together. ©he examiner typically instructs the
patient to hold his head still and follow only
with the eyes a finger or penlight that
circumscribes a large "H" in front of the
patient. By observing the eye movement and
eyelids, the examiner is able to obtain more
information about the extraocular muscles, the
levator palpebrae superioris muscle, and
cranial nerves III, IV, and VI.
! Since the oculomotor nerve controls most of
the eye muscles, it may be easier to detect
damage to it. Damage to this nerve, termed
is also known by
the symptoms, because of the
position of the affected eye.
! ©he oculomotor nerve also controls the
constriction of the pupils and thickening of
the lens of the eye. ©his can be tested in two
main ways. By moving a finger towards a
person's face to induce accommodation, as
well as them going cross-eyed, their pupils
should constrict.
©
! ©he
(the
, also called the , ) is a
motor nerve (a ³somatic efferent´ nerve)
that innervates a single muscle: the
muscle of the eye.
! ©he 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. It has the greatest
intracranial length. Along with the optic
nerve (cranial nerve II), it is the only cranial
nerve that decussates (crosses to the other
side) before innervating its target. £inally, it
is the only cranial nerve that exits from the
dorsal aspect of the brainstem.
6
! ©he
or
(the
, also called the
or simply ) is a ³somatic
efferent´ nerve that controls the movement
of a single muscle, the lateral rectus muscle
of the eye.
©
! ©he spinal accessory nerve provides motor
innervation from the central nervous system
to two muscles of the neck:
! the sternocleidomastoid muscle and the
trapezius muscle. ©he 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.
©est:
! £rom behind, examine for trapezius
atrophy, asymmetry.
! Pt. shrugs shoulders (trapezius).
! Pt. turns head against resistance: watch,
palpate SCM on opposite side
! ©he
is the twelfth
cranial nerve (XII), leading to the tongue.
©he nerve arises from the hypoglossal
nucleus and emerges from the medulla
oblongata in the preolivary sulcus
separating the
and the . It then
passes through the hypoglossal canal.
! It supplies motor fibres to all of the muscles
of the tongue, except the palatoglossus
muscle which is innervated by the vagus
nerve (cranial nerve X) or, according to
some classifications, by fibers from the
glossopharyngeal nerve
! ©o test the function of the nerve, a person is
asked to poke out their tongue. If there is a
loss of function on one side (unilateral
paralysis) the tongue will point towards the
affected side.
! ©he strength of the tongue can be tested by
getting the person to poke the inside of their
cheek, and feeling how strongly they can
push a finger pushed against their cheek - a
more elegant way of testing than directly
touching the tongue.
! ©he tongue can also be looked at for signs
of lower motor neuron disease, such as
fasciculation and atrophy.
! Paralysis/paresis of one side of the tongue
results in ipsilateral curvature of the tongue
(apex toward the impaired side of the
mouth) i.e., the tongue will move towards
the affected side.
! Listen to articulation.
! Inspect tongue in mouth for wasting,
fasciculations.
! Protrude tongue: unilateral deviates to
affected side.
©ounge examination