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DISORDERS OF
CRANIAL NERVES
BY

Dr. Puji Pinta O. Sinurat, Sp S.

Neurology Departement/ Medical Faculty
Sumatera Utara University
MEDAN
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The Cranial Nerves

12 pairs refer to by either name or
Roman numeral


- N I & N II : fiber tracts of the brain (not true nerves)

- N XI : derived, in part, from the upper cervical
segment of spinal cord.

- The remaining nine pairs : relate to the Brain Stem




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FUNCTIONAL ORGANIZATION OF
THE CRANIAL NERVES
Nerve Function Cr. Nerve
Sensory I, II, VIII
Somatic motor IV, VI, XI, XII
Somatic motor & sensory V
Somatic motor & parasymph III
Somatic motor,sensory &
parasympathetic VII, IX, X
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Cranial Nerve I : Olfactory Nerve
- Function : Smell

- The true N I : short connect. from
olfactory mucosa (nose) & olfactory bulb
(cranial cavity)

- Lie just above cribiform plate and below
the frontal lobe

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- Axons from olfac bulb olfact tract
primary olfact cortex (pyriform cortex),
entorhinal cortex and amygdala.
- Note : olfact impuls reach the cerebral
cortex without relay through thalamus
(a unique feature among the sensory
system)


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Clinical Correlation :

- Anosmia = absence of the sense of smell
- Dysosmia / Parosmia = distorsion of odor
perception (ex : empyema nasoph)
- Olfactory hallucination: temporal lobe seizure
(uncinate fits), Alzeimer dementia
- Olfactory agnosia loss of olfactory
discrimination
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ANOSMIA
- the most clinical abnormality
- Etiology :
* nasal : common cold, chr rhinitis, smoking
* olfactory neuroepithelial : head injury
tearing of filament, cranial surgery,
toxic (certain drugs)
* central (olfact pathway lesion): degenerative
disease, Temporal lobe epilepsi, frontal
lobe tumor, olfactory groove meningioma

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- Unilateral anosmia suggest compression of the
olfac bulb/tract by frontal lobe glioma, abscess, olfact
groove meningioma, sphenoid ridge meningioma and
pituitary & parasellar tumor.

Tumor compress ipsilateral optic nerve
optic atrophy

ICP papiledema contralaterally

Unilateral anosmia + ipsilateral optic atrophy &
contralateral papiledema FOSTER-KENNEDY
SYNDROM


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Cranial Nerve II : Optic Nerve
- Function : Vision
- arises from gangl cells in the retina
thrgh optic papilla to the orbit (within
meningeal sheaths) optic chiasm
optic tract (its axons) project to Sup Coll
& lat genicl bodies within the thalamus
(relays visual information) calcarine
cortex in the occipital lobe.

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Clinical correlation
Impaired vision in one eye ---- usually due to
involving the eye, retina, or optic nerve
If the lesion is in the opt chiasm, opt tract, or
visual cortex field defect in both eyes
Chiasmatic lesion (axons originate in the
nasal halves of the two retina) Bitemporal
hemianopia (charact : blindness in the lateral
or temporal half of the visual field for each
eye)

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Opt tract lesion homonimous
hemianopia (defect of temporal field of
one eye + nasal field of the other eye) in
wich the visual field defect is on the
opposite side to the lesion.

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Optic neuritis = inflammation of the optic
nerve ----- is associated with various
forms of retinitis such as simple,
syphilitic, diabetic, hemorrhagic and
hereditary

Papilledema ------ usually a symptom of
increased ICP caused by a mass (eg,
brain tumor) transmitted to optic disc
thrgh extension of subarachnoid space
around the optic nerve.

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Optic Atrophy ---- Is pallor of the optic
disc (change in color to light pink, white
or gray) due to demielination and axonal
degeneration of the optic n.
- decrease visual acuity
- Etio : tabes dorsalis, multiple sclerosis,
inherited


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Primary optic atrophy:
- occurs without preceding papiledema
- by a process that involves the optic n.
-Disc typically : uniformly white with clearly
outlined margin

* Secondary optic atrophy:
- is a sequel of papiledema
- disc is white, but the margins are grayish
and indistinct

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- Axons arise in the oculomotor nuclei
innerv levator of the eyelid, sup, inf & med
recti, inf oblique.
- The parasympathetic nucl portion of
oculomotor nucl (Edinger-Westphal nucl)
innerv pupillary spinchter and the ciliary
bodies (muscle of accomodation)
- Enters the orbit trough Sup Orbital Fissure
Cranial Nerve III : Oculomotor Nerve
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Cranial Nerve IV : Trochlear Nerve


- Nuclei : trochlear nucleus
- Enters the roof of orbit through the Sup
Orbital Fissure
- Innerv : Superior oblique muscle
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Cranial Nerve VI : Abducens Nerve

Nuclei : Abducens nucleus
Enters the orbit through Sup orbital
Fissure
Innerv : Lateral rectus m
Its long intracranial course
vulnerable to pathologic processes in
Posterior & midle Cranial fossa.


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The Cr nerves III, IV and VI control
eye movements. In addition, Cr N III
controls pupillary constriction.
Note : m. Levator palpebrae Sup has no
action on the eye ball, but lifts the upper
eye lid when contracted
Closing the eyelids by contrct of
orbicular m of the eye (innerv by N VII)
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Clinical correlation
The eyes are normally positioned the
image falls on exactly the same spot on the
retina of each eye.
Both eyes move in the same direction to
follow an object in space, but they move by
simultaneously contracting and relaxing
different muscles
The symmetric and synchronous movement
of the eyes is called Conjugate or Gaze
movement (conjugate = joined together)

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The slight displacement of either eye
Diplopia (double vision)
Strabismus : deviation of one or both eyes
Ptosis (lid drop) is caused by weakness or
paralysis of the levator palp sup m.
Opthalmoplegia : paralysis of cranial
nerves III, IV and VI
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a. Oculomotor (N III) paralysis :
1. External Opth :
- divergent strabismus
- diplopia
- ptosis
2. Internal Opth :
- dilated pupil
- loss of light & accomodation reflexes

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b. Trochlear ( N IV) paralysis
- slight convergent strabismus
- diplopia on looking downward.
(cannot look downward & inward difficulty
in descending stairs tilted the head as a
compensatory adjustment)
c. Abducens (N VI) paralysis
- the most common eye palsy (owing to the
long course of N VI).
- convergent strabismus
- diplopia.
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Cranial Nerve V : Trigeminal Nerve
The largest cranial nerve
Is a mixed sensory and motor nerve :
- Sensory root (large) carries sensation
from skin & mucosa of most head
- Motor root (smaller) innerv chewing m
(massetter, temporalis, pterygoids,
mylohyoid) and tensor tympani m of
middle ear. Nucleus : in the Pons
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Sensory root

- arise from cells in the semilunar (Gasserian,
Trigeminal) ganglion

- Contain 3 division Fibers:
1. Opthalmic div enters the skull thrgh Sup
Orbital Fissure lateral wall of cav sinus
2. Maxillary div enter the skull through For
Rotundum lower lateral of cav sinus
3. Mandibular div enter the skull thrgh For
Ovale (with the motor fibres) passed inf
to cav sinus



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* Corneal Reflex
- afferent : N V ( opthalmic div)
- efferent : N VII
* Jaw jerk reflex : Its aff & eff run in N V.


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Clinical correlation
- loss of sensation 1 sensory modalities
- paralysis m tensor tympani => impaired
hearing
- Paralysis of mastication m => mandibular dev
to the affected side
- Loss of reflex (corneal, jaw jerk)
- Trismus (lock jaw)
- Tonic spasm of the muscles of mastication
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TRIGEMINAL NEURALGIA
(TIC DOULOUREUX, PAROXYSMAL FACIAL PAIN)
Def : a cond charact by sudden, severe, lancinating
pain occuring in the distr of 1 div of N V.

Epid : 2-8/100.000/year. Female > Male

Etio : Idiopathic (most common cause), compression of
N V root (eg, tumor), demyelination, etc

Clin features : Pain
Site : face or mouth (commonly V2 or V3 div)
Trigger factors : talking, chewing, swallowing,
shaving, cleaning the teeth, wind blowing on the
face


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Trigger points : area around the nose, lips or
mouth
Nature : stabbing/ligthning or electric shock-like/
penetrating or cluster of stabbing pain
Duration : brief (seconds) and followed by long
pain-free intervals
Episodic pattern : may recur many times a day
and may remit
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Physical Exam :
- Normal in Idiophatic Trig Neuralgia
- Secondary causes underlying cause

Investigation : CT/ MRI brain scan
Diagnosis : Clinical
Treatment:
- most patient can be managed medically
(carbamazepin, Phenytoin, baclofen etc)
- Surgically

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Cranial Nerve VII : Facial Nerve
Consist of facial nerve proper & nervus intermedius

Axons of Facial n proper arise in the facial nucleus thrgh stylomast
foramen innerv muscl of facial expression, m.platysma and
stapedius m in the inner ear.

Nervus Intermedius sends parasympathetic pregangl fibres to
pterygopalatine gangl innerv Lacrimal gld, and
Via chorda tympani nerve to the submaxillary & sublingual ggln
innerv salivary gld




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- Visceral aff fibres of n. Intermed carries
taste sensation from the anterior 2/3 of the
tongue, via chorda tympani & lingual
nerve to solitary nucleus.
- Somatic afferent fibres from skin of ext ear
carried in the N VII brain stem
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Clinical correlation

Facial nucl receives crossed &
uncrossed fibres by way of corticobulbar
(corticonuclear) tract.
frontalis & orbic oculi m receives bilat
cortical innerv not paralyzed by
lesion in one motor cortex or its
corticobulbar pathway

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Peripheral facial paralysis (Bells palsy) =>
attempt to close the eyelid the eye ball
may turn upward (=bells phenomenon).
Symptoms & signs depend on the location of
the lesion : Lesion in or outside the For
stylomast flaccid paralysis of facial
expression m in the affected side.
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Lesion in the facial canal involving
chorda tympani nerve reduced
salivation and loss of taste sensation of
2/3 ant ipsilat of the tongue.
Lesion higher up in the canal
paralyze m stapedius.

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Is a double nerve
Arise from spiral and vestibular ganglia
in the labyrinth of the inner ear.
Passes into cranial cav via internal
acoustic meatus the brain stem
Cochlear nerve hearing (audition)
Vestibular nerve part of equilibrium
(position sense)
Cranial Nerve VIII :
Vestibulocochlear nerve
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Clinical correlation
DEAFNESS = hearing loss
- Conduction deafness impairment of sound
thrgh ext ear canal to endolymph and tectorial
membrane.
caused by mid or ext ear disease
- Nerve (sensoryneural) deafness caused by
interrupt of cochlear nerve fibres from the hair
cells to the brainstem nuclei (located : inner
ear / cochlear n in the int auditory meatus)
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TINNITUS : ringing, buzzing, hissing,
roaring or paper-crshing noises in the
ear
- frequently an early sign of peripheral
cochlear disease
NYSTAGMUS : involuntary movement
(back-and-forth, up-and-down, or
rotating) of the eyeballs




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VERTIGO : an illusory feeling of giddiness
with disorientasi of space.
- usually the results in a disturbance of
equilibrium
- often a sign of labyrinthine disease
originating in the middle or int ear
BENIGN PAROXYSMAL POSITIONAL
VERTIGO episodic rotational vertigo of
brief duration induced by head movement


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MENIERE SYNDROME :
- Recurrent episode of severe vertigo
associated with unilateral hearing
loss and tinnitus
- spontaneous recovery within hours or
days
- also known as endolymphatic hydrops

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Contains several types of fibers
- Branchial efff fibr from nucl ambiguous pass
to m. Stylopharyngeus
- Visceral eff fibr from nucl salivatory Inf pass
trough tympanic plexus & petrosal nerve to
the otic ggln
- Visceral aff fibr arise from unipolar cell in the
Inferior ganglia : carry taste sens from post
1/3 of the tongue
- Centrally : terminate in solitary tract and its
nucleus project to thalamus cortex

Cranial Nerve IX : Glossopharyngeal
Nerve
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Peripherally: visceral aff axons of N IX supply
general sensation to the pharynx, soft palate,
1/3 post of the tongue, tonsil, auitory tube,
and tympanic cavity.
N IX supply special receptor in the carotid
body and carotid sinus control of
respiration, blood pressure and heart rate.
.
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Clinical correlation
Pharyngeal (gag) reflex depends on N IX
for its sensory components (N X innerv
motor component).
Carotid sinus reflex depends on N IX for
its sensory comp.
Pressure over the sinus => slowing of
Heart rate and fall in BP.

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Glossopharyngeal neuralgia
Is the occurrence of spasm of pain in the
sensory distribution of the IX & X cr nerne.
Etio : unknown pressure or entrapment of
the IX & X cr nerve
Cl features :
- spasm of pain in the pharynx, often radiating
into the ear.
- Trigger point : in the throat.
- Duration : brief.
- Remission is common.
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Attack : associated with bradycardia,
cardiac arrhytmia, hypertension and
syncope ( due to vagal stimulation)
Diagnostic Procedure: MRI / CT scan
Treatment : determined by the cause
respon to Carbamazepin.
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* Branchial eff fibr from nucl ambiguous pass to
the muscle of soft palate and pharynx
via recurrent laryngeal nerve to intrinsic muscl of
larynx

* Visceral eff fibr from dorsal motor nucleus of the
vagus => to thoracic & abdominal viscera
Cranial nerve X : Vagus Nerve
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Somatic aff fibr of unipolar cells in Superior
ganglion send peripheral branch via auricular
branch of n X to the Ext auditory meatus &
part of the earlobe.
Visceral aff fibr of unipolar cells in Inferior
ganglion send peripheral branch to the
pharynx, larynx, trachea, esophagus, and
thoracic & abdominal viscera.


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Clinical correlation
Complete bilateral transection of vagus :
Fatal
Weakness / paralysis of vocal cord =>
difficulty in swallowing and cardia
arrhythmias.
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2 components : 1. Cranial component
2. Spinal component

Cranial components :
distributed in the pharyngeal and recurrent
laryngeal branches of the N X.
Spinal components :
Motor to sternclmast and upper part of
trapezius

Cranial Nerve XI : Accessory Nerve
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Clinical correlation
Unilateral LMN lesion weaknes of ipsilat
sternoclmast and upper part of trapezius
UMN lesion weaknes of ipsilat
sternoclmast and upper part of contralat
trapezius m. So that the patient cannot
elevate the shoulder of paralyzed arm nor
turn the head to wards the paralyzed side.

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The motor nerve to the tongue

Leaves the skull through hypoglossal canal
distributing branches to all muscles of the
tongue
Cranial Nerve XII : Hypoglossal Nerve
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Clinical correlation
LMN Hypoglossal Nerve palsy :
- Unilateral : mild dysarthria, wasting,
fasciculation & weakness of one side of the
tongue (ipsilateral to the lesion) with tongue
dev to opposite side, Laringeal shift to one
side on swallowing (contralat to the lesion)
- Bilateral : difficulty manipulating food in the
mouth, flaccid dysarthria (difficulty speaking)
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UMN Hypoglossal Nerve palsy:
- Unilateral : mild dysarthria, mild
tongue weakness contralat to the side
of the UMN lesion, Usually transient
- Bilateral : Severe dysarthria, spasticity
of the tongue slow movement



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