CHAPTER 9

THE CRANIAL NERVES

The lower medulla looks very similar to the spinal cord, one of the complicating factors
in higher levels of the brainstem are the nuclei of Cranial nerves 3-12. At first the tracts
and nuclei appear very complicated but there is an organizational schema that is
functional in nature.

All of the spinal nerves contain both sensory and motor functions and
can be organized on the basis of the functional components of each nerve.

1) General Somatic Afferent (GSA) fibers are related to receptors for pain temperture
and mechanical receptors in the skin, muscles and joints.

2) General Visceral Afferent (GVA) fibers are related to receptors in visceral
structures.

3) General Visceral Efferent (GVE) fibers are preganglionic autonomic fibers.

4) General Somatic Efferent (GSE) fibers innervate skeletal muscle (these are axons
of alpha and gamma motor neurons).

The cell bodies on which spinal afferents synapse and the cell bodies of the spinal
efferent fibers are located in portions of the spinal gray matter that are predictable from
embryological development. Embryologically ,the sulcus limitans separates the alar
plate (which becomes the posterior horn) from the basal plate (which becomes the
anterior horn).
Within both plates the cells concerned with visceral function are located near the sulcus
limitans.
For each of the four spinal functions there is a corresponding column of clells in the
spinal gray matter.
GSA and GSE extend the length of the cord.
GVA and GVE columns are found at T1 to L2-3 and T1 to S2-4.


Cranial nerves subserve the same functions for the head as so the spinal nerves for
the body.
All four of the spinal functional components are found in the cranial nerve PLUS there
are three components in addition to the four described for spinal nerves.
None of the cranial nerves contain all seven components.

The three additional functions are.
1) Special Somatic Afferents (SSA) sight, hearing, equilibrium
2) Special Visceral Afferents (SVA) smell and taste
3) Special Visceral Efferents (SVE) fibers innervate striated muscles
known as the branchiomeric muscles the muscles of facial expression,
phonation, mastication, and deglutation.

Cranial nerves can be divided into three general groups based upon the type of fibers
composing the nerve:
1) The somatic efferent nerves contain general efferents and
little or nothing else. (oculomotor III; trochlear IV; abducnes VI;
hypoglossal XII)

2) The branchiomeric nerves innervate branchial arch musculature.
They are the trigeminal V; facial VII; glossopharyngeal IX; vagus X)

3) The others I, II and VIII contain special sensory fibers (olfactory, optic and
auditory)

SOMATIC EFFERENT NERVES: III (oculomotor) , IV (trochlear) VI (abducens) AND
XII (hypoglossal)

The somatic effent nerves are the simplest of the cranial nerves. Each one contains
only one functional component GSE( general somatic efferent fibers ) except for Cranial
nerve III (oculomotor) which has a small component of general viseral efferent fibers

The nuclei of all of these nerves are located adjacent to the midline, near the aquaduct
of the fourth ventricle.

The first three are all muscles of the eye.
Oculomotor III
Cranial nerve III supplies almost all of the internal and external muscles (three
exceptions) of the ipsilateral eye. The fibers originate in the oculomotor nucleus located
at the level of the rostral midbrain.
Damage to one oculomotor nerve causes a series of deficits. The eye ipsilateral to the
damage deviates laterally (lateral strabismus). This is because the medial rectus is
paralyzed and the lateral rectus is unopposed. The patient often complains of double
vision (dipopia) and is unable to move the affected eye vertically or medially. In
addition, the sphincter pupillae and ciliary muscle are nonfunctional. The pupil on the
affected side is dilated (mydriasis) and will not constrict in response to light.

Trochlear IV
Cranial nerve IV supplies one small muscle, the superior oblique muscle. This little
muscle helps the eye to move downward and laterally, so it is used in reading or
walking down stairs.
It originates in the trochlear nucleus located at the level of the inferior colliculus. CN IV
is unique in two ways:
1) It is the only Cranial Nerve that is attached to the dorsal aspect
of the brainstem.
2) It is the only one to originate entirely from a contralateral
nucleus.
Damage to the trochlear is much less noticeable than that to the oculomotor or
abducens nerve.

Abducens nerve VI
Cranial nerve VI supplies the lateral rectus muscle. The fibers originate from the
ipsilateral abducens nucleus located in the caudal pons beneath the floor of the fourth
ventricle.
Damage to the abducens nerve causes medial strabismus (the affected eye deviates
medially).

Hypoglossal nerve (XII)
Cranial nerve XII supplies all the intrinsic and most of the extrinsic muscles of the
tongue. The fibers originate in the hypoglossal nucleus which extends from the caudal
medulla to the rostral medulla. It forms an elevation called the hypoglossal trigone.

Damage to the hypoglossal nerve causes weakness and atrophy (beause it is a lower
motor neuron lesion) of one side of the tongue. Protrusion of the tongue will result in
deveiation to the side of the leision. Bilateral leisions can create difficulty in eating and
speaking.




BRANCHIOMERIC NERVES (V, VII, IX, X, XI
The Trigeminal nerve (CN )
These nerves all innervate striated muscle of branchial arch origin. They all contain SVE
(Special Visceral Efferent) fibers. All also contain other fibers as well (except maybe CN
XI -the accessory). However, each nerve has one function with which it is associated.
Trigeminal nerve V is the major nerve for the head
Facial nerve VII is the motor nerve for facial expression
Glossopharyngeal nerve IX is the conveyor of tasts and pharyngeal sensation
Vagus nerve X carries the parasympathetic outflow to the thoracic &
abdominal viscera.
Accessory nerve XI is the motor nerve for the sternocleidomastoid and trapezius.


TRIGEMINAL NERVE V
The trigeminal nerve is responsible for the transmission of tactile, proprioceptive, pain
and temperature information from the head to the cerebral cortex, cerebellum and
reticular formation. There are three divisions of the trigeminal nerve:
the opthalmic V1
the maxillary V2
the mandibular V 3
Sensory nuclei
There are three sensory nuclei associated with trigeminal afferents. They form a long
continuous column that extends from the rostral midbrain to the upper cervical spinal
cord. Fig 9-9.
Craninal nerve 5, the spinal trigeminal nucleus, The afferents are somatiopically
arranged with the madibular fibers most dorsal, the maxillary fibers in between, and the
opthalmic fibers most ventral.
The nucleus and the tract extend to about the third cervical segment of the spinal cord.
There they blend into the posterior horn and ultimately into Lissaurs tract. This nucleus
is divided into three parts, the caudal nucleus, the oral nucleus and the interpolar
nucleus. Different types of afferents terminate at each level.
The nucleus has other connetions besides the direct and indirect pain pathways.
Some fibers project to the cerebellum through the inferior cerebellar
peduncle.
Some fibers carry tactile information.
There are reflex connections within the brainstem involving the reticular
formaiton and other cranial nerve nuclei. The most important of
these is probably the corneal reflex

main sensory nucleus,is located near the motor nucleus. It is associated with
discrimintive tactile and proprioceptive sensations. Tactile information from the head is
processed in the main sensory nucleus as well as in the spinal trigeminal nucleus, so
leisions in the medulla affecting the spinal tract and nucleus leave the sense of touch
relatively intact. See Fig. 9-15

mesencephalic nucleus, afferents from muscle spindles in the muscles of mastication
and mechanoreceptors from the teeth, gums and hard palate have their cell bodies in
the CNS in the mesencephalic nucleus rather than in the trigeminal ganglion. The
function of this nucleus is unclear.







FACIAL NERVE VII
General comments
The facial nerve is one of the general afferents, meaning it contains fibers belonging to
several different functional components. Cranial nerves IX (glossopharyngeal) and X
(vagus) are also general afferents.
All three nerves contain general somatic afferent (GSA) fibers from the skin in the area
around the outer ear.

All three also contain general visceral afferent (GVA) fibers. The facial nerve (GVA)
fibers innervate parts of the nasal cavity and soft palate.
Taste
Fibers from the facial nerve innervate taste buds in the palate and the anterior two-
thirds of the tongue. Taste buds are usually asociated with the tongue although they are
distributed over the palate and pharynx.
Taste is the result of three different kinds of input:
1) direct chemical stimulation of taste buds.
2) stimulation of olfactory recptors by vapors from food,
3) stimulation of chemical sensitive free nerve endings.

The solitary nucleus is the primary visceral afferent nucleus of the brainstem and
receives the gustatory afferents. The second order taste fibers do three things.
1) some participate in reflex activities such as coughing or swallowing,
2) others project to the cerebral cortex by the way of the thalmus
3) there is a hypothalmic limbic projection that is involved in autonomic reflexes
and in our subjective sense pleasantness of things we ingest.

Efferents
A small number of General Visceral Efferents travel in the facial nerve and innervate the
sublingual gland and the lacrimal gland. These fibers originate from the superior
salivary nucleus located in the reticular formation.
Most of the fibers of the facial nerve are Special Visceral Fibers (SVF) that innervate
muscles derived from the second branchial arch. These include the muscles of facial
expression and the stapedius muscle. They originate in the facial motor nucleus in the
ventrolateral tegmentum of the caudal pons.

The Glossopharyngeal nerve (iX)
The glossopharyngeal contains a number of general viseral afferents (GVA) fibers
including those from the:
carotid sinus and body,
the medial surface of the eardrum,
the posterior third of the tongue
the walls of the pharynx
most of these fibers enter the solitary tract and synapse on the solitary nucleus.
HOWEVER, fibers conveying information about pain from the pharynx and posterior
part of the tongue enter the spinal trigeminal tract and synapse on the spinal nucleus.
The same may be true of fibers carrying tactile and temperature sensations.
Also, glossopharyngeal afferents reach the part of the main sensory nucleus concerned
with intraoral sensation which is why the pharynx "feels" like a somatic structure even
though it is technically described as a visceral structure.
Special Visceral Efferents (SVE) innervate the stylopharyngus.

The Vagus Nerve (X)
The connections and components of the Vagus
Vagal GVA fibers innervate the larynx, esophagus and lower pharynx. Many are thought
to enter the spinal trigeminal tract and terminate on thespinal trigeminal nucleus.
The remainding GVA fibers enter the solitary tract and terminate in the caudal portion of
the solitary nucleus.

A major collection of GVE fibers travel in the vagus to the thorax and abdominal viscera.
Most originate in the dorsal motor nucleus of the vagus (the principal
parasympathetic nucleus of the brain). It is located in the floor of the fourth ventricle,
lateral to the hypoglossus nerve.
Other GVE fibers particularly those going to the heart originate in the nucleus ambiguus.

Vagal SVE fibers arize in the nucleus ambiguus and innervate most of the striated
muscles of the larynx and pharynx. The gag reflex is activated by these fibers.

The Spinal Accessory nerve(XI)
This is a motor nerve that receives projections from the contralateral motor cortex. This
nerve consists of fibers that originate from the most caudal portion of the
medulla(corticobulbar segment) and the anterior horn of the upper five spinal segments
(corticospinal segment).
They exit posterior to the dentate ligament and innervate the sternocleidomastoid and
part of the trapezius. Accessory nerve pathologies affect the abiliity to control head
movement. In addition to these SVE fibers there are also a few afferent fibers.


Trigeminal Neuralgia (tic douloureux)
This disorder is characterized by brief attacks of excruciating pain in one or more
divisions of the trigeminal nerve. There is often a trigger zone where tactile stimulation
will trigger an attack. It can usually be managed pharmacologically.


Glossopharyngeal Neuralgia
Pain in the posterior tongue or pharynx attacks can be set off by swallowing or talking.
Pharmacological relief is usually available or the dorso medial portion of the spinal
trigeminal tract is sectioned.


Facial Paralysis
Corticobulber fibers from one frontal lobe contact 3 groups of facial motor neurons
1. ipsilateral upper face
2. contraleteral upper face
3. contralateral lower face

A leision on one side will produce contralateral facial weakness and upper face
weakness on the side of the leision. Alternating syndromes in which long tract
symptoms are referred to one side and cranial nerve symptoms to another one are the
hallmark of brainstem leisions.

Vestibulocochlear nerve (VIII)
This nerve has two branches the vestibular, which mediates head position in space and
cochlear which is hearinhg. Both are attached to the brainstem at the junction of the
pons and the medulla.

Vestibular Nerve
This portion of the nerve originates in the hair cells of the crista of
the semicircular canals, the saccule and the utricle.
The primary cell bodies of the vestibular nerve are called bipolar cells and are found in
the vestibular ganglion of the internal auditory meatus. There are projections to
the vestibular complex in the floor of the fourth ventricle.
Ascennding projections from the vestibular nucleus include the cerebellum, the reticular
formation the medial longitudinal fasciculus ( which functions to communicate between
the occular cranial nerve and the vestibular nerve) and motor nuclei of other cranial
nerves.
The descending projections are to the spinal cord to coordinate limb movements for
balance while standing upright.

Acoustic Nerve
These fibers originate in the hair cells of the organ of Corti. The primary cell bodies of
the auditory nerve are the spiral ganglion which project to the cochlear nuclei in the
medulla.
Some of the fibers ascend uncrossed while others do cross the midline through
the trapezoid bodies.
Some of the fibers terminate in the superior olivary complex while others bypass it.
Projections from the superior olivary complex form thelateral lemniscus which ascends
to the inferior colliculus of the midbrain. From there fibers travel through
the branchium of the superior olivary complex to the medial geniculate body of the
thalmus. From the thalmus fibers pass through the posterior limband pprooject to the
auditory cortex in the temporal lobe.
Important characteristics: 1) crossed and uncrossed fibers create bilateral projections to
the auditory cortex, 2) tonotopic organization is maintained throughtout the levels of
projections.


Some Functional aspects of the Vestibulocochlear nerve (VIII)
Nystagmus
refers to rhythymic movements of one or both eyes. Movements can be horizontal,
vertical or rotary.








All of the spinal nerves contain both sensory and motor functions and
can be organized on the basis of the functional components of each nerve.

1) General Somatic Afferent (GSA) fibers are related to receptors for pain temperture
and mechanical receptors in the skin, muscles and joints.

2) General Visceral Afferent (GVA) fibers are related to receptors in visceral
structures.

3) General Visceral Efferent (GVE) fibers are preganglionic autonomic fibers.

4) General Somatic Efferent (GSE) fibers innervate skeletal muscle (these are axons
of alpha and gamma motor neurons).

The cell bodies on which spinal afferents synapse and the cell bodies of the spinal
efferent fibers are located in portions of the spinal gray matter that are predictable from
embryological development. Embryologically ,the sulcus limitans separates the alar
plate (which becomes the posterior horn) from the basal plate (which becomes the
anterior horn).
Within both plates the cells concerned with visceral function are located near the sulcus
limitans.
For each of the four spinal functions there is a corresponding column of clells in the
spinal gray matter.
GSA and GSE extend the length of the cord.
GVA and GVE columns are found at T1 to L2-3 and T1 to S2-4.


Cranial nerves subserve the same functions for the head as so the spinal nerves for
the body.
All four of the spinal functional components are found in the cranial nerve PLUS there
are three components in addition to the four described for spinal nerves.
None of the cranial nerves contain all seven components.

The three additional functions are.
1) Special Somatic Afferents (SSA) sight, hearing, equilibrium
2) Special Visceral Afferents (SVA) smell and taste
3) Special Visceral Efferents (SVE) fibers innervate striated muscles
known as the branchiomeric muscles the muscles of facial expression,
phonation, mastication, and deglutation.

Cranial nerves can be divided into three general groups based upon the type of fibers
composing the nerve:
1) The somatic efferent nerves contain general efferent efferents and
little or nothing else. (oculomotor III; trochlear IV; abducnes VI;
hypoglossal XII)
2) The branchiomeric nerves innervate branchial arch musculature.
They are the trigeminal V; facial VII; glossopharyngeal IX; vagus X)
3) The others I, II and VIII contain special sensory fibers (olfactory, optic and
auditory)