Cranial nerves notes

Title: Explain how you would test cranial nerves V, VII and XII, and give the anatomical
bases for your answer.

Plan:

Anatomy of CN V
Testing CN V
Conditions which would indicate abnormalities
Anatomy of CN VII
Testing CN VII
Conditions which would indicate abnormalities
Anatomy of CN XII
Testing CN XII
Conditions which would indicate abnormalities

Essay:
Cranial nerves are lower motor neurones that innervate the head. These nerves can
be of sensory, motor or mixed innervation. Some of these nerves can also carry
parasympathetic fibres. It is vital to test these nerves to localise any lesions, especially if
the patient is unconscious.
Cranial nerve V, also known as the Trigeminal nerve, is the largest paired cranial
nerve containing mixed
fibres. The sensory and motor nuclei are both found from the midbrain to the medulla. In
the pons, each type of nuclei combines to form the motor and sensory roots respectively.
The sensory root expands into the trigeminal ganglion in the trigeminal cave, which is a
depression found lateral to the cavernous sinus in the middle cranial fossa. The
peripheral aspects of this ganglion give rise to the 3 branches: ophthalmic (v1), maxillary
(v2) and mandibular (v3). It is essential to note that the sensory afferent fibres can travel
in the opposite direction to the pathway described above. Meanwhile, the motor root
travels below the sensory root and give fibres to V3 only.
V1 passes anteriorly in the lateral aspect of the cavernous sinus, superior to the
trochlear nerve, and exits the skull via the supraorbital fissure. V2 follows a similar
pattern but passes inferior to the trochlear nerve, and exits via the foramen rotundum.
V3 exits via the foramen ovale to enter the infra-temporal fossa.
V1 has 3 terminal branches which innervate the skin of scalp, upper forehead, upper
eyelid, upper nose. It also provides sensation to the cornea and conjunctiva and supplies
the mucous membranes of the ethmoid and sphenoidal sinuses, and the upper nasal
cavity. V2 has 14 terminal branches that innervate the lower eyelid, cheeks, nasal
mucosa, upper lip, upper teeth and the palate. V3 has 4 terminal branches which
innervate the skin over the mandible and the lower teeth. It also provides general
sensation to the anterior 2/3 of the tongue. V3s motor fibres supply the muscles of
mastication, tensor tympani, tensor veli palatini, anterior belly of the digastric muscle
and mylohyoid.
The trigeminal nerve can be tested for its sensory functions. The corneal reflex
tests for the competency of V1 as it participates in this polysynaptic circuitry as the
afferent limb, with CN VII being the efferent limb. After obtaining consent from the
patient, I will ask the patient to look upwards to avoid visual threat reflex, and I will
depress their lower eyelids. I will then press a wisp of a damp cotton wool against the
lateral edge of the cornea. I will look for direct (same eye) and consensual (opposite eye)

blinking, while conducting this test in each eye. An absent or asymmetrical blinking can
indicate a lesion anywhere in this reflex circuit.
Light touch tests for the sensory branches of CN V that innervate the face in the following
dermatome pattern as previously described: (insert diagram here).
I would ask the patient to close their eyes, and place a damp cotton wool at different
points on both sides of the patients face, and check if they can feel the sensation.
Absence of sensation on a particular dermatome could be indicative of a lesion on the
respective CN V branch anywhere along its sensory pathway. I would conduct the pain
and temperature tests in a similar way, but I would use a cold tuning fork for
temperature, and a disposable neurological pin, like Neurotip, for superficial pain.
The motor functions of the trigeminal nerve can be examined in two ways. The
jaw jerk reflex is conducted by asking the patient to let his mouth hang open loosely. I
would then place a forefinger between the lower lip and chin and percuss my finger
gently with the tendon hammer. I would look out for any reflex shutting of the jaw. A
normal response would be an absence or a slight presence of this reflex. Hyperreflexia is
associated with lesions in the upper motor neuron pathway, which projects to the
trigeminal motor nucleus. Both afferent and efferent limbs of this reflex are mediated by
only CN V. To examine the mastication muscles, I would first ask the patient to clench his
teeth. I would look for muscle wasting by palpating the masseters and the temporalis
muscles on either side. I would then ask the patient to depress their jaw against
resistance, observing for any deviation on either side. The muscle responsible for
depression is the lateral pterygoid muscle, and deviation is a result of the unopposed
lateral pteygoid muscle on the opposite side. Any abnormalities or muscle wasting could
be attributed to a lesion anywhere in the pathway from the upper motor neuron synapse,
to the neuromuscular junction. The lesion is present on the same side of muscle wasting
and deviation.
Common lesion areas affecting CN V could be in the brain stem, in the cerebellopontine angle, in the petrous part of the temporal bone or in the cavernous sinus, from
pathologies like tumours, thrombosis, infarction or infection. Trigeminal neuralgia is one
of the most significant diseases affecting CN V, resulting in paroxysmal pains due to the
compression of the nerve.
CN VII, also known as the facial nerve, is a paired cranial nerve containing mixed
and parasympathetic fibres. The nerve arises in the pons as a small sensory root and a
large motor root. Both roots travel through the internal acoustic meatus, which is a 1cm
opening in the temporal bone. Then, the roots enter the facial canal, which is Z-shaped
canal found in the temporal bone. Here, the roots combine to form a nerve. The nerve
forms a geniculate ganglion. Here, the nerve gives off parasympathetic fibres to the
various mucous glands via the greater petrosal nerve, motor fibres to the stapedius
muscle and special sensory fibre (taste) to anterior 2/3 of the tongue via the chorda
tympani. CN VII then exits the cranium via the stylomastoid foramen, found just behind
the styloid process of the temporal bone. Then, the nerve gives off motor branches to
some muscles of the ear, the posterior belly of the digastric muscle and the stylohyoid
muscle. The main branch of the facial nerve continues down to the parotid gland, where
it splits into its five terminal branches that innervate muscles of facial expression.
Clinical examination of this nerve is concentrated mainly around its motor and
taste functions. The first step in the motor examination is to observe any asymmetries,
especially in the palpebral fissure or the nasolabial fold. Next, I would observe any
involuntary or spontaneous movements in the face. Then, I would ask the patient to raise
his eyebrows, testing for frontalis muscle. I would ask the patient to close his eyes
against resistance, testing for Obicularis Oculi. I will ask the patient to smile, testing for
Risorius, levator labii superiorius and depressor labii inferiorus. Finally, I will ask the
patient to blow out his cheeks, testing for Buccinator and Obicularis oris. An absence of
these expressions can be either unilateral or bilateral. Lesions can be in the upper motor

neurons, which act contralaterally, or lower motor neurons, which act ipsilaterally.
Furthermore, if the lesion is in the upper motor neurones, frontalis and orbicularis oculi
are usually spared because of bilateral innervation to these muscles. To examine the
taste functions, I would ask the patient to put out his tongue. I would put cotton wool
dipped in different taste sensations (Sweet, sour, bitter) and apply them to the anterior
2/3 of the tongue. I would then ask the patient to indicate the taste felt. I have to ensure
that the patient rinses his mouth in between each taste to avoid any contamination. The
side of the tongue which is unable to detect the taste is the side of the facial nerve
affected.
Common pathologies of the facial nerve are Bells Palsy, an idiopathic paralysis of the
facial nerve, Herpes Zoster reactivation and tumours, which can compress the nerve
anywhere along its pathway from the cranium to the parotid gland.
CN XII, also known as the hypoglossal nerve, is the final paired cranial nerve
containing only motor fibres. CN XII arises from the hypoglossal nucleus in the medulla
oblongata, and passes laterally across the posterior cranial fossa under the subarachnoid
space. After exiting the cranium through the hypoglossal canal, it passes anteriorly to the
tongue, accompanied by C1 and C2 spinal nerves. In this pathway, the hypoglossal nerve
crosses both the internal and external carotid arteries. The hypoglossal nerve innervates
both the extrinsic and intrinsic muscles of the tongue, except for Palatoglossus, which is
innervated by the vagus nerve. Intrinsic muscles alter the shape of the tongue, and
extrinsic muscles move the tongue in various positions.
To test the competency of this nerve, I would ask the patient to open his mouth.
Then, I would look for any atrophy or fasciculations (quivering movements) of the tongue.
I would ask the patient to stick out his tongue and look for any deviation. I would then
ask the patient to move his tongue side to side, testing the competency of the extrinsic
muscles. I would test the power of the tongue by asking the patient to put his tongue
against his cheek, and I would counter that by pressing on the outside of the cheek.
Unilateral lesions of the lower motor neurone would affect the tongue ipsilaterally, with
deviations and atrophy on the same side. Lesions in the upper motor neurones will cause
contralateral muscle wasting and fasciculations. If the lesion is bilateral, then the whole
tongue will be affected, giving a thin autumn-leaf-like appearance. Tumours, stroke, brain
stem infections and ALS are some of the pathologies that affect the hypoglossal nerve.
(MARCH 2015 article try to include) In conclusion, understanding the function and
anatomy of each cranial nerve is crucial, for any pathology can be localised to a
particular nerve or nerve pathway by testing of each nerve through various modalities.