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26
Table 1.11 The function of third, fourth and sixth nerve and ocular muscles
Muscle Nerve Movement
Lateral rectus muscle Abducent nerve Horizontally laterally
Superior oblique muscle Trochlear nerve Depress the eye when it turns medially
Medial rectus muscle Oculomotor nerve Horizontally medially
Superior rectus muscle Oculomotor nerve Elevate the eye when it turns laterally
Inferior rectus muscle Oculomotor nerve Depress the eye when it turns laterally
Inferior oblique muscle Oculomotor nerve Elevate the eye when it turns medially
1 General History Taking andGeneral Examination
Extra ocular movement—It is
tested by inspecting any ptosis,
eye position.
• Trigeminal nerve—It is the largest
cranial nerve and provides sensory
and motor supply to face. It originates
from three sensory nuclei and one
motor nuclei. The sensory nuclei are
mesencephalic, principal sensory, spinal nuclei of trigeminal nerve; and
motor nuclei is motor nucleus of trigeminal nerve. From these nuclei, it
travels anteriorly to ventrolateral surface of pons. From here, it continues
as cisternal segment or prepontine segment, which runs in cerebellopontine
angle and at the petrous apex, it forms
the trigeminal ganglion, which houses
within Meckel’s cave. The sensory
part of nerve relay in ganglion but
motor part does not. The trigeminal
ganglion gives rise to three nerves,
named ophthalmic, maxillary and trigeminal (Fig.1.18a).
– Anatomy and pathway
Ophthalmic division of trigeminal nerve (Ophthalmic
nerve) —The ophthalmic nerve
(V1) is sensory nerve which
after arising from superior part
of trigeminal ganglion runs
within the lateral wall of the cavernous sinus inferior to oculomotor and trochlear nerve. It
enters the orbit through the
superior orbital ssure and
divides into three terminal
branches named frontal,
Lacrimal and nasociliary nerve
(Fig.1.18b). The frontal branch
gives supraorbital nerve and
supratrochlear to provide sensory innervation to forehead.
The nasociliary nerve gives ve
branches named posterior ethmoid nerve, anterior ethmoid
nerve, long ciliary nerve, infratrochlear nerve and branch to
ciliary ganglion. Ophthalmic
nerve gives sensory supply to
cornea, ciliary body, lacrimal
gland, conjunctiva. Other structures supplied by this nerve are
mucous membrane of nasal cavity, skin of eyelid, eyebrow.
Sensory part—The frontal
branch provides sensation to
skin of forehead, nasociliary
nerve supply the mucosa of
nasal cavity innervates the skin
and mucous membrane of derivatives of the frontonasal prominence derivatives like the skin of
the forehead, upper part of sinus,
upper eyelid, corner of eyes,
bridge of nose, cornea and
conjunctiva.
Parasympathetic part—The
parasympathetic post- ganglionic
bres from the pterygopalatine
ganglion travel with the zygomatic branch of maxillary nerve
to join the lacrimal branch then
innervate the lacrimal gland.
1.2 Examination ofPatient
27
a
Ophthalmic
zone
Maxillary area
Mandibular
zone
c
V-1
V-2
V-3
Tr igeminal ganglion
Function of V nerve
1- Opthalmic nerve (sensory supply)
Orbital structure
Skin of forehead, upper eyelid,
eyebrow, Part of nose
2- Maxillary nerve
Lower eyelids, upper gum, Cheek and
nose, palate and part of pharynx.
3- Mandibular Nerve
Sensory- Lower gum, Teeth, Lip and
part of tongue
Motor- Muscle of mastication
d e
b
Fig. 1.18 (a) Branches of trigeminal nerve and area of distribution, (b) Primary functions of V cranial nerve (trigemi-
nal nerve), (c–e) Tests of trigeminal nerve
Maxillary division of trigeminal nerve—Maxillary
nerve is second branch of trigeminal nerve provides sensory innervation of touch, pain
and temperature of face. It
arises from trigeminal ganglion courses in cavernous
Branches of Maxillary Nerve
Superior alveolar nerve (anterior, posterior
and middle), middle meningeal nerve,
infraorbital nerve, zygomatic nerve, inferior palpebral nerve, superior labial nerve,
pharyngeal nerve, greater palatine nerve,
lesser palatine nerves
sinus then enter to pterygopalatine fossa through foramen rotundum. It gives rise to
14 terminal branches, which
innervate the skin of face,
mucous membranes and maxillary sinuses, upper alveolus
and upper teeth (Fig.1.18b).
Sensory part—It supplies skin
in the skin of middle of the face,
mucous membranes in the upper
part of the mouth, palate, nasopharynx, Lower eyelid and its
conjunctiva, cheeks and maxil-
28
1 General History Taking andGeneral Examination
lary sinus, nasal cavity, lateral
nose, upper lip, and upper teeth
and gingiva.
Parasympathetic part—This
part innervates the lacrimal and
nasal glands.
Lacrimal glands: Post-ganglionic bres
from the pterygopalatine ganglion travel
along with zygomatic branch of V2 and
then join the lacrimal branch of V1. The
bres supply parasympathetic innervation to the lacrimal gland.
Nasal glands: Post- ganglionic parasympa-
thetic bres form posterior nasal nerve,
run to nasal cavity just below sphenopalatine foramen to innervate the
mucous glands of the nasal mucosa.
Mandibular division of trigeminal nerve—The mandibu-
lar nerve (V3) is third branch of
trigeminal nerve which sensory
and motor part. The sensory part
arises from trigeminal ganglion
and the motor part runs inferior
to the ganglion and joins the
sensory part just below the foramen ovale. Mandibular nerve
gives rise to four terminal
branches in the infra-temporal
fossa named buccal nerve, inferior alveolar nerve, auriculotemporal nerve and lingual nerve
(Fig. 1.18b). Mandibular nerve
provides motor supply to the
muscle of mastication and sensory supply to the oor of the
mouth, lower teeth, skin below
the mouth.
Sensory part—This is a major
part of mandibular nerve that
supplies the skin over the mandible, mucous membrane of
oor of mouth, external ear,
lower lip, chin and lower teeth
and associated gingiva.
Motor part—It innervates the
muscles of mastication (temporalis, masseter, pterygoids),
anterior belly of digastric muscle and mylohyoid muscle, tensor veli palatini and tensor
tympani.
Parasympathetic supply:
Submandibular and sublingual glands:
Pre-ganglionic parasympathetic bres
of facial nerve in chorda tympani nerve
travel along lingual nerve relay in submandibular ganglion. The postganglionic bres from the submandibular
innervate these glands.
Parotid gland: Pre- ganglionic bres of
glossopharyngeal nerve travel via lesser
petrosal nerve relay in the otic ganglion.
The post-ganglionic bres travel along
with the auriculotemporal branch of the
V3 to innervate the parotid gland.
– Clinical tests for trigeminal nerve
Ophthalmic division of trigeminal nerve
Tests for sensory function of
ophthalmic nerve (supercial
and deep)
Pin or cotton swab test—One
or both sides of the forehead are
touched with either a pin or cotton swab. The person will then
be asked whether they felt anything, and if so, where they felt it
(Fig.1.18e).
Corneal reex—The corneal
reex test also known as blink
test examines the reex pathway
involving cranial nerves V and
VII. During this test, patient is
1.2 Examination ofPatient
29
asked to look straight and now
examiner moves a wisp of cotton
from lateral side to touch cornea. In normal, there is reex
blinking.
Procedure of corneal reex test—After
explaining the procedure to patient, ask
him to look in the straight direction, then
gently touch the cornea at its junction with
the sclera with wisp of cotton from lateral
side. There is a rapid blink of the eye being
tested and a consensual blink of the other
eye. If there is seventh nerve weakness on
the side being tested, then observe the consensual reex. Afferent or sensory innervation of reex is through the ophthalmic
division of trigeminal nerve and efferent or
motor innervation by facial nerve
(Fig.1.18c).
Maxillary division of trigemi-
nal nerve
Sensory function:
Pin prick or cotton swab test—
Check the supercial (with wisp
of cotton) and deep sensation of
touch (with pin prick) in infraorbital area, cheek, upper lip, and
upper molar, incisor and canine
teeth and gingiva.
Mandibular division of trigeminal nerve
Sensory functions:
Pin or cotton swab test—The
supercial and deep sensation of
touch in lower third of face, chin
and lip, inferior teeth and anterior two third of tongue.
Motor functions:
Clenching test—This test is
done by asking the patient to
clench his or her jaws, now palpate the masseter and temporal
muscles for asymmetry of volume and for tone. The pterygoid
muscle is tested by asking the
patient to open the mouth against
resistance or move side by side
against resistance (Fig.1.18d).
Jaw jerk reex—It is tested by
placing a nger over chin and
then tapping the nger with a
hammer and look for jaw
movement.
• Facial nerve (Seventh nerve)
– Anatomy and pathway—The
facial nerve is predominantly a
motor nerve with parasympathetic
and sensory components. The motor
root of the facial nerve originates in
the facial (motor) nerve nucleus in
the pons of the brainstem and small
sensory root from sensory nucleus.
The sensory roots also known as
nervus intermedius contain parasympathetic bres, general sensory
bres and special sensory bres.
Facial nerve travels through the cerebellopontine angle to enters the
internal auditory meatus of the
temporal bone along with by the
vestibulocochlear nerve (CN VIII),
labyrinthine artery and vein. The
small sensory and large motor roots
fuse to form the facial nerve in
facial canal. Temporal part of facial
nerve has meatal, labyrinthine, tympanic and mastoid segment. The
greater supercial petrosal nerve
is the rst branch that arises from
geniculate ganglion and carries preganglionic parasympathetic bres
to the lacrimal gland. GSPN passes
beneath the trigeminal ganglion and
reaches the foramen lacerum where
it is joined by deep petrosal nerve to
become the nerve of the pterygoid
canal/vidian nerve to relay in the
pterygopalatine ganglion. The
post- ganglionic bres run along
zygomatic branch then lacrimal
30
a
SPL Lacrimal G.
1 General History Taking andGeneral Examination
nerve to lacrimal gland. Facial nerve
continues to travel along bony canal
and gives off the nerve to stape-
dius, the chorda tympani, nerve.
The pre-ganglionic parasympa-
thetic bres supply the submandibular, submaxillary glands and travel
in chorda tympani nerve and along
with lingual nerve to reach submandibular ganglion. Facial nerve exits
the skull at the stylomastoid foramen and divides into its terminal
branches within the parotid gland to
supply the muscles of facial expression. The principal muscles supplied by facial nerve are the
GSPN
Deep petrosal N.
frontalis, orbicularis oculi, buccinator, orbicularis oris, platysma, the
posterior belly of the digastric, and
the stapedius muscle (Fig.1.19a).
General sensory part—
General sensory bres in the
facial nerve are responsible for
transmitting signal of general
sensation from external acoustic
meatus, skin over the mastoid
and lateral pinna.
Special sensory part—Special
sensory bres (taste) in the
facial nerve carry taste sensation from anterior two third of
tongue.
N.to stapedius
Posterior
auricular N.
N. to
stylohyoid M
Chorda tympanic N.
N. to
digastric M
Temporal
Z
B
B
M
C
bc
Fig. 1.19 (a) Anatomy and pathway of facial nerve, (b–d) Clinical examinations of facial nerve
Linqual N.
Submandibular
ganglion
secretomotor to
submandibular
gland
d
1.2 Examination ofPatient
31
General/somatic motor part—
This part of facial nerve innervates
the muscles of facial expression
and muscles in the scalp derived
from the second pharyngeal arch,
as well as the stapedius muscle in
the ear, the posterior belly of the
digastric muscle and the stylohy-
oid muscle.
Visceral/autonomic (secretomotor) part—This is secreto-
motor/parasympathetic part of
nerve, which supplies lacrimal
gland, submandibular gland, sub-
lingual gland, as well as mucous
membranes of the nasal cavity,
hard palate and soft palates.
– Clinical tests for facial nerve
Clinical test for sensory
division
Special sensory function (taste)—Taste
function test.
General sensory function—Non-acoustic
reex or histelberger sign—The stimulation of posterior canal wall of ear
causes contraction of stapedius muscle
due to pressure of vestibular schwannoma on facial nerve.
Visceral/autonomic (secretomotor) func-
tion—Lacrimation (Schrimer’s test).
Clinical test for motor division
Test the muscular strength—Patient is
asked to close the eye tightly, now the
examiner will try to open the eye. Puff
the cheek, blow the whistle, show the
teeth and ask to smile (Fig.1.19b–d).
Flattening of the nasolabial groove
Blink: The eyelid on the affected side closes
later than the normal eyelid.
Mouth: The angle of mouth of affected
side droops, deviation of angle of mouth
on smile, unable to hold air in mouth,
drooling of saliva from mouth.
• Vestibulocochlear nerve
– Anatomy and pathway—This is
sensory nerve specialized for sound
reception and balance. It transmits
sound and equilibrium information
from inner ear to brain. It originates
from vestibular nuclei and cochlear
nuclei, then goes to the middle portion of the brainstem called the
pons. It courses between the pons
and medulla then in CP angle to
enter the internal auditory meatus
with facial nerve. In IAC, it divides
into vestibular and cochlear component to supply the cochlea and vestibule (Fig.1.20).
Fig. 1.20 Anatomy and
pathway of
vestibulocochlear nerve
Pontomedullary
junction
Medulla
Pons
Vestibulo-
cochler VIII N.
Internal
acoustic
meatus
Vestibular N.
Maculae
Cochlear
nerve
Cochlea
Semicircular
canal
Utricle
Saccule
32
St
a
b
1 General History Taking andGeneral Examination
– Clinical test
Hearing—tuning fork tests
Balance—vestibular function tests
• Glossopharyngeal nerve
– Anatomy and pathway—It is a
mixed nerve and provides afferent
sensory and efferent motor bres to
oropharynx. It originates from
medulla and exits the brainstem from
the sides of the upper medulla, anterior to the vagus nerve. It exits cranial
cavity through the jugular foramen
Fig. 1.21 (a) Anatomy
and pathway of
glossopharyngeal nerve,
(b) Gag reex
Tympanic
plexus
within a separate dural sheath remain
lateral and anterior to CNs X and XI,
and then it travels within the carotid
sheath and terminates in the lateral
pharyngeal wall. Motor bres of
nerve innervate the stylopharyngeus
muscle, sensory part supply the oropharynx, mucosal surface of tympanic membrane (TM), and
autonomic bres supply the parotid
gland, mucous membranes of the
posterior inferior mouth (Fig.1.21a).
LSPN
Auricubtemoral N.
Medulla
ICA
Jacobson’s N.
S
Soft palate
OTIC
Ganglion
Parotid gland
ylopharyngeus M.
Carotid sinus
Carotid body
Inferior constrictor
Tonsil
Tongue
1.2 Examination ofPatient
33
– Clinical tests for glossopharyn-
geal nerve
Sensory part of glossopharyngeal nerve
Gag reex—The posterior pharyngeal wall is touched with
swab, tongue depressor to check
presence or absence of gag
(Fig.1.21b).
The taste carrried by glossopharyngeal nerve from posterior 1/3
of tongue
Motor part of glossopharyngeal
nerve
Movement of uvula-visualizing
uvula deviation away from midline on saying aaa. In normal individual, uvula remains in midline.
• Vagus nerve
– Anatomy and pathway—It is the
longest nerve and has both sensory
and motor parts. The sensory part
originates from solitary nucleus as
well as spinal trigeminal nucleus
and motor part from nucleus
ambiguous as well as dorsal nucleus
of vagus in medulla oblongata. It
exits the medulla just below the
glossopharyngeal nerve then
courses towards the jugular foramen
to exit cranial cavity. Extracranially,
it travels down in the carotid sheath
in between internal jugular vein
and internal carotid artery and
lower down between CCA and
internal jugular vein (IJV) to enter
chest and abdomen. It has two sensory ganglia: the superior and the
inferior ganglia. Superior ganglion gives an afferent supply to the
skin in the concha of the ear and
cell bodies of visceral afferent
bres located in inferior ganglion.
Inferior ganglion gives off two
branches: the pharyngeal nerve and
the superior laryngeal nerve. The
efferent innervations convey general visceral efferent to the thorax,
abdominal viscera and muscles of the
pharynx and larynx. Afferents arise
from the external ear, external auditory canal, surface of the tympanic
membrane, pharynx, larynx, trachea,
oesophagus and viscera of the thorax
and abdomen (Fig.1.22a, b).
– Clinical tests for vagus nerve
Sensory (afferent)—Superior
laryngeal nerve
Motor (efferent)
Gag reex—The efferent limb is
supplied by the vagus nerve (cranial nerve X) from the nucleus
ambiguus. The afferent limb of
the reex is supplied by the glos-
sopharyngeal nerve (cranial
nerve IX), which inputs to the
nucleus solitarius and the spinal
trigeminal nucleus.
Vocal cords movement by indirect laryngoscopy:
• Spinal accessory nerve
– Anatomy and pathway—It is the
eleventh cranial nerve formed from
cranial and spinal contributions.
The spinal part originates from
neurones of the upper spinal cord
(C1–C5/C6 spinal nerve roots) and
coalesce to form the spinal part of
the accessory nerve. It runs superiorly to enter the cranial cavity via
the foramen magnum and in the
cranial cavity, it traverses the posterior cranial fossa to reach the jugular foramen. Before exiting the
skull, it briey meets the cranial
portion of the accessory nerve arise
from lateral aspect of the medulla
oblongata. Outside the cranium,
cranial XI either runs lateral or
medial to internal jugular vein. It
divides into two branches, one supplies the sternocleidomastoid and
another courses across the posterior
triangle of the neck to provide
motor innervation to the trapezius
(Fig.1.23a).
34
ab
Fig. 1.22 Anatomy and
pathway vagus nerve
Larynx
To trachea
Left recurrent
laryngeal nerve
1 General History Taking andGeneral Examination
Superior
laryngeal
nerve
Vagus
nerve
Aortic arch
Cranial root
Spinal root
C
1-C5
XI N.
Trapezious X
SCM
Fig. 1.23 (a) Spinal accessory nerve pathway, (b) Clinical tests for spinal accessory nerve
1.2 Examination ofPatient
35
Fig. 1.24 Pathway of
hypoglossal nerve
– Clinical tests for spinal accessory
nerve (Fig.1.23b)
Motor—shrugging of shoulders—The trapezius is tested by
asking the patient to shrug their
shoulders while applying
resistance.
The sternocleidomastoid is
assessed by asking the patient to
turn his/her head against resistance applied to the side of the
face. In cases of unilateral palsy,
the patient is unable to turn the
head to the side opposite the
lesion as the sternocleidomastoid muscle is weak.
• Hypoglossal nerve
– Anatomy and pathway—Hypo-
glossal nerve is motor nerve and
provides innervation to the tongue
musculature (both the intrinsic and
extrinsic muscles of tongue except
palatoglossal muscle). After originating from the hypoglossal
nucleus in medulla oblongata of
brain stem, it courses laterally
C1/C2 Roots
Inf. belly of
omohyoid
Hypoglossal nerve
Sternothyroid
Muscles of the tongue
Geniohyoid
Thyrohyoid
Sup. belly
of omohyoid
Sternohyoid
across the posterior cranial fossa
in subarachnoid space to enter the
hypoglossal canal. It exits hypoglossal foramen and passes inferiorly to the angle of the mandible,
passes between internal and external carotid arteries, and deep to
digastric muscle then it passes in
an anterior direction between the
submandibular duct and lingual
nerve to enter the tongue
(Fig.1.24).
– Clinical tests for hypoglossal nerve
Motor movement of tongue—
Patient is asked to protrude
the tongue and move both
sides, touch the upper incisor
and upper lip, press the cheek
with tongue on both sides.
Examiner should look for any
deviation or restricted movement during examination
(Fig.1.25a, b).
Atrophy of tongue—Power of
tongue is examined by asking
the patient to press the tip of