THE CRANIAL NERVES

Nerve Course Innervation Lesion Test

Olfactory nerve Can be considered an extension of brain. Only innervate roof of Loss of smell (anosmia) can Test by asking patient to
(I) 20 olfactory nerve bundles pass from the bulb of the nose – sensory to smell result from damage, perhaps identify strong smells (coffee
olfactory nerve  through cribiform plate of ethmoid in from: / chocolate) through each
anterior cranial fossa  roof of nose Fracture of cribifrom plate individual nostral.
Neuroma/meingioma
compressing the olfactory bulb
Optic nerve (II) Pass from back of eye  through orbit  through optic Retina Pituitary tumour  Careful testing of the visual
canal in sphenoid compression of optic chiasma: field of each eye
 Nerve impulses from lateral retina:  Bitemporal hemianopia –
 visual cortex of same side nasal ½ of retina (which
 Nerve impulses from nasal side of retina:  cross to recieves light from
other side in the optic chiasma temporal field) is
Optic chiasma lies in front of pituitary stalk & between insensitive to light
the terminal parts of internal carotid on either side.
Pressure to the side of the optic
chiasma:
 Nasal hemianopia

Occulomotor Passes from front of midbrain  between posterior All extrinsic muscle of the Lesions can lead to: Tested by asking the patient
nerve (III) cerebral and superior cerebral arteries  into cleft of eye except  Impaired eye movements to look side to side, and then
dura between free edge of tentorium & dura over  Superior oblique  Double vision up and down with the eye in
petroclinoid ligament  through lateral wall of  Lateral rectus  Drooping eyelid the medial, and then lateral
cavernosus sinus  superior orbital fissure (within  Involuntary levator position.
tendinous ring)  into orbit palpebrae superioris
Trochlear nerve Small & thread-like Superior oblique muscle Inability to look down at nose Ask the patient to look
(IV) Arises from back of midbrain  runs forwards under (although lesions are very rare) towards the nose (medially)
free edge of tentorium  passes beneath & lateral to III and then downwards.
 enters dura of lateral wall of cavernosus sinus 
lateral part of superior orbital fissure (outside tendinous
ring)  enters orbit  passes medially to superior
oblique muscle.
Trigeminal nerve Leaves anterolateral surface of pons  forwards over  Opthalmic division (Vi): passes through superior orbital fissure  orbit
(V) petrous crest with extension of dura and arachnoid
from posterior cranial fossa  forms a trigeminal  Maxillary nerve (Vii): passes forwards through the foramen rotundum 
ganglion in Meckel’s cave in apex of petrous bone  pterygopalatine fossa
3 large sensory divisions & a motor part which joins the
madibular (3rd) division
 Mandibular division (Viii): passes directly downwards through foramen ovale
into the infratemporal fossa.
Opthalmic (Vi) Runs through lateral wall of cavernus sinus  divides into 3 branches: Sensory:
Sensory  Frontal ( supra-orbital + supra-trochlear) – outside ring  Conjunctiva
 Lacrimal – outside ring  Skin of upper eyelid
 Nasociliary – inside ring  Bridge of nose & forehead
o Long ciliary nerves Cornea & sclera (via ciliary
o Short ciliary nerves branches)
o Anterior ethmoidal nerve (sensation to nose)

Long ciliary nerves: sensory + symp

Short ciliary nerves: sensory + symp + parasymp

Lacrimal nerve carries automomics to lacrimal gland:

Parasymp: CNVII  greater petrosal nerve
Tested for by touch,
Symp: internal carotid plexus  deep petrosal nerve
temperature, pressure and
Greater petrosal nerve + deep petrosal nerve = nerve of the pterygoid canal
pain, on dermatome of skin
Both pterygoid canal  pterygopalatine ganglion  synapse (PS)  maxillary nerve
in the forehead and face
(Vii)  zygomatic nerve  zygomaticotemporal nerve  lacrimal nerve  lacrimal
gland.
Maxillary division Lateral wall of cavernosus sinus  foramen rotundum  pterygopalatine fossa. Sensory:
(Vii) In the pterygopalatine fossa gives off branches through the:  Mid-face
Sensory • Infraorbital nerve: infraorbital fissure  infraorbital canal  infraorbital foramen (to  Nasal cavity
front of face)  Palate
All happens in • Nasopalatine nerve: Sphenopalatine foramen  nasal cavity  incisive foramen 
pterygopalatine hard palate Infraorbital:
fossa • Greater palatine nerve: palatine canal  hard palate (through greater + lesser palatine  Lower eylid + associated
foramina) conjunctiva
• Superior alveolar nerves (anterior/middle/post)  Skin of midface + upper e
o Post: own branch through alveolar foramen
Superior alveolar:
 o Mid + ant: branches of infraorbital nerve in the maxilla  Maxillary teeth
• Zygomatic nerve: carrying automonics which will end up in lacrimal nerve  Maxillary antrum
 Anterior – nose
Associated with the pterygopalatine ganglion which recieves parasympathetic from facial
(VII) [greater superficial petrosal nerve], and gives autonomic to each of the branches of Zygomatic
the maxillary. Skin over zygomatic +
temple

Autonomic:
 lacrimal gland, secretion
from nose, palate &
sinuses

Mandibular Passes through foramen ovale  infratemporal fossa Meningeal nerve: Test by asking the patient to
division (Viii) In the infratemporal fossa gives off:  Dura of middle cranial fossa clench jaw together and
Sensory + motor • Meningeal nerve (nervus spinosus) – through foramen spinosum  Mucosa of mastoid air cells. protrude jaw (checks motor
supply to muscles of
All happens in • Anterior division – motor to muscles of mastication Anterior division – motor: mastication).
infratemporal (+ long buccal nerve)  All the muscles of mastication
fossa  Tensor tympani (of middle ear) Sensory component of
• Posterior division – sensory:  Tensor veli palatini (only palate mandibular division is tested
o Lingual nerve: runs on surface of lateral and medial pterygoid muscle  muscle not supplied by pharyngeal by testing sensation over the
onto bone of mandible  travels medially across floor of mouth  hooks plexus) dermatome supplied by this
underneath submandibular duct  runs into the substance of the tongue  + sensory to cheek via long buccal nerve.
o Inferior alveolar nerve: enters mandible via mandibular foramen  exits nerve.
onto face through mental foramen to become mental nerve
o Auriculotemporal nerve (splits either side of the middle meningeal artery) Inferior alveolar nerve:
– carries parasymp to parotid  Sensation to pulp cavities of teeth
(+ small motor branch to mylohyoid + anterior digastric muscle)
 Mental nerve supplies:
Associated with otic ganglion which recieves parasympathetic from  Skin and mucosa of lower lip and
glossopharyngeal (via lesser superficial petrosal nerve) and sends it to parotid skin of chin.
gland (via auriculotemporal).
Lingual nerve:
Parasymps:  Carries general sensation to anterior
Chorda tympani: 2/3 of tongue.
Branch of facial nerve in middle ear  leaves the petrous temporal bone of  Carries pregang. parasymp from
middle ear through the petrotympanic fissure  submandibular ganglion  chorda tympani (VII) 
s/l + s/m salivary glands submandibular ganglion 
postgangs. to submandibular &
Lesser superficial petrosal nerve: sublingual salivary glands.
CNIX (jugular foramen)  LSPN  through petrous temporal bone and exits  Taste sensation from anterior 2/3 of
through foamen ovale  otic  auriculotemporal  parotid tongue  chorda tympani  facial
nerve VII

Auriculotemporal:
 Skin of temple, scalp, front of
auricle.
 Anterior of external auditory
meatus.
 Carries postganglionic parasymps 
parotid (from IX  lesser superficial
petrosal  otic ganglion 
auriculotemporal  parotid)

Abducent (VI) Leaves lower anterior aspect of the pons  runs long Supplies the lateral rectus Long course makes it vulnerable Ask the subject to follow an
way up clivis before piercing the dura  under muscle to injury object held out to the edge
petroclinoid ligament  within substance of cavernosus of the temporal field with
sinus  accompanies internal carotid through the sinus the eye of the same side.
  passes through medial superior orbital fissure
(through fibrous ring)
Facial (VII) Emerges between pons & medulla  passes laterally Bell’s palsy – often due to Tested by asking the patient
into internal acoustic meatus  laterally in meatus  inflammation of the facial nerve to blink/screw up eyes and
medial wall of middle ear cavity  geniculate ganglion in the facial canal of petrous show their teeth.
(contains sensory cell bodies)  turns posteriorly (genu) temporal bone.
in boney canal  runs to posterior wall of middle ear inability to blink
cavity  travels down posterior wall in middle ear inability to show teeth
cavity  leaves skull through stylomastoid foramen  paralysis of buccinator
enters the parotid gland  runs forwards through
substance of parotid (most superficial structure)  Stroke (upper motoneuron
splits into branches at anterior margin of parotid gland: Motor to all the muscles lesion):
 Temporal, zygomatic, buccal, marginal of facial expression. patient can still screw up
mandibular, cervical branches eyes and blink
paralysis of muslces below
Branches within middle ear: level of eyes in face.
 Greater superficial petrosal nerve (close to
geniculate ganglion). Travels in pterygoid canal.
Gives parasymp to pterygopalatine ganglion (Vii).
 Stapedius nerve (in middle ear cavity)
 Chorda tympani (just before it leaves through the
stylomastoid foramen, exits through pterotympanic
fissure  parasymp to submandibular ganglion via
lingual nerve)
Chorda tympani Branch of facial nerve just before it leaves through the stylomastoid Carries parasympathetic fibres to the
foramen  travels up over tympanic membrane & handle of the submandibular ganglion.
malleus  leaves skull through petrotympanic fissue 
immediately joins lingual nerve Carries special taste fibres from anterior
2/3 of tongue  facial nerve VII
Vestibulocochlear Emerges close to facial nerve between pons & medulla Nerve of hearing &
(VIII)  internal acoustic meatus  runs with facial nerve & balance
labyrinthine artery  cochlear & vestibular apparatus.
Divides into:
 Cochlear division
 Vestibular division
Cochlear division Have their sensory gangia in the modiolus of the cochlea Hearing Usually air-conducted sound is louder than bone-conducted
 sound. BUT if sound conducting pathway is damaged, then
bone-conduction becomes louder.
A tuning for placed 1st on the mastoid process (bone-
conduction), then beside the ear (air-conduction), will
distinguish this.
Vestibular Have their sensory ganglia in the internal acoustic Balance Ask patient to stand with feet together & eyes closed – patient
division meatus. will sway and fall to the side of the vestibular lesion.

Glossopharyngeal Leaves through jugular foramen (posterior cranial Motor: Stimulate the back of the
(IX) fossa). • Stylopharyngeus oropharynx.
There is a sensory ganglion just above and just below ‘Gag-reflex’ signals normal function
the jugualr foramen Sensory: of the glossopharyngeal.
Passes down neck between internal & external carotid • Middle ear
Travels in close association with stylopharyngeus. • Posterior 1/3 of tongue (both general sensation and
taste)
enters pharynx between superior and middle • Oropharynx
constrictor muscles. • Baroreceptors and chemoreceptors of carotid body &
 Contributes to sensory pharyngeal plexus sinus
 Runs to the back of tongue • Parasympathetic to the otic ganglion

Branch passes up to the middle ear, and forms lesser

superficial petrosal nerve  through foramen ovale 
otic ganglion (PS to the parotid)

Branch down to carotid body & sinus

Vagus (X) Leaves skull in jugular foramen – has 2 ganglia here Auricular branch:
which contain the sensory cell bodies.  Skin behind ear (Stimulation of auricular branch during operations may 
passes down neck in the carotid sheath  Posterior wall of vomitting via a vagal reflex)
Branches along its course: external auditory meat.
 Auricular branch – through petrous temporal bone
Pharyngeal branch: Test of vagal function:
 Pharyngeal branch – motor to pharyngeal plexus  Muscles of pharynx Ask patient to raise the soft palate (say ‘aaaah’) and swallow
Note this is mainly vagoaccessory fibres  levator palati Also check that there is sensation in the piriform fossa and
epiglottis.
 Superior laryngeal – arises high in neck and travels External superior
down behind the internal carotid laryngeal:
 o External superior laryngeal – motor to cricithyroid  Motor to cricothyroid
o Internal superior laryngeal – sensory
Internal superior
 Recurrent laryngeal: left (around aorta), right (around laryngeal:
subclavian artery).  Sensory to mucosa of
larynx above vocal folds
 Vagal trunks continue through thoracic inlet, found in  Inc vallecula
the thorax lying against:
Trachea on the right Recurrent laryngeal:
Arch of aorta on the left  Supply all intrinsic
muscles of larynx
except cricothyroid.
 Sensation to mucosa of
larynx below vocal
folds.
Accessory nerve Arises from both medulla (cranial root) and upper Cranial accessory:
(XI) cervical spinal segment (spinal root).  Larynx and pharynx with
Spinal root enters posterior cranial fossa through the branches of vagus
foramen magnum & joins with the cranial root.
Leaves the posterior fossa through the jugular foramen Spinal accessory: Spinal accessory nerve:
 Motor to  Ask patient to shrug their shoulders against reistance
 Cranial root immediately joins the vagus  sternocleidomastoid & from your hand
vagoaccessory nerve  distributed to: trapezius  Turn their face against the palm of your hand
o With pharyngeal nerve  pharyngeal plexus
o With laryngeal nerves  Tests the force of the sternocleidomastoid & trapezius
(right SCM turns face to the left, and vice versa)
 Spinal root runs into deep sternocleidomastoid 
obliquely across the posterior triangle  trapezius

Hypoglossal (XII) Leaves skull through foramen magnum but then Motor to all intrinsic and Tested by asking patient to stick their tongue out – the
immediately enters the hypoglossal canal just above the extrinsic muscles of the tongue deviates to the side of any hypoglossal nerve lesion.
occipital condyle tongue except
Swings outwards & laterally behind the vagus and palatoglossus.
internal & external carotids – quite superficial
At the level of the hyoid bone, the hypoglossal nerve
runs forwards with the lingual artery
 Runs over lateral aspect of hyoglossus

PARASYMP:

Note: for cranial nerve contributions to the ganglion of the head and neck: COPS 3977 (i.e. ciliary CN III, otic CN IX, pterygopalatine CN VII, and
submandibular CN VII)

Lesser petrosal nerve (IX)

CNIX (jugular foramen)  LSPN  through petrous temporal bone and exits through foamen ovale  otic ganglion  auriculotemporal nerve (branch of
Viii) parotid

Greater petrosal nerve (VII)

Facial nerve (close to geniculate ganglion in middle ear)  GSPN (pterygoid canal)  pterygopalatine ganglion  parasymp to branches of Vii

Occulomotor nerve (III)

Pregang PS (CNIII)  ciliary ganglion in orbit  postgang PS (short cilliary nerve, branch of Vi)  eye

Chorda tympani (VII)

Branch of facial nerve in middle ear  leaves the petrous temporal bone of middle ear through the petrotympanic fissure  joins lingual nerve 
submandibular ganglion  parasym to submandibular + lingual salivary glands

Origin of pregang PS Carrier of postgang PS (CNV)

V1 Ciliary ganglion Orbit CNIII Short ciliary (Vi) Ciliary body + iris
V2 Pterygopalatine ganglion Pterygopalatine fossa CNVII (GPN) Vii branches E.g. lacrimal
V3 Otic ganglion Infratemporal fossa CNIX (LPN) Auriculotemporal nerve (Viii) Parotid
V3 Submandibular ganglion Floor of mouth CNVII (chorda tympani) Lingual nerve (Viii) Sublingual + submandib g
CN 3 9 7 7
Ganglion C O P S
V nerve C A L L

SYMPATHETIC:

Pterygopalatine ganglion
Carotid plexus  deep petrosal nerve  pterygopalatine canal  pterygopalatine ganglion  branches of Vii

Orbit
Carotid plexus  nasociliary branch of Vi  long ciliary nerve + short ciliary nerve (via ciliary ganglion)

FACE
Sesory: V
Motor: VII

Vi Supra-orbital
5 branches Supra-trochlear
Infra-trochlear
Lacrimal
External nasal
Vii Infra-orbital
3 branches Zygomatotemporal
Zygomatofacial
Viii Auriculotemporal
3 branches Buccal
Mental

VII Posterior auricular

6 branches Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical
Frontal County Caecum (foramen) Emissary vein (nose to superior sag sinus)
Cricket Cribiform plate Olfactory nerve
Sphenoid Oh Optic canal Optic nerve + ophthalmic artery
So Superior orbital fissure III (S+I), IV, Vi (NC + F + L), VI
Radiaent, Rotundum (foramen) Vii (maxillary trigeminal)
Oh Ovale (foramen) Viii + accessory meningeal artery (MALE)
So Spinosum (foramen) Middle meningeal artery + vein + meningeal branch Viii
Lovely Lacerum (foramen) Nerve + artery pterygoid canal
Temporal- I’m Internal acoustic meatus CN VII + VIII (facial + vestibulocochlear)
occipital Jack Jugular (foramen) CN IX, X, XI + jugular vein + inf petrosal sinus
Hello! Hypoglossal canal CN XII (hypoglossal)

Superior orbital fissure:

III
superior division of the oculomotor nerve
inferior division of the oculomotor nerve

IV: trochlear nerve

Vi
lacrimal nerve
frontal nerve
nasociliary nerve

VI: abducens nerve (CN VI)

Foramen ovale: MALE

M: mandibular branch of trigeminal (Viii)
A: accessory meningeal artery
L: lesser petrosal nerve
E: emissary vein
Ovale = Otic ganglion

Foramen lacerum  pterygoid canal

Nerve of pterygoid canal:
o Greater petrosal nerve (parasymp from facial nerve CN VII)
o Deep petrosal nerve (symp from carotid plexus)

Foramen spinosum

Middle meningeal artery + vein

Meningeal branch Viii
Facial:
Greater superficial petrosal nerve  pterygopalatine
Chorda tympani  submandibular
CNIX:
Lesser superficial petrosal nerve  otic  auriculotemporal
SHOULD SAY IV not V