PNS Exam Full Study Guide

Neurology Exam Study Guide
PERIPHERAL NERVOUS SYSTEM SPINAL NERVES

Definitions
CNS PNS
Components Brain, Spinal Cord Spinal Nerves, Cranial
Nerves
Bundle of axons Tract Nerve
Collection of nerve cell Nucleus Ganglion (ganglia, pl)
bodies
Peripheral Nervous System

o 12 pairs of cranial nerves arise from brain stem
o 31 pairs of spinal nerves arise from spinal cord
o Organized as follows:
Peripheral Nervous System
Somatic Nervous System
Autonomic Nervous System
o Sympathetic Nervous System
o Parasympathetic Nervous System
Peripheral Nerve Structure
o Fiber consists of axon, neurolemma (myelinated or unmyelinated), and surrounding endoneurial CT
Myelinated nerve fiber = Somatic (Sensory/GSA or Motor/GSE)
Unmyelinated nerve fiber = Autonomic (GVE)
o Bundled into fascicles surrounded by dense CT perineurium (sheath)
o The peripheral nerve fascicles, the vasa nervosum (minute blood vessels), fatty tissue, and lymphatics
are all ensheathed by thick epineurium to form a peripheral nerve
A. Spinal Cord
Differences in lengths of 3 Major Structures: Spinal Cord, Dural Sac (Meningeal Layers: Dura, Arachnoid, Pia),
and Vertebral Column
o Vertebral Column longest; extends all the way to coccyx
o Dural Sac/Meninges extends to S2
o Spinal Cord tapers caudally and ends at the intervertebral disc between L1 and L2 at conus
medullaris
Spinal cord descends from caudal portion of the Brainstem (Medulla Oblongata), passes through foramen
magnum at base of the skull
Cord descends through the Vertebral Canal within a closed dural (thecal) sac surrounded by the 3 meningeal
layers, which extends to S2
Spinal cord doesnt have the same diameter throughout its descent
o Large diameter by the Cervical/Cranial region and the Lumbar region need to provide a rich and
complex innervation
o Cervical and Lumbosacral enlargements in spinal cord give rise to spinal nerves contributing to the
brachial and lumbosacral plexuses innervate the upper and lower limbs,
respectively
Spinal Cord Segments
o Pair of spinal nerves arises from each segment of the spinal cord
o Each pair of spinal nerves formed by the convergence of fibers arising
from the dorsal and ventral aspects of the segment
o GSA fibers form the dorsal root and GSE fibers form the ventral root
o Spinal segments have rootlets and roots
B. Spinal Nerves
Fibers: Arising from each segment are GSA and GSE fibers
o (GSA) Somatic afferent supply dermatome, a specific segment of skin
o (GSE) Somatic efferent supply a myotome, a specific mass of muscle
Since the spinal cord and spine are unequal in length, there is:
o Disparity in the location of most cord segments and intervertebral
foramen through which the spinal nerve emerges
o Variation in the length and orientation of the nerve roots
Lumbar and sacral roots are long travel a great distance before exiting; cervical roots are
shorter
1. Roots
o Dorsal (Posterior) Root comprised of somatic afferent fibers carrying sensory information from
periphery to CNS (spinal cord)
o Ventral (Anterior) Root comprised of somatic efferent fibers carrying information from CNS to
periphery (e.g. skeletal muscle)
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2. Mixed Spinal Nerve in IV foramen
o Both afferent and efferent fibers, extremely short, just
long enough to pass out of foramen, out of spine
3. Rami
o Dorsal (Posterior) Rami smaller, carry both afferent
and efferent fibers to posterior, back
o Ventral (Anterior) Rami larger, carry both afferent
and efferent fibers to ventral body wall and extremities
4. Spinal Cord
o Spinal Gray (butterfly shaped Gray Matter) have dorsal
and ventral horns where spinal nerves arise
o White Matter myelinated axons
C. PNS Innervation
Peripheral Nervous Fiber Source Fiber Type Target
System
Somatic GSA - Somatic Joints, skin, Somatosensory CNS
- Body wall and afferents skeletal muscle fibers
extremities GSE - Somatic CNS Somatomotor Skeletal Muscle
efferents fibers
Visceral GVA - Visceral Viscera, vessels Viscerosensory CNS
- Viscera (internal afferents fibers
organs) GVE - Visceral CNS Visceromotor Glands, smooth
efferents fibers muscle, cardiac
= Autonomic muscle
Nervous System
Afferents convey info to CNS
Efferents convey info from CNS
Both Somatic and Visceral parts of the PNS have afferent and efferent fibers
D. Somatic Nervous System (SNS) 1 NEURON

Concerned with bodily movements and sensations
SENSORY GSA Somatic Afferent Fibers
o Somatosensory fibers transmit info to the CNS concerning:
Touch, pain, pressure, and temperature from the skin
Pain and proprioception from muscles, tendons, and joints
Proprioception unconscious perception of movement and spatial awareness;
first modality of somatic sensation to be compromised with consumption of
excess alcohol
MOTOR GSE Somatic Efferent Fibers
o Somatomotor fibers stimulate voluntary and reflex contraction of skeletal muscles derived from
myotomes of somites
In the SNS, there is only ONE NEURON between the CNS and either: 1) the muscles innervated by GSE fibers,
or 2) the sensory receptors innervated by GSA fibers
o 1 neuron b/w CNS and target for efferent; 1 neuron b/w peripheral tissues and CNS for afferent NO
SYNAPSES
1. Somatic Afferents (GSA)

o Dermatome specific area of skin supplied by somatic
afferents in a single spinal nerve
Dermatomes overlap loss of a single spinal nerve or
dorsal root doesnt produce anesthesia, will not end up
with diminished reception in body wall since there is
overlap of adjacent nerves
o NOTE that the skin of face and anterior scalp are innervated by
CN V (trigeminal), a CN not a spinal nerve
o Cutaneous nerves & Exteroreceptors (Cutaneous/Peripheral
Sensory Receptors)
Cutaneous receptors that transduce stimulus from skin
to the CNS via action potentials. Each receptor is sensitive to a particular form of physical
energy, or stimulus. They include:
Mechanoreceptors respond to deformation or displacement sensitive to touch, vibration
Thermoreceptors respond to changes in temperature
Nociceptors respond to stimuli that damage tissue crushing, cutting
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Receptors are continuous with central processes of pseudounipolar sensory neurons whose cell
bodies are located in the Dorsal Root (spinal) Ganglion swelling of the nerve where
neuron cell bodies are found
o Ventral root does not have a ganglion
Exteroceptive information, along with information from proprioceptors located in muscles,
tendons, and joints, enters the spinal cord via the central processes of the neurons in the
dorsal root ganglion
o Peripheral inputs are relayed directly to the spinal cord via central processes (no
synapses)
Signals that enter the spinal cord can enter:
o White matter taking it up to brain for higher level processing
o Gray matter ventral gray synapses on motor neurons, includes spinal reflexes (e.g.,
get burned and pull hand away)
o Inputs into the spinal cord from the Dorsal root are segregated by modality (functional
segregation)
Ex: Proprioceptive input White matter Brain
Ex: Pain (Nociceptive) and Temperature Ventral Horn Gray Matter Reflex
o Referred Visceral Pain (pg 5) communications b/w SA and VA fibers; pathologies of internal
structures (visceral) can be experienced as pain in the body wall (somatic) far from the actual internal
organ b/c of these communications
2. Somatic Efferents (GSE)

o Contraction of skeletal muscle is a direct result of stimulus by
lower motor neurons (located in either the cranial nerve nuclei
of the brainstem or the ventral horn of the spinal cord). Impulses
from cortex in brain are transmitted to lower motor neurons (via
upper motor neurons?)
Large, myelinated alpha motor neurons predominate;
travel through spinal root, out of spinal column, to muscles
o The ventral roots of spinal nerves convey the axons of alpha (and
gamma) motor neurons whose cell bodies are located in the
ventral horn (NOT in an external ganglion like in dorsal root) to the
mixed spinal nerve
SE fibers in Ventral Rami supply ALL muscles EXCEPT
intrinsic back muscles
SE fibers in Dorsal Rami supply intrinsic back muscles
o Lower Motor Neurons located in Brainstem Nuclei axons found in 9 of the 12 pairs of CNs
o Motor Unit comprised of a single alpha motor neuron in the anterior/ventral horn of the spinal gray
and all the muscle fibers it innervates
Each muscle fiber is innervated by a single alpha motor neuron, but each neuron innervates
many muscle fibers
Within a muscle, the fibers belonging to one motor unit are distributed over a wide territory,
and intermingle with the fibers of other motor units
o Most of the skeletal muscles of the body are formed by the fusion of 2 or more myotomes of the
developing somites; each myotome within a muscle is associated w/ specific SE fibers; therefore, most
muscles are innervated by peripheral nerves containing fibers of 2 or more adjacent spinal cord
segments/spinal nerves
Ex: Multi-Segmental Muscle Innervation: 3 different Ventral Roots (from 3 diff spinal cord
segments) 3 Spinal Nerves Single Peripheral Nerve Muscle Innervation
Single Ventral Root contains SE fibers targeted towards different, specific myotomes Spinal
Nerves come together and exchange fibers (Spinal Nerve Plexus) form Peripheral Nerves
containing SE fibers from at least 2 Spinal Cord Segments
o The terminal ends of alpha motor axons branch repeatedly, lose their myelin sheaths and terminate
near the middle of muscle fibers at a neuromuscular junction they lose their myelin sheaths as
they reach the muscle
o Peripheral Nerve Injuries:
Irritative nerves vulnerable to pathology in confined space
o Caused by acute or chronic mechanical trauma or inflammation (compression,
stretching)
o May initiate impulses in sensory OR motor fibers (due to nerve irritation)
SA fibers stimulated pain or parasthesia (altered sensation)
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SE fibers stimulated uncontrollable contraction of skeletal muscle fibers
(twitching)
Destructive actual damage to nerve
o May result from trauma or neuropathy
o Motor symptoms destroy SE fibers paralysis or paresis (weakness)
o Sensory symptoms destroy SA fibers anesthesia (no sensation) or hyperesthesia
(diminished sensation)
E. Visceral Component Viscera (Internal Organs)

1. Motor (GVE) components = Autonomic Nervous System (ANS)
o Control smooth muscles
o Glands (salivary, palatine, digestive)
o Cardiac muscle
o ANS is part of PNS, but the visceral efferent neurons are under control of higher CNS centers it gets
signals from brain
2. Sensory (GVA) components triggers ANS
o Convey normally vague and poorly localized organic pain as well as visceral sensations which are
primarily affective in nature (e.g., hunger, satiety, nausea, anxiety, stress) (But note referred pain)
E.g. stomach ache poorly defined (vs. a cut)
o Visceral Afferent fibers course along with sympathetic nerves; VA fibers
can also convey information related to visceral reflexes and
physiological sensations from:
Mechanoreceptors distension in walls of GI tract, respiratory
structures and bladder as well as baroreceptors in arteries
(e.g. filling of bladder conveyed by visceral afferents carried by
splanchnic nerves)
Chemoreceptors changes in partial pressure of O2 and CO2
in blood (blood gas and pressure), changes in blood pH and
changes in concentration of H+ ions in stomach
F. Autonomic Nervous System (ANS) (GVE)
2 NEURON RULE for motor innervations
o Preganglionic/synaptic 1st neuron has cell body in CNS; post-
ganglionic 2nd neuron is located in an autonomic ganglion
o Preganglionic axon leaves CNS and terminates by synapsing on the 2 nd
neuron
o Postganglionic axon leaves the ganglion and innervates smooth muscle, a gland or the heart
o All preganglionic fibers are cholinergic; use acetylcholine as their neurotransmitter
o Sympathetic
Preganglionic axon is SHORT (close to vertebral column), postganglionic neuron in a
paravertebral/sympathetic chain (closer) or prevertebral (further) ganglion near the CNS
Norepinephrine is released at postganglionic terminal (adrenergic ending)
o Parasympathetic
Preganglionic axon is LONG, postganglionic neuron is in a ganglion on or in the walls of the
target organ
Acetylcholine is released at postganglionic terminal (cholinergic ending)

1. Parasympathetic Division Rest and Digest Craniosacral System
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o Conserves energy, restores body resources chilling
out, rebuilding body resources and tissues
o Anabolic, restricted distribution
o KNOW: Craniosacral System
Preganglionic cell bodies located in:
1) Brain stem nuclei
2) S2-S4 ventral horns
Pelvic Splanchnic nerves (think
P.S. = ParaSympathetic; and S =
Splanchnic/Sympathetic) axons
leaving S2-S4 spinal nerves
o ***KNOW: Preganglionic parasympathetic axons
leave brainstem in 4 CN: III, VII, IX, and X
(oculomotor, facial, glossopharyngeal, vagus)
CRANIAL parasympathetic (via CN): III,
VII, IX fibers synapse in ganglia located in
head; X fibers synapse in ganglia in neck,
heart, thorax, abdomen (upper GI)
SACRAL parasympathetic (via pelvic
splanchnic nerves): S2 to S4 fibers
synapse in ganglia in lower GI, pelvis,
perineal (erectile tissue) organs
2. Sympathetic Division Fight or Flight Thoracolumbar
System
o Arousal of body and preparation to deal w/
threatening stimuli
o Catabolic (maintains stimulated state), widely
distributed
o Preganglionic Sympathetic Fibers
KNOW: Preganglionic cell bodies located in: T1-L2 Intermediolateral horns
Extra horn in T1-L2 segments with sympathetic cell bodies; runs up and down
Axons leaving via spinal nerves head for sympathetic trunk via white rami
communicantes
Sympathetic Trunks/Chains
Bilateral chains of interconnected paravertebral ganglia that lie in paravertebral
gutters along each side of spine from the base of skull to coccyx
Chains extend more superiorly and inferiorly (from base of skull to coccyx) than the
presympathetic outflow from cord (T1-L2)
White Rami Communicantes (connects spinal nerve to sympathetic chain preganglionic
flow into chain)
After traversing IV foramina, the T1-L2 spinal nerves send preganglionic sympathetic
fibers to sympathetic chain via white rami communicantes
4 fates of preganglionic sympathetic fibers reaching the sympathetic chain via white rami:
1. Enter the chain and synapse at nearest ganglion
2. Ascend chain and synapse at a more superior ganglion (closer to head)
3. Descend chain and synapse at a more inferior ganglion
4. Pass through the chain without synapsingsynapsing somewhere else (becomes
splanchnic nerves)
o Postganglionic Sympathetic Fibers (that have synapsed in sympathetic chain)
3 Ways Postganglionic Sympathetic Fibers (that have synapsed in chain) get to targets:
1. Most postganglionic sympathetic fibers rejoin spinal nerves for distribution to the body wall via
gray rami
Gray Rami Communicantes (connects sympathetic chain to spinal nerve

postganglionic flow out of chain)
o Gray rami convey postganglionic sympathetic fibers leaving the chain back to
the spinal nerves
o EVERY spinal nerve receives some postganglionic sympathetic fibers
via gray rami
o These fibers supply body wall structures requiring autonomic innervations
Structures receiving sympathetic innervations ONLY
o Sweat glands
o Arrectores pilli smooth muscle of hair follicles (e.g. cats hair stands on
end, also in humans)
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o Vascular smooth muscle vasoconstriction of peripheral muscles;
vasodilation of vessels to skeletal muscles
Summary: White rami communicantes bring preganglionic sympathetic fibers
from Spinal Nerves T1-L2 to sympathetic chain; Gray rami communicantes
take postganglionic sympathetic fibers away from Sympathetic Chain and
direct back to Spinal Nerves Body wall sympathetic innervation
White and Gray rami together
associated with T1-L2 only; Gray Rami
alone associated w/ ALL spinal nerves
b/c they return fibers to spinal nerves
responsible for innervation of body
wall
To turn off body wall structures turned
on by a sympathetic stimulus, you
remove the stimulus
2. TO HEAD: Some postganglionic axons arising
from Cervical Ganglia leave sympathetic chain
and form a Periarterial Plexus (like NVB)
around the carotid arteries and their branches
to reach cranial and cervical viscera
Piggy back on carotids to reach
targets in head and neck
Horners Syndrome: condition that
results from disruption of this plexus
(symptoms include: Ptosis, Miosis, Anhidrosis)
3. TO VISCERA: Some postganglionic axons leave chain as Direct Visceral Branches to cervical
and thoracic viscera including the heart and lungs
Direct visceral branches also convey GVA fibers (follow path of GVE) IN REVERSE from
viscera to cervical and upper thoracic spinal nerves via white communicating rami (going
backwards)
Sympathetic fibers in abdomen travel with visceral afferents, which transmit pain from
GI tract
These pain afferents may stimulate GSA fibers in the dorsal roots of these spinal
nerves and produce Referred Visceral Pain (pg 2) in the body wall or extremities
(e.g., angina, myocardial infarction pain can be perceived far away from site of pain)
o Cross talk b/w visceral and somatic afferents; as VA fibers make way to brain
they may stimulate SA fibers in dorsal roots of spinal nerves
o Visceral pain = dull, not localized, organ-related pain
o Somatic pain = sharp, localized, pain in body wall
o A lack of oxygen to cardiac muscle (Ischemia) may produce Referred Cardiac
Pain
Visceral afferent from heart sympathetic chain white rami
communicantes dorsal root ganglion dorsal root dorsal horn
stimulate Somatic afferents
Visceral afferent pain fibers accompanying sympathetic nerves also transmit pain from:
o Nociceptors stimulated by excessive distension of a part of the GI tract or
bladder
o Strong contractions of smooth muscle in the wall of a visceral structure such as
the uterus
o Fate #4: Splanchic (Visceral) Nerves
Bundles of preganglionic sympathetic axons which exit the sympathetic chain without
synapsing
Splanchnic nerves synapse in collateral or prevertebral ganglia located anterior to the
abdominal aorta and common iliac arteries
Nerves contain Preganglionic Sympathetic fibers destined for the abdomen; pierce the
diaphragm en route and seek synapse on neurons in Preaortic (Prevertebral) Ganglia; a few
nerves pass through these ganglia and synapse in the Adrenal Medulla
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Prevertebral ganglia at: celiac trunk, superior
and inferior mesenteric arteries, renal arteries
Postganglionic sympathetic fibers arising from
the prevertebral ganglia reach their visceral
targets by forming a periarterial plexus
along arteries arising from the abdominal aorta
Upon reaching the GI tract, these postganglionic
sympathetic fibers contribute to the formation of the
Enteric Nervous System (enteric related to
intestines) within the walls of GI structures from the
esophagus to the anal canal where they facilitate
contraction of smooth muscle sphincters and inhibit
both peristalsis and glandular secretion (slows down
digestion, sphincters closed, slow peristalsis)
The splanchnic nerves also convey GVA fibers from
viscera to the dorsal roots of spinal nerves T5-L2 via
the white communicating rami; these pain afferents
may stimulate GSA fibers in the dorsal root and
produce referred pain
Pain from abdominal viscera is consistently referred to
specific regions of the body wall as well
PERIPHERAL NERVOUS SYSTEM CRANIAL NERVES

Cranial Nerve Fibers
CN Components
o In addition to GSE, GSA, GVE, or GVA fibers, CNs may also contain: SSA, SVA, SVE
Special Somatic Afferents (SSA) convey info related to those special senses which relate the body
to the external environment
o Ex: vision from retina; sound from cochlea; equilibrium from labyrinth of inner ear
Special Visceral Afferents (SVA) convey info related to those special senses associated with
ingestion of food
o Smell and Taste of food; Evolved to help appreciate good food and stay away from bad food
Special Visceral Efferents (SVE) fibers innervating skeletal muscle derived from pharyngeal arches
o CN V, VII, IX, X all have SVE fibers
Lower Motor Neurons that give rise to Efferent fibers in CNs are located in the Motor Group of Cranial
Nerve Nuclei (in those CNs that have a motor component)
Some CNs have purely sensory (afferent), motor (efferent) or both (mixed) fibers
Primary Sensory Neurons that give rise to Afferent fibers in CNs are located in Ganglia outside the CNS
and project to secondary neurons in the dorsal gray of the brainstem
CN I: Olfactory Nerve
FIBER TYPES = SVA
NUCLEI = Anterior olfactory nucleus
SUMMARY: Olfactory Mucosa/Epithelium contains Primary Olfactory

Sensory Neurons/Olfactory Cells central processes of Primary Sensory
Neurons/Olfactory Axons Olfactory Bulbs (on cribriform plate) contains
Secondary Olfactory Sensory Neurons central processes form Olfactory
Tract Rhinencephalon
Transmits the sense of smell from receptors in the olfactory epithelium in
the nasal cavity to the brain
Olfactory Bulbs
o Rest on cribriform plate of ethmoid
o Olfactory Tract connects bulbs to the brain
o Cribriform plate through small openings transmits multiple
rootlets/Olfactory Afferent Fibers (of CN I) from olfactory mucosa
(epithelium) of the nose to olfactory bulbs
Olfactory Mucosa (Epithelium)
o Located in upper nasal cavity (lateral wall and nasal septum)
o Olfactory receptors concentrated in olfactory mucosa (limited
distribution in humans)
o Primary olfactory sensory neurons located in olfactory mucosa;
Secondary olfactory neurons are in the bulb and tract
CN I and CN II technically not cranial nerves, but axons from primary sensory neurons (b/c they
dont lead to the CNS)
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Olfactory nerves = Bundles of axons piercing the cribriform plate
o Epithelium kept moist by olfactory glands, where aromatic molecules are sensed and detected
Bowmans glands secrete moisture in which odorants are dissolved
Olfactory Cells
o Olfactory Cells are Primary sensory neurons whose peripheral processes act as sensory receptors
Their unmyelinated central processes, olfactory axons, pierce the cribriform plate in bundles
o Axons synapse on secondary sensory neurons in the bulb, whose central processes form the olfactory
tract
o Most tract fibers project to Rhinencephalon (think rhino, big nose) in CNS or "Nose Brain" CNS
structures concerned w/ olfaction; piriform lobe is the site of primary olfactory cortex
o Also projects to autonomic sensors mediating visceral responses such as salivation or nausea via the
hypothalamus
Clinical Correlates
o Olfaction Loss: Lesions on underside of frontal lobes or floor of anterior cranial fossa
o Generally result in unilateral Anosmia, Hyposmia or Smell Distortion
1. Anterior-posterior (AP) head injuries
Head moved anteriorly/posteriorly in a forceful manner
Nerve rootlets vulnerable to shearing in acceleration/deceleration injuries of head and
neck, resulting in partial/complete loss of smell (only temporary b/c olfactory neurons
constantly replenished)
Hyposmia reduced sense of smell
Anosmia complete loss of smell
May involve subarachnoid tears and CSF leakage (CSF rhinorrhea) to nasal cavity; even
from nasal cavity to oral pharynx metallic taste
Concern of air leakage in brain, infection
2. Tumors, abscesses, or meningiomas (benign tumor of meninges) of the anterior cranial
fossa
3. Frontal lobe masses or abscesses - can contract olfactory bulb
4. Neurodegenerative Disease Alzheimers, Parkinsons
5. Toxic chronic smoking
o Food lacks flavor when nose is stuffed because chewing food
leads to release of odorants into the nasal cavity from behind
through the pharynx rather than through the nostrils
CN II: Optic Nerve

FIBER TYPES = SSA
NUCLEI = Lateral Geniculate Nucleus of the thalamus
SSA fibers mediate vision from photoreceptors (rods and cones) of the
retina to the brain (signal travels in reverse direction as does light)
o Photoreceptors (rods and cones) Bipolar Cells
Ganglion Optic Nerve
Retinal photoreceptors
o Rods and Cones transduce light energy into an electrical
signal which passes to Bipolar cells (primary sensory neurons in the visual pathway), then to
Ganglion cells (secondary sensory neurons), whose axons form optic nerves
o Rods 2 layers of stacked membranes associated with visual pigments thought to function in the
perception of dim light
o Cones less numerous, and number of discs varies, but they are crucial to visual acuity and color
vision
o Light goes through numerous layers before stimulating rods and cones, whose signals are sent to the
bipolar layer and then the ganglion layer
Anatomy of eye:
o Cornea very thin layer
o Sclera white fibrous layer that attaches eye muscles of ocular motility
o Lens shape changed by smooth muscle to adjust vision from far to near
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o Fovea Centralis small depression in the macula
lutea; has the densest concentration (1:1) of cones
to ganglion cells for maximal acuity and color vision;
fovea is a blind spot
o Central Retinal Artery branch of Ophthalmic
artery; reaches the Optic disc and the artery divides
into 4 branches
Retinal arteries are end arteries they have
no anastomoses
Ophthalmoscopic examination of the Optic
Fundus (interior surface of the eye opposite
the lens; includes: retina, optic disc, macula,
fovea) is a key part of clinical neurological
evaluation look for Papilledema
o Optic Nerve; Optic part of Retina
o Lamina Cribrosa region with many small holes in
the sclera; a cribriform structure; axons of the ganglion cells escape the retina and eyeball to converge
and form the optic nerve
Course
o Axons of ganglion cells converge toward the optic disc near the center of the retina, where they turn
posteriorly, pass through the sclera and exit the eyeball as the optic nerve
o Optic Nerve (a CNS tract) leaves through the Lamina Cribrosa, is bathed in CSF, and surrounded by the
3 meningeal layers
o The nerves course through the optic canals and end at the Optic Chiasm where decussation of fibers
occurs (in chiasmatic groove) optic nerves swap and travel to the other side
Two halves of retina: left half and right half (temporal and nasal
halves)
2 axon bundles arise from each retina, the lateral bundles course
on the same side, while the medial bundles cross at the optic
chiasm and merge with the lateral bundle from the opposing
retina to form right and left optic tracts
ONLY Axons from the nasal (medial) halves of the retinas
cross the midline at the optic chiasm
Fibers from the nasal half of the left eye and the temporal half of
the right eye form the right optic tract; and the fibers from the
nasal half of the right eye and the temporal half of the left form
the left optic tract (T/N; N/T)
o Most axons in each optic tract terminate in the Lateral Geniculate
Nucleus of the Thalamus
Some axons in the Optic Tract project to brainstem nuclei to
provide visual input crucial to reflex maintenance of balance, eye
position, and control of the size of the pupil
o Visual inputs project to Primary Visual Cortex surrounding the calcarine fissure in the occipital
lobes of the brain (back of brain)
The Optic Nerve is technically not a nerve, but a white matter tract of the CNS because it is
1. Comprised of axons of secondary rather than primary sensory neurons (like CN I)
2. Covered w/ CNS myelin and ensheathed by the meninges
Clinical Correlates
o Papilledema swelling of the nerve that results from compression due to increased pressure in the
subarachnoid space
o Optic fibers are vulnerable in the chiasmatic groove to lesions of the pituitary gland and the ventral
diencephalon
o Central artery of retina = end artery
No peripheral anastomoses with other vessels. If artery occluded or torn, photoreceptors lose
blood supply and blindness results. Diabetics are vulnerable
CN II Lesions
o Prechiasmatic lesion is prior to optic chiasm, at retina or optic nerve
Macular degeneration (aging of sight), Glaucoma (atrophy of the optic disc w/ increase in optic
pressure), Optic Neuritis (MS), Facial Trauma (blunt force trauma of eye blow out fracture of
orbit, sharp force)
Example: right monocular blindness caused by right optic nerve loss ipsilateral visual field
defect
If the nerve injury is incomplete scotoma, or blind spot in that eyes visual field
Normal: Left: T / N, Right: N / T; Pathology: Left: T / N, Right: X / X
o Chiasmatic lesion to optic chiasm, to decussating axons Tunnel Vision
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Caused by: Pituitary adenomas (increase in size impinges upon fibers at chiasm), Internal
carotid artery aneurysm
Example: Bitemporal hemianopsia caused by sectioning of optic chiasm temporal visual fields
lost, resulting in loss of peripheral vision (= loss of right and left temporal halves)
Left: X / N, Right: N / X
o Postchiasmatic lesion to optic tract, LGN or optic radiations (after optic chiasm)
Example: Left homonymous hemianopsia caused by sectioning of right optic tract loss of
input from contralateral visual fields of both eyes (Left: X / N, Right: X / T)
CN VIII: Vestibulocochlear Nerve
FIBER TYPES = SSA
NUCLEI = Vestibular nuclei, Cochlear nuclei in medulla
Anatomy
o Organs of hearing and balance are in petrous part of temporal bone dense compact bone for protection
o Ear Pathway: Auricle (Cartilaginous) External Auditory Meatus/Canal Tympanic Membrane/Eardrum
o External acoustic meatus has cartilaginous components laterally which are continuous with the auricle
and lead to the bony meatus
o Tympanic membrane eardrum; impt in functional conduction of sound; physically separates the external
auditory canal from the middle ear cavity
o Tympanic cavity middle ear; malleus, incus, stapes
o Semicircular Canals of the Middle Ear part of the vestibular apparatus of the ear
o Cochlea of inner ear
Nerve conveys sensory input concerning sound
from cochlea and equilibrium from semi-
circular canals of vestibular system to the
brainstem
Course: Nerve arises from sulcus between pons
and medulla (brainstem) and travels laterally at
the Cerebello-pontine angle and enters the
Internal acoustic meatus (transmits CN VII and
VIII)
Membranous labyrinth
o Labyrinth contains endolymph, and is
divided into:
1. Vestibule (2 sacs saccule, utricle)
2. Semi-circular canals (3)
3. Cochlea (spiral duct)
o Series of communicating sacs and ducts suspended in the bony labyrinth within the otic capsule of the
petrous temporal bone
Interval separating the membranous labyrinth from the surrounding bony labyrinth is filled with
CSF-like fluid, perilymph (separates bony from membranous)
CN VIII has distinct vestibular and cochlear portions:
A. Cochlear Nerve - Auditory
Carries SSA fibers for hearing, composed of the
central processes of neurons in the Spiral
Ganglia
Sound waves in the air are funneled through
the external auditory meatus and induce
vibration of the tympanic membrane and
ossicles in the tympanic cavity stapes
moves in and out of the oval window
generating pressure waves within the
perilymphatic fluid of the inner ear
The perilymphatic fluid wave travels through
the perilymphatic fluids in the cochlea
enters Scala Vestibuli initiates wave in the
Cochlear Duct vibrates the basilar
membrane of the Organ of Corti, stimulating hair cells (responsible for acoustic perception) that
transmit APs to bipolar neurons whose cell bodies are in the spiral ganglion
Specific frequencies of sounds stimulate specific hair cells in diff areas along basilar
membrane Place Principle short waves/high frequency act at base of cochlea, long
waves/low frequency act at apex of cochlea
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Central projections from the cochlear (auditory) nerve to cochlear nuclei are located in the medulla
(caudal pons)
Cochlear nuclei are tonotopically organized; low frequency fibers synapse on the Anterior
Cochlear Nucleus, high frequency fibers synapse on the Posterior Cochlear Nucleus
Acoustic inputs project to cortex in the temporal lobe along the lateral sulcus (aka silvan sulcus),
but the processing of bilateral acoustic inputs begins in the brainstem
Times of arrival and intensity of differences between left and right ears are analyzed to
permit localization of sound sources; brainstem nuclei help us locate where sound
source before we appreciate the sound
Stapedius muscle (VII) attaches to stapes and Tensor Tympani muscle (V) attaches to malleus
These muscles contract reflexively to protect the cochlea from loud sounds and lower
volume of own speech
In brain stem, there are connections b/w VIII, VII, V that trigger contraction of muscles
B. Vestibular Nerve Posture, Balance and Equilibrium
Composed of central processes of bipolar neurons in the Vestibular Ganglion
Perception of position and motion relative to gravity; orientation of head and body in relation to
vertical
Sense movement when walking/running and keep eyes level when moving up and down,
side to side
Primarily provides sensory inputs about the head on the body
The peripheral processes of the bipolar neurons convey input from:
1. Maculae of the utricle and saccule, otolithic organs that detect linear acceleration and
motion due to gravity and translational movement
2. Ampullae of the semi-circular canals - detect changes in angular motion and rotary
acceleration of the head in any direction relative to vertical
CNS relies on other sensory modalities in addition to Vestibular to determine overall body position and movement
o Visual Inputs convey info about mvmt with respect to envt and the direction of vertical
Vestibuloocular (VOR) combo of vestibular and visual inputs
Reflex coordinates eye mvmts to compensate for mvmts of the head so that visual fixation upon
a chosen object may be maintained (you can keep your eyes on one object while your head is
moved)
o Proprioceptors conveys inputs about joint position and muscle stretch, providing info concerning the
relative alignment of body segments to each other and to the support surface
With visual inputs control of posture
o Vestibuloreticular outputs: mediate Motion Sickness; get info from visual, vestibular, and proprioceptive
and send info to CNS
Clinical Correlates
o Lesions of VIII
Causes:
Viral labyrinthititis viral infection of labyrinth
Menieres Disease imbalance of endolymph
Acoustic neuroma benign tumor of Schwann cells (insulate CN VIII) on endoneurium of
VIII
o Both VII and VIII are vulnerable to benign acoustic neuromas as they enter the
internal acoustic meatus in the posterior cranial fossa
Symptoms: Sensorineural deafness, Tinnitus (ringing), Dizziness, Vertigo (illusory perception of
motion), Nausea and Vomiting, Nystagmus (oscillation of eyeballs)
CN V: Trigeminal Nerve
FIBER TYPES = SVE, GSA
NUCLEI = Pontine (principal sensory) nucleus, Spinal nucleus, Mesencephalic nucleus, Motor nucleus
Receives sensation from the face and innervates the muscles of mastication
Trigeminal nerve emerges from the lateral aspect of the midpons within the posterior cranial fossa as a large
sensory root and a small motor root
GSA mediate sensation from: skin of face and anterior scalp, mucosa of the oral and nasal cavities (including
tongue and paranasal sinuses), most meninges, eyeball (cornea and conjunctiva), teeth and gingiva,
nasopharyngeal mucosa; as well as Proprioception from 1st arch muscles (of mastication) and TMJ
o GSA fibers project to the Sensory Nuclei of CN V
o Mesencephalic Nucleus proprioception contain cell bodies of primary sensory neurons
concerned with proprioception
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Much proprioception in the mandible want controlled mvmt to protect teeth during
mastication
o Pontine Trigeminal (Principal Sensory) Nucleus touch sensation from face
Supply dermatomes of face and scalp
o Spinal Trigeminal Tract and Nucleus pain and temperature long, thin nucleus (medulla to C2)
Also receives GSA inputs from CN VII, IX, X
o NOTE: Sensory afferent cell bodies usually found in dorsal root ganglia outside of CNS
EXCEPT proprioception, which goes to mesencephalic in the CNS
o Pontine and Spinal Trigeminal Nuclei contain secondary neurons receiving input from primary neurons
in the Trigeminal Ganglion located in the Trigeminal Impression of Meckels Cave in the middle
cranial fossa
o All 3 divisions of CN V contribute meningeal branches (innervate dura of the anterior and middle
cranial fossa + falx cerebri and tentorium cerebelli), which helps explain referred pain of brain
freeze (IX is other one that innervates meninges)
SVE limited to mandibular division, branchial efferents innervate the 8 muscles derived from 1st pharyngeal
arch: 4 muscles of mastication, 2 muscles of the floor of mouth (mylohyoid, and anterior digastric), 2 tensors
(tensor tympani, tensor veli palatini)
o Arise from the Motor (or Masticator) Nucleus of CN V in the tegmentum of the pons
o Fibers arising in motor nucleus are found only in V3
KNOW: 4 pairs of parasympathetic ganglia (ciliary CN III, pterygopalatine CN VII, submandibular CN VII,
otic CN IX) of the head are all suspended from branches of CN V and all send postganglionic fibers via
terminal branches of the nerve to reach their targets
A. V1: Ophthalmic Division
FIBER TYPES = GSA
In the orbit, these fibers innervate the cornea (covers and protects lens), conjunctiva (line eyelids; white
parts of eye), and parts of sclera (thick, white tunic covering eyeball)
Course: leaves brainstem and enters orbit through superior orbital fissure, passing through cavernous sinus
3 main branches of V1 NFL:
1. Nasociliary Nerve innervates nose and eye; supplies ethmoid air sacs, nose innervates anterior
of nose (V2 has the rest); innervates the orbit through the annular tendon
Ethmoidal Nerve innervates ethmoid air sacs, the anterior branch continues to the lateral
nasal wall and septum:
Anterior and posterior ethmoidal nerves enter the ethmoidal sinuses and continue to
nose
Suspensory Root of Ciliary Ganglia (parasympathetic CN III)
Ciliary Nerves long and short convey trigeminal fibers to the cornea and the conjunctiva,
but also serve to piggyback autonomic fibers, both sympathetic and parasympathetic (short
ciliary), towards their targets in the eyeball
Infratrochlear skin at bridge of nose, including lacrimal sac and structures around medial
corner of the eye
2. Frontal Nerve passes through orbit, does NOT supply any orbital structures, branches in orbit:
Supraorbital Nerve forehead and scalp skin, frontal sinus
Supratrochlear Nerve conjunctiva, upper eyelid, forehead, lateral nose
Branches have a cutaneous distribution to the skin of the forehead and the nasal root
3. Lacrimal Nerve innervates lacrimal gland skin and conjunctiva; sits in small depression/fossa in
underside of the orbit
B. V2: Maxillary Division:
FIBER TYPES = GSA
Course: passes cavernous sinus, foramen rotundum to pterygopalatine fossa
3 main branches of V2 ZIPNS:
1. Zygomatic Nerve travels from the pterygopalatine fossa through the inferior orbital fissure and
then branches and passes through respective foramina
Zygomaticotemporal Nerve
Zygomaticorbital Nerve
Zygomaticofacial Nerve
2. Infraorbital Nerve travels from the pterygopalatine fossa through the inferior orbital fissure, on
floor of orbit above maxillary sinus (subject to pathology in orbit or sinus), and then passes through the
infraorbital foramen where it branches into 3
Superior Labial Nerve skin of upper lip
Nasal Branch skin of lateral nose
Inferior Palpebral skin of eyelid
3. Palatine Nerve (pick up parasympathetic fibers from pterygopalatine ganglion to palatine glands)
Greater Palatine Nerve passes greater palatine foramen to hard palate, mediating
sensation
Lesser Palatine Nerve passes lesser palatine foramina to soft palate, mediating sensation
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**NOTE: Pterygopalatine Ganglion is suspended from V2 within the pterygopalatine fossa
It receives preganglionic inputs from the Greater Petrosal Nerve (VII)
Postganglionic parasympathetics are distributed by terminal branches of V2 to lacrimal
gland, nasal mucosa, and palatine glands
Pharyngeal branch of V2 stems from the pterygopalatine ganglion
4. Nasopalatine Nerve passes through incisive canal to reach anterior side of hard palate
5. Superior Alveolar Nerves (PSA, MSA, ASA)
Posterior Superior Alveolar Nerve
Middle Superior Alveolar Nerve
Anterior Superior Alveolar Nerve
The superior alveolar nerves course along the walls of the maxillary sinuses to form the
Superior Dental Plexus and give rise to dental branches to the apices of the maxillary
tooth roots
Infection of the hard-to-drain maxillary sinuses may produce compression of the superior
alveolar nerves and produce referred dental pain
Maxillary (V2) Injection Sites
o Introducing dental anesthesia through infiltration and block injections requires understanding
peripheral distribution of V2 and V3 where the nerves innervate dentition, gingiva, and tongue
o Infiltration injections (for maxilla) where a needle placing anesthetic on very thin alveolar bone
can deliver anesthesia, coursing through the very thin alveolar bone in order to reach the nerves that
you intend on blocking
Bone of maxilla alveolar is thin, mandibular alveolar is thicker, and lends itself to block
injections
o Block injections (for mandible) delivery of anesthetic through the soft tissue as close to the actual
nerves as possible
o PSA Injection (different if wisdom teeth removed)
The needle pierces the muccobuccal fold at M2 (2nd molar) and is advanced to the injection site
above the roots of M3
Introduce the needle above the second maxillary molar, and then slowly advance it
posteriorly and upward, and inject just above the roots of M3
Anesthetize: M2, M3 and the distal and palatal roots of M1 will be anesthetized
o MSA Injection
The anesthetic is delivered above the root tips of the 1st maxillary premolar
Anesthetize: 2 premolars and the mesial root of M1
o ASA Injection
The anesthetic is delivered in the canine fossa above the root tip of the maxillary canine
Anesthetize: incisors and the canine (beware the central incisor b/c it may receive ASA from
other side)
o Hard Palate Injections necessary for anesthetizing mucosa of primary and secondary hard palates
and nasopalatine nerve
Primary hard palate the anesthetic is injected into the incisive foramen on either side of the
incisive papillae
Secondary hard palate the Greater Palatine Nerve may be blocked along an imaginary line
halfway b/w the midpalate raphe and the free gingival edge
o Maxillary Nerve Block (Rare)
A long needle is passed through the greater palatine foramen and canal into the
pterygopalatine fossa; very difficult
Blocks all of maxillary nerve and its branches; if missed transient weakness of ocular optics
+ temporary blindness
Performed for patients with significant disease in mid-facial region
C. V3: Mandibular Division (only branch with SVE)
Course: passes through foramen ovale to infratemporal fossa
SVE
o SVE fibers innervate: 4 muscles of mastication (temporalis, massester, lateral pterygoid, medial
pterygoid), tensor tympani, tensor veli palatini, mylohyoid, and anterior digastric
o Muscular Branches:
Deep Temporal Nerves temporalis
Masseteric Nerve masseter comes through mandibular notch b/w coronoid and condylar
processes to enter masseter
Lateral Ptyerygoid Nerve lateral pterygoid
Medial Ptyerygoid Nerve medial pterygoid
Nerve to Mylohyoid mylohyoid, anterior digastric
Nerve to Tensor Veli Palatini tensor veli palatini
Nerve to Tensor Tympani tensor tympani (link to stapedius, VII)
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o Otic Ganglion one of the 4 parasympathetic ganglia of the head; innervation to parotid gland for
salivation; branches include filaments to Tensor Tympani and to Tensor Veli Palatini
GSA
o 4 Main Sensory Branches (BAIL):
(Long) Buccal Nerve mediates sensation from the skin superficial to, and the mucosa deep
to, the Buccinator
Does NOT innervate the buccinators, the facial nerve does (buccal branch); innervates
skin superficial to muscle and oral vestibule deep to muscle (can make popping sound
with finger in cheek)
Auriculotemporal Nerve formed by 2 roots which surround the middle meningeal artery as
it approaches foramen spinosum; vulnerable to fractures of the neck of the condyle
Inferior Alveolar Nerve through mandibular canal
Dental Branches (Plexiform) multiple fibers coming off, exchanging, before going to
root
Mental Branches
Incisive Branches terminal branches of inferior alveolar
Lingual Nerve to tongue provides general sensation to: mucosa of the presulcal tongue
(anterior 2/3 of/body), floor of the mouth, mandibular gingivae
**NOTE: Chorda Tympani from VII joins the Lingual Nerve in the infratemporal fossa. Both are
destined to mediate sensation from the anterior 2/3 of tongue (V touch, pain, temp,
proprioception; VII taste)
Chorda Tympani also contains GVE fibers (parasympathetic) which synapse in the
submandibular ganglion
Postganglionic parasympathetics arising from the submandibular ganglion travel
with terminal branches of the Lingual Nerve to innervate the submandibular and
sublingual salivary glands
Mandibular (V3) Injection Sites
o Mandibular Block above lingula and mandibular foramen
Should anesthetize the inferior alveolar and lingual nerves with a single needle penetration
Anesthetic is deposited just above the mandibular foramen where the inferior alveolar nerve
enters the mandible and on the lingual nerve as the needle is retracted
Lingual nerve innervates posterior aspect of teeth/gums
Inferior Alveolar Nerve blocks ALL teeth
Posterior penetration may lead to injection of anesthetic into the parotid gland capsule
producing transient, unilateral facial paralysis makes patient look like they have Bells Palsy
o Long Buccal Block
Often performed to complement the mandibular block, the gingival branches of the long buccal
nerve supply the buccal gingiva adjacent to the mandibular molars
Careful not to inject anesthetic into temporalis
o Mental Block
For blocking a portion of the inferior alveolar and mental nerves to anesthetize the premolars,
canines, and incisors, the needle penetrates the mucobuccal fold adjacent to the premolars
and is directed towards the mental foramen (mental nerve)
Clinical Correlates
o Septic thrombosis: V1 and V2 pass through cavernous sinus, vulnerable to pathological conditions
o Blunt force trauma to face can damage nerves bones tend to fracture in predictable ways
o Trigeminal Neuralgia (Tic doloureux)
Symptoms: sharp, wave-like pain; intermittent unilateral (occurs on one side), disabling
INTENSE facial pain (suicidal). Almost always adults, often seniors
Usually in V2 or V3
Etiology: demyelination or compression of the sensory root endocranially (by the superior
cerebellar artery) (MS); post-herpetic neuralgia (result of herpes); tongue piercing; idiopathic
(unknown reason); but NOT OF DENTAL ORIGIN
Treatment: analgesics, anticonvulsants, surgical decompression, rhizotomy (cut/kill root),
gamma knife ablation (radiation to kill root)
o CN V Lower motor neuron lesions (SVE)
Paralysis or atrophy of masticatory muscles
Ipsilateral deviation of jaw upon protrusion lateral pterygoids responsible for protrusion one
side unopposed, deviates to side of lesion
Contralateral deviation of soft palate and uvula
o Additional Lesions
Herpes zoster infection
Dental and facial trauma
Neoplasm: trigeminal Schwannomas (benign), cerebellopontine angle tumors
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Hansens disease (leprosy)
CN III, IV, VI: Oculomotor, Trochlear, Abducent Nerves General

III, IV, VI and V1 transmitted through cavernous sinus and superior orbital fissure
Common tendinous ring (annular tendon) gives rise to rectus muscles
o II, III, VI pass through ring
o IV does NOT pass through ring, only innervates superior oblique
o III divides into superior and inferior divisions
Superior innervates superior rectus, levator palpebrae superioris
Inferior innervates inferior oblique, inferior rectus, medial rectus
Extraocular Muscle Review
o Orbital and Optical (visual) Axes of each eye are not aligned symmetrically
o Eyeball movements are considered to start from a resting position with the visual axes of both eyes
parallel to each other and to the median sagittal plane
o ELEVATION and DEPRESSION occur around mediolateral axis (up, down movement) through center of
eyeball
o ABDUCTION and ADDUCTION occur around a vertical axis (left, right) through center of eyeball
o EXTERNAL ROTATION (extorsion) and INTERNAL ROTATION (intorsion) occur around anteroposterior
axis through center of eyeball with reference to 12 oclock position
o Muscle movements
Medial rectus (1 axis) adducts
Lateral rectus (1 axis) abducts
Inferior oblique (3 axes) elevates, abducts, extorts
Superior oblique (3 axes) depresses, abducts, intorts
Superior rectus (3 axes) elevates, adducts, intorts
Inferior rectus (3 axes) depresses, adducts, extorts
o Eye movements
Focus up, right: (R) IO, (L) SR Focus up, left: (R) SR, (L) IO
Focus right: (R) LR, (L) MR Focus left: (R) MR, (L) LR
Focus down, right: (R) SO, (L) IR Focus down, left: (R) IR, (L) SO
Focus up: (R and L) SR + IO Focus down: (R and L) IR + SO
o Testing (H-Test)
Important for diagnosing lesions of III, IV, and VI, the midbrain and pons
Some muscles share common functions (e.g., elevation and depression), need to isolate and
test each muscle separately
Accomplished by moving eye so as to place the selected muscle at maximal mechanical
advantage, and its synergist at a disadvantage, by either abducting or adducting the eye
Right Eye
MR (III) move left to nose (medially)
LR (VI) move right away from nose (laterally)
IO (III) move left to nose (medially) (SR knocked out), then up
SR (III) move right away from nose (laterally) (IO knocked out), then up
SO (IV) move left to nose (medially) (IR knocked out), then down
IR (III) move right away from nose (laterally) (SO knocked out), then down
When muscle knocked out/eliminated, it can no longer move along axis
Elevation requires both IO and SR to move eye up. When you move laterally then up, a vector
is eliminated. Muscle needs to be perpendicular, not parallel in axis
Maintaining focus on a moving object, or shifting focus from one object in your visual field to another requires
coordination, not just of the individual muscles in each orbit, but the groups of muscles in both orbits that can
move the eyes simultaneously
Clinical Correlates
o 3 nerves (CN III, IV, VI) are vulnerable to compression and lesion within cavernous sinus resulting from:
1. Septic Thrombosis
Spread of infection from emissary veins (scalp, oral cavity, etc.) to cavernous sinus,
leads to compression of nerves
2. Intracavernous Internal Carotid Artery (ICA) Aneurysms
CN VI (Abducent) most vulnerable to compression since it lies closest to ICA
3. Aneurysms of Components and Branches of Circle of Willis
Left and right cavernous sinuses connected infections can spread
Blood flow out of ICA to Circle of Willis aneurysm can compress
Blood moves forward to orbit through ICA
4. Laterally expanding Pituitary Tumors
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o Eye Muscle Lesions
Lesions of CN III, IV, VI produce Ophthalmoplegia paralysis of extraocular musculature
Right Oculomotor Nerve Lesion (GSE) Lesion of all Oculomotor Muscles (MR, IR, SR, IO)
Eyeball down and out; right eye abducted and slightly down/depressed with eyelid
drooping
o LR (VI) and SO (4) are unopposed; so all muscles are paralyzed except LR and
SO
Ptosis (drooping of eyelid) from paralyzed levator palpebrae superioris
Eyeballs not moving consensually
Strabismus Cause Lesion of Abducent CN VI Muscle (LR)
Paralysis of Lateral Rectus
Inability to direct both eyes towards the same object, which produces Diplopia (double
vision)
Eyeball is adducted due to unopposed pull of the ipsilateral Medial Rectus muscle
Right Trochlear Nerve (CN IV) Palsy Lesion of CN IV Muscle (SO)
Loss of SO (depresses and abducts), the eyeball is elevated and adducted
Will have vertical diplopia (images doubled in the superior-inferior direction)
Challenging when walking down stairs as one sees 2 of each stair; occurs b/c one
typically looks down going down stairs and the affected eye cannot be depressed as
much as the normal eye
Fix tilt head away from the side of lesioned eye, adjusting posture and head position
to align visual axes
o In order to maintain or change visual fixation on a moving object, the eyes must move together with
exquisite precision as a result of coordinated contraction of the extraocular muscles in each orbit;
requires CNS coordination and control above the brainstem nuclei of CNs (Supranuclear
mechanisms)
CN III: Oculomotor Nerve

FIBER TYPES = GSE, GVE
NUCLEI = Oculomotor nucleus, Midbrain Edinger-Westphal nucleus (parasympathetic)
Course: arises from medial aspect of cerebral peduncles of midbrain. Transmitted through the cavernous sinus
and the superior orbital fissure (III, IV, VI and V1)
III divides into superior and inferior divisions, which collectively perform most eye movements
o Superior Division innervates superior rectus, levator palpebrae superioris
o Inferior Division innervates inferior oblique, inferior rectus, medial rectus
GSE fibers innervate most extraocular muscles (except superior oblique and lateral rectus)
GVE fibers are preganglionic parasympathetics synapsing in the ciliary ganglion
SUMMARY: Midbrain Nucleus of Edinger-Westphal (Primary Neuron) Inferior Branch of Oculomotor Nerve
Ciliary Ganglion (Secondary Neuron) via Nasociliary Nerve of Ophthalmic Branch of CN V1 Pupillary
Constrictor and Ciliary Muscles
A. Parasympathetics (GVE) Inferior Division
o GVE fibers of CN III (preganglionic parasympathetics) are carried in the inferior division and they
synapse in the ciliary ganglion
o Postganglionic fibers carried by branch of Ophthalmic nerve (Nasociliary) to targets (pupillary
constrictor and ciliary muscle)
o 2 NEURON RULE: CNS Origin: in midbrain, Nucleus of Edinger-Westphal; Synapse: Inferior division
of III synapses in Ciliary Ganglion; Piggy back: V1 (short ciliary nerves); Innervates: Pupillary
Constrictor, Ciliary Muscle
o Ciliary muscle contraction adjusts shape of lens to keep image of an object moving nearer to the
eyes in sharp focus
Lens is biconvex, shape and thickness is adjustable by ciliary muscle to change from near to
far, adjust vision
Smooth muscle adjusts shape of the lens in response to parasympathetic and
sympathetic input
Contraction of the ciliary muscle increases curvature of lens (more rounded) and enables
accommodation, an adaptation of the visual apparatus for near viewing; requires constriction
of the pupil and convergence of the eyes by adduction and depression
As object moves closer, medial rectus adducts eyes to midline, changing shape and thickness
of lens through contraction of ciliary muscle, making lens more rounded and changing
refraction of light
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o Pupil - the central aperture of the iris, like the diaphragm of camera. Diameter is under control of 2
antagonistic muscles: the Pupillary Constrictor (parasympathetic) and the Pupillary Dilator
(sympathetic)
Light directed into either usually produces bilateral pupillary constriction
Anisoceria inequality in the size of the two pupils under changing light conditions
(suggests a lesion in pupillary autonomic pathway; ex: Glaucoma)
Pupil constriction is final part of accommodation reflex
Pupil can be in normal state, miosis (fully constricted), or mydriasis (fully dilated)
o The pupillary constrictor and ciliary muscle are innervated by postganglionic parasympathetics arising
from the ciliary ganglion
**KNOW: Rule postganglionic axons arising from the 4 pairs of parasympathetic ganglia in the head
reach their targets by piggy-backing on branches of CN V
o All get to targets by traveling on branches of trigeminal nerve means of getting from ganglion to
target
**KNOW: CN III is one of 4 nerves that carry parasympathetic fibers: III, VII, IX, X
B. Sympathetics
o 2 NEURON RULE: CNS Origin: T1-T2 intermediolateral cell column; Synapse: Superior Cervical
Ganglion; Innervates: Pupillary Dilator Muscle, Superior Tarsal Muscle of upper eyelid
o Almost all postganglionic sympathetic fibers supplying the head are distributed through the periarterial
plexuses which surround the internal carotid artery and its branches
o The postganglionic sympathetic innervations of the head arise from the Superior Cervical Ganglion
and travel with carotids to targets; highest ganglion of the sympathetic chain, sits in fascia that cover
the prevertebral muscles (scalene, longus coli, etc.)
o Preganglionic sympathetic innervation of the orbit arises from the T1-T2 cord segments, ascending
through the cervical sympathetic chain and synapsing in the superior cervical ganglion. The
postganglionic fibers run in the internal carotid nerve and plexus and then enter the orbit
o They run through the ciliary ganglion WITHOUT synapsing and travel on ciliary nerves to reach their
targets
o Sympathetics in the orbit innervate:
Pupillary Dilator (mydriasis)
Smooth Muscle of Superior Tarsal Portion of Levator Palpebrae Superioris (Muellers
Muscle)
Ophthalmic artery and its branches (distribute to the forehead + root and bridge of the
nose)
Clinical Correlates
o Parasympathetic path lesion to CN III
Pupillary Constrictor pupil will be dilated, pupillary light reflex will be lost shine light into
someones eye and it wont constrict; dilation of iris since parasympathetics are interrupted
and dilator pupillae is unopposed
Ciliary Muscle near vision is impaired, cant maintain focus as an object moves closer, cant
adjust thickness of lens no accommodation b/c ciliary muscle paralyzed
o Sympathetic
Horners Syndrome (disruption of periarterial plexus postganglionic sympathetics from
cervical sympathetic chain with internal carotid artery to orbit)
Miosis - a fixed, constricted pupil lost innervations from pupillary dilator
Partial Ptosis droopy eyelid superior tarsus smooth muscle knocked out, but
skeletal muscle in levator palpebrae works
Anhydrosis loss of forehead sweating as sympathetic innervations of the
supraorbital and supratrochlear branches of the ophthalmic artery are lost
CN IV: Trochlear Nerve

FIBER TYPES = GSE
NUCLEI = Trochlear nucleus
GSE fibers innervate the superior oblique muscle only, which depresses, pulls laterally/abducts, and intorts
the eyeball
CN IV does NOT pass through common tendinous ring (annular tendon)
Course: exits brain below inferior colliculus on dorsal aspect of midbrain, and has the longest intracranial
course of all of the CN
o Only CN that arises from dorsal aspect of midbrain, others are from ventral
o Transmitted through the cavernous sinus and the superior orbital fissure (III, IV, VI and V1)
CN VI: Abducent Nerve

FIBER TYPES = GSE
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NUCLEI = Abducent nucleus
GSE fibers innervate the lateral rectus muscle only, which abducts the eye
Course: leaves brain in the inferior pontine sulcus, and has the longest intradural course (in dura mater) of all
of the CN, so it is often involved in intracranial disease. Transmitted through the cavernous sinus and the
superior orbital fissure (III, IV, VI and V1)
CN VII: Facial Nerve

FIBER TYPES = SVE, GSA, GVE, SVA
NUCLEI = Facial nucleus, Solitary nucleus, Superior salivatory nucleus
Provides motor innervation to the muscles of facial expression and stapedius, receives the special sense of
taste from the anterior 2/3 of the tongue, and provides secretomotor innervation to the salivary glands (except
parotid) and the lacrimal gland
2 Primary Roots:
o Motor Root larger division branchial motor fibers (SVE) derived from pharyngeal arch 2
o Nervus Intermedius smaller division
Preganglionic parasympathetics (GVE) (GVE in III, VII, IX, X)
Special sensory fibers (SVA taste)
General sensory fibers (GSA)
SVA and GSA afferent fibers in the nervus intermedius have their primary cell bodies in the
geniculate ganglion (sharp bend) within the temporal bone
Nuclei
o Motor Nucleus of Facial Nerve (SVE)
Located in caudal pons, gives rise to branchial efferent (SVE) fibers which constitute the largest
part of the nerve and innervate muscles from 2nd pharyngeal arch
Internal Genu of Facial Nerve motor fibers (SVE) that wrap around abducent nucleus
o Superior Salivatory Nucleus (GVE) - Gives rise to preganglionic parasympathetic (GVE) fibers in
the nervus intermedius (chorda tympani)
o Nucleus Solitarious (Solitary Nucleus) (SVA) termination for taste fibers at rostral end
o Spinal Nucleus of Trigeminal (CN V) (GSA) termination for general sensory fibers
Course: emerges from brainstem at inferior pontine sulcus, in line with the postolivary sulcus of the
medulla. The nerve lies in the angle between the lateral pons and the inferior aspect of the cerebellum, the
cerebellopontine angle.
o VII transits the sub-arachnoid space and enters the temporal bone through the internal acoustic
meatus (along with VIII)
o It courses through the facial canal, and takes a sharp turn at the geniculate ganglion, where it
branches into 3 GVE fibers:
1. Greater Petrosal Nerve exits the temporal bone to middle cranial fossa through the hiatus
of the greater petrosal nerve; It exits the fossa via foramen lacerum and passes through
the pterygoid canal to reach the pterygopalatine ganglion (preganglionic)
2. Nerve to Stapedius (innervates Stapedius muscle) (link to other muscle in ear, tensor
tympani, from V3)
3. Chorda Tympani passes along lateral wall of the tympanic cavity (runs b/w malleus and
incus) and exits skull through iter chordae anterius at medial end of petrotympanic
fissure (splits anterior and posterior mandibular fossa) to enter the infratemporal fossa
o The Trunk exits the cranial base via stylomastoid foramen
Exiting trunk fibers innervate the muscles of facial expression, stylohyoid, and posterior
digastric
5 Segments of VII (in order):
1. Labyrinthine passes above the bony labyrinth housing vestibular system (1st portion upon entry into
internal acoustic meatus)
2. External Genu includes the geniculate ganglion (area of bend) gives rise to Greater Petrosal
Nerve
3. Tympanic travels posteriorly and laterally along the medial wall of the middle ear cavity
4. Mastoid gives rise to Nerve to Stapedius and Chorda Tympani
5. Trunk innervate muscles of facial expression, stylohyoid and posterior digastric
A. Branchial Motor SVE

o SVE fibers innervate 2nd arch derivatives: Muscles of facial expression (calvaria to platysma),
Stylohyoid and Posterior Digastric, and Stapedius
o Most SVE fibers in the Trunk ramify within the Parotid Plexus
o Parotid Plexus Branches (Two Zebras Bit My Coccyx (Painfully)):
1. Temporal frontalis ask patient to raise eyebrow
18
2. Zygomatic orbicularis oculi (3 parts) ask patient to shut eye tight, problem if cant shut
tightly, tears
3. Buccal buccinators ask patient to pucker lips, bare upper teeth, blow out, or whistle
4. Marginal Mandibular lower lip muscles ask patient to bare lower teeth
5. Cervical platysma ask patient to flare skin of neck
6. (Posterior Auricular Nerve) external ear muscles, occipitalis
B. Parasympathetics GVE
1. Greater Petrosal Nerve conveys secretomotor fibers which, after synapsing in the pterygopalatine
ganglion, innervate the lacrimal gland, nasal, and paranasal mucosa and palatine glands
2 NEURON RULE: CNS Origin: Pons, Superior Salivatory Nucleus; Synapse:
Pterygopalatine Ganglion; Piggy back: V2; Innervates: Lacrimal Gland, Nasal and
Paranasal Mucosa, Palate (palatine glands)
Nerve of the Pterygoid Canal (aka Vidian Nerve): formed by the joining of the Greater
Petrosal Nerve and the Deep Petrosal Nerve (postganglionic sympathetic) in the pterygoid
canal; only the parasympathetics of the Greater Petrosal Nerve will synapse on the ganglion
Lacrimal gland innervated by postganglionic autonomic fibers that accompany the Zygomatic
branch of V2
Nasal mucosa innervated by postganglionic autonomic fibers that accompany Posterior Lateral
Nasal and Nasopalatine branches of V2
Palatine glands innervated by postganglionic autonomic fibers that accompany Greater +
Lesser Palatine of V2
2. Chorda Tympani conveys
secretomotor fibers which synapse in
submandibular ganglion and
innervate the submandibular and
sublingual salivary glands
2 NEURON RULE: CNS
Origin: Pons, Superior
Salivatory Nucleus;
Synapse: Submandibular
Ganglion; Merge: V3
Lingual Nerve; Innervates:
Submandibular and
Sublingual Salivary Glands
Chorda tympani merges and
rides with Lingual Nerve (V3) to submandibular and sublingual salivary glands
C. Taste SVA
o Taste Buds microscopic specialized cellular arrangements around the gustatory nerve endings of CN
VII, IX, and X (send nerve sensations back via these CN)
Found in lingual dorsum and sides of tongue, epiglottis, lingual aspect of soft palate, posterior
(oro)pharynx
Most in troughs surrounding vallate papillae, anterior and parallel to the sulcus terminalis.
Some in fungiform and foliate papillae.
Filiform papillae of anterior 2/3 contain general sensory nerves (GSA) ONLY (no taste buds) via
Lingual Nerve (V3)
Taste Modalities: Salt, Sour, Sweet, Bitter, Umami
o Gustatory receptors on anterior 2/3 of tongue convey information via chorda tympani (carries both
GVE and SVA fibers) to the Geniculate Ganglion and on to the Solitary Nucleus
o Some sources: the Greater Petrosal Nerve, also carries some SVA taste fibers from the mucosa of
the soft palate (in addition to GVE), and Chorda Tympani as well (taste fibers from mucosa of soft
palate)
D. General Sensory GSA
o Most minor component of CN VII
o Posterior auricular nerve contains some afferent fibers, conveying general sensation from
structures around the external ear:
Skin of the concha of the external ear
Small patch of skin behind the ear overlying the mastoid process
Portion of the superficial aspect of the tympanic membrane (ear drum)
Clinical Correlates
o Schwannoma may compress VII
o Parotid gland tumors may compress or destroy facial nerve fibers. Parotid malignancy spread of
metastatic cells may travel through stylomastoid foramen, back through facial canal to brain, can be
fatal
o Mastoid infections pain spreads out of mastoid process to skin, mediated by somatic afferents of VII
o Central (supranuclear) and peripheral (infranuclear) facial paralysis
o Bells Palsy (pg 11)
19
Spontaneous, acute unilateral paresis (weakness) or paralysis of the muscles of facial
expression
Results from:
Peripheral lesion of CN VII at or distal to the stylomastoid foramen
Inflammation of the facial nerve and edema with compression in the facial canal
Viral infection (neuronitis) or vasospasm
Symptoms: facial asymmetry with gravitational sagging of face and scalp (tonus of facial
muscles), inability to wrinkle forehead on command (frontalis), failure to retain tears
(orbicularis oculi) and saliva (orbicularis oris) in orbit and mouth, retention of food in oral
vestibule (buccinators)
The location and extent of lesion will determine which symptoms will be presented long
course of nerve
The symptoms of a peripheral lesion of CN VII may be more extensive depending on the exact
location of the lesion between the Pons and the Stylomastoid Foramen symptoms allow you
to locate lesion
o Gustatory Dysfunction: usually produces Ageusia (total absence of the ability to taste), Hypogeusia
(diminished ability to taste), or Dysgeusia (altered taste sensation)
CN XI: (Spinal) Accessory Nerve

FIBER TYPES = GSE
NUCLEI = Nucleus Ambiguus, Spinal accessory nucleus
GSE fibers innervating SCM and Trapezius (large neck muscles)

Controls muscles of the neck and overlaps with functions of CN X. Examples of symptoms of damage: inability
to shrug, weak head movement, velopharyngeal insufficiency)
Course: XI comes up from the neck and enters skull (posterior cranial fossa) through Foramen Magnum (spinal
root only) and leaves skull through Jugular foramen (along with IX and X)
Divided into 2 roots:
1. Spinal root from Accessory Nucleus in the lateral ventral horns of C1-5, ascend to foramen magnum
and exits via jugular foramen
2. Cranial root fibers dont arise from cervical spinal cord segments, but from Nucleus Ambiguus in the
medulla; fibers exit the Jugular foramen and join the Vagus, not continuous with spinal root
Innervates: Sternocleidomastoid, Trapezius
Clinical Correlates
o Vulnerable to lesion as it crosses the posterior cervical triangle
o Takes out SCM and trapezius
o Lesions of CN XI:
Weakness in contralateral rotation of the head against resistance (SCM contraction on right
turns head left)
Shoulder Drop ipsilateral sagging of the pectoral girdle and shoulder; drop of the shoulder
on side of lesion
Cervical Plexus
FORMED BY: C1-C4 Ventral Rami
Cervical Spinal Nerves contribute to the formation of the Cervical Plexus

Ventral Rami (of Spinal Nerves): typically supply skin of anterolateral body wall and the extremities, innervate
hypaxial muscles derived from the hypomeres of the myotomes of the somites, often converge to form
plexuses where fibers are exchanged and give rise to named peripheral nerves (ex: brachial plexus cervical
nerves, upper limbs; lumbosacral plexus lower limbs)
Cervical Vertebrae vs Cervical Spinal Nerves: C1 Spinal Nerves b/w skull and atlas (atlantooccipital), C2 Spinal
Nerves b/w atlas and axis, C8 Spinal Nerves b/w C7 and T1
o With exception of C8 (which overlies T1), each cervical nerve is numbered according to the vertebra
beneath it (ex: C6 Spinal nerve b/w C5 and C6); Thoracic, Lumbar, and Sacral Spinal Nerves numbered
according to vertebra above it
Muscular Branches of Cervical Plexus: innervate anterior and prevertebral cervical musculature and the
diaphragm
Ansa Cervicalis (loop of nerves that are part of the Cervical Plexus)
o Innervates most of the Infrahyoid strap muscles (Sternohyoid, Omohyoid, Sternothyroid; NOT
Thyrohyoid directly innervated by C1 fibers)
o Formed by Two Roots
Superior Root Descendens Hypoglossi; arises from C1
Inferior Root arises from C2 and C3
20
Phrenic Nerves: arise bilaterally within contributions from C3, C4, and C5 Ventral Rami (keep the diaphragm
alive) and descend through the neck along the anterior scalene muscles to reach the thoracic cavity and
innervate the diaphragm
o Also innervate the parietal pleura lining the thorax
o Referred pain in shoulder when the gallbladder expands from inflammation and rubs up against the
diaphragm (innervated by Phrenic Nerve)
Cutaneous Nerves (Four Groups)
1. Lesser Occipital Nerve innervates the posterior scalp, runs along the posterior triangle of the neck;
fibers from C2
2. Greater Auricular Nerve innervates the external ear, runs along the External Jugular Vein; fibers from
C2 and C3
3. Transverse Cervical Nerves ultimately pierces a thin muscle of the anterior skin Platysma; fibers
from C2 and C3
4. Supraclavicular Nerve innervates skin over the clavicle and pectoral region (shoulder pad area);
fibers from C3 and C4 (same fibers as phrenic nerve why an inflamed gallbladder would experience
pain by shoulder; C4 dermatome)
o Branches of the Cervical Plexus (Lesser Occipital and Greater Auricular Nerves) join with branches of
CN V provide cutaneous innervation of the
face
o Nerves may be blocked by an injection at
ERBs Point (Puncta Nervosum) point along
the edge of SCM
CN XII: Hypoglossal Nerve

FIBER TYPES = GSE
NUCLEI = Hypoglossal nucleus
Contains somatic efferent (GSE) fibers to all intrinsic

and most extrinsic (Hyoglossus, Styloglossus,
Genioglossus) muscles of the tongue.
Provides motor innervation to the muscles of the
tongue and other glossal muscles. Important for
swallowing (bolus formation) and speech articulation.
The long, thin Hypoglossal Nucleus (extends full length of the medulla) containing the cell bodies of the
lower motor neurons of CN XII is located in the medulla in the floor of the fourth ventricle
Course:
o Numerous rootlets arise from the pre-olivary sulcus of the medulla, course across the anterolateral
aspect of foramen magnum, and converge on the hypoglossal canal as the Hypoglossal Nerve
o After exiting the skull, it courses inferiorly and laterally between the internal carotid artery and internal
jugular vein, then loops anteriorly above the greater horn of the hyoid deep to the posterior digastric
to the anterior floor of the mouth
o The nerve continues on the lateral surface of the hyoglossus, passes above the free posterior border of
the mylohyoid, and divides to supply: All intrinsic tongue muscles,
Hyoglossus, Styloglossus, Genioglossus, NOT Palattoglossus
o XII lies inferior to the 2 sensory nerves of the tongue: Lingual Nerve (V3)
and Glossopharyngeal (IX)
XII is accompanied by fibers of C1 ventral ramus, which leave in the
Descendens Hypoglossi. These C1 fibers:
o Form the superior root of the ansa cervicalis
o Innervate the thyrohyoid directly
o Innervate the geniohyoid directly
Clinical Correlates
o Carotid endarterectomy XII is vulnerable to injury in this procedure
o CN XII Lesions
Unilateral Lesion: integrity of nerve is tested by asking patient to
protrude tongue and observing results; tongue will deviate to the
side of the hypoglossal lesion upon protrusion due to the
unopposed action of the contralateral genioglossus muscle
Fibrillations and fasciculations (twitching) if CN XII is
irritated
Mild Dysarthria (altered speech; particular difficulty with producing lingual consonants
Tumors or Meningiomas of the posterior cranial fossa or nasopharynx
ICA aneurysm or dissection below the skull
IJV puncture below the skull base
21
Lesions within the sublingual space of the tongue Neoplasm (carcinoma), Infection
(odontogenic abcess), Iatrogenic (procedure)
CN IX: Glossopharyngeal Nerve
FIBER TYPES = SVE, GSA, GVE, SVA, GVA

NUCLEI = Nucleus ambiguus, Inferior salivatory nucleus, Solitary nucleus, (Spinal trigeminal nucleus)
Receives taste from the posterior 1/3 of the tongue, provides secretomotor innervation to the parotid gland,
and provides motor innervation to the stylopharyngeus (essential for tactile, pain, and thermal sensation).
Sensation is relayed to opposite thalamus and some hypothalamic nuclei.
Functional components of IX:
o GSA from mucosa of tympanic cavity, auditory tube, auricle (skin), posterior 1/3 tongue,
oropharynx, fauces and soft palate
o SVA mediate taste from posterior 1/3 of tongue
o GVA from carotid body chemoreceptors and carotid sinus baroreceptors at level of bifurcation of
common carotid
o GVE to otic ganglion preganglionic parasympathetic ganglia innervate parotid salivary gland
o SVE 3rd arch stylopharyngeus muscle (lone muscle)
A. Afferents
o Cell bodies of all sensory neurons (GSA, GVA, SVA) are located in Superior and Inferior Ganglia of
CN IX located just above and below the jugular foramen, outside of but close to CNS
o Central processes of the pseudounipolar sensory neurons in the 2 ganglia project as follows:
SVA (Taste) fibers project to the Solitary Nucleus (rostral/upper)
GVA fibers project to the Solitary Nucleus (caudal/inferior)
GSA fibers project to the Spinal Trigeminal Nucleus
B. Efferents
o SVE lower motor neuron cell bodies are located in the Nucleus Ambiguus of the Medulla source
of neurons found in Vagus N
o GVE preganglionic parasympathetic neurons are located in the Inferior Salivatory Nucleus of the
Medulla
o IX and X are close to each other a lot of interchange of fibers
Before descending into the deep neck by coursing posterior to the styloid process, IX gives off:
1. Tympanic Nerve (GSA)
The tympanic nerve immediately re-enters the temporal bone via the tympanic canaliculus and
ramifies to form the Tympanic Plexus in the tympanic cavity (middle ear) provides sensory
fibers for the middle ear
Branches of the Tympanic Plexus innervate mucosa lining the following:
Tympanic Cavity, Auditory Tube (aka Eustachian), Mastoid Air Cells
They mediate the pain of otitis media (middle ear infection)
Mastoid antrum opening b/w middle ear cavity and mastoid air cells. Infection (otitis
media) can spread to air cells
Lesser Petrosal Nerve (from Tympanic Nerve) parasympathetic
Summary: Inferior Salivatory Nucleus Glossopharyngeal Nerve Tympanic Nerve
Tympanic Plexus Lesser Petrosal Nerve (preganglionic parasympathetics)
through Foramen Ovale to Infratemporal Fossa Otic Ganglion Postganglionic
Parasympathetics (w/ Auriculotemporal Nerve of V3) Parotid Gland Innervation
2. Carotid Sinus Nerve encompassed in carotid sheath
GVA fibers from baroreceptors in the carotid sinus and chemoreceptors in the carotid
body. These signals for blood pressure and blood gas content are taken back to brain stem
Lesion produces transient or sustained hypertension
o Multiple pharyngeal branches of IX then unite with branches of the Vagus to form the Pharyngeal
Plexus (composed of IX, X) near the middle constrictor
o Pharyngeal branches from IX supply sensory fibers to oropharyngeal mucosa and mediate the
afferent limb of the gag reflex process: soft palate elevates, stimulation normally produces soft
palate elevation and pharyngeal constriction
o Nerve gives rise to a muscular branch to lone 3 rd arch muscle, stylopharyngeus (only pharyngeal
muscle not innervated by X)
Stylopharyngeus (SVE, 3rd arch) passes through gap b/w superior and middle constrictors,
along with CN IX
o The nerve then curves forward and enters the pharynx between the superior and middle
constrictors along with stylopharyngeus en route to the posterior 1/3 of tongue
IX terminates in tonsilar and lingual branches:
3. Tonsilar Branch - GSA
Supplies the palatine tonsil, fauces, and soft palate (GSA)
22
4. Lingual Branches (2) GSA, SVA
Transmit GSA and SVA (touch and taste) sensation from posterior 1/3 of tongue
o The posterior 1/3 of tongue lacks small papillae, (featuring instead the nodules of lymphoid tissue
which collectively form the lingual tonsil)
o Gustatory and general sensory nerve ending in the posterior 1/3 convey information via both general
and special sensory fibers in the lingual branches of CN IX
C. GVE
o 2 NEURON RULE: CNS Origin: Medulla, Inferior Salivatory Nucleus; Preganglionic Fiber:
Lesser Petrosal Nerve (from Tympanic Nerve); Synapse: Otic Ganglion (ear); Piggy backs:
Auriculotemporal Nerve (V3); Innervates: Parotid Gland
Course: Rootlets of IX emerge from medulla between the olive and the inferior cerebellar peduncle. The
jugular foramen transmits CN IX (also X, XI), which passes most anterior and medial. IX is independent of X
and XI, being physically separated by a fibrous membrane
Clinical Correlates
o The nerve may be lesioned during tonsillectomy, eliminating all sensation from the posterior 1/3 of
tongue. A surgeon may mistakenly cut, removing all fibers sensory and general from the posterior
tongue
CN X: Vagus Nerve
FIBER TYPES = SVE, GSA, GVE, SVA, GVA

NUCLEI = Nucleus ambiguus, Dorsal motor vagal nucleus, Solitary nucleus
Supplies branchiomotor innervation to most laryngeal and pharyngeal muscles; provides parasympathetic
fibers to foregut and midgut (nearly all thoracic and abdominal viscera down to the splenic flexure); and
receives the special sense of taste from the epiglottis. A major function: controls muscles for voice and
resonance. Symptoms of damage: dysphagia (swallowing problems).
Course: Leaves the medulla in the postolivary sulcus by multiple rootlets, they are joined by fibers of the
cranial root of CN XI arising from nucleus ambiguus at the jugular foramen (longest course from brainstem to
thorax, through diaphragm). Enters into the jugular foramen in a common meningeal sheath along with IX and
XI.
Functional components:
o SVE to 4th and 6th arch skeletal muscles of larynx, pharynx, palate, and upper esophagus
o GVE to laryngeal and pharyngeal mucosa, esophagus, heart, pulmonary system, and GI muscles and
glands
o SVA taste from epiglottis and valleculae (trough-like spaces b/w lingual tonsils and epiglottis)
o GSA from auricle, mastoid region, posterior cranial fossa meninges (V is other nerve that innervates
meninges), EAM, larynx, and laryngopharynx
Internal branch of superior laryngeal nerve: mucosa of supraglottic larynx and afferent limb of
the cough reflex.
o GVA - from visceroreceptors of larynx, pharynx, heart, esophagus, GI tract, trachea, bronchi, lungs,
and aortic arch receptors (like carotid body, mechno and chemoreceptors)
Nuclei
o SVE fibers arise from: Nucleus Ambiguus (ambiguous!, they come from cranial root of XI)
Innervates everything of larynx, pharynx, palate, EXCEPT stylopharyngeus (IX) and
tensor veli palatini (V3)
o GVE fibers arise from: Dorsal Vagal Nucleus
o Jugs and Knobs
The Superior (jugular) and Inferior (nodose knobular) Ganglia are exclusively sensory with
the jugular concerned with somatic sensation, the nodose with visceral sensation
SVE from Nucleus Ambiguus (innervates laryngeal and pharyngeal musculature)
o Give rise to laryngeal skeleton. 4th arch: thyroid and epiglottic cartilages of larynx; 6 th arch: cricoids,
arytenoids, and corniculate cartilages of larynx
o 3 Branches:
Pharyngeal Nerve joins CN IX to form the pharyngeal plexus
Superior Laryngeal Nerve
External Branch innervates laryngeal musculature, the cricothyroid (causes vocal
ligaments to become elongated/taut, tensing vocal ligaments and raising pitch of
speech)
o Lesion monotonous speech b/c circothyroid responsible for high and low
pitch
Recurrent (Inferior) Laryngeal Nerve
Innervates the intrinsic laryngeal muscles with the exception of cricothyroid.
Vagus nerve goes down and then loops back up where it turns into the recurrent
laryngeal. The courses of the left and right nerves differ for developmental reasons.
23
Left recurrent laryngeal goes down much further and wraps around aorta. Right wraps
around the right subclavian.
o EXCEPTIONS: musculature not innervated by CN X: Pharynx - stylopharyngeus (IX), Palate tensor
veli palatini (V3)
GSA
o Auricular Branch auricular nerve re-enters tympanic bone through mastoid canaliculus and exits
through tympanomastoid fissure
Auricular branch is only cutaneous branch of Vagus
Mediates the pain of otitis externa (swimmers ear)
Ear Cough reflex when you stimulate the ear here you reflexively cough to clear the upper
airway tricking the brain into thinking the larynx is being stimulated
o Meningeal Branch Vagal innervation of meninges of posterior cranial fossa (V is other one that
innvervates meninges)
o Internal Branch of Superior Laryngeal Nerve nerve innervates the mucosa of the
supraglottic larynx and mediates the afferent limb of the cough reflex
Innervates pyriform recesses, upper part of larynx b/w vestibule and vestibular folds. Passes
through cricothyroid ligament
o Vagus is responsible for sensory innervation of the laryngopharynx above levels of C6
SVA
o SVA fibers mediate taste from epiglottis and valleculae via the Superior Laryngeal Nerve (Internal
Branch)
GVA
o GVA fibers, many of which convey visceral pain, course along with vagal parasympathetics (GVA and
GVE stick together)
o Physiological sensations from Visceroreceptors:
Mechanoreceptors responding to distension in walls of GI tract, respiratory structures,
and baroreceptors in arteries
Chemoreceptors responding to changes in partial pressure of blood gas, blood pH, and H ion
concentration in stomach (along aorta)
GVE
o 2 NEURON RULE: CNS Origin: Medulla, Dorsal Motor Nucleus of Vagus; Preganglionic Fiber:
Vagus Nerve; Synapse: Terminal (enteric) ganglia (multiple in neck, thorax, abdomen);
Innervates: Heart and lungs; FOREGUT AND MIDGUT - Gut, pancreas, biliary tree (liver, gall
bladder, spleen); Mucosa of larynx and pharynx
o In order to reach the thorax and abdomen, CN X courses through the deep neck within the carotid
sheath
o As it approaches mediastinum, it gives rise to:
Pulmonary Plexus
Parasympathetic vagal inputs facilitate contraction of smooth muscle which constricts
bronchial tubes
(Left and right vagus loses identity, forming esophageal plexus, and then reconstitutes
and regains identity.)
Cardiac Plexus
Superficial Cardiac Plexus located on the underside of the aortic arch
Deep Cardiac Plexus located on the tracheal bifurcation
Coronary Plexus small ganglia where preganglionic cardiac fibers synapse along the
coronary arteries
Parasympathetic inputs to the cardiac plexus result in the following (building up
resources, rest):
o Deceleration of heart rate (slow hearts contractile property)
o Reduction of strength of myocardial contraction
o Vasoconstriction of coronary arteries
Inferiorly, esophageal plexus formed by vagal and sympathetic fibers along
esophagus in posterior mediastinum (left and right vagal nerves come together to form
esophageal plexus)
As they approach diaphragm and abdomen, vagal fibers reconstitute as anterior
and posterior vagal trunks that pass through the esophageal hiatus due to Gut
Rotation of the Embryonic Foregut
Turning of stomach left and right become anterior, posterior due to curve of
stomach
o Parasympathetic Summary:
Foregut and midgut receive CN X innervations (preganglionic parasympathetics Enteric
Ganglia (Submucosal and Myenteric), the hindgut receives sacral nerve innervations pelvic
splanchnic nerves from S2, S3, S4.
24
Inhibit contraction of sphincters, stimulate glandular secretions, stimulate contraction of
smooth GI muscle promoting peristalsis, allowing food to be moved and processed for anabolic
processes, building up system resources
Promote Digestion
Clinical Correlates
o ***KNOW: Gag Reflex: IX afferent and X efferent
o Unilateral lesion of Vagus (one side) can lead to abnormal gag (normal gag is bilateral contraction)
CONTRALATERAL posterior pharyngeal wall deviating away from the lesion
The soft palate will drop ipsilaterally due to loss of levator veli palatini as the patient
experiences nasal speech and nasal reflux of liquids on swallowing; involvement of the
constrictors may result in dysphagia (difficulty in swallowing)
o Recurrent Laryngeal Nerve Pathology or Excision
Both sides of the nerve are vulnerable to pathology or excision of thyroid gland can cut
when removing thyroid gland due to cancer, growth
Left is distinct because its vulnerable to pulmonary or mediastinal (near heart)
pathology. Tumor of the lobe may lead to destruction of left recurrent.
Injury to either vagus nerve will result in ipsilateral paresis or paralysis of these muscles,
producing rough, rapsy hoarseness and a less mobile or fixed vocal cord
25

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Neurology Exam Study Guide

PERIPHERAL NERVOUS SYSTEM SPINAL NERVES

Peripheral Nervous System

D. Somatic Nervous System (SNS) 1 NEURON

1. Somatic Afferents (GSA)

2. Somatic Efferents (GSE)

E. Visceral Component Viscera (Internal Organs)

Acetylcholine is released at postganglionic terminal (cholinergic ending)

Gray Rami Communicantes (connects sympathetic chain to spinal nerve

PERIPHERAL NERVOUS SYSTEM CRANIAL NERVES

SUMMARY: Olfactory Mucosa/Epithelium contains Primary Olfactory

CN II: Optic Nerve

CN III, IV, VI: Oculomotor, Trochlear, Abducent Nerves General

CN III: Oculomotor Nerve

CN IV: Trochlear Nerve

CN VI: Abducent Nerve

CN VII: Facial Nerve

A. Branchial Motor SVE

CN XI: (Spinal) Accessory Nerve

GSE fibers innervating SCM and Trapezius (large neck muscles)

Cervical Spinal Nerves contribute to the formation of the Cervical Plexus

CN XII: Hypoglossal Nerve

Contains somatic efferent (GSE) fibers to all intrinsic

CN IX: Glossopharyngeal Nerve

FIBER TYPES = SVE, GSA, GVE, SVA, GVA

FIBER TYPES = SVE, GSA, GVE, SVA, GVA

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