Autonomic innervation

 What structures need autonomics? Glands, smooth muscles, BV, cardiac muscle
o Sympathetic
 Sweat glands, blood veslces
o Parasympathetic and some sympathetic
 Glands [mucus and salivatory and lacrimal
o Smooth muscles in the eye
 Sympathetic  dilator papillae, superior tarsal
 Parasympathetic [sphincter papillae, ciliary muscles]
 Cranial nerves with parasympathetic
o Cranial nerves 3,7,9,10
o Trigem is responbile to distribute the postganglionic fibers [just distributes]
o 4 ganglia have the postganglionic cell bodies
 Ciliary, otic, submandibular, and ppg
 Ganglia
o Ciliary
 Sensory root – nasociliary v1
 GVE-P Root – CN3
 GVE-2 Root – internal cartoid
o Pterygopalatine Ganglion
 Sensory root – Pterygopalatine nn (V2)
 GVE-P root – CN VII (greater petrosal n)
 GVE-S root – internal carotid n. (deep petrosal n)
o Submandibular Ganglion
 Sensory root – Lingual n (V3)
 GVE-P root – CN VII (chorda tympani n)
 GVE-S root – external carotid n.
o Otic Ganglion
 Sensory root – Auriculotemporal n (V3)
 GVE-P root – CN IX (lesser petrosal n)
 GVE-S root – external carotid n.
 Occulomotor nerve oathway
o 2 components
 Parasympthatics
 Distributes them to sphincter and ciliary
o Sphincter
 Function  constrict
o Ciliary musle
 Accomidation
 Found in the ciliary body
 Lens takes it shape and when contracted lens
becomes round to read near things
o Dysfunction

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  Mydrisis [dialation]
 Loss of accommodation
o Loss in right eye  consentual respone with no direct
 Facial n
o Greater petrosal  to mucus secreting gland of the head
and lacrimal
 Gets to mucus glands in the nasal glands
 Function
 Lacrimal gland  increases secretion
 Mucus secreting glands  increases
secretion
 Dysfunction  dryness [Dry eye and dry nose]
o Chorda tympani  sumbandiublar and sublingual
 Function
 Sumandiublar and sublingual glands 
increases secretion
 Dysfunction  decreased salivary fluid
production
 Glossophyrngeal  parotid gland
o know where these nerves are in the head
 Tympanic branch first passes through middle
ear
 Parasymoathetic reforms into middle cranial
cavity foramen ovale
o Function:
 partiod gland  increase secretion [decrease secretion]
 Dysfunction: decreased salivatory function
 Vagus
o Gives branches to a bunch of stuff

Sympathetics in the head

 Know where pre and post ganglionic cell body locations are
 Where are preganglionic neuron has to take
o Upper thoracic
 Post ganglionic cell bodies  found in superior cervical
ganglion
 Function of sympathetic eye
o Pupillary dilation of dilator pupillae m
o Superior tarsal m assist with the elevation of the upper eyelid
 Dysfunction from loss of sympathetic to the head
o Constrict of the pupil [miosis]

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 o Ptosis  loss of tarsal
 Occulormotor ptosis  sever and cant be overcome
 Sympathetic tarsal loss  loss is not as severe because pt can compensate with
LPS
 Glands
o Little/weak innervation
 Skin and face
o Sweat glands/blood vessles to face mostly constriction
o Dysfunction  no sweating
 Horner’s syndrome
o Ptosis  elevation of the upper eyelid is weakend
o Miosis  constriction form loss of dilator mucle
o Anhidrosis  loss of sweat

Cranial nerves

Must know

1) Course (including foramina traversed) and brainstem

2) Function(s)

3) Common causes for lesions

4) Symptoms due to injury

 CN 1  olfactory nerve
o SVA – olfaction
o Arises from neural ectorderm of the fac
o Passes through the ethmoid bone
o Foramen  cribiform
 CN 2  optic nerve
o SSA – vision
o Carries info back to orbit through the optic canal to the cranial cavity
o Visual impairment is developed from directly from the brain [meninges] in subarachnoid
space
 Pressure around the brain leads to pressure on the optic nerve
o Artery right through the nerve  Central retinal artery+vein  compression of these
two
 Pappiladema  from pressed against Central retinal vein  no BF out of CN
 3 occulomotor
o GSE  extraocular eye muscle [not from arches]
 LPS
 Superior rectus/inferior rectus/medial rectus/inferior oblieuq [Skeletal]
o GVE-P  intraocular eye muscles
 Ciliary muscle [Smooth]
 Sphincter pupillae

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 o Function
 Opening the eye [upper eyelid]
 Test pupillary light reflex
 Afferent 3,
 Efferent 3 GVE
 Accomedation/convergence [innervation of medial rectus]
 Afferent CN 2
 Efferent CN 3 GSE and GVE
o Lesions
 Compression
 Uncal hernation
 Anuresm of the posterior cereral or superior cerebellar artery
 Increased cranial pressure
 Diabetic nuropthyor hypertension
 Results in
 Paralysis of most extraocular eye muscles (eye will be held in down/out
position)
 Paralysis of levator palpebrae superioris (ptosis or inability to elevate
eyelid)
 Paralysis of sphincter pupillae muscle (pupil will be dilated and won’t
constrict during pupillary light response).
 Paralysis of ciliary muscle (loss of accomodation)
 Positioning 
 Compression injuries will cause damage to GVE-P portion of nerve 1st ;
thus loss of pupillary constriction will present first. [medical emergency]
 With diabetic neuropathy (or hypertension), the vasa nervorum is
affected – thus the more deeply placed GSE fibers will be affected first
and there will often be pupillary sparing.
 CN 4
o Innervates superior oblique
o GSE  superior oblique [Down and out] [Test in and down]
o Exits dorsal surface of the brain stem!!!!! Only one
o Exits through superior orbital fissure
 CN 5 trigeminal nerve
o SVE -1 Arch 1 derivate muscle
 Mastication and MATT
 Temporalis
 Masseter
 Medial pterygoid
 Lateral pterygoid
 Mylohyoid
 Anterior belly of digastric
 Tensor tympani

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  Tensor veli palatini
o GSA
 Face
 Teeth, tongue and oral cavity
 xternal ear
 Paranasal sinuses
 Nasal cavity
 Eye and conjunctiva
 Dura mater
o Trigeminal ganglion[  cell body of the sensory component with no synapse here
 V1  NFL nerve enters through superior orbital fissure and innervates eye and
nasal cavity
 V2  Foramen rotundem into pterygopalatine ganglion to maxillary teeth, nasal
cavities, palate and middle face
 V3  through foramen ovale into infratemporal fossa and innervates sensory
information into lower face tongue, oral cavity and mandibular teeth.
 Motor component to muscles of mastication
 Pterygoids move muscles back and forth
 Tensor tympani and tesnor veli palatini
o Lesion of trigem nerve injury
 Sensory deficits to facial dermatome
 Loss of corneal reflex, if V1 is involved.
 Dust or dirt in the eye/touch the eye
 What makes you blink  orbicularis occuli by facial
o Inhibition of LPS [3] and tasrsal [sympathetic]
o Trigem sense and facial acts
 Weakness of mm of mastication, if V3 is involved. In some patients, the jaw may
deviate to the side of lesion, due to imbalance of pterygoid muscles.
 Some patients develop hyperacusis, due to paralysis of tensor tympani. [V3]
 CN 6  abducens
o Abducts the eye through lateral rectus
o Nucleus at pontine  enters by superior orbital fissure
o Cavernous sinus infection can affect the Cn 6
 Internal carotid aneurism  abducens  medial deviation is a medical
emergency
 Cn 7 facial
o SVE  arch 2 muscles[Skeletal muscle]
 Muscles of facial expression
 Posterior belly of digastric
 Stylohyoid
 Stapedius
o GVE-P
 Glands  secretion/lubrication
 Greater petrosal and chroda tympani

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  Most mucous-secreting glands of deep head
 Lacrimal gland
 Submandibular and sublingual gland

o SVA
 Taste to anterior tongue
o GVA
 Nasopharynx
o GSA
 External ear
o Leaves the skull through the internal acustic meatus
 Bends posterior through facial canal of the middle ear and leaves the skull to get
to the stylomastiod
o Branche
 Greater petrosal  parasympathetic in the PPG  to lacrimal and mucus glands
of nose
 Originates at geniculate ganglion and passes through [no synapse] to
get to PPG
 Posterior wall  nerve of stapedius SVE
 Just passes through the mddle ear
 Goes to infratemporal fossa through the oral cavity for anterior tongue
o Lesions
 SVE motor impairment  ipsilateral
 Paralysis or weakness of muscles of facial expression (Bell’s palsy).
 Weakness/loss of corneal reflex.
 Paralysis or weakness of posterior digastric and stylohyoid.
 Paralysis or weakness of stapedius muscle (may experience
hyperacusis)
 GVE – P motor impairment all ipsilateral
 Dry mouth (xerostomia) due to loss of innervation to submandibular
and sublingual glands (chorda tympani).
 Dry eye due to loss of innervation to the lacrimal gland (greater
petrosal)
 Dry nasal cavities due to loss of innervation to mucous-gland (greater
petrosal).
 CN 8 vestibulocholear
o SSA hearing [choclear portion
o SSA- Balance, proprioception (vestibular portionEnter internal occustic meatus and
stops in internal ear
o Lesion  acustic neroma of shwancell origin
 Tinnitus/dizziness/hearing loss
 Can have bells palsy
 Loss of taste
 Dryness of the head

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  8 and 7 will be hit together
 CN 9
o SVE – Arch 3 muscle
7+9+10 all have  Stylopharyngeus
taste o GVE-P
 Parotid gland
o SVA
 External ear
o GVA
 Most of pharynx, auditory tube, posterior 1/3 of tongue, middle ear, carotid
body, carotid sinus

o GSA
 Taste to posterior 1/3 of tongue [circumvallate papillae  leads to loss of taste]
o Tympanic branch  middle ear innervation
 GVE –p --> forms lesser petrosal  cranial cavity  out of foramen ovale 
infratemporal fossa  otic ganglion
 GVA
o Cartoid branch
 GVA
 Part of the reflex arch that regulates heartrate, composition of blood,
blood pressure, regulates RR, HR
o Stylophargnus
 Only skeletal muscle innervated by glosso
 SVE
o Pharyngeal, tonsillar and lingual branches
 GVA SVA to tongue
o Lesion
 SVE Motor Impairment
 Stylopharyngeus
 GVE-P Motor Impairment
 Dry mouth (xerostomia) due to loss of innervation to the parotid gland
(lesser petrosal branch)
 Sensory Impairment
 Loss of taste to the posterior tongue
 Loss of general sensation to most of pharynx.
 Patient may report difficulty swallowing
 Loss of gag reflex (In by 9; out by 10)
o Afferent limb is CN IX
o Efferent limb is CN X

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 Vagus nerve
o SVE – Arch 4 and 6 muscle [Palate, pharynx and larynx]
 Muscles of palate (except tensor veli palatini)
 Muscle of pharynx (except stylopharyngeus)
 Laryngeal muscles
 Esophageal muscles
o GVE-P
 Visceral structures (smooth muscle, glands, arteries) of neck, thorax,
 2/3 of abdomen
o SVA
 Epiglottic portion of tongue(not really clinically important)
o GVA
 General sensation (mainly stretch) to lower respiratory tract, thoracic viscera
 2/3 of abdominal viscera

o GSA
 External acoustic meatus;
 external surface of tympanic membrane
o Branches
 Meningeal
 Auricular n (GSA)
 Pharyngeal branches
 SVE, GVE – p
 Superior laryngeal n
 (SVE ; GVE-P; GVA; SVA)
 Recurrent laryngeal n
 (SVE; GVE-P; GVA)
 Cardiac, Pulmonary, GI, Renal branches
 (GVE-P; GVA)
o Issues
 Sagging of the Phoushal pillars
 Deviation of the uvula
 CN 11 Spinal accessory Nerve
o GSE/SVE  sternocleiodomastiod and trapezius [MOTOR TO SKELETAL]
 Motor nerve arises in the cervical nerve
 Ascends through foramen magnum and exists through jugular foramen
o Functions of the muscles
 Trapezius
 Elevates the shoulders and abduction [upward rotation of the scapula]
 Sternoclinomastiod
 Rotates the head in opposite direction and elevates the chin

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 o Test:
 Head rotation  SCM
 Elevation of the shoulder  trapezius
 Weakness of abduct  trap
 CN 12
o GSE
 All intrinsic tongue muscles
 Extrinsic muscles of tongue (styloglossus, hypoglossus, genioglossus); but not
palatoglossus
o Lesion
 If tongue deviates upon protrusion, this is often indicative of a hypoglossal
nerve lesion.
 Tongue will point to side of lesion.
 LMN  Atrophy and fasciculation with lesion
 UMN [will be contra]

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Autonomics

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