CRANIAL NERVES

LESIONS
Nur Adilah Mohd Radzi
SN: 24
MN: 27

Objectives
Functions of all the cranial nerves
Common effects of lesions of the
cranial nerves
Clinical examination

Introduction
12 pairs of cranial
nerves
Contains only sensory
fibres Sensory
cranial nerves: I, II and
VIII
Predominantly motor in
function Motor
cranial nerve: III, IV,
VI, XI and XII

Both sensory &

motor fibres Mixed
cranial nerve: V,
VII, IX and X
Lesion: A region in
an organ/ tissue
which has suffered
damage through
injury or disease

CN I: Olfactory Nerve
Sensory cranial nerve
Function: Smell
Resides on the roof of
the nasal cavity
From theolfactory
mucosa foramina
on thecribriform
plate olfactory
bulb olfactory tract

CN I: Olfactory nerve
Lesion Anosmia,
Hyposmia, Parosmia,
Olfactory hallucination
Anosmia &
Hyposmia
Unilaterally Tumour
of olfactory bulb or
frontal lobe,
Meningioma
Bilaterally Common
cold, Head injury,
Atrophic rhinitis

Parosmia
(distortion of smell
sensation)
Olfactory
hallucination
Causes:
- Mental disorders
- Epilepsy
- Head injury

CN I: Clinical Examination
Smell is tested in
eachnostrilseparate
ly by placing stimuli
under one nostril
and occluding the
opposing nostril
Eg: orange/lemon
peel, coffee, or
vinegar -

CN II: Optic Nerve

Function: Vision

CN II: Optic Nerve

Lesion visual field defects & loss of
visual acuity
Causes of lesion:
Fractures in the orbit
Brain lesions
Damage along the visual pathway
Diseases of the nervous system
Pituitary gland tumor
Cerebral aneurysm

CN II: Damage along the visual

pathway

CN II: Clinical Examination

Test for: Acuity, Colour, Fields,
Reflexes

CN II: Clinical Examination

Visual fields are
tested by asking
the patient to look
directly at you
whilst you wiggle
one of your fingers
in each of the four
quadrants.

Visual reflexes
Place one hand
vertically along the
patients
Shine a pen torch
into one eye and
check the
constriction of both
pupils

CN III,IV & VI: Oculomotor, Trochlear

& Abducens
Function: Control the muscles that
move the eyeballs
Lesion: Strabismus, ptosis, diplopia
Causes of damage:
Trauma to the skull or brain
Compression
Lesions of the superior orbital fissure

CN III,IV & VI: Clinical

Examination
The finger is
moved in an "H"
shape and the
patient is asked to
report
anydiplopia

Pupillary reflex
Theaccommodation
reflexis tested by
moving the target
towards the
patient's nose

CN III: Oculomotor Nerve

A motor nerve
Functions:
- Control
movements of
eyeball
- Controls the size
of pupil
- Involved in
accommodation of
vision

The lesion in this

nerve may result
in:
i. Ptosis
ii. Nystagmus
iii. Strabismus
iv. Diplopia

CN III: Oculomotor Nerve

i. Ptosis
Causes:
Impairment of CN
III functions
Myasthenia gravis

ii. Nystagmus
- Jerky movement of
the eyeball

CN III: Oculomotor Nerve

iii. Strabismus
- Squint
- 2 separate images
are perceived
(diplopia)

iv. Diplopia
Causes:
- Can also happen in
CN III, CN IV & CN
VI

CN IV: Trochlear Nerve

A motor cranial nerve
Supply superior oblique muscle of
eyes
Function: Depress eyes when in
adduction
Lesion Diplopia (double vision)

CN V: Trigeminal Nerve
Mixed cranial nerve, largest
3 branches:
i. V: Opthalmic Nerve Eye
ii. V: Maxillary Nerve
Upper jawbone
iii. V: Mandibular Nerve
Lower jawbone
. Functions:
- Carrying general sensation
from different part of the
face, head & neck
- Mastication

Lesion will cause:

Sensory deficit
Motor deficit
Reflex deficit

Characterized by:
- Loss sensation of touch,
temperature and
proprioception
- Paralysis of the muscle
of mastication
- Loss of corneal reflex

CN V: Trigeminal Nerve
Lesion of 1 or more branches:
Trigeminal
neuralgia
(tic douloureux)
Sharp cutting/tearing pain,
lasts for few seconds to
minutes
Common in people >60 years
old
Causes: Looping blood vessel,
defective myelin sheath
Can be the first sign of a
disease: Diabetes, multiple
sclerosis, lack vitamin B

CN V: Clinical Examination
1. Light touch, pain
& temperature
2. Corneal reflex
3. Muscle of
mastication
(masseter &
temporalis
muscles)
4. Jaw jerk

CN VI: Abducens Nerve

A motor nerve
Innervates lateral
rectus muscle
Lesion may cause
diplopia and squint

CN VII: Facial Nerve

Mixed nerve
Functions:
Facial expressions,
Taste sensation
(anterior 2/3)

CN VII: Facial Nerve

Lesion Bells Palsy
Causes:
Viral or bacterial
infection
Damage to the nerve by
trauma, tumors & stroke

CN VII lesion also

causes:
- Dry cornea; loss of taste on
anterior two third of
tongue.

CN VII: Clinical Examination

1. Check for facial
expression
i. Raise both eyebrows
ii. Frown
iii. Close both eyes
tightly
iv. Show both upper
and lower teeth
v. Smile
vi. Puff out both cheeks

2. Check for taste

sensation

CN VIII: Vestibulocochlear
Nerve
Sensory cranial
nerve
2 branches:
I. Vestibular
Carry impulses
for
equilibrium
II. Cochlear
Carry impulses
for hearing

CN VIII: Vestibulocochlear
Nerve
Lesion to vestibular
branch:

Lesion to cochlear
branch

Vertigo
Causes:
- Tinitus,
Ataxia
- Trauma - Deafness
Nystagmus
- Middle ear
infection
- Lesions

CN VIII: Clinical Examination

Hearing function
1. Whisper
2. Rinnes Test
3. Webers test

Vestibular function
1. Check the patient
history
giddiness,
dizziness, vertigo
2. Rombergs test
3. Nystagmus

CN IX: Glossopharyngeal
Nerve
Mixed cranial nerve
Functions:
- Activation of
pharyngeal reflex
- Taste sensation
(posterior 1/3)
- Saliva secretion
- Regulation of
blood pressure

CN IX: Glossopharyngeal
Nerve

v.
Lesions:
Glossopharyngea
i. Dysphagia
l neuralgia
(Difficulty in
- Repeated
swallowing)
episodes of severe
ii. Aptylia
pain in the tongue,
(Decrease saliva
throat, ear, and
secretion)
tonsils, lasting from
iii. Ageusia (Loss
a few seconds to a
of taste sensation)
few minutes
Causes of Lesion:
iv. Hoarseness
Trauma, Pressing
of blood vessels,

CN IX: Clinical Examination

1. Taste sensation
(Posteriorly)
2. Gag reflex

CN X: Vagus Nerve
Mixed nerve
Widely distributed in the head, neck,
thorax and abdomen

CN X: Vagus Nerve
Lesion:
Loss of pharyngeal & palatal reflex
Gastric acid secretion, gall bladder emptying
Dysphagia
Tachycardia, impairment to blood pressure
regulation
Uvula deviates to the healthy side
Paralysis to the vocal cords
aphonia

CN X: Vagus Nerve
Causes of lesion:
Mass in the posterior fossa
Bony fracture damage the exit
from jugular foramen
Neuritis (eg: herpes zoster)

CN X: Clinical Examination
1. Observe the arch of palate & uvula
when the patient say aaah
2. Gag reflex
3. Visceral function

CN XI: Accessory Nerve

Motor cranial nerve
2 fibres: Cranial fibre & Spinal fibre
Spinal fibre has 2 parts:
Cranial portion swallowing movement
(larynx,
pharynx, soft palate
Spinal portion Head & shoulder
movements (sternocleidomastoid &
trapezius muscle)

CN XI: Accessory Nerve

Lesions may
cause:
- Inability to raise
shoulders
drooping of
shoulder
- Difficulty to turn
head

Causes of Lesion:
- Mass lesion at the
base of the skull
- Interruption of
nerve due to
complication of
lymph node biopsy

CN XI: Clinical Examination

Trapezius & sternocleidomastoid
muscles

CN XII: Hypoglossal Nerve

Motor cranial nerve
Functions:
Movement of
tongue, assist in
speech &
swallowing

CN XII: Hypoglossal Nerve

Lesion may
produce:
- Dysarthria
- Dysphagia
- Atrophy &
weakness of
tongue

Causes of lesion:
- Bony fracture
- Mass lesion
- Congenital
malformation (rare)
- Carotid dissection

CN XII: Clinical Examination

Inspect for tongue atrophy,
fasciculation or asymmetry
Check for the strength of the tongue
muscles

Conclusion

References
Principles of Anatomy & Physiology, 13th Edition,
Gerard J. Tortora & Bryan Derrickson
Fundamentals of Neurology, Mark Mumenthaler,
Heinrish Mattle with Ethan Taub, International
Edition
Textbook of Physical Physiology, G K Pal & Pravati
Pal, 2nd Edition
Current Medical Diagnosis & Treatment
(CMDT),Tierney, McPhee & Papadakis Lange, 43 rd
Edition