Cranial nerve examination

Introduction
There are 12 pairs of cranial nerves, that exit the skull through fissures and foramen to
supply the Head, Neck, Thorax and Abdomen. They carry both afferent and efferent
supplies, in addition to these there is afferent to special senses like smell, sight, hearing,
taste and touch.
They can be Sensory, Motor and Mixed.
They are namely;
I Olfactory Nerve
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI Abducent
VII Facial
VII Vestibulo-Cochlear
IX Glossopharyngeal
X Vagus
XI Accessory Spinal
XII Hypoglossal

CRANIAL ATTACHMENT
NERVE IN BRAIN

CN I and II Forebrain

CN III and Midbrain

IV

CN V, VI, Pons
VII and
VIII

CN IX, X, Medulla
XI and XII
CN-I : OLFACTORY NERVE
First cranial nerve, with the origin in upper part of nasal cavity and insertion in the
forebrain. It is Sensory in nature.
ORIGIN : Olfactory Receptor nerve cells are present in the olfactory mucosa of upper
part of nasal cavity.
Insertion: Primary and Secondary Olfactory Cortex
The Receptor Cell consists of two parts;
• Small Bipolar cells : (16-20 million) fine hair like structure arises from coarse
peripheral process, known as olfactory hair, which react to odour and stimulate the
olfactory cells.
• Fine Central process : (20) these are olfactory nerve fibres, that bundle up and pass
through opening of cribriform plate of ethmoid bone to enter olfactory bulb.
Olfactory bulb:
A round ovoid structure, present in forebrain, contains several types of nerve cell. The
incoming Olfactory Nerve fibres, synapse with the Mitral Cells present in the bulb, and
also with smaller tufted or granular nerve cells. Narrow band of white matter, running
from the posterior end of Olfactory bulb, it is divide into two parts;
Olfactory striae:
• Lateral Olfactory Striae: relay into the olfactory cortex { periamygdaloid and
pepriform area thr primary olfactory cortex}
• Medial Olfactory Striae: relay into the opposite olfactory bulb.
Entorhinal area (area 28) of the parahippocampal gyrus,
which receives numerous connections from the primary olfactory cortex, is called the
secondary olfactory cortex.
Examination of Olfactory Nerve
1. Ask the patient if they notice changed smell perception?
2. Patient is asked to pinch one nostril and identify and distinguish common strong
smelling substances ( coffee, orange, peppermint, lemon, cinnamon)
3. Repeat with the other side.
RESULT:
Lack of smell sensation is known as Anosmia
Decreased sensation of smell is known as Hyposmia.
Inflammatory and Obstructive Disorder
• Rhinitis
• Sinusitis
• Rhino-Sinusitis
• Nasal and Antral Polyp
Head Trauma
• Destruction or trauma to olfactory neurons, olfactory bulbs/tract or direct damage to
the olfactory area in cerebral cortex.
• Fracture of anterior Cranial Fossa or cribriform plate, LeFort Fracture III
• Abscess in frontal lobe of brain or a meningioma in anterior cranial fossa that impinge
upon the olfactory bulb or tract.
Ageing and Neurodegenerative disease
• There is generally decreased sensitivity to smell as a person ages due to loss of
olfactory bulbs and decrease in surface area of olfactory epithelium
• Parkinsons, Alzheimer disease, Lewy Body dementia show a strong co relation with
Anosmia.
Congenital Conditions
• Congenital conditions that are associated with anosmia include Kallmann syndrome
and Turner syndrome.
Other Traumatic or Obstructive Conditions
• toxic agents such as tobacco, drugs, and vapors that can cause olfactory dysfunction,
• post-viral olfactory dysfunction,
• Common conditions that can uncommonly cause anosmia include diabetes
mellitus  and  hypothyroidism.
 • Medications can sometimes lead to olfactory defects as an unwanted side effect.
These medications include beta blockers, anti-thyroid drugs, dihydropyridine, ACE
inhibitors, and intranasal zinc. 
• Rare tumours like Olefactory Neuroblastoma.
CN –II: OPTIC NERVE
Human vision is Binocular, Stereoscopic and Coloured. The vision is aided by Cranial
Nerve II – the optic nerve, it originates from the retina of the eye and ends in the
forebrain. It is Sensory in nature.
There are in total four fields of vision; upper temporal and lower temporal ; upper nasal
and lower nasal, has following pathway
Optic nerve ,Optic chiasma, Optic tract, Lateral geniculate body, Optic radiation body,
Visual cortex,
Optic Nerve:
Made up of axons of ganglion cells of retina. Converge on optic disc and exit from eye, 3-
4mm from nasal side of its centre, as optic nerve. Leaves orbital cavity through the optical
canal, and unites with opposite optic nerve to form optic chiasma
Optic chiasma
Present at junction of anterior wall and floor of 3rd ventricle. Fibres of Nasal half crosses the
midline to enter optic tract. Whereas the fibres of Temporal fibre relay into the same side.
Optic tract
Fibres from optic tract passes posterolaterally and synapses with nerve in lateral geniculate
body. Few nerve fibres also synapses with nerves in pretectal nucleus and superior colliculus
of midbrain for light reflex.
Lateral Geniculate Body
Small oval shaped projection of thalamus. Has 6 layers and synapse with nerve fibres from
optic tract.
Optic Radiation
These are axon of nerve cells that exits from the Lateral
Geniculate Body.
Visual Cortex
Area 17, is known as Visual Cortex , present on upper and
lower lip of calcarine sulcus, on medial surface of cerebral
hemisphere. Also synapses with nerves in Area 18 and 19.
Area 18 and 19 – also known as Visual Association Cortex,
is responsible
for recognition of objects and perception of color.
 REFLEXES
Pupillary light reflex: light shone in one ey, it
constricts and also opp pupil constricts ( direct and consensual light reflex.)
Accomodation reflex : when eye adjust from distant object to near object the pupil constricts
Corneal Reflex : light touching of cornea results in blinking
Pupillary skin reflex : dilation of pupil due to pinching
Visual body reflex movement of head and neck while reading, scanning
movements
EXAMINATION OF OPTIC NERVE
TEST 1:
For Visual Acuity: Snells chart
TEST 2:
For Visual Field: a red pin is held equidistant from yourself and the patient and
gradually moved into centre of vision
until it is visible to both yourself
and the patient.
TEST 3:
For Pupillary Reflex : using a pen torch, light is shone
the pupils should constrict irrespective which eye is
tested first.
TEST 4:
For Accommodation Reflex: Patient is asked to focus on distant objects, then
finger is placed on tip of nose, and asking them to focus on it. The eyes
should
converge and constriction of pupil occurs.
TEST 5:
Colour Plates: Ishihara Chart
Lesions affecting the Nerve:
Trauma
Galucoma
Raised Intracranial Pressure
Neoplasms
Radiation
Toxins/drugs

CN- III: OCULOMOTOR NERVE

It is the third cranial nerve and is entirely a motor nerve. Originates from midbrain and
innervates and supply the extraocular and intraocular muscles of the eye. It is in series with
IV, VI and VIII cranial nerves, through the fibre of medial longitudnal fasciculus.
Main Motor Nucleus : Present in anterior part of grey matter , in midbrain at the level of
Superior Colliculus.
Accessory parasympa-thetic nucleus: Also known as Edinger- Westphal Nucleus. Present
posterior to the the main motor nucleus.
Supply the extraoral and intraoral muscles. Also supply constrictor muscles of iris and ciliary
muscles
COURSE OF THE NERVE:
The nerve fibres emerging from the MAIN MOTOR NUCLEUS, are known as Oculomotor
Nerve. The nerve emerges on the anterior surface of midbrain, an continues into middle
cranial fossa, and pierces the lateral wall of cavernous sinus, here it divides into : Superior &
Inferior Ramus.It enters the eye through Superior Orbital fissure and supply the following
extraocular muscles : Levator Palpebral Superioris : Inferior Rectus
: Superior Rectus : Inferior oblique
: Medial Rectus
Preganglionic fibres from the Accessory Parasympathetic Nucleus, travel with oculomotor
fibre up to the orbit, and relay into ciliary ganglion. The postganglionic fibres supply the
intraocular muscle : Constrictor pupillae or Iris and Ciliary muscles through the Short
Ciliary Nerve.
FUNCTION : Lifiting of upper eyelid, Medial, upward and downward movement of eye,
Constriction of pupil, accommodation of eye.
CN-IV : TROCHLEAR NERVE
It is purely motor in function. Originates from the anterior part of grey matter, below the
occluomotor. It passes posteriorly around central grey matter to reach posterior surface of
midbrain It is the only one to leave through posterior sufarce of brainstem, it emerges from
midbrain and immediately decussates with the opposite nerve. It passes through middle
cranial fossa, into the cavernous sinus wall. It enters the orbit through the Suprerior Orbital
Fissure and supplies the Superior Oblique Muscle, it helps in lateral and downward
movement of the eye.
CN-VI : ABDUCENT NERVE
It is a small, completely motor nerve.
ORIGIN : It originates beneath the floor of upper part of Fourth Ventricle, close to the
midline
COURSE: Passes anteriorly through the pons. It emerges in the groove between lower
border of pons and medulla oblongata.Passes through the cavernous sinus , lying below
and laterally to ICA.
INNERVATION: Enters the orbit through Superior orbital fissure.It supplies the Lateral
Rectus.It helps in lateral movement of the eye.

EXAMINATION OF III,IV,VI CRANIAL NERVE

■ TEST 1 : check for the signs of ptosis or squint
■ TEST 2 : check for eye movements by forming letter “H” in front of patient by using
finger/pen torch, asking the patient to follow by eyes only keeping head still.
■ TEST 3 : checking for paralysis, nystagmus, diplopia
 RESULT:
Conditions affecting Occulomotor Nerve;
• Divergent squint and Diplopia : Paralysis of extraocular muscles
• Ptosis : paralysis of Levator Palpebrae { Horner’s Syndrome, Myasthenia Gravis }
• Dilated Pupil : Paralysis of sphincter papillae, Aneurysm, Tumour, Brainstem Stroke
• Orbital apex syndrome
Condition affecting Trochlear Nerve:
• Eye elevation and outward rotation and diplopia on looking down:
Parlysis of Superior Oblique
Tumour a
Aneurysm
Cavernous Sinus Thrombosis
Orbital apex syndrome
Conditions affecting Abducent Nerve:
• Convergent Squint and Diplopia :
Paralysis of Lateral Rectus
Aneuyrsm
Tumour
Cavernous Sinus Thrombosis
Orbital apex syndrome

CN- V : TRIGEMINAL NERVE

It is the fifth cranial nerve, it has both Sensory and Motor functions. It mostly supplies the
face.To greater part of head, it has a sensory supply, whereas for muscle of mastication it
gives an motor supply. It has three parts, two of which are purely sensory and the third largest
part is mixed.
■ Main Sensory Nucleus
Posterior part of Pons, continuous with Spinal nuclei
■ Spinal Nucleus
Extends inferiorly the whole length of medulla, and upper part of spinal chord as far as 2nd
cervical segment
■ Mesence-phalic Nucleus
Column of Unipolar cells present in lateral part of gray matter, extend inferiorly into pons
 ■ Motor Nucleus
Present in pons medial to Main Sensory Nuclei
SENSORY COMPONENT
Pain, Temperature, Touch and Pressure are
carried by the divisions of Trigeminal Nerve,
from skin and mucous membrane to the
TRIGEMINAL GANGLION. The post ganglionic
fibers form a large sensory root and divide into
Ascending and Descending Fibers, when entering
Pons.
Ascending Fibres: relay into Main Sensory Nucleus, and carry touch and pressure.
Descending Fibers: relay into Spinal Nucleus and carry pain and temperature
TRIGEMINAL GANGLION
Also Known as SEMILUNAR GANGLION/ GASSERIAN
GANGLION is crescent-shaped ganglion, which lies within a
pouch of dura mater called the Trigeminal or Meckel cave.
Proprioceptive impulses from muscle of mastication, teeth and
temporomandibular joint relay into Mesencephalic Nucleus,
bypassing the Trigeminal Ganglion. Axons from nuclei, cross
median plane and ascend as Trigeminal Lemniscus It terminates
in ventral posteromedial nucleus of Thalamus. Further terminate
into Post Central Gyrus ( area 3,2,1)of cerebral cortex
MOTOR COMPONENT
ORIGIN: Right and Left Cerebral hemisphere, red Nucleus and Mesencephalic Nucleus.
Leave anterior aspect of pons as a small motor root. Passes out forward of posterior cranial
fossa and rests on upper surface of apex of petrous part of temporal bone.
INNERVATION: Muscle of mastication and other muscles
Tensor veli palatini
Tensor tympani
Mylohyoid
Ant. Belly of digastric

EXAMINATION OF TRIGEMINAL NERVRE

To check Sensation
TEST 1 : close the eyes of patient, and using cotton wool and Neuro
pin, on the face to differentiate between light touch and pain.
TEST 2 : Corneal Reflex – gently touching the cornea with cotton wisp --------- which results
in stimulation of ophthalmic nerve, due to which there is bilateral blinking (facial nerve)
To check Motor Function :
Test 1 : check muscle of mastication, palpating masseter, temporalis, while in rest and
clenching position and asking them to open their mouth.
TEST 2 : Jaw Jerk Reflex
Relax their jaw and ask them to open their mouth a little, place your thumb on their chin and
tap the tendon hammer
A Higher Central Lesion (Eg. Cerebral Or Thalamic)
will have to be contralateral to the clinical findings. A lesion of the unilateral cortex will
usually result in contralateral paralysis of the muscles; however, a unilateral cortical lesion
does not affect the muscles of mastication; this is because the motor nucleus receives bilateral
cortical input. Therefore, those muscles will still receive innervation from the other side of
the cortex.

CN- VII : FACIAL NERVE

It is the seventh cranial nerve. It is has both sensory and motor components. It is the nerve of
second brachial arch.
Main Motor Nucleus : ( lower part of pons) Part of Nucleus supplies upper part of face –
receives corticonuclear fibres from both cerebral hemisphere. Part of nucleus supplying lower
part of face – receives corticonuclear fibres from C/L side of cerebral hemisphere.
ParaSympathetic Nucleus: ( posterolateral to main motor nucleus)
• SUPERIOR SALIVATORY NUCLEUS: receives afferent from
hypothalamus, through autonomic descending pathway – information
regarding taste.
• LACRIMAL NUCLEUS: Afferent from hypothalamus for emotional
response.
• Also from Sensory Nucleus of Trigeminal nerve, for reflex lacrimation due to
irritation of cornea/conjunctiva
Sensory Nucleus : it is the upper part of Nucleus of tractus solitarus.
• Motor Root
Travel posteriorly around medial side of Abducent nerve. Pass around nucleus, in floor of 4th
ventricle, and pass anteriorly to emerge from brainstem
• Sensory Root
Also known as Nervus Intermedius. Formed by central process of geniculate ganglion
Efferent preganglionic parasympathetic fibers from the parasympathetic nuclei. Both roots
emerge from anterior surface of brain stem. Pass laterally in posterior cranial fossa with
Vestibulocochlear Nerve, and enter Internal Acoustic Meatus, in petrous part of temporal
bone. At bottom of meatus, it enters the Facial Canal, and runs laterally through inner ear. At
medial wall of Tympanic Membrane it forms Sensory Geniculate Ganglion. It emerges from
Stylomastoid foramen crossing at base of styloid process, and enters the posteromedial
surface of Parotid gland. At the neck of mandible, it divides into terminal branches.

• Motor nucleus: facial expression, the auricular muscles, the

stapedius, the posterior belly of the digastric, and the stylohyoid muscles
• Superior salivatory nucleus &Lacrimatory nucleus
Submandibular and sublingual salivary glands , nasal and palatine gland Lacrimal glands
• Sensory Nucleus
Taste fibres from anterior 2/3rd of tongue , floor of the mouth and palate.

EXAMINATION OF FACIAL NERVE

TEST 1 : General inspection for facial droop, asymmetery,
abnormalities in eye closure.
TEST 2: examination of Facial expression muscles.
• raise the eyebrows ------ frontalis
• tight closure of eyes ------ orbicularis oculi
• whistling/ blowing out cheeks ---- buccinator
• showing teeth----- orbicularis oris
TEST 3 : Taste Test- ask the patient about altered taste
sensation
testing with sweet and salty solutions
LESIONS AFFECTING FACIAL NERVE
SUPRANUCLEAR LESION – UPPER MOTOR
NEURON LESION
Causes ; Trauma, Stroke, Neoplasm , Granulomatous Meningitis. Affect the Corticobulbar
tract.
Symptoms: facial palsy of contralateral side of lower 2/3rd of
the face.Sparing of muscles of Forehead and Orbicularis Oculi.
( weak but well preserved eye closure)
INFRANUCLEAR LESION – LOWER MOTOR
NEURON LESION
Causes ; Trauma, Stroke,Neoplasm,Granulomatous
Meningitis
Symptoms: Ipsilateral Palsy Of Complete Half Of Face
Mouth Droop
Flattening Of Nasolabial Fold
Inablitilty To Close Eyes
Smoothening Of Brows
Depending upon level, of involvement, precise location of lesion
can be evaluated:
1. Pons: I/L facial plasy, palsy of lateral rectus muscle.
2. Cerebellopontine angle: I/L facial palsy, decreased secretion
of saliva and tears, hyperacusis and loss of taste (ageusia).
 3. Facial canal between the internal acoustic meatus and the geniculate ganglion : I/L
facial palsy, decreased secretion of saliva and tears, hyperacusis and ageusia
4. Above origin of Stapedius Nerve: I/L facial palsy, decreased salivary secretion,
ageusia, hypercusis
5. Below Origin of Stapedius Nerve: I/L facial palsy, decreased salivary secretion,
ageusia 
6. Branch of chorda tympani; I/L facial palsy
RAMSAY HUNT SYNDROME
Involvement of geniculate ganglion by Herpes – Zoster infection leads to - I/L Facial palsy,
hyperacusis, ageusia, decreased salivation and lacrimation.
CROCODILE TEAR SYNDROME
In case of damage to Facial nerve proximal to Geniculate Ganglia, the regenerating fibres of
submandibular salivary gland, grows into the preganglionic secretomotor fibres of Lacrimal
gland, hence patients lacrimates while eating.
Bilateral Facial Palsy
Acute Idiopathic polyneuritis, Sarcoidosis, Posterior Cranial Fossa tumour

CN VIII : VESTIBULO-COCHLEAR NERVE

It is a completely Sensory Nerve, it transmits all the sensory information from internal ear to
CNS. Also known as Auditory Vestibular Nerve or Stato-Acoustic Nerve.
VESTIBULAR NERVE: from utricle and saccule, provide information about position and
movement of head. Impulses are carried by nerve fibres of Vestibular ganglion. The afferent
fibres enter brainstem, at groove between pons and medulla .The fibres here divide: Short
Ascending, Long Descending, and few fibres pass directly to Cerebellum. The fibres the
relay into Vestibular Nucleus. The Vestibular Nucleus has four parts; Lateral, Superior,
Medial, Inferior. They give efferent to Spinal chord, Cerebellum, and to Cranial nerve III, IV,
VI. These connections to other Cranial nerves enable the movements of the head and the
eyes to be coordinated so that visual fixation on an object can be maintained. In addition,
information received from the internal ear can assist in maintaining balance by influencing
the muscle tone of the limbs and trunk. The Ascending fibers also relay into Cerebral cortex,
from where it is thought to relay in the Ventral Posterior Area of Thalamus. For orientation of
individual consciously in space.
COCHLEAR NERVE
Conduction of the sound impulses form the Organ of Corti, in Cochlea.Impulses carried by
cental process of nerve cells present in Spinal Ganglia of Cochlea. Enter brain stem at the
anterior surface, at lower border of Pons. Where it relays into two nucleus, the Anterior and
Posterior Nucleus.The nucleus are present at the anterior surface of Inferior Cerebellar
Peduncle. They send nerve fibre to Trapezoidal body and Olivary Nucleus. From here they
are carried upto the Primary auditory Cortex ( Area 41, 42) through Lateral Lemniscus, and
Medial Geniculate body.
EXAMINATION OF VESTIBULO-
COCHLEAR NERVE
TEST 1: Gross testing, whispering a number
of things, while blocking the other ear, and
asking to repeat them.
TEST 2: Rinne’s Test : patients ability to hear a tone conducted via air and then bone
{ mastoid process}.
512 Hz vibrating tuning fork, held one inch in front of ear, and then with its base on mastoid
process, till no noise is appreciated. Ask the patient if sound was higher in air or bone.
TEST 3: Weber Test : comparison between bone conduction, to asses unilateral hearing loss,
and also to differentiate between Rinne’s test.Tuning fork placed at centre of forehead, then
asked if sound hear in middle or to one side of head.If, sound lateralizes to one side:
Contralateral sensorineural hearing loss- sound louder in healthy ear. Ipsilateral conductive
hearing loss – sound louder in affected ear.
CONDUCTIVE DEAFNESS ( failure of sound waves to reach cochlea)
Otitis media
Paget’s disease
Perforated ear drum
CORTICAL DEAFNESS
Due to bilateral or dominant posterior temporal lobe lesion. Results in in failure to understand
spoken language though hearing is preserved.
SENSORINEURAL DEAFNESS ( failure of transmission of action potential, due to cochlear
disease)
Congenital
Acquired: Presbycusis (ageing)
Noise induced
Ototoxicity (drugs)

CN IX: GLOSSOPHARYENGEAL NERVE

It is the ninth cranial nerve, and derived from the Third brachial arch. It has both sensory and
motor components.
NUCLEUS OF NERVE
■ Main Motor Nucleus
 ■ Sensory Nucleus
■ Parasympathetic Nucleus
Nerve arises as rootlets from anterior surface of medulla
and passes laterally in posterior cranial fossa. Exist
through Jugular foramen, where there is superior and
inferior ganglia.
It then descend in upper part of neck with IJV and ICA.
Sensory supply to Stylopharyngeus, superior and middle
constrictor muscle of pharynx, mucous mem. of pharynx
and posterior 1/3rd of tongue.

CN X : VAGUS NERVE
It is the tenth cranial nerve, and has both sensory and motor component.
Main Motor Nucleus : Present deep to reticular formation in medulla oblongata. Receives
corticonuclear fibres from both cerebral hemisphere.
Efferent- constrictor muscle of pharynx and intrinsic muscle of larynx.
Parasympathetic Nucleus: Forms the Dorsal Nucleus of Vagus, and is present posterolateral
to the Hypoglossal Nucleus.
Afferent: from Hypothalamus and glossopharyngeal nerve
Efferent: to involuntary muscles of thorax and abdomen.
Sensory Nucleus: Forms lower part of nucleus of tractus solitarus. Taste sensation carried to
Inferior Gangalion of Vagus, which are carried further by efferent which cross the median
plane to reach the ventral group of nuclei. Afferent for common sensation are carried upto
Superior Ganglion of vagus, but ends in Spinal nu. of Trigeminal nerve
Arises as rootlets from the anterolateral surface of upper part of medulla oblongata. It passes
laterally in the posterior cranial fossa, and leaves through jugular foramen. Below the jugular
foramen, Vagus nerve has two ganglia : Superior Ganglia,Inferior Ganglia. The vagus nerve
descends vertically in the neck within the carotid sheath with the internal jugular vein and the
internal and common carotid arteries.It continues as Pharyngeal and Recurrent Laryngeal
branch.The nerve continues downward direction in upper part of neck, where it is joined by
Cranial root of Accessory nerve.Right Vagal branch enters Thorax, along posterior surface of
esophagus, and forms Posterior Vagal trunk, suppling the abdomen. Left Vagal Branch enters
thorax, forms pulmonary plexus, and runs along Anterior surface of esophagus, and forms
Anterior Vagal trunk, suppling the abdomen.
EXAMINATION OF GLOSSOPHARYNGEAL AND VAGUS NERVE
TEST 1: patient is asked for speech and swallowing difficulties. Gross assessment of speech
for hoarseness and nasal character.
TEST 2: Patient is made to say “ aahh” and with pen torch, elevation of soft palate and uvula
is assessed for any deviation.
TEST 3: Tactile sensation is generally tested, by gently touching the back of palate with
wooden spatula and asked to compare on both side.
LESIONS OF IX AND X NERVE
LESIONS OF IX NERVE
IX NERVE PALSY – base of skull tumour
- stoke /trauma
Altered sensation to palate and pharynx.
LESIONS OF X NERVE
Lesion of recurrent laryngeal branch.
-Weak cough/ dysphonia
X NERVE PALSY – base of skull tumour
- stoke /trauma
Asymmetry of soft palate
Loss of gag reflex.
BULBAR PALSY: weakness/ palsy of muscles supplied by CN IX, X,XI, XII.
Acute : polio, diphtheria
Chronic: Stroke , tumour

CN XI : ACCESSORY NERVE
It is the eleventh cranial nerve, having two parts : Cranial Root
: Spinal Root
It is completely motor nerve. Formed from nerve cells of Nucleus Ambiguus, receives
bilateral corticonuclear fibres from cerebral hemisphere
Cranial Root
The nerve then, emerges from the Anterior Surface of Medulla, and runs laterally in posterior
cranial fossa. Joins the spinal root in the here. They exit through Jugular Foramen, and then
seperates and the cranial root joins the Vagus Nerve. Formed by axons of Spinal Nucleus,
present in Anterior grey column of Spinal cord, from C1-C5
Spinal Root
It emerges from spinal cord, form Nerve trunk, and enter skull through Foramen Magnum, it
passes laterally to join Cranial Root, Passes through Jugular Foramen. After emerging from
foramen, it separates and supplies to deep part of Sternocleidomastoid muscle and Trapezius
muscle
EXAMINATION OF ACCESSORY NERVE
TEST 1 : Bulk and Tonicity of SCM is palpated.
Strength of SCM is tested by asking patient to turn their
head against resistance.
Left SCM is tested by asking patient to turn their head towards right, with a hand placed on
the right side of chin, stopping the movement.
TEST 2 : Bulk and Tonicity of Trapezius is palpated.
Strength of Trapezius is tested by asking the patient to shrug the ipsilateral shoulder, and
maintain in elevation while downward force is applied.

CN XII : HYPOGLOSSAL NERVE

It is the twelfth nerve, and is completely motor nerve.
Hypoglossus Nucleus: present near midline , beneath floor of 4th ventricle. Receives B/L
innervation of corticonuclear fibres The nerve fibres passes anteriorly through Medulla, as
and emerge as series of roots.It crosses Posterior cranial fossa, and leaves through
Hypoglossal Canal. In neck, it passes between IJV
and ICA, reaching lower border of posterior belly
of digastric. Crosses ICA & ECA and loop of
lingual artery, it lies deep to posterior margin of
mylohyoid, and supplies muscle to tongue. Upper
part of the nerve is joined by C1 fibres from
cervical plexus
EXAMINATION OF HYPOGLOSSAL NERVE
TEST 1 : The patient is assessed for wasting as
well the speed of tongue movement.
The patient is asked to protrude the tongue, move it
side to side quickly.
TEST 2 : the strength of tongue is checked by asking the patient to press the tongue on side
of cheek whilst applying pressure on the cheek.
Unilateral Lower Motor Neuron LesionAtrophy and Deviation to the I/L side on
protrusion. Dysarthria, difficulty in speech and lingual sounds
Bilateral Lower Motor Neuron Lesion
bilateral wasting and fasiculation of tongue.
Bilateral Upper Motor Neurone Lesion
Hypokinesia of tongue usually associated with motor neurone disease, demyelination of
nerve.

Faculty of Dental sciences

SGT University
DEPARTMENT OF ORAL MEDICINE & RADIOLOGY
(2019-2022)

SEMINAR
TOPIC: Cranial Nerve Examination
MODERATOR: Dr. Shantanu Dixit

PRESESENTED BY: DR. BHARGAVI SOOD

SIGNATURE OF HOD