Introduction History Parts of Nervous system

CNS PNS

Development of brain Cranial nerves

Applied anatomy

Conclusion References

All living organisms are able to detect changes within themselves and in their environments
External environment Internal environment

Nervous systems are of two general types, Diffuse Centralized

 By means of nerves, the pathways of the senses are distributed like the roots and fibers of a tree. - Alessandro Benedetti, 1497 Ancient medical practitioners understand that nerves served two functions: Movement & Sensation 4th century B. C., the Greek philosopher Aristotle believed firmly that the nerves were controlled by and originated in the heart Six centuries later, the Roman physician Galen, Brain was the most important organ of the body, with the nerves emanating from it.

 In the human brain there are approximately 10 billion neurons The most significant specialized features of nerve cells their axons, dendrites and synapses Nerve cell processes are quite thin, often less than a micron (1m) in diameter

Axon length may reach well over a meter

Development of human brain

Almost all neurons are generated during prenatal life Nervous system first appears about 18 days after conception, with the genesis of the neural plate Functionally first sign of reflex activity during second prenatal month

2.5 million neurons must be generated per minute during the entire prenatal life

EMBRYOLOGY
THREE ECTODERMAL SOURCES A. DORSAL NEURAL TUBE B. NEURAL CREST C. SURFACE EPITHELIUM PLACODES 7 WEEK IUL NEURAL TUBE FLEXES TELENCEPHALON DIENCEPHALON MESENCEPHALON METENCEPHALON MYELENCEPHALON

 3rd week-nueral plate

 MOTORS NERVE C N V,VII,IX,X,XI,XII --FROM METENCEPHALON & MYELENCEPHALON SENSORY NERVES --- FROM DIENCEPHALON & MESENCEPHALON BY 5 & 6 WEEK IUL FULL COMPLEMENT OF TWELVE CRANIAL NERVES ARE FORMED MYELINATION 12 WEEK IUL TO 3-4 YRS AFTER BIRTH

 Brain- control center of nervous system receives sensory input from spinal cord as well its own nerves. ex: olfactory, optic Spinal cord- conducts sensory information from PNS to brain. Conducts motor information from brain to our various effectors Serves as minor reflex center

BRAIN
FORE BRAIN Cerebrum diencephalon MID BRAIN HIND BRAIN Medulla oblongata Pons cerebellum

BRAIN STEM

Medulla Oblongata, pons & Mid Brain

CRANIAL NERVES 12 pairs

Receives information from and controls activities of head and neck Cranial nerves pass through foramina of skull

SPINAL NERVES 31 pairs 8 Cervical 12 Thoraxic 5 Lumbar 5 Sacral 1 Coccygeal Receives information from and controls activities of trunk and limbs. Spinal nerves leave through intervertebral foramina

Autonomic Nervous System

Division of PNS.

Automatically controls involuntary functions.

Consists motor neurons arising from brainstem and spinal cord that carry nerve impulses to smooth muscle in glands, bloodvessels, cardiac muscle and other organs.

SYMPATHETIC NERVOUS SYSTEM Typically excitatory, Prepares body for stress.

PARA SYMPATHETIC NERVOUS SYSTEM Restores or maintains energy. Ex: Slowing heart rate, Speeding up movement of intestines.

Ex: Increase in heart rate, Slowing the movement of intestines

FIRST SPINAL ANESTHESIA, 1906

Also known as subarachnoid block Dr. A. Morton of San Francisco

L1 L2 L3

Classification of neurons Based on no. of neurites

CLASSIFICATION ACCORDING TO THE SIZE

GOLGI TYPE I NEURONS GOLGI TYPE II NEURONS

CLASSIFICATION ACCORDING TO THEIR FUNCTION

SENSORY MOTOR

NEUROGLIA

Neuroglia
Non excitable cells in which support neurons
TYPES OF NEUROGLIA

ANATOMIC TYPES OF RECEPTORS

NON ENCAPSULATED RECEPTORS Free nerve endings Merkels discs Hair follicle receptors

ENCAPSULATED RECEPTORS Meissners corpuscles Pacinian corpuscles Ruffinis corpuscles

Functional components
Functions performed by each type of fiber contained within given nerve, as a class the several specialized fiber types referred by the generic term Functional components

TYPES
A) GENERAL: refers to stimuli conducted throughout the entire body, common to both cranial and spinal nerves.

Ex: touch, pressure, vibration, pain, thermal sensation and proprioception

B) SPECIAL: Afferent information is encoded by highly specialized sense organs and transmitted to the brain in certain cranial nerves (I, II, VII, VIII, IX) Ex; olfaction, vision, taste, hearing and vestibular function

II.

A) SOMATIC: Refers to skin and muscles of body wall B) VISCERAL: Organs within the body cavities

III.

A) AFFERENT: or sensory means the direction of conduction is towards the CNS B) EFFERENT: or motor means the direction of conduction is away from CNS ( Brain to effector)
A) GENERAL AFFERENT: fibers carry sensations of pain, temperature, touch and pressure from widely distributed receptors to brain. B) GENERAL EFFERENT: Includes all motor fibers to skeletal muscles, smooth muscles, cardiac muscle or glands.

IV.

Various combinations of terms to describe 4- general components types

Somatic, Visceral, Afferent and Efferent

GSA: Transmit incoming sensations of pain, temperature, touch and pressure from the body wall to the spinal cord and brain. GSE: Fibers convey motor impulses to skeletal muscles

GVA: Fibers transmit pain from the viscera. Also conduct specialized afferent impulses such as those concerned with blood pressure and regulation of other visceral activities. GVE: fibers transmit outgoing impulses to smooth muscles, cardiac muscle and glands

3 special functional components found only in cranial nerves

SSA: Fibers related to sight and hearing SVA: Fibers to taste and smell.

SVE: Fibers convey outgoing impulses to muscles derived from mesoderm of branchial arches.
This include muscles of mastication and facial expression and the muscles of pharynx and larynx.

1. Olfactory nerve 2. Optic nerve 3. Occulomotor nerve 4. Trochear nerve 5. Trigeminal nerve 6. Abducent nerve 7. Facial nerve 8. Vestibulocochlear nerve 9. Glossopharyngeal nerve 10. Vagus nerve

11. Accessory nerve

12. Hypoglossal nerve

Sensory

Motor

Mixed

Olfactory nerve
Function: smell Cells of origin: olfactory mucosa in the nasal cavity Component: Special Afferent Exit from skull: cribriform plate of ethmoid bone

Applied anatomy
Anosmia: loss of olfaction unilateral/ bilateral Unilateralfrontal lobe tumors Bilateral Common colds, other forms of rhinitis severe anterior cranial fossa injury Hyperosmia: hysterias Caprosmia :unpleasant odour due to decomposition of the tissues in the individual. CEREBROSPINAL RHINORRHOEA Clinical Testing Each nostril tested separately using common test odours. Nasal infections spread along the nerve - Meningitis Identification or awareness of odour precludes anosmia 50% pts anosmia temporary, peak recovery 10 weeks

Optic nerve
Nerve of sight

Developmentally optic nerves and retinae are

out growths of brain Functional component is: Special Afferent 4cm long 25m intraorbital

5mm intracanalicular
10mm intracranial

Optic N

intraorbital
25mm long sinus course Posteriorly: surrounded by 4 recti muscles Anteriorly: separated by fat in which ciliary vessels and nerves are embedded

Intra orbital

Optic N Optic canal

In optic canal

5mm long Superiomedial to ophthalmic artery Medially: from sphenoidal and posterior ethmoidal sinuses by osseous lamina Anterior to canal: nasociliary nerve and opthalmic artery cross above the optic nerve

Optic N Intra cranial

Intracranial

10mm long runs posteriomedially from optic canal to optic chaisma Here fibers from nasal half of retina cross over & form optic tract Near the chaisma: Above: anterior cerebral artery Lateral: internal carotid artery

Optic N

Applied anatomy of optic nerve

Lesions involving the retina or optic nerve on one side result in unilateral symptoms. Complete destruction- Unilateral blindness Partial involvement- loss of vision in affected area Scotoma

Bilateral loss of vision generalized disorder ex: hypertension, diabetes, multiple sclerosis

Optic N

Applied anatomy of optic nerve

Optic neuritis: pain in and behind the eye on
ocular movements and on pressure. - papilloedema is less but more of loss of vision Demyelinating diseases causes of CNS septic focus in teeth or PNS meningitis, encephalitis, syphilis vit B deficiency

Papilloedema: swelling of I part of optic nerve or

optic disc - consequence of intracranial neoplasm

CLINICAL TESTING
Acuity of vision : counting of fingers snellens chart. Field of vision : confrontation test. Colour vision : holgrems color wool test, ishiharas chart,

Oculomotor nerve
Supplies all extraocular muscles (SO4 and LR6) Through ciliary ganglion : splinter pupillae and ciliaris

oculomotor

Functional component

GSE- for movements of eyeball

GVE: contraction of pupil and accommodation GSA: proprioceptive impulses from muscles of eyeball

oculomotor

Oculomotor nerve
Nucleus : ventromedial part central grey

matter of mid brain at the level of

superiorcollicus Origin: from midbrain

oculomotor

Passes btw superior cerebral and posterior cerebral arteries Runs forwards on lateral side of posterior communicating artery to reach cavernous sinus

oculomotor

Enters cavernous sinus by piercing posterior part of its roof on lateral side In part of sinus nerve divides into superior and inferior branches

oculomotor

Two divisions enter into orbit through middle part superior orbital fissure In fissure nasociliary nerve lies btw them, abducent nerve inferolateral to them

oculomotor

In orbit Small upper division: superior rectus Larger division: three branches Medial rectus Inferior rectus Inferior oblique

Ciliary ganglion
Peripheral parasympathetic ganglion placed in course oculomotor nerve Lies btw optic nerve and tendon of lateral rectus muscle
Edinger- westphal nuclues Motor root Nasociliary N Sensory root Splinter pupillae Ciliaris Short ciliary N Eyeball

Sympathetic root

ICA Post ganglionic fibres superior cervical ganglion

Blood vessel-eyeball Dilator pupillae

Applied anatomy of oculomotor nerve

Lesions ex: tumors, hemorrhage, aneurysm of circle of willis, that completely paralyse the nerve shows : ptosis, mydriasis, divergent strabismus, diplopia, loss of light and accomodation reflexes, slight proptosis.

Applied anatomy of oculomotor nerve

Webers syndrome: midbrain lesion causing contralateral hemiplegia and ipsilateral paralysis

Clinical testing of 3rd nerve

Finger following tests: patient instructed to
follow examiners finger eyes in all cardinal directions of gaze. Determine whether paralysis of one or more extraocular muscles. A pocket torch shown onto the eye, from the side to eliminate an accommodation reflex . This is tested by asking to focus upon an object approaching him

Trochlear Nerve
Supplies only superior oblique muscles Functional components: GSE: lateral movements of eyeball GSA: proprioceptive impulses from superior oblique muscle

Trochlear N

Trochlear Nerve
Nuclues: ventromedial part central grey matter of mid brain at the level of superiorcollicus Emerges from below the inferior collicus

Trochlear N

Trochlear Nerve
Nerves decussate with each other & peirce the medullary velum on dorsal surface of midbrain. Passes btw posterior cerebral arteries and sup cerebellar arteries to appear ventrally Enters cavernous sinus runs forwards in the lateral wall btw oculomotor and ophthalmic nerve

Trochlear N

Enters orbit lateral part of superior orbital fissure

Trochlear N

In passes medially above levator palpebral superioris and ends by supplying superior oblique muscle.

Trochlear N

Applied anatomy
When Trochlear nerve is damaged: Diplopia occurs on looking downwards. Vision is single so long as the eyes look above the horizontal plane.

Cause: brainstem lesion along nerve course orbital fracture

Trigeminal nerve
N. Trigeminus; Fifth Or Trifacial Nerve Largest cranial nerve Proprioceptive impulses:- deep pressure and kinethesis Exterioceptive impulses:- touch pain and temp

 Nerve is attached to lateral part of pons by its two roots , MOTOR and SENSORY Motor Root: SUPERIOR NUCLEUS cells occupying the whole length of the lateral portion of the gray substance of the cerebral aqueduct. Inferior or chief nucleus is situated in the upper part of the pons Fibers from both nucleus unite in pons, and form the motor root moves forwards in pons to its point of emergence

Sensory root: Fibers of the sensory root arise from the cells of the semilunar ganglion which lies in apex of the petrous part of the temporal bone On entering the pons, divide into upper and lower roots The upper root ends in nucleus situated in the pons lateral to the lower motor nucleus The lower root descends through the pons and medulla oblongata Lower root is sometimes named the spinal root of the nerve

Mesencephalic root of trigeminal nerve Consists of afferent fibers that accompany motor root which ascend to reach mesencephalic nucleus Fibers concerned with perfect synchronization in

controlling biting force of jaws

Trigeminal ganglion
Sensory ganglion of 5th CN Puedounipoloar nerve cells

Crescentic or semi lunar in shape with convexity facing anteriomedially

Present in trigeminal cave a special space in dura mater- surrounded by CSF along with motor root Convex surface; Three divisions Concave surface:-

Receives sensory root

Divisions of trigeminal nerve

Trigeminal N Ophthalmic

Ophthalmic nerve

Sensory nerve

smallest of the three divisions

From medial part of ganglion lateral wall of cavernous sinus

Enters orbit through SOF

In middle cranial fossa Nervus tentorii

Br to 3,4, and 6th CN

Trigeminal N Ophthalmic

Before entering to SOF Frontal N Nasociliary N. Lacrimal N

Trigeminal N Ophthalmic Lacrimal

Lacrimal nerve

Smallest br Lateral angle of SOF

Trigeminal N Ophthalmic

Lacrimal nerve

Lacrimal

Supplies sensory fibres to lacrimal gland and adjacent conjunctiva Postganglionic secretary fibres from sphenopalatine ganglion travel along ..

Trigeminal N Ophthalmic Frontal

Frontal nerve

Largest br. Enters orbit SOF Curves lateral border of superior rectus muscle

Trigeminal N Ophthalmic Frontal

Reaches upper surface of levator of upper eyelid Middle of orbit divides into Supraorbital N Supratroclear N

Trigeminal N Ophthalmic Frontal

Supra-orbital nerve

Largest br. of frontal nerve Leaves orbit supraorbit foramen Supply skin: Upper eyelid, Forehead and Anterior scalp region to vertex of skull

Trigeminal N Ophthalmic Lacrimal

Supratrochlear nerve

Smallest branch of frontal nerve Passes toward upper medial angle of orbit Pierces the fascia of eyelid to supply skin of upper eylid Lower medial portion of eyelid

Trigeminal N Ophthalmic Nasociliary

Nasociliary nerve

Internal br Third main br of ophthalmic division Enters into orbit SOF

Trigeminal N Ophthalmic Nasociliary

Branches In orbit In Nasal cavity Supply MM lining of cavity On Face Terminal br: skin medial parts of eyelids Lacrimal sac Bridge of nose

Trigeminal N Ophthalmic

Nasociliary nerve...

Nasociliary

In orbit 1.Long root of ciliary ganglion Sensory fibres pass through ganglion without synapse cont short ciliary nerves 2.Long ciliary nerves 2 to 3 iris and cornea Postganglionic fibres superior cervical ganglion

Trigeminal N Ophthalmic nasociliary

Nasociliary nervE...
3.Posterior ethmoidal nerve PE Canal MM lining of post ethmiodal and sphenoid sinus

Trigeminal N Ophthalmic nasociliary

4.Anterior ethmoidal nerve Continues medial wall of orbit Upper part of nasal cavity Internal nasal branches
Septal br: Lateral br: ant ends of superior and middle nasal conchae

External nasal branches

Lower edge of nasal bone: skin-tip and ala nose

OphthalmIc division

To be continued..

references
Grays anatomy The anatomical basis of clinical practice, 39th edition, Susan Standring B.D.Chaurasias human anatomy, Vol 3: 4th edition New atlas of human anatomy : Thomas Mc cracken

Cunninghams Manual Of Practical Anatomy. Vol 3:

Head & Neck & Brain. 15th ed. Text book of oral surgery : Neelima malik

Maxillary Nerve

Trigeminal N Maxillary

Maxillary Nerve
Entirely sensory Origin: semilunar ganglion Course: Lower part of cavernous sinus

Trigeminal N Maxillary

During course- gives of In 4 regions 1. Middle cranial fossa Meningeal 2. Pterygopalatine fossa Ganglionic Zygomatic PSA 3. Infraorbital groove & canal MSA and ASA 4. On face Palpebral Nasal Superior labial

Trigeminal N Maxillary

In pterygopalatine fossa
Zygomatic N Lateral surface orbit Zygomaticofacial N Perforates orbicularis oculi skin prominence of face Zygomaticotemporal N Thro Zygomaticotemporal fossa pierces temporal fascia- skin of temple

Trigeminal N Maxillary

Pterygopalatine Nerves

Ganglionic brances: Orbital br: IOF- periosteum of orbit Nasal br: PS lateral nasal br: MM of nasal septum and posterior ethmiodal sinus Medial or septal br: nasopalatine - premaxilla

Trigeminal N Maxillary

Pterygopalatine Nerves
Palatine br Anterior palatine: Greater palatine foramen Middle palatine: lesser palatine foramen Posterior palatine: lesser palatine foramen Tonsil

Trigeminal N Maxillary

Pterygopalatine ganglion
Parasympathetic root: Sympathetic root Sensory root

Vasomotor nerves to MM of nose, palate

Trigeminal N Maxillary

Posteriosuperior alveolar nerve

Arises from nerve just before it enters the infraorbital groove descend on the tuberosity of the maxilla Then enter the posterior alveolar canals Posteriolateral wall maxillary sinus -and three twigs to each molar tooth

Trigeminal N Maxillary

Middlesuperior alveolar nerve

posterior part of the infraorbital canal runs downward and forward in a canal supply the two premolar teeth forms a superior dental plexus Dental nerves - Interdental branches and

- Interradicular branches

Trigeminal N Maxillary

In infra-orbital groove
Anterior superior alveolar nerve
just before its exit from the infraorbital foramen

descends in a canal in the anterior wall of the maxillary sinus

Divides into branches which supply the incisor and canine teeth Nasal branch - supplies the mucous membrane of the anterior part of the inferior meatus and the floor of the nasal cavity

Trigeminal N Maxillary

Terminal branches on face

1.Inferior palpebral br Pass upwards: skin of lower eyelid 2.Lateral nasal br Side of nose 3. superior labial br Skin , muscles and mucosa of upper lip

Maxillary division

Mandibular Nerve

N. MANDIBULARIS; INFERIOR MAXILLARY NERVE

Largest of the three divisions The large sensory root arises - semilunar ganglion Motor fibers derived from motor cells in medulla oblongata- joins sensory root just out side of skull

Trigeminal N Mandibular

Leave the skull through the foramen ovale to

enter the infratemporal fossa

Passes between tensor veli palatini and deep lateral pterygoid

Beyond this junction:

Small anterior trunk Large posterior trunk

Trigeminal N Mandibular

Branches from main trunk Nervous spinosus: passes into middle cranial fossa-dura and mastoid cells

Trigeminal N Mandibular

Nerve to internal pterygoid muscle Tensor velipalatini and tensor tympani

Trigeminal N Mandibular

Branches from divided nerve

Sensory br: buccal nerve Passes btw two heads of lateral pterygoid Downwards and forwards-

Anterior division

skin and MM buccinator Labial aspect of gums of premolar and molar teeth

Trigeminal N

Mandibular Motor br:

1. Masseteric Anterior Emerges: upper border of lateral pterygoid In front TMJ enters the deep surface of the masseter Supplies TMJ

Trigeminal N Mandibular Anterior

Motor br: 2. Deep temporal nerve 2 anterior and posterior Anterior : upwards and crosses the infratemporal crest of spheniod bone Posterior: deep part of temporal muscle and supplies it

Trigeminal N Mandibular Anterior

Motor br: 3. Pterygoid nerve: Enters the medial side of external pterygoid

Trigeminal N Mandibular

Posterior division

Large division: Extends downwards and medially Auriculotemporal Lingual Inferior alveolar nerve

Trigeminal N Mandibular

Auriclotemporal nerve

Arises by a medial and lateral root

Posterior Roots embrace the middle meningeal artery and unite behind

the artery - United nerve passes posteriorly deep to the external pterygoid muscle and neck of the condyle

Trigeminal N Mandibular Posterior

Auriculotemporal nerve
fascia and then crosses the posterior root of the zygomatic arch

--traverses the upper deep part of the parotid gland or its

Branches :

Articular

Trigeminal N Mandibular

Lingual nerve

Smaller to two terminal br of post. Division Posterior Contributes sensory fibers to the mm of the floor of mouth & gingiva on lingual surface of mandible

Trigeminal N Mandibular Posterior

Inferior alveolar nerve

Largest br of posterior division

Trigeminal N Mandibular Posterior

In mental foramen: Mental Nerve: skin of the chin and lower lip Incisive Nerve: Fine incisive plexus supplies cuspid and incisor teeth

Mandibular division

Applied anatomy
Trigeminal neuralgia: char by extremely severe shock like or lancinating pain limited to one or more branches of trigeminal nerve. Etiology: pathosis along course of nerve brain stem tumor or infarction C/F: persons > 40 yrs women > men right side > left Pain searing, stabbing or lancinating Initiated by touching trigger zone Spasmodic contractions of facial muscles- tic douloureux

Trigeminal neuralgia:
Treatment: Initial treatment topical capsaicin Anticonvulsant medn pain control Nuerosurgical procedures: a. b. c. d. glycerol rhizotomy decompression Microvascular decompression Neurectomy

Applied anatomy
Sensory distribution explains why headache is common symptoms involvement of nose, teeth and gums, eyes and meninges. Referred pain : cancer of tongue- pain radiates to the ear and to the temporal fossa Infra orbital nerve anesthesia: Tapping on unanesthetized tooth Inferior dental nerve and lingual nerve greater risk during removal of posterior teeth

CLINICAL EXAMINATION OF 5th nerve

MOTOR EXAMINATION

MUSCLES OF MASTICATION : clench the teeth (tempo, messeter) One side paralyzed jaw deviates same side PARALYSIS OF MYLOHYOID AND ANTERIOR BELLY OF DIGASTRIC Palpation of flabbiness or flaccidity of the floor of mouth
PARALYSIS OF TENSOR TYMPANI Difficulty in hearing high tones..

CLINICAL EXAMINATION OF 5th nerve

SENSORY EXAMINATION Examine skin and mucous membrane pain, touch, pressure and temperature Teeth are examined by heat and cold test, percussion for proprioceptors touch Corneal Reflex,

Abducens nerve
6th cranial nerve Functional component: GSE: lateral movements of eyeball GSA: proprioceptive impulses from lateral

rectus
Nucleus : in the floor of 4th ventricle

Course and distribution

Nerve attached to lower border of pons Runs upward to reach cavernous sinus Lies lateral to internal carotid artery Enters orbit through middle part sup orbital fissure Ends by supplying LR at its ocular surface

Applied anatomy/ 6TH Nerve

Paralysis of abducent nerve results in Medial convergent squint Diplopia Cause: Brain lesion Cavernous sinus lesion extending into orbit. CLINICAL TESTING: Ask the patient to follow the finger of the examiner in all the directions.

Facial nerve
Seventh CN- mixed Nerve of second brachial arch

Facial N

Functional components:
SVE: GSA GVE SVA lacrimal, muscles &of Facial submandibular, Fibers from skin Taste sensation from sublingual glands, bone elevation of hyoid palate external ear anterior2/3 of tongue and pharynx

SVE

GVE

SVA

GSA

Facial N

Nucluei
Motor Nucleus Superior Salivatory nucleus Lacrimatory nucleus Nucleus of the Tractus Solitarius

Facial N

Course and distribution

Attached to brain stem by Sensory (nervous intermedius) Motor root

Facial N

course and distribution

Lies medial to 8th CN and runs laterally and forwards towards internal acoustic meatus Nerves accompanied by labrinthine vessels-

Near bottom of meatus two roots form single trunk

Facial N

In facial canal divided in three parts

First part: directed laterally above vestibule (genu) Second : runs backwards in medial wall of middle ear Third : vertically downwards

Leaves skull stylomastoid foramen

Facial N

Extracranial course
Crosses lateral surface of base of styloid process Enters posteromedial surface of parotid glands runs

forwards through gland crossing retromandibular vein and

ECA Behind neck of mandible- 5 branches

Facial In facial canal

Branches in facial canal

parasympathetic fibers( postganglionic fibers) supply lacrimal gland and mucosal glands of nose, palate and pharynx

I. Greater petrosal nerve carries gustatory and

II. Nerve to stapedius III. Chorda tympani

fibers supply submn & sublingual sal gland & taste fibers from ant 2/3rd of tongue.

Facial N

As its exist from sylomastiod foramen

i. Posterior auricular-Auricularis, posterior occipitalis, intrinsic muscles

on back of auricle

ii.

Digastric branch-post belly of digastric

iii. Stylohyoid branch-stylohyoid muscle

Facial N

Terminal branches with In parotid gland

Facial N

Applied anatomy
Preservation of Facial nerve is an important step In Parotid surgery, it is found b/w mastoid process & bony part EAM At birth mastoid process is absent Facial nerve superficial & vulnerable Caution < 4yrs Damage to a facial nerve is common with the fracture of temporal bone

Damage to facial nerve incorrect deposition of LA during inferior alveolar nerve block

Facial N

Applied anatomy
Damage to nerve above its chordatympani branch---loss of taste sensation at ant 2/3rd of tongue and decrease in salivation. Damage above the stapedius branch hyperacusis Involvement of the nerve at the level of geniculate ganglion- decrease in lacrimation Damage of the nerve within IAMDeafness Facial nerve may be injured during fracture of the base of the skull, forceps delivery, middle ear infections, tumours, meningitis.

Facial N

Facial Paralysis

Facial N

Facial Paralysis
UPPER MOTOR NEURON Lesions is above the pons. LOWER MOTOR NEURON Lesions is in the pons or in the pathway from pons to its exit. Furrows are absent on looking upwards of the affected side of face.

Patient can make furrows on looking upwards

Lower part of the face is involved The whole face and forehead on the opposite side of the involved on the same side of lesion. the lesion.
Isolated involment of this type is rare. It is invariably associated with hemiplegia . Isolated involment of this type is common. It may be associated with hemiplegia .

Facial N

BELLS PALSY
Coined in 1829 by William bell A syndrome that consisted of ipsilateral facial paralysis with intact facial sensation

Etiology: Ischemia, edema, compression of the nerve Herpes simplex-1 virus,

Facial N

Clinical features/ Bells palsy

Lesion unilateral Unable to laugh/ smile Cannot blink his eyes Unable to raise eyebrows Absence of wrinkles on forehead Drooping- corner of mouth

Infection of eyes

Facial N

Treatment
Corticosteroids
Adults: Prednisone 20 mg QID 5 days Children: Prednisone 1 mg/kg/day

Acyclovir
Adults: 2g per day, 7 days. With varicella zoster 4g per day Children: 80 mg/kg per day, 5 days

Protecting eyes:
-eye drops/artificial tears -ointment at bed time -goggles for dust protection

Facial N

Facial nerve testing

Observation Sensory: Taste to anterior 2/3 of tongue

Secretory functions Schirmers test: Amount of tear secreted evaluated by hanging a strip of litmus paper on eye lid and note moistening

Facial N

Motor ability Ability to frown Smile, show teeth Puff out checks whistle, close eyes

8 8th CN

Vestobulocochlear nerve statoacoustic; auditory

Eight cranial nerve Vestibular part: position and balanced sense or equilibrium Cochlear part: Hearing Both contains Somatic Afferent fibres

8th CN

Vestubular nuclei
superior and inferior medial and lateral Partly in medulla and pons

Vestibular pathway
Impulses arising in labyrinth Influence the movements of eyes, head, neck and trunk

Internal acoustic meatus

Auditory path way Cochlear nuclei

-Inferior cerebellar peduncle Hair cells of organ of corti situated in cochlear duct of internal ear

8th CN

Applied anatomy/ 8th nerve

Lesions of the nerve cause hearing defects. hearing impairment may be due
-Diseases of nerve: Nerve deafness -Diseases of middle ear: Conductive deafness

Rinnes & Webers test:

Principle: aerial conduction of sound is better than bony conduction. In conductive deafness, bony conduction is better In nerve deafness, both are lost.

8th CN

Rinnes test:
Vibrating tuning fork held opp the ear & then on mastoid process.

Webers test:
- Vibrating tuning fork placed on the centre of forehead

Patient asked to compare relative loudness of fork in 2 instances

- Vibration heard better on

the side of middle ear disease

9th CN

Glossopharyngeal nerve
9th cranial- mixed Supplies tongue and pharynx

9th CN

SVE stylopharyngeal GVE - Secretomotor-parotid GVA - Sensory to pharynx, tonsil and post 1/3 of tongue

Functional components :

9th CN

Nuclei
Nucleus Ambiguus Inferior Salivatory Nucleus Tractus Solitarius

9th CN

Course and relation 9th cn

Intracranial:
At the base of brain, nerve attached by 3-4 filaments to the upper part of medulla Filaments unite to form a single trunk , passes laterally towards jugular foramen

9th CN

Extra cranial course

Descends b/w IJV & internal carotid artery Pass toward the lateral aspect stylopharyngeous Pass b/w ext & int carotid arteries Reaches side of pharynx

9th CN

IX

Branches and distribution

Otic Ganglion

Pharyngeal branches

Nerve supply of tongue

Posterior 1/3 including vallate pappilla General sensationsV3 Taste-VII General sensations

and taste-IX

9th CN

Applied anatomy 9th CN

Transient or sustained hypertension may follow surgical section of nerve, reflecting involvement of carotid branch.

Isolated lesions of the nerve: loss of sensation over soft palate,pharynx & post. 1/3rd of tongue, Taste sensation lost over postsulcal portion & gag reflexes absent. Gag reflux: Stimulation of posterior pharyngeal wall excites glossopharyngeal sensory fibers & initiates gag reflex

9th CN

Applied anatomy 9th CN

Glossopharyngeal neuralgia: rare condn paroxysmal pain i.e similar to trigeminal neuralgia- behind the angle of jaw and with in the ear

Cause: vascular tumors

Trigger zones: pharynx, post. 1/3rd of tongue, ear & infraauricular areas. Treatment: similar to Trigeminal neuralgia

9th CN

Testing glossopharyngeal nerve

Sensation of pharynx & post. 1/3rd of tongue- tested by touching these areas with wooden spatula.

- On tickling, there is reflex contraction throat muscles. No contraction if nerve paralyzed.

Taste sensation on post 1/3rd of tongue is tested. Its lost in 9th nerve lesion Cause: brainstem lesion penetrating neck injury

Vagus N

Vagus nerve
Extensive course through head, neck, thorax & abdomen Bears 2 ganglia Superior ganglia : In Jugular foramen Inferior ganglion : Near base of the skull

Vagus N

Functional components
GVE fibers: originate from dorsal nucleus of vagus nerve short postganglionic fibers innervate cardiac muscles, smooth muscles and glands of viscera SVE fibers: originate from ambiguus, to muscles of pharynx and larynx GVA fibers: carry impulse from viscera in neck, thoracic and abdominal cavity to nucleus of solitary tract GSA fiber: sensation from auricle, external acoustic meatus and cerebral dura mater

Vagus N

Origin: Intracranially 10 rootlets unite to form large

trunk Leaves cranial cavity through jugular foramen

Vagus N

Course & relations in head & neck

Descends within carotid sheath b/w IJV & common carotid arteries. At the root of neck, enters thorax

Vagus N

Branches in the head and neck

In jugular foramen Meningeal branches
Dura of posterior cranial fossa

Auricular branches
Crosses facial canal 4mm above the stylomastoid foramen Emerges thru tympanomastoid fissure ends by supplying

Concha and root of auricle Posterior half of external auditory meatus Outer surface of tympanic membrane

Vagus N

Branches in the head and neck

Branches in neck: Pharyngeal br Musscles of pharynx and palate (tensorpalati) Carotid Carotid body

Vagus N

Branches in the head and neck

Superior laryngeal External Cricothyroid muscle Inferior constrictor Pharyngeal plexus Internal Thryohyoid memberane larynx (vocal cords) Right Recurrent laryngeal Cardiac

Vagus N

Applied anatomy/ 10th nerve

Paralysis of vagus nerve produces - Nasal regurgitation of swallowed liquids -Nasal twang in voice - Hoarseness of voice -Flattening of the palatal arch -Cadaveric positioning of vocal cord -Dysphagia Irritation of rt. recurrent laryngeal nerve by enlarged lymphnodes in children may produce a persistent cough

Vagus N

Applied anatomy/ 10th nerve

Irritation of auricular branch in ext. ear (by ear waxing, syringing. Etc) : reflexly produce persistent cough vomiting/ even death due to sudden cardiac inhibition

Clinical testing Compare the palatal arches on 2 sides when pt. say ah -On paralysed side, no elevate & uvula pulled to normal side

11th C N

Accessory nerve
2 roots, cranial and spinal Cranial root -accessory to vagus Spinal root --more independent course

Both roots have SVE

11th C N

Accessory Cranial nerve

CRANIAL XI

Spinal XI } Pharyngeal To Trapezius & Sternomastoid External Laryngeal

Spinal XI Recurrent Laryngeal

11th C N

Spinal root II nerve

XI

11th C N

Applied anatomy/11th nerve

Torticollis: wry neck Causes: congenital fibrosis within one SCM local disease/ trauma Treatment: surgical division of spinal accessory nerve

11th C N

Clinical Testing:
Ask the patient to shrug his shoulders against
resistance and comparing the power of 2 sides

Ask the patient to turn face to opposite side

against resistance. Compare the power on 2 sides. (SCM)

12th C N

Hypoglossal nerve
12th cranial nerve - supplies the extrinsic & intrinsic
muscles of tongue Functional components:
GSA: Carries proprioceptive impulses from muscles of tongue to
brain GSE: Fibres arise from the hypoglossal nucleus which lies in

medulla, in the fourth ventricle deep to hypoglossal triangle

12th C N

origin
Origin: fibers arise from hypoglossal nucleus Exit from skull; hypoglossal canal

12th C N

Course and relation

Arises by several rootlets at base of brain.

Rootlets merge into a trunk,passes out from brain via hypoglossal canal. At level of mn foramen turns antly deep to angle of mandible
Deep to post. Belly of digastric & stylohyoid-- ramifies to supply muscles of tongue

12th C N

Branches of distribution/12th nerve

Branches arising from Hypoglossal nerve proper: Supply all muscles of tongue except palatoglossus

12th C N

Branches of distribution/12th nerve

B) Branches of Hypoglossal nerve containing fibers of C1:
i. ii. Meningeal branch- hypoglossal canal Descendens hypoglossi Branches -Thyrohyoid -Genio hyoid.

12th C N

Applied anatomy/ 12th nerve

Injury to hypoglossal nerve: produce paralysis of muscles of tongue on side of lesion. produce difficulty with speech, mastication & swallowing. If lesion infranuclear: - hemiatrophy of affected half of tongue -muscular twitchings

If lesion supranuclear: -spastic paralysis without wasting to contralateral side of tongue

12th C N

Clinical testing/ 12th nerve

Ask patient to protrude tongue if nerve paralyzed, deviates to paralyzed side

Power of tongue musculature tested by asking to push each cheek out with tongue against resistance & comparing power on both sides

Cervical plexus
Formed by ventral rami of upper 4 cervical nerves. Supplies some neck muscles, diaphragm & areas of skin on head, neck & chest Situation: opp. a line drawn down the side of neck from root of auricle to level of upper border of thyroid cartilage.

Position and relation

Posteriorly: levator scapulae and the scalenous medius Anteriorly: prevertebral fascia, IJV and Sternocleidomastoid

Branches
Deep

Superficial

Ascending Descending

Medial Lateral

Branches Ascending Superficial

Greater Auricular (C2,3) Lesser Occipital (C2)

Transverse Cutaneous (C2,3)

Branches Descending Superficial

Supraclavicular (C3,4) -Medial -Intermediate -Lateral (Posterior)

Deep Branches Medial Series

Communicating Branches With: Hypoglossal C1 Vagus C1,2 Symapathetic C1-4 Muscular Branches to: Rectus Capitis Lateralis C1 Rectus Capitis Anterior C1,2 Longus Capitis C1-3 Longus Colli C2-4 Inferior Root of Ansa Cervicalis C2,3 Phrenic Nerve C3-5

Deep Branches Lateral Series

Communicating: Accessory C2,3,4 Muscular Branches: Sternocleidomastoid C2,3,4 Trapezius C2,(3) Levator Scapulae C3,4 Scalenus Medius C3,4 Scalenus Anterior C4-C6 Scalenus Posterior C6-8

references
Grays anatomy The anatomical basis of clinical practice, 39th edition, Susan Standring B.D.Chaurasias human anatomy, Vol 3: 4th edition New atlas of human anatomy : Thomas Mc cracken

Cunninghams Manual Of Practical Anatomy. Vol 3:

Head & Neck & Brain. 15th ed. Text book of oral surgery : Neelima malik