NEUROLOGY | OTRP 2022

CRANIAL NERVES
GOLD RANK REVIEW CENTER

NAMES LOCATION
(O O O To Touch And Feel Virgin Girl’s Vagina AH) • All CN are located in the brainstem except: CN1 and CN2
CN1 Olfactory Smell (Anosmia) o CN1 – telencephalon
CN2 Optical Vision (Anopsia) o CN2 – diencephalon (“di” = 2)
CN3 Oculomotor PERRLA • 3 Components of the Brainstem:
Superior Oblique (down & in— o Midbrain – CN3 and CN4 (midbrain = 2 syllables)
CN4 Trochlear
intorsion) o Pons – CN 5, 6, 7, 8 (pons = 4 letters)
V1: Ophthalmic division o Medulla Oblongata – CN 7, 8, 9, 10, 11, 12
CN5 Trigeminal V2: Maxillary division • used for neurologic examination—manifestations of CN
V3: Mandibular division
affected relate to part of brainstem involved
Lateral Rectus (eye abduction)
CN6 Abducens o if diplopia = pons (CN6)
(Diplopia)
o if dysphagia = MO (CN9, 10)
CN7 Facial (Bell’s Palsy)
Vestibulocochl Balance and Hearing (Meniere’s Brainstem Stroke Syndrome
CN8
ear Disease) Weber medial basal 3
Glossopharyng Syndrome midbrain
CN9 MIDBRAIN
eal Gag reflex (Dysphagia) Benedikt tegmentum of 3
CN10 Vagus Syndrome the midbrain
Spinal SCM and Trapezius Locked-In bilateral basal all in the pons
CN11
Accessory pons (5, 6, 7, 8)
PONS
CN12 Hypoglossal Tongue movements Millard- lateral pons 6, 7
Gubler
• Optic n. – MC is homonymous hemianopsia MEDULLA Wallenburg lateral medulla 5
• Trochlear n. – Superior Oblique [look at tip of the nose]
• largest cranial nerve: Trigeminal n. • Wallenburg Syndrome – aka “Pica Syndrome”
o Posterior Inferior Cerebellar Artery is affected in
• longest cranial nerve: Vagus n.
• Trigeminal n. = triCHEWminal Wallenburg

o Tic Douloureux – trigeminal neuralgia o only syndrome with (+) Dysphagia

▪ bc it’s the only one in the medulla (CN9, 10)
▪ painful tic near the eye
o only syndrome with (+) Horner’s Syndrome
▪ Q1: ax that might aggravate tic douloureux pain:
o (+) Cross Hemianesthesia
• listening to music
▪ loss of pain and temp in ipsilateral face and
• crying
contralateral body
• walking in the mall
o most affected is CN5 (that’s why ipsilateral face is
• eating lunch (bc tri CHEWminal)
affected)
• Abducens n. = abduSIX (CN6)
▪ CN5 is the largest cranial nerve thus it has sensory
o Abducens n. – diplopia d/t absence of eye abduction
nuclei in all 3 parts of the brainstem
• Facial n. – Bell’s Palsy (aka “Prosopoplegia” / “Refrigeration
▪ 3 Sensory Nuclei of CN5:
Palsy”)
SENSORY NUCLEI FUNCTION
• Vestibulocochlear n. – Meniere’s Disease (vertigo, tinnitus,
Midbrain Mesencephalic Nucleus Proprioception
sense of fullness) Pons Main Sensory Nucleus Light touch
• Hypoglossal n. – tongue deviations MO Spinal Nucleus Pain and temp
o R CVA = tongue deviates to the L; L CVA = tongue
deviates to the R
NEUROLOGY | OTRP 2022
CRANIAL NERVES
GOLD RANK REVIEW CENTER

• Q1: Thrombosis of R PICA: loss of pain & temp on R face and GENERAL FUNCTIONS
L body Se Se Mo Mo Mi Mo Mi Se Mi Mi Mo Mo:
• Q2: If basal midbrain is affected, what is the stroke • Pure Sensory – 1, 2, 8
syndrome? Weber • Pure Motor – 10, 9, 7, 5
• Q3: CN5 Nucleus affected in Wallenburg: Spinal Nucleus • Mixed – 3, 4, 6, 11, 12
o Wallenburg is an MO affectation. Spinal Nucleus is in the MO. That’s • Codes:
why Wallenburg has loss of pain and temperature
o 1975: Mixed cranial nerves (CN 10, 9, 7, 5)
o Wallenburg will have (+) light touch and proprioception
o 1973: Parasympathetic (CN 10, 9, 7, 3)
o 1971: Vagal System (CN 10, 9, 7, 11 [cranial part])
EXIT POINTS
• Vagal System
• Cristy Often Stays FResh FOr Ina, Jake, Holly
o 2 nuclei of Vagal System:
Cribriform Plate of CN1
▪ Nucleus Ambiguus – motor nucleus (CN 9, 10, 11)—
Ethmoid
supplies muscles of the pharynx
Optic Canal CN2
▪ Nucleus Solitarius – sensory nucleus (CN 7, 9, 10)
Superior Orbital Fissure CN3, 4, 5 (v1), 6
o Reflexes of the Vagal System:
Foramen Rotundum CN5 (v2—maxillary)
▪ Gag Reflex
Foramen Ovale CN5 (v3—
▪ Cough Reflex
mandibular)
▪ Vomiting Reflex
Internal Acoustic Meatus CN7, 8 ▪ Salivary-Taste Reflex – when you taste smth, you salivate
Jugular Foramen CN9, 10, 11 ▪ Carotid Sinus Reflex –  pressure =  HR
Hypoglossal Canal CN12 • done for tachycardic patients

• Magtinda ng Maxx sa Rotunda

• Si Mandi nagjogging sa Oval TRIVIAS
• Clinical Correlation: Jugular Foramen Syndrome • largest cranial nerve: Trigeminal n. (CN5)
o may impinge the 3 cranial nerves that exit in the jugular • longest cranial nerve:
foramen o extracranial: Vagus n. (CN10)
• Q1: True about Jugular Foramen Syndrome (CN 9,10,11), o intracranial: Trochlear n. (CN4)
except: • Trochlear n. (CN4)
o dysphagia (CN 9, 10) o thinnest cranial n.
o absent gag reflex (CN 9, 10) o only crossed (“Stupid” cranial n.)
o weak SCM (CN11) o only cranial nerve arising from the dorsum of the
o loss of taste in ant. 2/3 of tongue (CN7)—posterior 1/3 of brainstem
tongue (CN9) • thickest myelin sheath: Optic n. (CN2)
o NOTA o MC affected in Multiple Sclerosis (Optic neuritis)
• Cranial nerves that exit the Cavernous Sinus: CN 3, 4, 5 o MC affected in increased ICP (Papilloedema)
(v1,v2), 6 o Marcus-Gunn Pupil (Swinging Light Test—dilation of
• Q2: Cranial nerves that exit the cavernous sinus, except: pupil)
Mandibular division of CN5 • Conditions affecting Oculomotor n. (CN3):
o Weber
o Benedikt
o Syphilis → complication: Argyll Robertson Pupil
(“Prostitute Pupil”)
NEUROLOGY | OTRP 2022
CRANIAL NERVES
GOLD RANK REVIEW CENTER

▪ light reflex, pupils don’t react; accommodation; pupils react o often seen in CVA (Anterior Circulation Stroke) [Amaurosis
o Diabetes Mellitus (CN 3, 6) = Anterior]
o Myasthenia Gravis (CN 3, 4, 6)—(+) ptosis, diplopia o d/t occlusion of ICA (first branch of ICA is Ophthalmic a.)
o TBI (CN 3, 7, 1)—(+) anosmia • tests used:
o Parkinson’s Disease (CN 3, 7, 9) o Snellen’s Chart – for central visual acuity
• Conditions affecting Facial n. (CN7): o Confrontation Test – for peripheral visual acuity
o Bell’s Palsy • other tests used:
o Mobius Syndrome o Ishihara Chart – color vision test
▪ congenital absence of both CN7 (bilateral facial o Tonometry – for IOP measurement (intraocular
weakness) pressure)
o Ramsay-Hunt – Bell’s Palsy + Herpes Zoster (shingles) ▪ Glaucoma – increased IOP
o Leprosy – aka “Hansen’s Disease” (CN 7, 5) o Retinoscopy – tests refraction errors
o Lyme Disease – tick-borne (L = 7)
o Millard-Gubler (CN 6, 7) Visual Pathway
o Sjogren’s Syndrome – dry eyes, dry mouth, RA (CN 7, 9)
Pituitary tumors are
▪ CN7 supplies the lacrimal gland → dry eyes found in the optic
▪ CN7 and 9 supplies the salivary gland → dry mouth chiasm resulting in
Bitemporal hemianopsia

CN1: OLFACTORY NERVE

• for the sense of smell
• affectation results in anosmia
• MC contused d/t its location
o CN1 is in the undersurface of the brain, on the irregular surface of
bones below, so during contusion, there is shearing underneath
• CSF Rhinorrhea secondary to basilar skull fracture
o basilar fracture = fracture in the base of the skull
o results in CSF leaking out of the skull and through the
nose
o otorrhea – CSF out of the ear; sialorrhea – CSF out of the mouth • images are inverted so temporal and nasal fibers cross each
other
CN2: OPTIC NERVE • temporal fibers cross, nasal fibers remain on same side
• for the sense vision • Lateral Geniculate Body – located in the thalamus to relay
• from the diencephalon visual information
• affectation results in anopsia • Occipital Cortex (area 17) – from optic radiation
o Myopia – near-sighted (impaired far vision)
• Quadrantanopsia
o Hyperopia – far-sighted (impaired near vision)
o Upper fibers see lower visual field; Lower fibers see upper
o Presbyopia – old-sighted (comes with age)
visual field
▪ Presbycusis – old-age decrease in hearing
o Left sees right; Right sees left
o Nyctalopia – night-blinded (vitamin A [Retinol] deficiency)
▪ retinol is needed for rhodopsin production (receptor for rods—
for night vision)
• Amaurosis Fugax
o aka “Monocular Blindness”
NEUROLOGY | OTRP 2022
CRANIAL NERVES
GOLD RANK REVIEW CENTER

LESION MANIFESTATION o CN2 and CN3 affectation bc both are involved in pupillary
Ipsilateral monocular light reflex
Optic Nerve
blindness Pupillary Light Reflex
Bitemporal hemianopsia (loss • Afferent: CN2
Optic Chiasm (2o to pituitary
of peripheral vision)—tunnel • Efferent: CN3
tumor)
vision • Normal Response:
Optic Tract o (+) Direct Light Reflex: ipsilateral
Contralateral homonymous
Optic Radiation pupil constriction
hemianopsia
Occipital Cortex o (+) Consensual Light Reflex:
Optic Radiation: Upper fibers Contralateral inferior contralateral pupil constriction
(parietal lobe) quadrantanopsia (CN2)
Optic Radiation: Lower fibers Contralateral superior • Q1: Light was shown to the R eye. (–) Direct
but (+) Consensual. What CN is affected?
(temporal lobe) quadrantanopsia
o R CN2
• Q1: R homonymous hemianopsia. Where is the lesion? o L CN2
o R optic n. o R CN3
o occipital cortex o L CN3
o R optic tract • Q2: Light was shown to the R eye. (–) Direct and (–) Consensual. Light
o L optic radiation was shown to the L eye. (+) Direct and (+) Consensual. What CN is
• Q2: Lesion to the R optic tract. What are the manifestations? affected?
o R nasal + R temporal visual field loss o R CN2
o L nasal + L temporal visual field loss o L CN2
o R nasal + L temporal visual field loss o R CN3
o L nasal + R temporal visual field loss o L CN3
• Q3: R CVA patient č homonymous hemianopsia. Initially, where should
things be put? CN3, 4, 6: OCULOMOTOR, TROCHLEAR, ABDUCENS N.
o R side of bed (R CVA = L homonymous hemianopsia; put things in
• Code: EM3LR6SO4
intact visual field)
o L side of bed Superior Rectus
• Q4: R superior quadrantanopsia: L optic radiation (lower fibers) Inferior Rectus
CN3 (Oculomotor n.)
• Q5: Lesion to upper fibers of L optic radiation: R inferior Inferior Oblique
quadrantanopsia
Medial Rectus
• Q6: Lesion to the temporal fibers of R optic radiation: L superior
quadrantanopsia
Superior Oblique CN4 (Trochlear n.)
Lateral Rectus CN6 (Abducens n.)

CN3: OCULOMOTOR NERVE • Only extraocular muscles inserted at the back of the sclera:
• Ɛdinger-Westphal nucleus superior and inferior oblique
• PERRLA (Pupils Equally Round, Reactive to Light and
Accommodation)
• Ptosis – weakness of levator palpebrae superioris
o may happen in: Myasthenia Gravis, CN3 Palsy, Horner’s
Syndrome, Edema d/t Infection
• damage causes mydriasis (pupil dilation) • Cardinal Gaze: (IO MR SO – medial)
• Anisocoria – unequal size of pupils o Look to the RIGHT: R lateral rectus + L medial rectus
o Look to the LEFT: L lateral rectus + R medial rectus
NEUROLOGY | OTRP 2022
CRANIAL NERVES
GOLD RANK REVIEW CENTER

o Loop UP and to the RIGHT: R superior rectus + L inferior CN5: TRIGEMINAL N.

oblique • largest cranial nerve
o Look UP and to the LEFT: L superior rectus + R inferior o d/t presence of Gasserian Ganglion
oblique • Tic Douloureux (“Trigeminal Neuralgia”)
o Look DOWN and to the RIGHT: R inferior rectus + L • Motor: muscles of mastication
superior oblique o Masseter
o Look DOWN and to the LEFT: L inferior rectus + R o Internal Pterygoid Closes jaw
superior oblique o Temporalis
• Clinical Correlation
o External Pterygoid Opens jaw
o Diplopia (4/6)
o only muscle of mastication with 2 heads: Pterygoids
▪ Vertical – CN4
o Additional muscles innervated by Trigeminal n. (CN5):
▪ Horizontal – CN6
▪ Digastric (anterior belly) – posterior belly is CN7 bc 5 is first before 7
o Strabismus (3/6)
▪ Mylohyoid
▪ Internal (esotropia) – CN6 (six = internal) ▪ Tensor Tympani – tenses the tympanic membrane to dampen sound
• strong pull of medial rectus (CN3) and weak lateral rectus ▪ Tensor Veli Palatini – tenses the palette
(CN6)
• Sensory: facial sensation
▪ External (exotropia) – CN3 (three = external)
o larger root of CN5
• strong pull of lateral rectus (CN6) and weak medial rectus
• V1: Ophthalmic Division – sensation to eyes and nasal
(CN3)
mucosa (sensory)
• V2: Maxillary Division – supplies gums and teeth (sensory)

• Q1: Patient complains of diplopia when looking RIGHT. (just horizontal) • V3: Mandibular Division (mixed—motor and sensory)
o R CN4
o L CN4 Code: IPSIX Corneal Reflex – aka Blink Reflex
o R CN6 • afferent: CN5 v.1
o L CN6
• efferent: CN7 (innervates orbicularis oculi to close eyelid)
• Q1: Patient complains of diplopia when looking RIGHT and DOWN.
(vertical)
o R CN4 Sneeze Reflex
o L CN4 • afferent: CN5 v.1
o R CN6 • efferent: CN9, 10 (innervates pharynx to expel the irritant)
o L CN6
• when you look at a bright light, cornea sends signal to the
• CN4 is contralateral because the superior oblique works
ophthalmic division which informs that there is an irritant →
opposite
sneeze reflex
Compensations to Correct Diplopia (just count letters)
• Tilt – CN4 (tilt contralaterally)
3 Sensory Nuclei of Trigeminal n.:
o Tilt to the left = R CN4
• Midbrain = Mesencephalic Nucleus (proprioception)
• Rotate – CN6 (IPSIX, rotate ipsilaterally)
• Pons = Main Sensory Nucleus (light touch)
o Rotate to the left = L CN6
• MO = Spinal Nucleus (pain and temperature)—affected in
Wallenburg
NEUROLOGY | OTRP 2022
CRANIAL NERVES
GOLD RANK REVIEW CENTER

CN7: FACIAL NERVE

• Motor: muscles of facial expression ▪ MC site of Bell’s Palsy: Stylomastoid foramen
o Corrugator supercilii – frowning ▪ 5 Branches of the Facial n.: The Zebra Bumped My Car

o Occipitofrontalis – surprise • Temporal

o Zygomaticus major – smile • Zygomatic

o Risorius – grimace • Buccal

o Mentalis – doubt • Mandibular

o Procerus – distaste • Cervical

• Q1: Lesion of CN7 at the stylomastoid foramen will result in:
o Orbicularis oris – kissing
o loss of taste at the ant. 2/3 of tongue
o Orbicularis oculi – winking
o hyperacusis
o Buccinator – suck and blow / Trumpeters muscle o facial palsy
o Levator anguli oris – sneering o AOTA
o Platysma – egad • Q2: Lesion of CN7 at the brainstem level will result in:
o loss of taste at the ant. 2/3 of tongue
o hyperacusis
• Additional muscles innervated by Facial n. (CN7):
o facial palsy
o Digastric (posterior belly) o AOTA
o Stylohyoid • Stroke vs Bell’s Palsy
o Stapedius – smallest muscle in the body o Bell’s Palsy: ipsilateral facial palsy (peripheral CN7 lesion)
▪ hyperacusis – increased sensitivity to sound d/t o Stroke: contralateral lower quadrant facial palsy (central
paralysis of stapedius CN7 lesion)
• Sensory: taste (ant. 2/3 of tongue) ▪ d/t involvement of corticobulbar tract
o via chorda tympani – fiber of CN7 responsible of taste in
tongue
CN8: VESTIBULOCOCHLEAR NERVE
o loss of taste: Ageusia
• Meniere’s Disease
o post. 1/3 of tongue is by CN9 (7 is first before 9)
• Vestibular Component
o general sensation of ant. 2/3 of tongue: CN5 (pain and
o for balance
temp)
o vestibular apparatus – organ for balance
o general sensation of post. 1/3 of tongue: CN9
o CN8 Dysfunctions:
• Autonomic: Salivary (sublingual and submandibular) and
▪ Disequilibrium
Lacrimal glands
▪ Vertigo – MC: Benign Paroxymal Positional Vertigo
o Great petrosal branch of facial n.: lacrimal gland
▪ Nystagmus
• Anatomic Route of Facial n. (CN7):
• Cochlear Component
o Sensory branch of CN7: MO (nervus intermedius)
o for hearing
o Motor branch of CN7: Pons → Internal Acoustic Meatus
o Organ of Corti – organ for hearing
→ Facial Canal → Stylomastoid Foramen → splits into 5
o CN8 Dysfunctions:
branches
▪ Deafness
Nerve to stapedius • Conduction Deafness – outer (e.g., impacted
cerumen) and middle ear damage
Pons IAM Facial Stylomastoid • Sensorineural Deafness – inner ear damage
Canal Foramen

Chorda tympani
NEUROLOGY | OTRP 2022
CRANIAL NERVES
GOLD RANK REVIEW CENTER

• Cortical Deafness – Brodmann’s Area 41 o Q4: Dysphagia and Dysphonia: CN 10

(Heschl’s gyrus) damage; aka “Pure Word
• to determine lateralization, check uvula deviation (“AHH!”)
Deafness”
o uvular deviation goes towards the strong side
• Tuning Fork Tests (both for auditory acuity) o tongue deviation goes towards the weak side
o Weber Test – for lateralization of hearing loss • Q5: When patient said “ahh!,” uvula deviated to the R side. Lesion is in:
o Rinne Test – compares air conduction with bone left CN10

conduction
CN11: SPINAL ACCESSORY NERVE
CN9: GLOSSOPHARYNGEAL NERVE • only cranial nerve passing through the foramen magnum
• Motor: innervates the stylopharyngeus muscle • Lateral Winging of the Scapula (“Sliding Door Paralysis”)
• Sensory: taste and general sensation of posterior 1/3 of • Radical Neck Dissection
tongue • 2 Parts of Accessory Nerve:
• Autonomic: innervates the parotid gland; monitors carotid o Cranial Part

body and sinus ▪ involved in the vagal system

▪ innervates the pharynx
o Carotid Reflex: CN9 (afferent) and CN10 (efferent)
o Spinal Part
▪ innervates the SCM (C2, C3) and trapezius (C3, C4)
CN10: VAGUS NERVE
• SCM: ipsilateral side flexion; contralateral rotation
• longest cranial nerve ▪ Q1: Touching L ear with L shoulder tests which cranial nerve? L CN 11
• Motor: innervates muscles of pharynx and larynx
o larynx – “Voice Box”; for phonation CN12: HYPOGLOSSAL NERVE
o Dysphonia – difficulty in sound production • innervates the tongue muscles
o Aphonia – absence of sound production • Dysarthria
o Hoarse Voice o primarily affects CN12 but also affects CN5 (cheeks), CN7
• Sensory: (lips), CN 10 (palette)
o skin of pinna of external ear (massage results in vagal o dysarthria: speech problem (articulation)
stimulation) o aphasia: language problem
o sensation to larynx, pharynx, and epiglottis • Tongue Muscles:
• Autonomic: innervates thorax and abdomen o Palatoglossus – tongue elevation (supplied by the
o thorax: heart (bradycardia), lungs (brochoconstriction) pharyngeal plexus—CN9, 10)
o abdomen/GIT: stomach (increased motility), liver, o Genioglossus – tongue protrusion
pancreas, intestines o Hyoglossus – tongue depression
o CN 10 consists of 75% of parasympathetic nervous o Styloglossus – tongue curling upward and backward
system • to determine lateralization, check tongue deviation
• Q1: Innervates the muscles of the pharynx: CN 9, CN 10
o LMN: ipsilateral deviation
• Q2: Innervates the muscles of the larynx: CN 10
o UMN: contralateral deviation
Gag Reflex o deviates toward the weak side bc the side isn’t pushing tongue
• aka “Swallowing Reflex” outward
• afferent: CN 9 o Q1: R hemiplegia: Tongue deviates: to the right
• efferent: CN10 o Q2: Lesion on L CN12. Tongue deviates: to the left
• Dysphagia – CN9 and 10 damage
o Q3: Dysphagia: CN 9 and 10