Farjana Sharmin

Junior Consultant & Outpatient Incharge

Lecture of BHPI
Cranial Nerve Disorder
Contents
• Introduction
• Disorders of cranial nerve
• Overview of cranial nerve
• Function of cranial nerves
• Bells palsy
• Trigeminal neuralgia
• Acoustic neuroma
• Accessory nerve palsy
• Glossopharyngeal neuralgia
• References
Introduction

• Cranial nerve disorder is impaired functioning of one of the twelve cranial

nerves.
• It is possible to have a disorder affect more than one cranial nerve at a
time. Conditions and symptoms vary depending on which nerve is affected.
 Cranial nerve
• Cranial nerves are the nerves that originate directly from the brain
(including the brainstem).

• They relay information between the brain and parts of the body,
primarily to and from regions of the head and neck.

• They are bundles of sensory or motor fibers that innervate muscles or

glands, carry impulses from sensory receptors, or have a combination
of motor and sensory fibers.
Number of Cranial nerves
There are 12 pairs of cranial nerves on both sides,
which are numbered I–XII as follows:
I. Olfactory (CN I)
II. Optic (CN II)
III. Oculomotor (CN III)
IV. Trochlear (CN IV)
V. Trigeminal (CN V)
VI. Abducens (CN VI)
VII. Facial (CN VII)
VIII. Vestibulocochlear (CN VIII)
IX. Glossopharyngeal (CN IX)
X. Vagus (CN X)
XI. Accessory (CN XI)
XII.Hypoglossal (CN XII)
Figure: Cranial nerves (inferior surface of brain)
Function of cranial nerves
Cranial nerve Region of brain Sensory and/ or motor Function

I. Olfactory Cerebrum Sensory Olfaction or sense of smell

II. Optic Cerebrum Sensory Vision
III. Oculomotor Midbrain Motor Eye movement, eyelid elevation, pupillary
constriction, lens accommodation
IV. Trochlear Midbrain Motor Eye movement
V. Trigeminal Pons Mixed Sensory: Sensation of face, sense of taste

Motor: Mastication (biting and chewing)

VI. Abducens Ponto medullary Motor Eye movement (lateral)
region
VII. Facial Ponto medullary Mixed Sensory: Sense of taste (ant 2/3 of tongue)
region Motor: Facial expressions, eye closing,
salvation, lacrimation
Cont…
Cranial nerve Region of brain Sensory and/ Function
or motor
VIII. Vestibulocochlear Ponto medullary Sensory Balance and hearing
region
IX. Glossopharyngeal Medulla oblongata Mixed Sensory: Taste and sensation of post 1/3 of
tongue, pharynx sensation, chemo/baro receptor

Motor: Swallowing, salvation

X. Vagus Medulla oblongata Mixed Sensory: Sensation of ear skin, pharynx, larynx,
thorax, abdomen, taste/ sensation of epiglottis
Motor: Swallowing, speech, cough, autonomic
(parasympathic)

XI. Accessory Medulla oblongata Motor Shoulder shrug, head turning

and cervical spine
XII. Hypoglossal Medulla oblongata Motor Movement of tongue
Cont…

Figure: Supply of cranial nerve

 Disorders of cranial nerve damage
I. Olfactory nerve - Anosmia, hyposmia, dysosmia
II. Optic nerve - Glaucoma, optic neuritis
III.Oculomotor nerve - Third nerve palsy
IV. Trochlear nerve - Fourth nerve palsy or trochlear nerve or superior
oblique palsy
V. Trigeminal nerve -Trigeminal neuralgia
VI. Abducens nerve - Sixth nerve palsy or abducens nerve palsy
VII.Facial nerve - Bell’s palsy, Facial palsy, Ramsay Hunt syndrome
Cont…
VIII. Vestibulocochlear nerve - Acoustic neuroma and Ménière’s
Disease
IX. Glossopharyngeal nerve - Glossopharyngeal neuralgia
X. Vagus nerve - difficulty speaking or loss of voice or hoarse or wheezy
voice, trouble drinking liquids, loss of the gag reflex, pain in the ear,
unusual heart rate, abnormal blood pressure, decreased production of
stomach acid, nausea or vomiting, abdominal bloating or pain
XI. Accessory nerve - Accessory nerve palsy
XII.Hypoglossal nerve - Hypoglossal nerve palsy
• Glaucoma is a group of eye conditions that damage the optic nerve, the
health of which is vital for good vision. This damage is often caused by
an abnormally high pressure in your eye. Glaucoma is one of the
leading causes of blindness for people over the age of 60.
• Optic neuritis (ON) is when your optic nerve becomes inflamed. ON
can flare up suddenly from an infection or nerve disease. The
inflammation usually causes temporary vision loss that typically
happens in only one eye. Those with ON sometimes experience pain.
• Anosmia is the partial or complete loss of the sense of smell. This loss
may be temporary or permanent. Common conditions that irritate the
nose’s lining, such as allergies or a cold, can lead to temporary anosmia.
• Hyposmia, or microsmia, is a reduced ability to smell and to detect odors. A
related condition is anosmia, in which no odors can be detected. Some of the
causes of olfaction problems are allergies, nasal polyps, viral infections and head
trauma.
• Dysosmia is a disorder described as any qualitative alteration or distortion of the
perception of smell.
• Ménière's disease (MD) is a disorder of the inner ear that is characterized by
episodes of feeling like the world is spinning (vertigo), ringing in the ears
(tinnitus), hearing loss, and a fullness in the ear. Typically, only one ear is
affected initially; however, over time both ears may become involved. Episodes
generally last from 20 minutes to a few hours.The time between episodes
varies. The hearing loss and ringing in the ears can become constant over time.
 Bell’s palsy

Definition:
Bell’s palsy is a condition that causes
the facial muscles to weaken or become
paralyzed.

This condition is named after the

Scottish anatomist Charles Bell, who
was the first to describe the condition.

Figure: Bell’s palsy

Causes of bell’s palsy:
• Unknown
• Virus that causes cold
sores ( Herpes simplex),
chickenpox and shingles
(Herpes zoster I)
• Injury, like getting hit
really hard in the face
• Diabetes
• Ear infections
 Clinical features
• Rapid onset of weakness to total paralysis on one side of the face causing half
of the face dropping (opposite side)
• Dryness and trouble closing effected eye
• Drooling
• Loss of taste at affected part of the tongue
• Mild pain
• Low muscle tone
• Pain behind or in front of one ear
• Increased sensitivity to sound on the affected side
• Inability to make facial expressions
Muscles effected
• Frontalis (wrinkles in forehead)
• Orbicularis oculi (gentle/strong eye
closer)
• Corrugator (draws eyebrows together)
• Orbicularis Oris (protrudes lip)
• Zygomaticus minor & major (draws
corner of mouth lat. & upward)
• Buccinator (promotes mastication)
• Platysma (depresses mandible)
Diagnosis
• Physical Presentation of the Patient:
Diagnosis of Bell’s palsy will often involve
observing facial movements such as blinking
of eyes, lifting eyebrow, smiling, and
frowning, among other movements.
• CT scan
• MRI
Difference of Bell’s palsy, Facial palsy & Ramsay Hunt syndrome

Traits Bell’s palsy Facial palsy Ramsay Hunt

syndrome
Cause Herpes zoster I Herpes zoster II Herpes zoster I
Pain Mild Moderate Severe
Muscle tone Low High Low
Face deviation Opposite Same Opposite
Eye Opening Closing Opening
Blister Absent Present Absent
Prognosis 80-85% 60-65% 55-60%
 Management
Medical management:
o Steroids to reduce the swelling around the nerve
o Acyclovir for viral infection

Physiotherapy management:
• Care of eye: In the early stages of treatment, the most important thing to do
is to check that the patient is caring for the affected eye in an appropriate way.
• Trophic stimulator: To stimulate motor or trigger point for 5minutes to
restore motor function
• Apply ice if swelling present
Cont…
• Gentle stroking massage: In distal to proximal laterally upward direction; applied
daily for 3 to 5 minutes. This helps to maintain blood flow and prevent contracture.
• Passive movement to increase PROM
• Active assisted movement to increase AAROM
• Active movement to increase AROM
• PNF techniques are used for reeducation
• Quick stretching to regain rising of eyebrow and movement of the corner of
mouth
• Stretching of muscles of unaffected side to prevent contracture
• Electrotherapy:
Ultrasound (stage I)
TENS and trophic stimulator (stage II, III)
Cont…
• Functional activity
• Advise:
Smile, grin, say ‘O’ Whistle Blowing air Chewing gum

Hold straw in mouth-

suck and blow
Whistle
Squeeze eyes closed
then open wide
Chew bubblegum Grin then frown Squeeze eyes then wide open
Trigeminal neuralgia
• Trigeminal neuralgia is sudden,
severe facial pain which is often
described as a sharp shooting pain or
like having an electric shock in the
jaw, teeth or gums.

• It is typically characterized by short

term, unilateral facial pain following
the sensory distribution of cranial
nerve V, the Trigeminal Nerve.
Branches of trigeminal nerve
It has three major branches:
• Ophthalmic nerve (V1) 1st branch
- sensory
• Maxillary nerve (V2) 2nd branch -
sensory
• Mandibular nerve (V3) 3rd branch
- sensory and motor. Controlling
the muscles of mastication:
Temporalis and Masseter.
Causes of trigeminal neuralgia
In many cases, the cause of trigeminal nerve is unknown. However,
known causes include:
• A swollen blood vessel or tumor that puts pressure on the nerve
• Multiple sclerosis, a condition that damages the myelin sheath
• Physical damage to the nerve like injury, a dental or surgical
procedure, or infection.
• Bony disorders like Paget's disease
• Osteogenesis imperfecta
Clinical features
The pain in TN is usually localized in one side of the face and is felt in
contact of a light touch or a sound. It's usually triggered by the
following activities:
• Brushing teeth,shaving, rubbing or touching the painful area of the face
• Eating or drinking
• Speaking
• Being exposed to the wind
• Pain in the cheek, jaw, teeth, gums, and lips
• Pain in one side of the face
• Tingling or numbness in the face before starting to feel pain
Diagnosis
• The diagnosis of TN is almost entirely based on the patient's history
and in most cases no specific laboratory tests are needed.
• MRI scanning is often indicated simply to exclude other causes of the
pain, such as pressure on the trigeminal nerve from Acoustic Neuroma.

Management
Medical management:
Drugs:
 Anti-epileptic drugs combined with carbamazepine
 Muscle relaxants and tricyclic antidepressants
 Glycerol injections
Cont…
Surgery:
 Microvascular decompression

Physiotherapy management:
• Cold or ice for pain relief
• Isometric neck exercises to help maintain strength
• Relaxation techniques such as deep breathing exercises
• Cardiovascular exercises to improve health and fitness levels
• Functional Activities for problems associated with ADLs
• Patient's education on diet, management of sleep, and rest
• Advice on how to avoid using cold water for drinking and washing their face
but also chewing with the non affected side.
Figure: Isometric neck exercise
Acoustic neuroma or Vestibular schwannoma
Acoustic or cochlear Schwannoma = Nerve Sheath
portion of vestibular nerve Tumor
Neuroma =Nerve Tumor
Acoustic Neuroma
• An acoustic neuroma also known as vestibular schwannoma , is a type of
benign tumor that grows in the canal connecting the brain to the inner ear.
• Acoustic neuroma usually arises from the Schwann cells covering this
nerve and grows slowly or not at all. Rarely, it may grow rapidly and
become large enough to press against the brain and interfere with vital
functions. If tumors become large enough to press on the brain stem or
cerebellum, they can be deadly.
• Acoustic neuroma tend to affect adults aged 30 to 60
 Cause
Most acoustic neuroma are random and usually have no obvious cause, although a small
number of cases (5%) are the result of a genetic condition called neurofibromatosis type
2 (NF2).Beside this, expose to high radiation is the only known environment risk factor
for it.
Type
There are 2 types of acoustic neuroma
a) Unilateral acoustic neuroma: This is the most common type which
affects only one ear. This tumor may develop at any age. It most often
happens between the ages of 30 and 60.
b) Bilateral acoustic neuromas: This type affects both ears and is
inherited. It is caused by neurofibromatosis-2 (NF2).
Clinical manifestation
Early signs
These are the most common symptoms of acoustic neuroma:
• Hearing loss on one side, can’t hear high frequency sounds
• Feeling of fullness in the ear
• A ringing in the ear (tinnitus), on the side of the tumor
• Dizziness
• Balance problems or unsteadiness
• Facial numbness and tingling with possible, though rare, paralysis of a facial nerve
• Headaches, clumsy gait, and mental confusion
• Vertigo
• Facial paresthesia
Late signs
An acoustic neuroma growing towards the skull base can interfere with
the functions of other cranial nerves and vessels.
• If the 7th cranial nerve (Facial Nerve) is impaired Facial palsy
• If the 5th cranial nerve (Trigeminal Nerve) is impaired
Trigeminal neuralgia
• It is similar with the 9th cranial nerve ( Glossopharyngeal Nerve) and
10th cranial nerve (Vagal Nerve).Impairments to these nerves lead to
problems swallowing, painful swallowing and taste disorders in the
back third of the tongue, amongst other problems.
Diagnosis
• Magnetic Resonance Imaging (MRI)
• Computer Tomography (CT)
• Audiometry

Audiometry
Management
Medical management:
There are three options for managing a vestibular schwannoma:
(1) Observation
(2) Surgical removal: Microsurgery techniques are used to remove the
tumor .
(3) Radiotherapy: Radiotherapy methods to reduce size of tumor and
prevent further growth
Physiotherapy management
Post surgery
Vestibular rehabilitation incorporating adaptation, habituation, balance and
mobility has been demonstrated to improve balance.

To improve balance:

A) Sitting:
-Reaching : Static & Dynamic
-Pelvic tilting exercise
B) Standing:
-Static
-Dynamic
Cont…
- Stepping forward
- Stepping backward
- Sit to stand
- One leg standing
- Reaching: a. Static b. Dynamic
- Squatting
- Weight shifting
- Stair practice
- Turning mat use
- Walking practice in different surface
Cont…

To improve coordination:
• Finger nose coordination
• Heel shin coordination
Accessory nerve palsy

Accessory nerve palsy is an injury

to the spinal accessory nerve which
results in diminished or absent
function of the sternocleidomastoid
muscle and upper portion of the
trapezius muscle.

Muscles innervated by the accessory nerve

Cause
Medical procedures are the most common cause of injury to the spinal accessory
nerve.
• Neck trauma
• Wrenching injury to arm or neck(A sharp twist or sudden jerk straining muscles or
ligaments)
• Surgical procedures such as lymph node biopsy, parotid surgery, carotid surgery.
• Radiation therapy to the lymph nodes in the neck
• Aneurysms of the internal carotid artery(An aneurysm is an abnormal bulge or
ballooning in the wall of a blood vessel. "A proportion of these patients will go on
to have a rupture. And the challenge with rupture is that it's unpredictable.“)
• Fracture of the atlas bone or hyoid due to direct trauma
Clinical features
• Patients with spinal accessory nerve paralysis often exhibit signs of
lower motor neuron disease such as diminished muscle mass.
• Partial paralysis of the sternocleidomastoid and trapezius muscles.
• Interruption of the nerve supply to the sternocleidomastoid muscle
results in an asymmetric neckline.
• Weakness of the trapezius muscle can produce a drooping shoulder,
winged scapula, and a weakness of forward elevation of the
shoulder.
Diagnosis
The function of accessory nerve is measured in neurological
examination.
• Inspection
• Range of motion testing
• Strength testing
Physiotherapy management
• Sling use several hours a day to help with pain management
• Hydrotherapy program
• Strengthening exercises for whole shoulder girdle with particular
focus on Trapezius and SCM
• Stretching of muscles in the shoulder and neck
• Proprioceptive training
• Home exercise program
Surgical Intervention

• Nerve surgery, nerve grafting, nerve regeneration

• Tendon of muscle transfers to stabilize scapula eg scapulothoracic
fusion
Glossopharyngeal Neuralgia
Glossopharyngeal Neuralgia

• Glossopharyngeal neuralgia (GPN) is a rare

condition that can cause sharp, stabbing, or
shooting pain in the throat area near the tonsils,
the back of the tongue or the middle ear.
• The pain occurs along the pathway of the
glossopharyngeal nerve (9th cranial nerve),
which is located deep in the neck.
• It typically occurs in individuals over 40 or 50-
years-old.
Cause
• Often there is no apparent cause for the condition.
• Compression of the glossopharyngeal nerve by a blood vessel near
the brainstem may irritate the nerve and cause pain.
• In other cases, an elongated styloid process (a bone in the neck near
the nerve) can cause pain. This condition is called Eagle syndrome.
Clinical features
A sharp, jabbing pain deep in the throat, or in the tongue, ear, and
tonsils, lasting a few seconds to a few minutes.
Some people describe the feeling of a sharp object lodged in the
throat. The pain usually has the following features:
• Affects one side of the throat
• Can last several days or weeks, followed by a remission for months
or years
• Occurs more frequently over time and may become disabling
Diagnosis
Clinical diagnosis:
The diagnosis of glossopharyngeal neuralgia is primarily clinical,
meaning that it is based on a patient’s history and symptoms.
Objective diagnosis:
There is no specific test for GPN. Sometime MRI of the brain and
brainstem is performed.
Management
Medical management:
In most situations, anticonvulsant drugs are the first line of treatment. If drug therapy is
not effective or if a patient has troublesome side effects from the medication, surgery is
considered.
Drugs:
• Anticonvulsants
• Antidepressants
• Anesthetics
SURGERY:
1. Micro vascular decompression
2. Gamma Knife Radiosurgery
Physiotherapy management
Pain management:
• Positioning
• Soft tissue mobilization Grade-I, II
• Slow stretching
• Electrotherapy
References
• Katusic SK; Beard CM; Wiederholt WC; Bergstralh EJ; Kurland LT Incidence, clinical features, and prognosis in Bell's palsy,
Rochester, Minnesota, 1968-1982. Ann Neurol. 1986; 20(5):622-7
• Peiterson,E. Bell's Palsy; the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Oto-
Laryngologica. Supplementum 2002;549:4-30
• Holland NJ, Weiner GM. Recent developments in Bell's Palsy. BMJ 2004; 329(7465):553-7
• The me anatomy. The accessory nerve. Available from: https://teachmeanatomy.info/head/cranial-nerves/accessory/ (last
accessed 22.3.2019)
• theanatomyroom. Cranial nerve 11 0f 12. Available from; https://www.youtube.com/watch?v=Ps7L7RS8VNY (last accessed
22.3.2019)
• Misty Suri. Spinal accessory nerve injury. Available from:
http://www.mistysurimd.com/patient-info/conditions-procedures/shoulder/spinal-accessory-nerve-palsy/ (last accessed
22.3.2019)
• Ahmed A. When is facial paralysis Bell palsy? Current diagnosis and treatment. Cleve Clin J Med. 2005;72(5):398-401, 405
• Zakrzewska JM, Linskey ME. Trigeminal neuralgia. Bmj. 2014 Feb 17;348:g474
• What is Trigeminal Neuralgia? Available from:https://fpa-support.org/learn/ (accessed 29 September, 2020)
• Zakrzewska JM, Linskey ME. Trigeminal neuralgia. Bmj. 2014 Feb 17;348:g474
Cont…
• Trigeminal Neuralgia. Available from: https://www.urmc.rochester.edu/neurosurgery/services/conditions/trigeminal-
neuralgia.aspx ( Accessed 2 September 2020)
• Vasappa CK, Kapur S, Krovvidi H. Trigeminal neuralgia. Bja Education. 2016 Oct 1;16(10):353-6.
• Oncol Lett. 2013 Jan;5(1):57-62. Epub 2012 Oct 31. Clinical features of intracranial vestibular schwannomas. Huang X, Xu J,
Xu M, Zhou LF, Zhang R, Lang L, Xu Q, Zhong P, Chen M, Wang Y, Zhang Z.
• Neuroradiology. 1992;34(2):144-9.fckLRMagnetic resonance imaging of acoustic neuromas: pitfalls and differential
diagnosis.fckLRLhuillier FM, Doyon DL, Halimi PM, Sigal RC, Sterkers JM.
• AJNR Am J Neuroradiol. 1986 Jul-Aug;7(4):645-50.fckLRCT in diagnosis of acoustic neuromas.fckLRWu EH, Tang YS,
Zhang YT, Bai RJ.
• J Neurosurg. 2012 Sep;117(3):514-9. doi: 10.3171/2012.5.JNS111858. Epub 2012 Jun 22. Paradoxical trends in the management
of vestibular schwannoma in the United States. Lau T, Olivera R, Miller T Jr, Downes K, Danner C, van Loveren HR, Agazzi S.
• Régis J, Roche PH, Delsanti C, Thomassin JM, Ouaknine M, Gabert K, et al. Modern management of vestibular schwannomas.
Prog Neurol Surg 2007;20:129-41.
• https://medlineplus.gov/ency/article/001636.htm
• https://www.msdmanuals.com/home/brain,-spinal-cord,-
and-nerve-disorders/cranial-nerve-disorders/glossopharyngealneuralgia