CRANIAL NERVES

Vishnu Karunakaran Neuroscience & Neurological Disorders Medical Faculty Udayana University Denpasar

Introduction Cranial nerves are nerves that emerge directly from the brain stem, in contrast to spinal nerves which emerge from segments of the spinal cord.1 There are twelve pairs of cranial nerves; they are attached to the brain and are transmitted through foramina in the base of the cranium.2-9 They are: I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal
Figure 1: Inferior view of the brain and brain stem showing cranial nerves.

The first two cranial nerves attach directly to the forebrain while the rest attach to the brain stem.3,7 Human cranial nerves are nerves evolutionarily homologous to those found in many other vertebrates. Cranial nerves XI and XII evolved in the common ancestor to amniotes (non-amphibian tetrapods) thus totaling

twelve pairs. These characters are synapomorphies (traits that are shared by two or more taxa and their last common ancestor) for their respective clades. In some primitive cartilaginous fishes, such as the spiny dogfish or mud shark (Squalus acanthias), there is a terminal nerve numbered zero (as it exits the brain before the traditionally designated first cranial nerve).1 The function of the cranial nerves is for the most part similar to the spinal nerves, the nerves that are associated with the spinal cord. The motor components of the cranial nerves are derived from cells that are located in the brain. These cells send their axons (bundles of axons outside the brain is a nerve) out of the cranium where they will ultimately control muscle (e.g., eye movements), glandular tissue (e.g., salivary glands) or specialized muscle (e.g., heart or stomach). The sensory components of cranial nerves originate from collections of cells that are located outside the brain. These collections of nerve cells bodies are called sensory ganglia. They are essentially the same functionally and anatomically as the dorsal root ganglia which are associated with the spinal cord. In general, sensory ganglia of the cranial nerves send out a branch that divides into two branches: a branch that enters the brain and one that is connected to a sensory organ. Examples of sensory organs are pressure or pain sensors in the skin and more specialized ones such as taste receptors of the tongue. Electrical impulses are transmitted from the sensory organ through the ganglia and into the brain via the sensory branch that enter the brain. There are two exceptions to this rule that should be noted when the special senses of smell and vision are discussed. In summary, the motor components of cranial nerves transmit nerve impulses from the brain to target tissue outside of the brain. components transmit nerve impulses from sensory organs to the brain.6-8 Sensory

Cranial Nerve Nuclei A cranial nerve nucleus is a collection of neurons (gray matter) in the brain stem that is associated with one or more cranial nerves. Axons carrying information to and from the cranial nerves form a synapse first at these nuclei. Lesions occurring at these nuclei can lead to effects resembling those seen by the severing of nerve(s)

they are associated with. All the nuclei excepting that of the IV nerve supply nerves of the same side of the body.1,5

Figure 2: Locations of each cranial nerve nuclei

Motor and sensory nuclei of the cranial nerves are the relay stations for impulses from higher nerve centers to effectors and from peripheral impulses to nerve centers that are higher in the central nerve system. The motor or efferent cranial nerves arise within the brain from groups of nerve cells which constitute their nuclei of origin. The sensory or afferent cranial nerves arise from groups of nerve cells outside the brain; these nerve cells may be grouped to form ganglia on the trunks of the nerves or may be situated in peripheral sensory organs such as the nose and eye. The central processes of these cells run into the brain, and there end by arborizing around nerve cells, which are grouped to form nuclei of termination. The nuclei of origin of the motor nerves and the nuclei of termination of the sensory nerves are brought into relationship with the cerebral cortex, the former through the geniculate fibers of the internal capsule, the latter through the lemniscus. The geniculate fibers arise from the cells of the motor area of the cortex, and, after crossing the middle line,

end by arborizing around the cells of the nuclei of origin of the motor cranial nerves. On the other hand, fibers arise from the cells of the nuclei of termination of the sensory nerves, and after crossing to the opposite side, join the lemniscus, and thus connect these nuclei, directly or indirectly, with the cerebral cortex.2-5

Afferent Nuclei Nerve fibers which carry general sensory information such as touch, pressure, pain and temperature from the head, enter the brain through the trigeminal nerve at the pons and terminate in the trigeminal sensory nucleus. The somatic afferent nuclei are the most laterally placed of the cranial nerve nuclei. These are the trigeminal nucleus (V), the cochlear nuclei (VIII), and the vestibular nuclei (VIII). This is a large nucleus that extends throughout the whole length of the brainstem and caudally into the cervical spinal cord. Fibers that convey the unique senses of hearing and motion/positional sense run in the vestibulocochlear nerve. The general

somatosensory nuclei are represented by the three sensory nuclei of the trigeminal nerve: nucleus mesencephalicus, nucleus pontinus (nucleus sensibilis principalis) and nucleus spinalis.1-3,7 The term special sensory has been used to describe the olfactory and optic nerves, because of their origins in the specialized sensory organs, namely the nasal epithelium and the eye, respectively, and because of their forebrain origins, as opposed to the brainstem origins of the other cranial nerve nuclei. The special somatosensory nuclei are located in the recessus lateralis ventriculi quarti region, which are the vestibular nuclei. The cochlear nuclei, which is situated more laterally, has close topographic connections with the pedunculus cerebellaris caudalis.1-3,7 Visceral afferent nuclei are the most medially placed compared to all the sensory neuron groups. Visceral afferents, which include taste fibers, terminate in the nucleus solitarius of the medulla.2,7

Efferent Nuclei The nuclei of the somatic efferent cell column lie near the midline and mediate eye movements (III, IV, and VI) and tongue movements (XII). Somatic efferent (SE) nerves innervate the skeletal muscles derived from the somites. A part of the somatomotor nuclei is located at the base of the fossa rhomboidea and another part is at the base of aquaductus mesencephali (cerebrum). The oculomotor nucleus lies in the ventral apex of the periaqueductal grey of the midbrain at the level of the superior colliculus. Its efferent fibers run in the oculomotor nerve to innervate the levator palpebrae superioris and all of the extraocular muscles, except the superior oblique and lateral rectus. The trochlear nucleus also lies in the midbrain, at the ventral border of the periaqueductal grey, but at the inferior colliculus level. Fibers leave in the trochlear nerve to innervate the superior oblique muscle of the eye. The abducens nucleus is located in the caudal pons beneath the floor of the fourth ventricle. Its efferents run in the abducens nerve and innervate the lateral rectus muscle. In the medulla, the hypoglossal nucleus innervates the intrinsic and extrinsic muscles of the tongue via the hypoglossal nerve.1-3,7 Visceral efferents (VE) are preganglionic cranioparasympathetic fibers that innervate smooth muscles of the inner eye (III), the lacrimal and salivary glands (VII, IX), and bowel, heart, and lung muscles that mediate secretions and movement (XI). The visceromotor nuclei retain their primitive position near the ventricular composition of the brain. It encompasses nucleus salivatorius cranialis and caudalis, and nucleus dorsalis nervi vagi.1-3,7 The nuclei of the branchiomotor (special somatomotor nuclei) cell column, which innervate striated muscles derived from the branchial arches, is situated on the lateral part of the somatomotor nuclei columns. Due to neurobiotaxis, these nuclei move towards the ventrolateral part of the brainstem but still retain their craniocaudally oriented cell columns. In the tegmentum of the mid-pons is located the trigeminal motor nucleus, which supplies fibers to the trigeminal nerve and innervates the muscles of mastication, tensor tympani, tensor veli palitini, mylohyoid and the anterior belly of the digastrics muscle. In the caudal pontine tegmentum lies the facial

motor nucleus. This innervates the muscles of facial expression and the stapedius muscle via the facial nerve. Within the medulla lies the nucleus ambiguus. This long nucleus sends motor fibers in the glossopharyngeal, vagus and cranial part of the accessory nerve to innervate muscles of the pharynx and larynx.1-3,7 Lateral to the branchiomotor nuclei are the parasympathetic visceral efferent nuclei. The parasympathetic cell column consists of preganglionic parasympathetic neurons that send axons into the III, VII, IX, and X cranial nerves. These are the Edinger-Westphal oculomotor nucleus (III); which lies in the midbrain periaqueductal grey matter adjacent to the oculomotor nucleus, the superior (VII) and inferior (IX) salivatory nuclei; which lie in the pontine tegmentum, and the dorsal motor nucleus of the vagus (X); which lies in the medulla. The superior salivatory nuclei supply preganglionic fibers to the facial nerve, which terminate in the pterygopalatine and submandibular ganglia. Postganglionic fibers from the pterygopalatine ganglion innervate the lacrimal gland, nasal and oral mucous membranes, while those from the submandibular ganglion innervate the submandibular and sublingual salivary glands. The inferior salivatory nucleus sends preganglionic fibers into the glossopharyngeal nerve, which terminate in the otic ganglion. This ganglion sends postganglionic axons to the parotid salivary gland. The rostral position of the dorsal motor nucleus of the vagus nerve lies immediately beneath the floor of the fourth ventricle, lateral to the hypoglossal nucleus. Fibers leave in the vagus nerve and are widely distributed to thoracic and abdominal viscera.3,7

Cranial Nerve I: Olfactory nerve

Figure 3: Olfactory nerve; chemoreceptor cells of the nose

supplies

the

The olfactory nerve, or cranial nerve I, is the first of twelve cranial nerves. It is instrumental in the sense of smell. This is a pure sensory nerve fiber. The cell bodies of the olfactory nerve are in the nasal mucosa. Their axons form the olfactory nerves which ascend through the cribriform plate to synapse in the olfactory bulb of the brain. Olfaction is less developed in humans than in other mammals such as rodents. As a chemical sensor, the olfactory system detects food and influences social and sexual behavior. The specialized olfactory epithelial cells characterize the only group of neurons capable of regeneration. Humans are able to detect many different airborne chemicals at low concentrations. Olfaction and taste work together to achieve the sensation referred to as taste; if for any reason olfaction is impaired, the patient complains that food cannot be properly tasted. In contrast to the taste system, which distinguishes relatively few modalities of sour, sweet, bitter, and salt, the olfactory system can distinguish very many different odorants, which contribute to the subtle modality of smell.1,3,10-13

Figure 4: Anatomy of the olfactory nerve

The specialized olfactory receptor neurons of the olfactory nerve are located in the olfactory mucosa of the upper parts of the nasal cavity. The olfactory nerves do not form two trunks like the remaining cranial nerves, but consist of a collection of many sensory nerve fibers that extend from the olfactory epithelium to the olfactory bulb, passing through the many openings of the Cribriform plate of the Ethmoid bone; a sieve-like structure. Olfactory receptor neurons continue to be born throughout life and extend new axons to the olfactory bulb. These olfactory receptors are actually bipolar cells, with short, tubular dendrites leading towards the surface and the tips contain smooth cilia, and axons that exit the inside of the unmyelinated cell-body. Olfactory ensheathing glias wrap bundles of these axons and are thought to facilitate their passage into the central nervous system.1,2,11,13

Olfactory bulb Olfactory tract Cribriform plate of ethmoid bone Fascicles of olfactory nerve (I) Nasal mucosa

Figure 5: Anatomy of the olfactory nerve

The olfactory system is completely neural, since the receptors are modified neurons that transduce and transmit olfactory inputs to the brain via the olfactory bulb, the lateral olfactory tract, and from there to the olfactory cortex. The sense of smell (olfaction) arises from the stimulation of olfactory (or odorant) receptors by small molecules of different spatial, chemical, and electrical properties that pass over the nasal epithelium in the nasal cavity during inhalation. These interactions are transduced into electrical activity in the olfactory bulb which then transmits the electrical activity to other parts of the olfactory system and the rest of the central nervous system via the olfactory tract. The olfactory system is unique among the senses, in that receptors project directly to cortex; the other senses relay through the thalamus. The olfactory bulb is part of the forebrain, situated on its ventral surface in the olfactory sulcus (the cranial roof of nasal cavity), and attached to it by the olfactory tract. The olfactory tract branches out into a trifurcation posteriorly: stria olfactoria lateralis (largest) which will reach and terminate in the anterior part of the uncus (primary olfactoric cortex area); stria olfactoria medialis which reaches the medial cerebral hemispherium surface and ends in the cerebral cortex right next to the anterior lamina terminalis in Brodmann 25 area; stria olfactoria intermedia which terminates at the cortex in the substantia perforate anterior region.1-3,5,7-9,11-13

The olfactory nerve is the shortest of the twelve cranial nerves and only one of two cranial nerves (the other being the optic nerve) that do not join with the brainstem. The effect of damaged olfactory nerve is impaired sense of smell. Clinical test which can diagnose the impairment is by determining whether subject can smell (not necessarily identify) aromatic substances such as coffee, vanilla, clove oil, or soap. Anosmia follows damaged olfactory nerves. There is loss not only of the sense of smell but also of the flavor, other than the basic tastes, of foods. Anosmia usually occurs due to head trauma and can happen when meningiomas invade olfactory nerves.1,4,7

Cranial Nerve II: Optic nerve

Figure 6: Optic nerve; supplies the photoreceptor cells of the retina

The optic nerve, also called cranial nerve II (nerve of sight), transmits visual information from the retina to the brain. The eye and optic nerve develop as an outgrowth of the embryonic brain and the nerve is therefore enveloped in meninges. The optic nerve is composed of axons of the ganglion cells in the eye. This is a pure sensory nerve fiber. This nerve travels posteromedially from the eye, exiting the orbit at the optic canal in the lesser wing of the sphenoid bone. The optic nerves join each

other in the middle cranial fossa to form the optic chiasm. The cell bodies are in the retina and the axons pass back in the optic nerve to the optic chiasma where the axons from the nasal halves of the retina cross over but those from the temporal side continue on the same side. They then form the optic tract on each side.1,3-5,10,12,13 The optic nerve is the second of twelve paired cranial nerves but is considered to be part of the central nervous system as it is derived from an outpouching of the diencephalon during embryonic development. All of the optic nerve fibers arise from the ganglionic cells in the retina and in between these fibers is a matrix of neuroglial network. Consequently, the fibres are covered with myelin produced by oligodendrocytes rather than the Schwann cells of the peripheral nervous system and are encased within the meninges. Therefore the distinction of nerve is technically a misnomer, as the optic system lies within the central nervous system and nerves exist, by definition, within the peripheral nervous system. The optic nerve is ensheathed in all three meningeal layers (dura, arachnoid, and pia mater) rather than the epineurium, perineurium, and endoneurium found in peripheral nerves. Fibre tracks of the mammalian central nervous system (as opposed to the peripheral nervous system) are incapable of regeneration and hence optic nerve damage produces irreversible blindness. In the posterior part where the optic nerve exits the optic bulb, the optic nerve is penetrated by the arteria centralis retinae, which is a branch of the opthalmic artery. It is followed by the vein and are directed ventrally towards the center of the optic nerve disc.1,2,5

Figure 7: Central connections of the optic nerve

The optic nerve is composed of retinal ganglion cell axons and Portort cells. It leaves the orbit (eye) via the optic canal, running posteromedially (the optic canal is located superomedially from the superior orbital fissure) towards the optic chiasm where there is a partial decussation (crossing) of fibres from the temporal visual fields of both eyes. The fibers that form the decussation are those that arise from the nasal half/medial retina, which continue to the optic tract on the contralateral side. The fibers from the temporal half/lateral retina do not form the decussation and continue to the optic tract on the ipsilateral side. Most of the axons of the optic nerve terminate in the lateral geniculate nucleus from where information is relayed to the visual cortex, while other axons terminate in the pretectal nucleus and are involved in

reflexive eye movements and other axons terminate in the suprachiasmatic nucleus and are involved in regulating the sleep-wake cycle. Most of these fibres terminate in the lateral geniculate body.1-3,5,7,8,13 From the lateral geniculate body, all the cells reach out their axons to Brodmann 17 area and fibrae geniculocalcarinae, and form the optic radiation, which terminates in the primary visual cortex of the occipital lobe. The optic radiation fibers circulate around the cornu inferius and posterius ventriculi lateralis before terminating at area striata. Fibers carrying information from the contralateral superior visual field traverse the temporal lobe (Meyer's loop) to terminate in the lingual gyrus below the calcarine fissure in the occipital lobe, and fibers carrying information from the contralateral inferior visual field terminate in the visual cortex above the calcarine fissure.1-3,5,7,13

Cranial Nerve III: Oculomotor nerve

Oculomotor nerve (III) Superior branch Inferior branch Ciliary ganglion Superior orbital fissure

Figure 8: Oculomotor nerve; supply muscles of the eyeball and eyelid

The oculomotor nerve is the third of twelve paired cranial nerves. It controls most of the eye's movement, constriction of the pupil, and maintains an open eyelid. The main aim of eye movement is to focus external objects on to the fovea of the eye, and to keep the focus on the fovea. The eye has to be stabilized even when the head moves. Each eye has six extraocular muscles, and each eye has five movements, which are governed by three bilateral groups of brain stem oculomotor nuclei. The

oculomotor nerve supplies somatic motor fibers to all the ocular muscles, except the Obliquus superior and Rectus lateralis; it also controls, through its connections with the ciliary ganglion, smooth muscle within the eye using parasympathetic neurons.1,3,5,7,10,12,13 The oculomotor nerve contains two types of fibers: somatic efferent fibers (derived from oculomotor nucleus) and visceral efferent fibers (derived from Edinger-Westphal nucleus). The motor neurons serving the extraocular muscles have their cell bodies in the oculomotor nucleus, which lies at the base of the periaqueductal grey of the midbrain at the superior colliculus level. The oculomotor nucleus, which consists of mutipolar neurons resides at the ventral area of the substantia grisea centralis. Preganglionic parasympathetic neurons are derived from the Edinger-Westphal nucleus, which consists of small, ovoid neurons that resemble the dorsal nucleus of vagus nerve, and supplies the two intraocular muscles: constrictor pupillae and ciliary muscle. It is located at the tip and dorsomedial part of the cranial oculomotor nucleus.1,2,5,7,8

Figure 9: Nerves of the orbit

On emerging from the brain, the nerve is invested with a sheath of pia mater, and enclosed in a prolongation from the arachnoid. It passes between the superior cerebellar (below) and posterior cerebral arteries (above), and then pierces the dura mater anterior and lateral to the posterior clinoid process, passing between the free and attached borders of the tentorium cerebelli. It runs along the lateral wall of the cavernous sinus, above the other orbital nerves, receiving in its course one or two filaments from the cavernous plexus of the sympathetic, and a communicating branch from the ophthalmic division of the trigeminal. It then divides into two branches, which enter the orbit through the superior orbital fissure, between the two heads of the Rectus lateralis. Here the nerve is placed below the trochlear nerve and the frontal and lacrimal branches of the ophthalmic nerve, while the nasociliary nerve is placed between its two rami.1,2,5,7 In the orbit, the visceral efferent fibers run towards the ciliary ganglion on the lateral side of the optic nerve. The preganglionic parasympathetic fibers form a synapsis at this ganglion, while the postganglionic parasympathetic fibers from ciliary ganglion enter the bulbus oculi to serve the ciliary muscle and sphincter papillae muscle. These visceral efferent fibers are also the efferent part from arc of the pupil light reflex and accommodation-convergence reflex.2

Pupillary Light Reflex The size of the pupil regulates the amount of light that enters the eye. The direct light reflex happens when the constriction of the pupil is caused by illumination of the retina through contraction of the sphincter pupillae muscle, thus reducing the amount of light reaching the retina. Although only one retina is illuminated, both eyes pupils constrict, causing the constriction of the nonilluminated eye to be called as consensual light reflex. Lesion of the oculomotor nerve on either side can cause mydriasis (dilated pupil) and iridoplegia (loss of pupillary light reflex.2,4,7-9,13

Accommodation Reflex The eyes converge when objects move closer, and diverge when objects move away. This is controlled by the vergence system. The lens of the eye must also accommodate for moving objects through contractions of the ciliary muscle. Fixation upon a nearby object, by convergence of the optic axes, involves concomitant contraction of the ciliary muscles to increase the convexity of the lens, thus focusing the image. Pupillary constriction also accompanies this phenomenon, which involves the visual cortex with the corticobulbar fibers activating the parasympathetic neurons of the Edinger-Westphal nuclei bilaterally. Lesion to the oculomotor nerve with respect to accommodation reflex is loss of convergence reflex and accommodation (cycloplegia).2-4,7-9,13

Cranial Nerve IV: Trochlear nerve

Figure 10: Anatomic overview of the trochlear nerve

The trochlear nerve is a motor nerve (a somatic efferent nerve) that innervates a single muscle: the superior oblique muscle of the eye. The trochlear nerve is purely a motor nerve. It arises from a nucleus situated in the floor of the cerebral aqueduct, opposite the upper part of the inferior colliculus and next to the dorsal fasciculus longitudinalis medialis. The trochlear nerve is unique among the cranial nerves in several respects. It is the smallest nerve in terms of the number of axons it contains. It has the greatest intracranial length. Along with the optic nerve (cranial nerve II), it is the only cranial nerve that decussates before innervating its target. Finally, it is the only cranial nerve that exits from the dorsal aspect of the brainstem.1,2,4,5,7,12,13 The nerve is directed across the superior cerebellar peduncle, and then winds forward around the cerebral peduncle, instantly above the pons, pierces the dura mater in the free border of the tentorium cerebelli, just behind, and lateral to, the posterior clinoid process, and passes forward in the lateral wall of the cavernous sinus, between the oculomotor nerve and the ophthalmic division of the trigeminal. It crosses the oculomotor nerve, and enters the orbit through the superior orbital fissure. It now becomes the highest of all the nerves, and lies medial to the frontal nerve. In the orbit it passes medially, above the origin of the levator palpebra superioris, and finally enters the orbital surface of the obliquus superior and innervates the superior oblique muscle.1,5,6,10

Figure 11: The cavernous sinus

In the lateral wall of the cavernous sinus the trochlear nerve forms communications with the ophthalmic division of the trigeminal and with the cavernous plexus of the sympathetic. In the superior orbital fissure it occasionally gives off a branch to the lacrimal nerve. It gives off a recurrent branch which passes backward between the layers of the tentorium cerebelli and divides into two or three filaments which may be traced as far as the wall of the transverse sinus.5

Cranial Nerve V: Trigeminal nerve

Figure 12: Trigeminal nerve; supplies the forehead, cheek, and masticator muscles

The trigeminal nerve is responsible for sensation in the face, forehead, nasal cavity, dura mater, major intracranial blood vessels, tongue, gums and teeth (touch, and temperature). It contains branchiomotor and general somatic afferent fibers (which are extroceptive and proprioceptive). Sensory information from the face and body is processed by parallel pathways in the central nervous system. The trigeminal nerve is primarily a sensory nerve, but it also has certain motor functions (biting, chewing, and swallowing). The trigeminal nerve is the largest cranial nerve and is the great sensory nerve of the head and face, and the motor nerve of the muscles of mastication.1-5,7-9,12,13

The trigeminal nerve arises from the brain at the side of the pons by a motor and a sensory root. The sensory root carries the trigeminal ganglion which consists of the cell bodies of the sensory axons and lies in a depression on the petrous temporal bone. They pass backward below the superior petrosal sinus and tentorium cerebelli, and, entering the pons, divide into upper and lower roots. The upper root ends partly in a nucleus which is situated in the pons lateral to the lower motor nucleus, and partly in the locus caeruleus; the lower root descends through the pons and medulla oblongata, and ends in the upper part of the substantia gelatinosa of Rolando. This lower root is sometimes named the spinal root of the nerve. It then divides into ophthalmic, maxillary and mandibular divisions. The motor root forms part of the mandibular division. The fibers of the motor root arise from two nuclei, a superior and an inferior. The superior nucleus consists of a strand of cells occupying the whole length of the lateral portion of the gray substance of the cerebral aqueduct. The inferior or chief nucleus is situated in the upper part of the pons, close to its dorsal surface, and along the line of the lateral margin of the rhomboid fossa. The fibers from the superior nucleus constitute the mesencephalic root: they descend through the mid-brain, and, entering the pons, join with the fibers from the lower nucleus, and the motor root, thus formed, passes forward through the pons to its point of emergence.1,5,10

Figure 13: Anatomy of the trigeminal nerve, and its sensory and motor branches

The ophthalmic branch, or first division of the trigeminal nerve, is a sensory nerve. It enters the orbit of the eye and carries sensory information from the cornea, ciliary body and iris, lacrimal gland and conjunctiva, mucous membrane of the nasal cavity, and skin of the eyelids, eyebrow, forehead, and nose. It is the smallest of the three divisions of the trigeminal, and arises from the upper part of the semilunar ganglion as a short, flattened band, which passes forward along the lateral wall of the cavernous sinus, below the oculomotor and trochlear nerves; just before entering the orbit, through the superior orbital fissure, it divides into three branches, lacrimal, frontal, and nasociliary. The ophthalmic branch is joined by filaments from the cavernous plexus of the sympathetic, and communicates with the oculomotor, trochlear, and abducent nerves; it gives off a recurrent filament which passes between the layers of the tentorium.1,3-6,9,13 The maxillary branch, or second division of the trigeminal, is a sensory nerve. The maxillary branch carries sensory information from the lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the posterior region of the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of the meninges. It travels forward in a groove on the floor of the middle cranial fossa, and exits the cranial cavity through the foramen rotundum. It is intermediate, both in position and size, between the ophthalmic and mandibular. It begins at the middle of the semilunar ganglion as a flattened plexiform band, and passing horizontally forward, it leaves the skull through the foramen rotundum, where it becomes more cylindrical in form, and firmer in texture. It then crosses the pterygopalatine fossa, inclines laterally on the back of the maxilla, and enters the orbit through the inferior orbital fissure; it traverses the infraorbital groove and canal in the floor of the orbit, and appears upon the face at the infraorbital foramen. At its termination, the nerve lies beneath the Quadratus labii superioris, and divides into a leash of branches which spread out upon the side of the nose, the lower eyelid, and the upper lip, joining with filaments of the facial nerve.1,3-6,9,13 The mandibular division is mixed, containing motor and sensory fibers. It exits the cranium through the foramen ovale. The mandibular branch supplies the

teeth and gums of the mandible, the skin of the temporal region, the auricula, the lower lip, the lower part of the face, and the muscles of mastication; it also supplies the mucous membrane of the anterior two-thirds of the tongue (the lingual nerve). It is the largest of the three divisions of the fifth, and is made up of two roots: a large, sensory root proceeding from the inferior angle of the semilunar ganglion, and a small motor root (the motor part of the trigeminal), which passes beneath the ganglion, and unites with the sensory root, just after its exit through the foramen ovale. Immediately beneath the base of the skull, the nerve gives off from its medial side a recurrent branch (nervus spinosus) and the nerve to the Pterygoideus internus, and then divides into two trunks, an anterior and a posterior.1,3-6,9,10,13

Cranial Nerve VI: Abducens nerve

Figure 14: Abducens nerve; supplies the lateral rectus muscle

The abducens nerve or abducent nerve is a somatic efferent nerve that controls the movement of a single muscle, the lateral rectus muscle of the eye. It is another pure motor nerve fiber and originates from the abducens nucleus situated in the upper part of the rhomboid fossa, close to the middle line and beneath the colliculus facialis. They pass downward and forward through the pons, and emerge in the furrow between the lower border of the pons and the upper end of the pyramid of the medulla oblongata. It has a long intracranial course (so is often the first nerve to be affected in raised intracranial pressure) to the cavernous sinus, where it is closely applied to the internal carotid artery, and thence to the orbit via the superior orbital fissure. From the nucleus, fibers are said to pass through the medial longitudinal fasciculus to the oculomotor nerve of the opposite side, along which they are carried to the Rectus medialis. The Rectus lateralis of one eye and the Rectus medialis of the other may therefore be said to receive their nerves from the same nucleus.1,2,4-10,12,13

Figure 15: The path of the abducens nerve

Before entering the orbit via superior orbital fissure, the abducens nerve traverses in the cavernous sinus. In the cavernous sinus, the oculomotor, trochlear,

and ophthalmic nerves are placed in the lateral wall of the sinus, in the order given, from above downward. The abducent nerve lies at the lateral side of the internal carotid artery. As these nerves pass forward to the superior orbital fissure, the oculomotor and ophthalmic divide into branches, and the abducent nerve approaches the others; so that their relative positions are considerably changed.1,-6

Cranial Nerve VII: Facial nerve

Figure 16: Facial nerve; supplies the facial area and the front of the tongue

The facial nerve emerges from the brainstem between the pons and the medulla, and controls the muscles of facial expression, and taste to the anterior twothirds of the tongue. It also supplies preganglionic parasympathetic fibers to several head and neck ganglia, the posterior digastric, stapedius, and stylohyoid muscles. The facial nerve consists of a motor and a sensory part, the latter being frequently described under the name of the nervus intermedius. The two parts emerge at the lower border of the pons in the recess between the olive and the inferior peduncle, the motor part being the more medial, immediately to the lateral side of the sensory part is the acoustic nerve.1-5,7-10,12,13 The facial nerve leaves the brain near the cerebellum and passes laterally into the internal auditory meatus. It reaches the medial wall of the middle ear and turns

backwards and downwards to leave the skull via the stylomastoid foramen. It then traverses the parotid gland, in which it divides into five branches (temporal, zygomatic, buccal, marginal mandibular and cervical) which are distributed to the muscles of facial expression, the platysma and the posterior belly of the digastric. In the middle ear it gives off the greater petrosal branch which carries parasympathetic fibres to the sphenopalatine ganglion and thence to the lacrimal gland. In the middle ear it also gives off the chorda tympani which joins the lingual nerve and is distributed with it.1,4-6,10

Temporal Zygomatic Buccal Mandibular Cervical Stylomastoid foramen

Figure 17: The five major branches of the facial nerve

The motor facial nucleus, which is a multipolar columnar neuron, located in the lateral tegmentum pontis and directly next to the cranial nucleus ambiguus. This nucleus is the center for branchiomotor fibers that initially traverse dorsomedially towards the rhomboid fossa and subsequently encircling the cranial part of nucleus abducens. The cranial salivatory nucleus is a small group of neurons at the dorsolateral part of formatio reticularis pontis, next to the cranial part of caudal salivatory nucleus. This nucleus is the center for visceromotoric, secretomotoric, or preganglionic parasympathetic fibers. Outside the central nervous system, these fibers also form the nervus intermedius, and branch out into nervus petrosus superficialis major and tympanic chord. Facial nerve gustatory fibers carry taste impulses from the two-third part of ventral dorsum linguae. Facial nerve also contains general somatic afferent fibers, which are limited in number and non-essential.2,5-8

Lesions of the facial nerve are the most frequent cause of loss of facial reflexes and facial paralysis. Bell's palsy is one type of idiopathic acute facial nerve paralysis, which is more accurately described as a multiple cranial nerve ganglionitis that involves the facial nerve, and most likely results from viral infection and also sometimes as a result of Lyme disease. It represents an acute unilateral inflammatory lesion of the facial nerve. Iatrogenic Bell's palsy may also be as a result of an incorrectly placed dental local-anesthetic (Inferior alveolar nerve block).1,3,4,7

Cranial Nerve VIII: Vestibulocochlear nerve

Figure 18: Vestibulocochlear nerve; supplies the balance and hearing organs

The vestibulocochlear nerve (also known as the auditory or acoustic nerve) is responsible for transmitting sound and equilibrium (balance) information from the inner ear to the brain. This nerve is purely a sensory nerve. It consists of two distinct

sets of fibers which differ in their peripheral endings, central connections, functions, and time of medullation. The vestibulocochlear nerve innervates the hair cell receptors of the inner ear. It carries vestibular information to the brain from the semicircular canals, utricle, and saccule providing the sense of balance. It also carries information from the cochlea providing the sense of hearing. This cranial nerve branches into the vestibular branch (balance) and the cochlear branch (hearing). The cochlear fibers originate from the spiral ganglion. It is soft in texture and devoid of neurilemma.1,2,4-10,12,13 The vestibular nerve, the nerve of equilibration, arises from bipolar cells in the vestibular ganglion, ganglion of Scarpa, which is situated in the upper part of the outer end of the internal auditory meatus. The vestibular nerve travels from the vestibular system of the inner ear. The vestibular ganglion houses the cell bodies of the bipolar neurons and extends processes to five sensory organs, which are the medial vestibular nucleus, the lateral vestibular (Deiters) nucleus, the superior vestibular nucleus, the inferior vestibular nucleus, and the cerebellum. Three of these are the cristae located in the ampullae of the semicircular canals. Hair cells of the cristae activate afferent receptors in response to rotational acceleration. The other two sensory organs supplied by the vestibular neurons are the maculae of the saccule and utricle. Hair cells of the maculae activate afferent receptors in response to linear acceleration. The hair cells are oriented in the labyrinth of the ear through the orientation of the canals and of the otolith organs, the saccule and utricle. The peripheral fibers divide into three branches: the superior branch passes through the foramina in the area vestibularis superior and ends in the utricle and in the ampullae of the superior and lateral semicircular ducts; the fibers of the inferior branch traverse the foramina in the area vestibularis inferior and end in the saccule; the posterior branch runs through the foramen singulare and supplies the ampulla of the posterior semicircular duct.1-5,7,8

Figure 19: The course and connections of the vestibulocochlear nerve in the temporal bone

The cochlear nerve, the nerve of hearing, arises from bipolar cells in the spiral ganglion of the cochlea, situated near the inner edge of the osseous spiral lamina. The peripheral fibers pass to the organ of Corti. It is the inner hair cells of the organ of Corti that are responsible for activation of afferent receptors in response to pressure waves reaching the basilar membrane through the transduction of sound. The central ones pass down the modiolus and then through the foramina of the tractus spiralis foraminosus or through the foramen centrale into the lateral or outer end of the internal auditory meatus. The nerve passes along the internal auditory meatus with the vestibular nerve and across the subarachnoid space, just above the flocculus, almost directly medially toward the inferior peduncle to terminate in the cochlear nucleus. The ventral cochlear nucleus is located on the anterolateral surface of pedunculus cerebellaris caudalis while the dorsal cochlear nucleus is located on the dorsolateral surface of pedunculus cerebellaris caudalis. All the fibers that exit the cochlear nuclei move medially towards the border between medulla oblongata and pons, and are grouped into three categories of stria acusticae. They are stria acustica ventralis, stria acustica dorsalis, and stria acustica intermedia.1-5,7,13

Cranial Nerve IX: Glossopharyngeal nerve

Figure 20: Glossopharyngeal nerve; supplies the back of the tongue, soft palate and reflex control of the heart

The glossopharyngeal nerve contains both motor and sensory fibers, and is distributed, as its name implies, to the tongue and pharynx. It exits the brainstem out from the sides of the upper medulla, just rostral (closer to the nose) to the vagus nerve. The glossopharyngeal nerve innervates the pharynx (upper part of the throat), the soft palate and the posterior one-third of the tongue. It carries sensory information (touch, temperature, and pressure) from the pharynx and soft palate. It carries taste sensation from the taste buds on the posterior one third of the tongue. It provides somatic motor innervation to the throat muscles involved in swallowing, salivation, and gagging. It provides visceral motor innervation to the salivary glands. This cranial nerve also supplies the carotid sinus and reflex control to the heart. It is composed of both sensory and motor axons and originates from the nucleus ambiguous in the reticular formation of the medulla.1,3-5,9,10,12,13

There are a number of functions of the glossopharyngeal nerve, which are receiving general sensory fibers (ventral trigeminothalamic tract) from the tonsils, the pharynx, the middle ear and the posterior 1/3 of the tongue, receiving special sensory fibers (taste) from the posterior one-third of the tongue, receiving visceral sensory fibers (chemoreceptors and baroreceptors) from the carotid bodies, supplying parasympathetic fibers to the parotid gland via the otic ganglion, supplying motor fibers to stylopharyngeus muscle, the only motor component of this cranial nerve, and contributing to the pharyngeal plexus. In the pharyngeal plexus, the fibers of the glossopharyngeal and vagus nerve are intertwined, making it hard to determine a pure lesion of the glossopharyngeal nerve.1-3,7,8,10

Glossopharyngeal nerve (IX) Parotid salivary gland Parasympathetic fibers Superior ganglion Jugular foramen Inferior ganglion Otic ganglion Carotid sinus Pharyngeal muscles

Figure 21: The glossopharyngeal nerve and associated organs

The sensory fibers arise from the cells of the superior and petrous ganglia, which are situated on the trunk of the nerve. When traced into the medulla, some of the sensory fibers, probably sympathetic afferent, end by arborizing around the cells of the upper part of a nucleus which lies beneath the ala cinerea in the lower part of the rhomboid fossa. Many of the fibers, probably the taste fibers, contribute to form a strand, named the fasciculus solitarius, which descends in the medulla oblongata. Associated with this strand are numerous nerve cells, and around these the fibers of the fasciculus end. The somatic sensory fibers, few in number, are said to join the

spinal tract of the trigeminal nerve. The carotid branch of the glossopharyngeal contains two sets of afferents. One set runs centrally from the baroreceptor stretch receptors in the wall of the carotid sinus at the beginning of the internal carotid artery. These receptors respond to changes in the systolic pressure. These afferents synapse centrally in the medial portion of the solitary nucleus. Another set of afferents run centrally from the glomus cells of the carotid body. The nerve endings of these afferents are chemoreceptors, which respond to O2 and CO2 partial pressure changes in the blood. Their afferents terminate centrally in the dorsal respiratory nucleus.3,5,7,13 The somatic motor fibers spring from the cells of the nucleus ambiguus, which lies some distance from the surface of the rhomboid fossa in the lateral part of the medulla, innervates the stylopharyngeus muscles, which takes part in swallowing and, are continuous below with the anterior gray column of the medulla spinalis. From this nucleus the fibers are first directed backward, and then they bend forward and laterally to join the fibers of the sensory root. The nucleus ambiguus gives origin to the motor branches of the glossopharyngeal and vagus nerves, and to the cranial part of the accessory nerve. The sympathetic efferent fibers from the nucleus beneath the ala cinerea, the dorsal nucleus, are probably both preganglionic motor fibers and preganglionic secretory fibers of the sympathetic system. The secretory fibers pass to the otic ganglion and from it secondary neurons are distributed to the parotid gland; the postganglionic nerve innervates the salivary parotid gland.3,5,7,13

Cranial Nerve X: Vagus nerve

Figure 22: Vagus nerve; supplies parts of the abdominal cavity

The vagus nerve is also called pneumogastric nerve since it innervates both the lungs and the stomach. It is the longest cranial nerve innervating many structures in the throat, including the muscles of the vocal cords, thorax and abdominal cavity. The vagus nerve is the main parasympathetic nerve, having very extensive motor and sensory components. Upon leaving the medulla between the olivary nucleus and the inferior cerebellar penduncle, it extends through the jugular foramen, then passing into the carotid sheath between the internal carotid artery and the internal jugular vein down below the head, to the neck, chest and abdomen, where it contributes to the innervation of the viscera. Besides output to the various organs in the body the vagus

nerve conveys sensory information about the state of the body's organs to the central nervous system.1,3-6,12 The vagus nerve encompasses a number of fibers. The nucleus ambiguus, which is a source of branchiomotor fibers, is a long cell columnnext to the cranial part of the accessory nucleus and is composed of somatomotor and visceromotor cells. The nucleus dorsalis nervi vagi, where the vagus nerves preganglionic parasympathetic fibers arise, is a long cell column near the fossa rhomboidea. The nucleus solitaries, which is located near the tractus solitaries, is divided into two different functional neuron groups; the nucleus parasolitarius, which is on the ventrolateral side of tractus solitaries, is a general visceral afferent, and receives impulse from thoracic and abdominal viscera; while the nucleus gustatorius, which is a small group of neurons on the dorsomedial side of tractus solitaries, is a special visceral afferent fiber. The nucleus spinalis nervi trigemini, which receives extroceptive impulses from a section of the skin bordered around the porus acusticus externus by the general somatic afferent fibers of the vagus nerve.2

Figure 23: The vagus nerve and associated organs

The vagus is attached by eight or ten filaments to the medulla oblongata in the groove between the olive and the inferior peduncle, below the glossopharyngeal. The sensory fibers arise from the cells of the jugular ganglion and ganglion nodosum of the nerve, and, when traced into the medulla oblongata mostly end by arborizing around the cells of the inferior part of a nucleus which lies beneath the ala cinerea in the lower part of the rhomboid fossa. These are the sympathetic afferent fibers. A few of the sensory fibers of the vagus, probably taste fibers, descend in the fasciculus solitarius and end around its cells. The somatic sensory fibers from the posterior part of the external auditory meatus and the back of the ear, probably join the spinal tract of the trigeminal as it descends in the medulla. General visceral afferent fibers convey visceral impulses from tunica mucosa centrally. The afferent fibers convey information from the general sensation receptors in the pharynx, larynx, oesophagus, tympanic membrane, external auditory meatus and part of the external ears concha, the chemoreceptors in the aortic bodies and baroreceptors in the aortic arch, and the receptors that are widely distributed throughout the thoracic and abdominal viscera.2,4-7,12,13 The motor fibers of the vagus nerve arise from the nucleus ambiguus of the medulla. They innervate the muscles of the soft palate, pharynx, larynx and upper part of the oesophagus, and are important in speech and swallowing control. The sympathetic efferent fibers, distributed probably as preganglionic fibers to the thoracic and abdominal viscera, i. e., as motor fibers to the bronchial tree, inhibitory fibers to the heart, motor fibers to the esophagus, stomach, small intestine and gall passages, and as secretory fibers to the stomach and pancreas, arise from the dorsal nucleus of the vagus. The filaments of the nerve unite, and form a flat cord, which passes beneath the flocculus to the jugular foramen, through which it leaves the cranium. After its exit from the jugular foramen the vagus is joined by the cranial portion of the accessory nerve, and enlarges into the ganglion nodosum; through this the fibers of the cranial portion of the accessory are principally distributed to the pharyngeal and superior laryngeal branches of the vagus, while some of its fibers descend in the trunk of the vagus to be distributed with the recurrent nerve and the

cardiac nerves. The vagus nerve passes vertically down the neck within the carotid sheath, lying between the internal jugular vein and internal carotid artery as far as the upper border of the thyroid cartilage, and then between the same vein and the common carotid artery to the root of the neck. The further course of the nerve differs on the two sides of the body.2,4-7,10,12,13

Cranial Nerve XI: Accessory nerve

Figure 24: Accessory nerve; supplies the head, neck column and associated structures

The accessory nerve is a nerve that controls specific muscles of the neck. It is pure motor nerve fiber. The accessory nerve originates from neuronal cell bodies located in the cervical spinal cord and caudal medulla. Most are located in the spinal cord and ascend through the foramen magnum and exit the cranium through the jugular foramen. The accessory nerve consists of two parts: a cranial and a spinal.1-7,12 The cranial part (ramus internus; accessory portion) is the smaller of the two. Its fibers arise from the cells of the nucleus ambiguus and emerge as four or five delicate rootlets from the side of the medulla oblongata, below the roots of the vagus.

It runs laterally towards the jugular foramen, where it interchanges fibers with the spinal portion or becomes united to it for a short distance; here it is also connected by one or two filaments with the jugular ganglion of the vagus. It then passes through the jugular foramen, separates from the spinal portion and is continued over the surface of the ganglion nodosum of the vagus, to the surface of which it is adherent, and is distributed principally to the pharyngeal and superior laryngeal branches of the vagus. Through the pharyngeal branch it probably supplies the musculus uvulae and levator veli palatini. The cranial branch provides somatic motor innervation to some of the muscles in the throat involved in swallowing. This cranial branch is accessory to vagus nerve, with the fibers of the cranial root traveling the same extracranial path as the branchial motor component of the vagus nerve.2,3,5-8,12

Spinal Accessory Nerve

( )

Figure 25: The accessory nerve and associated parts

The spinal part (ramus externus; spinal portion) is firm in texture, and its fibers arise from the motor cells in the lateral part of the anterior column of the gray substance, projecting from the five most rostral segments of the spinal cord. The spinal accessory nerve provides motor innervation from the central nervous system to two muscles of the neck: the sternocleidomastoid muscle and the trapezius muscle. The sternocleidomastoid muscle tilts and rotates the head, while the trapezius muscle has several actions on the scapula, including shoulder elevation and adduction of the scapula. Passing through the lateral funiculus of the medulla spinalis, they emerge on its surface and unite to form a single trunk, which ascends between the ligamentum denticulatum and the posterior roots of the spinal nerves; enters the skull through the foramen magnum, and is then directed to the jugular foramen, through which it passes, lying in the same sheath of dura mater as the vagus, but separated from it by a fold of the arachnoid. In the jugular foramen, it receives one or two filaments from the cranial part of the nerve, or else joins it for a short distance and then separates from it again. The nerve then descends obliquely behind the digastricus and stylohyoideus to the upper part of the sternocleidomastoideus; it pierces this muscle, and courses obliquely across the posterior triangle of the neck, to end in the deep surface of the trapezius. As it traverses the sternocleidomastoideus it gives several filaments to the muscle, and joins with branches from the second cervical nerve. In the posterior triangle it unites with the second and third cervical nerves, while beneath the trapezius it forms a plexus with the third and fourth cervical nerves, and from this plexus fibers are distributed to the muscle.1-3,5,7,8,10,12,13

Cranial Nerve XII: Hypoglossal nerve

Figure 26: The hypoglossal nerve and associated parts

The hypoglossal nerve is the motor nerve of the tongue. It provides somatic motor innervation to the muscles of the tongue. This pure motor nerve originates from the hypoglossal nucleus located in the tegmentum of the medulla oblongata in the preolivary sulcus separating the olive and the pyramid. The hypoglossal nucleus receives afferents from the solitary nucleus and trigeminal sensory nucleus, which are involved in chewing, sucking and swallowing. It also receives corticobulbar fibers from the contralateral motor cortex, which serve in tongue movements such as speech. It is also used as a sensory neuron to taste bitter.1-3,5,7,8,12,13 It passes through the hypoglossal canal. On emerging from the hypoglossal canal, it gives off a small meningeal branch (the descendens hypoglossi) and picks up a branch from the anterior ramus of C1. This joins the descendens cervicalis, derived from C2 and 3, to form the ansa cervicalis. From this, branches arise to supply the

strap muscles, i.e. sternothyroid, sternohyoid, thyrohyoid and omohyoid. It spirals behind the vagus nerve and passes between the internal carotid artery and internal jugular vein lying on the carotid sheath. After passing deep to the posterior belly of the digastric muscle, it passes to the submandibular region to enter the tongue. It supplies motor fibres to all of the muscles of the tongue, except the palatoglossus muscle which is innervated by the vagus nerve via the pharyngeal plexus. The innervations of the tongue are ipsilateral.1,2.4-6,10

Summary In conclusion, the cranial nerves play an extremely important role in our body, thus affecting our life. Whether it is sensory or motor, somatic or visceral, general or special, they all play a vital role in determining the quality of life in an individual. Lesions and degenerations to the cranial nerves profoundly inhibit an individual from going about his/her everyday life. For example, the motor neuron disease is a chronic degenerative disorder which is seen in those aged over 50 years. The corticobulbar tracts projecting to the nucleus ambiguus and hypoglossal nucleus degenerate, leading to dysphonia, dysphagia, dysarthria, and weakness and spasticity of the tongue. One of the probable causes of this disorder is due to damage by compression caused by tumors in the nerve areas. Therefore, it is essential that concern towards cranial nerves should be emphasized from a very young age. Early detections may provide a better outcome for most individuals.

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http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/h_n/cn/cn1/cnintr o.htm. 7. Crossman AR, Neary D. Cranial nerves and cranial nerve nuclei. Neuroanatomy: An Illustrated Colour Text, 3rd ed Spain: Elsevier Limited; 2005. p.101-113. 8. El Rakhawy MT. The cranial nerves. Neuroanatomy for Medical Students, 1st ed Cairo: Cairo University Publications; 1975. p.146-181. 9. Astrid, Hans-Frieder M. Reference Tables: the cranial nerves. In: Eder D, Kaminsky SL, Bertram J (eds). Laboratory Atlas of Anatomy and Physiology, 4th ed New York: McGraw-Hill; 2003. p.141-167. 10. Faiz O, Moffat D. The head and neck. Anatomy at a Glance, 1st ed Oxford: Blackwell Science Ltd; 2002. p.126-131. 11. Vokshoor A, McGregor J. Anatomy of Olfactory System. E Medicine. [Cited 2010 March]. Available from: http://emedicine.medscape.com/article/835585overview.

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