CN 9,10, 11 and 12

Glossopharyngeal nerve

Motor to stylopharyngeus muscle

Sensory to posterior 1/3 tongue
Parasympathetic to parotid salivary gland

Note: IX, X. Glossopharyngeal and Vagus Nerves

These two nerves are considered together because they exit from the
brain stem side by side, and have similar and frequently side-by-side
and overlapping functional and anatomical distributions in the
periphery. Also, these nerves connect with many of the same brain
stem nuclei (dorsal motor nucleus of the vagus, nucleus ambiguus,
nucleus solitarius, spinal nucleus of the trigeminal) and are often
damaged together.
9th nerve testing and palsy

Palsy causes difficulty swallowing, taste impairment, sensation

impairment to palate/parynx, post 1/3 tongue
Supranuclear causes of dysfunction
Stroke( PICA)
Tumour
LMN causes of dysfunction
Affected with impingement of jugular foramen with CN 10
and 11
Test with CN 10 by
Visualize lifting of pharynx
Gag reflex

Note: Glossopharyngeal nerve lesions produce difficulty swallowing;

impairment of taste over the posterior one-third of the tongue and
palate; impaired sensation over the posterior one-third of the tongue,
palate, and pharynx; an absent gag reflex; and dysfunction of the
parotid gland.
For all practical purposes, the ninth nerve cannot be tested separately,
and isolated lesions are almost unknown. In the cerebellopontine
angle, the eighth and ninth nerves can be involved by tumors. At the
jugular foramen the ninth, tenth, and eleventh nerves can all be
involved (e.g., by a glomus tumor or other masses). Diphtheria can
cause ninth nerve paralysis. Glossopharyngeal neuralgia, similar to

trigeminal neuralgia, does occur rarely. It consists of a stabbing,

lancinating pain at the base of the tongue or around the palate.

VAGUS overview
Tenth cranial nerve
Also provides parasympathetic to viscera and
sensation from viscera
Mediates vasovagal responses
via parasympathetic action on heart rate, BP
Links with Glossopharyngeal (Gag reflex, carotid sinus massage)
and trigeminal nerves(spinal trigeminal nucleus)
Has motor, sensory, special sensory and parasympathetic actions
Afferent
Solitary nucleus- receives afferent taste in and primary sensory
afferents from visceral organs
Efferent
Dorsal nucleus of vagus nerve parasympathetic output to the
viscera.
Nucleus ambiguus motor to constrictor muscles of pharynx and
larynx, parasympathetic neurons to heart
Vagal pathology
PICA stroke
Nucleus Ambiguus affected in lateral medullary stroke
losing motor to pharynx and larynx
Vasovagal syncope
Stimulus of vagal nerve parasympathetics (carotid sinus
massage, pain, emotion,
Reduced heart rate, decreases BP
Recurrent laryngeal nerve palsy
Vulnerable where nerve dips beneath aorta ( left) or
subclavian vein ( right) and travels through thyroid
Hoarse voice
Aortic aneuysm, surgical thryoid intervention
Treatment for epilepsy
VNS for intractable seizures
Note: Vagus nerve lesions produce palatal and pharyngeal paralysis;
laryngeal paralysis; and abnormalities of esophageal motility, gastric
acid secretion, gallbladder emptying, and heart rate; and other
autonomic dysfunction.

Bilateral supranuclear denervation leads to dysphagia and dysarthria.

This occurs in a condition known as pseudobulbar palsy. Multiple small
lesions in the cortex and/or brainstem interrupt the corticobulbar
supply to the motor nuclei of various cranial nerves. Etiologies include
multiple sclerosis, hypertensive lacunes, and other causes of
bihemispheric disease.
Bilateral nuclear involvement of the vagus causes death with
pharyngeal and laryngeal paralysis and cardiac arrhythmias. Unilateral
nuclear or infranuclear involvement of the vagus causes ipsilateral
paralysis of the soft palate, pharynx, and larynx. The voice is hoarse or
nasal, the involved palatal arch is paralyzed, and liquids will enter the
nasopharynx or trachea. The vocal cord on the involved side is
paralyzed. Causes include meningitis, carotid aneurysms, neoplasms,
trauma, and diphtheria. Diseases that involve all peripheral nerves,
such as diabetes and amyloidosis, and toxins such as lead, produce
neuropathies of these nerves. Neoplasms can involve the nerve at any
point in its course.
Recurrent laryngeal nerve paralysis is an important condition. There is
paralysis of the vocal cord ipsilaterally. The voice may be hoarse but
can be normal, with the lesion discoverable only by laryngoscopy.
Bilateral recurrent laryngeal paralysis produces paralysis of both cords,
with a whispering voice, stridor, and even death due to tracheal
obstruction by the cords. Causes of recurrent laryngeal damage include
surgery on neoplasms of the thyroid, cervical adenopathy of any cause,
aortic aneurysms, mediastinal tumors, and lead poisoning.
Swallow syncope, or unconsciousness produced by swallowing, is a
rare complication of ninth and tenth nerve lesions. The probable
mechanism is a vasovagal reflex produced by esophageal distention,
with resulting cardiac inhibition. A similar syncopal syndrome has been
reported with glossopharyngeal neuralgia.
Clinical PICA stroke

Contralateral torso pain and temp loss

Ipsilateral face pain and temp loss
Ataxia
Horners
Dysphagia and dystonia
Vertigo

Note: This syndrome is characterized by

sensory deficits affecting the trunk and
extremities on the opposite side of the
infarction and sensory deficits affecting the face and cranial nerves on
the same side with the infarct. Specifically, there is a loss of pain and

temperature sensation on the contralateral (opposite) side of the body

and ipsilateral (same) side of the face. This crossed finding is
diagnostic for the syndrome.
Clinical symptoms include difficulty swallowing, or dysphagia slurred
speech, ataxia, facial pain, vertigo, nystagmus, Horner syndrome,
diplopia, and possibly palatal myoclonus.
Affected persons have difficulty in swallowing (dysphagia) resulting
from involvement of the nucleus ambiguus, as well as slurred speech
(dysarthria)and disordered vocal quality (dysphonia) . Damage to the
spinal trigeminal nucleus causes absence of pain on the ipsilateral side
of the face, as well as an absent corneal reflex.
The spinothalamic tract is damaged, resulting in loss of pain and
temperature sensation to the opposite side of the body. The damage to
the cerebellum or the inferior cerebellar peduncle can cause ataxia.
Damage to the hypothalamospinal fibers disrupts sympathetic nervous
system relay and gives symptoms analogous to Horner syndrome.
Nystagmus and vertigo, which may result in falling, caused from
involvement of the region of Deiters' nucleus and other vestibular
nuclei. Onset is usually acute with severe vertigo.
Lateral Medullary Syndrome

Spinothalamic tracts
Decending nucleus & tracts of V
Preganglionic sympathetic fibres
Inf cerebellar peduncle
Nucleus ambiguus
Vestibular nuclei

More lateral medullary symptoms

Nucleus ambiguus
Branchiomotor to nerves 9,10 & 11
Inferior cerebellum peduncle
Cerebellar signs
D dysdiadochokinesis
A Ataxia
S slurred speech
H hypotonia
I intention tremor
N nystagmus
G gait abnormality
Note: This nucleus lies dorsal and lateral to the inferior olive. Cells in
nucleus ambiguus contain motor neurons associated with three cranial
nerves (rostral pole =C.N. IX=glossopharyngeal; middle part =C.N.
X=vagus; caudal pole =C.N. XI=spinoaccessory). Axons arising from
nucleus ambiguus pass laterally and slightly ventrally to exit the

medulla just dorsal to the inferior olive. These axons then course with
the three cranial nervesIX (glossopharyngeal), X (vagus) and XI
(spinoaccessory)to innervate the striated muscles of the soft palate,
pharynx, larynx, and upper part of the esophagus.
IX stylopharyngeus muscle
X palatal muscles; levator veli palatini (with assistance from V for the
tensor veli palatini; of little clinical significance), most of the
pharyngeal muscles (with assistance from IX), laryngeal muscles and
striated muscles of the esophagus-palatoglossus too!
XI laryngeal muscles (cranial portion)

Accessory nerve CNXI

Motor nerve formed by
cranial nerve and spinal nerve root
Nucleus Ambiguus provides motor
to cranial nerve
Leaves skull through Jugular
foramen (with CN9,10)
Innervates SCM and Trapezius
Testing and pathology
Test by turning head and shrugging shoulders against
resistance
Damage
Lateral winging of scapular
Causes
Compression at Jugular foramen (with 9 &10)
PICA stroke
Spinal problems ( ALS, polio, syringomyelia)
Note: Two types based on direction of inferior border of scapula medial
winging
serratus anterior (long thoracic nerve) lateral winging trapezius (CN XI
- spinal accessory nerve)

Hypoglossal nerve CN12

Motor

to all intrinsic muscles of tongue as well as styloglossus,

hyoglossus and genioglossus
Motor nucleus
in medial medulla
Bilateral cortical innervation
except for genioglossus ( pulls tongue forward)

Summary:

The vagus nerve has varied

and complex functions
Vasovagal syncope can be
caused by stimulation of the
vagal nerve by a variety of ways
Tongue innervation is complex