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Neuromuscular > Lecture 2 - Cranial Nerves > Flashcards

Lecture 2 - Cranial Nerves Flashcards

1
Q

LMN Symptoms

A

Single limb paralysis

Flaccid muscle tone

Hyporeflexia

Muscular atrophy

Fibrillation/fasciculation

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2
Q

Symptoms of Cerebellar Syndrome

A

Incoordination/ ataxia

Dysmetria

Dysdiadochokinesis

Intention Tremor

Rebounding

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3
Q

Incoordination/Ataxia

A

A complex movement is decomposed

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4
Q

Dysmetria

A

Unable to measure distance or speed

Under- or Over-shooting

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5
Q

Dysdiadochokinesis

A

Alternate motion rate (pa pa pa)

Alternate sequential rate (pa ta ka)

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6
Q

Intention Tremor

A

Not resting tremor

Tremor when attempting to make an intentional movement

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7
Q

Rebounding

A

Inability to judge when the resistance has disappeared

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8
Q

Symptoms of Basal Ganglia Syndrome

A

Involuntary Movements:

Chorea

Dyskinesias

Hypokinesias

Athetosis

Rigidity

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9
Q

UMN Symptoms

A

Hemiplegia

Spastic tone

Resistance to passive movement

Hyperreflexia

Atypical Reflexes
- Babinski

No atrophy

No denervation

Muscles are paralyzed but they don’t die because they are hyper reflexive

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10
Q

Branchial Arches

A

There are 6 branchial arches that turned into muscles when we were born.

They are classified as Special Visceral Efferent even though they are under voluntary control

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11
Q

First Arch

A

Moror branch of the Trigeminal Nerve

Special Visceral Efferent

Muscles of mastication

Additional muscles:
Mylohyoid, ant. belly of digastric, tensor tympani, tensor veli palatini

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12
Q

Second Arch

A

Facial Nerve

Muscles of facial expression:
Buccinators, auricularis, frontalis, platysma, orbicularis oris, orbicularis occuli

Additional muscles:
stapedius, stylohyoid, posterior belly of digastric muscles

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13
Q

Third Arch

A

Glossopharyngeal Nerve

Innervates the stylopharyngeus muscle
- deals with swallowing

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14
Q

Fourth and Sixth Arches

A

Vagus Nerve

5th arch disappears

Superior and recurrent laryngeal nerves

Pharyngeal and laryngeal muscles:
cricothyroid, levator veli palatini
- deals with swallowing and phonation

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15
Q

Unnumbered Gill Structures

A

Spinal accessory nuclei in C1-C5

Sternocleidomastoid and trapezius muscle

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16
Q

Functional Classifications

A

****Put in Picture

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17
Q

Classification - General Somatic Efferent

A

General Somatic Efferent = innervation of the skeletal muscles (somite)

Includes: 
Ocular muscles (CNs Oculomotor (III), Trochlear (IV), Abducens(VI)
Lingual muscles (CN hypoglossal (XII) 
   - All muscles of the tongue are somite
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18
Q

Classification - General Visceral Efferent

A

Synonym for Autonomic Nervous System

Smooth muscles to regulate pupillary reactions, gland secretion, and muscles of the heart, trachea, bronchi, esophagus, and viscera (ANS) :

Edinger-Westphal Nucleus (Oculomotor - III)
Superior Salivatory Nucleus (Facial - VII)
Inferior Salivatory Nucleus (Glossopharyngeal - IX)
Dorsal Motor Nucleus (Vagus - X)

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19
Q

Classification - Special Visceral Efferent

A

Branchial Efferent - muscles of face, mandible, pharynx, larynx, and neck. Includes:

Motor nucleus of the Trigeminal - V
Motor nucleus of the Facial - VII
Nucleus Ambiguous of Glossopharyngeal - IX, Vagus - X
Accessory motor nuclei (in upper cervical C1-C5 segments)
Motor nucleus of spinal accessory - XI

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20
Q

Classification - Special Somatic Efferent

A

Does not exist

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21
Q

Classification - General Somatic Afferent

A

Somesthetic input (pain, temperature, touch) from the skin and somatic muscles in the head, neck, and face includes:

Trigeminal - V sensory nerve
- chief sensory nucleus and spinal descending nucleus

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22
Q

Classification - General Visceral Afferent

A

General sensation, pain, and temperature from visceral structures from pharynx, palate, larynx, aorta, and abdomen includes:

Glossopharyngeal - IX
Vagus - X

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23
Q

Classification - Special Somatic Afferent

A

Special senses

Includes:

Optic - II (vision)
Vestibulo-acoustic - VII (audition and equilibrium) Also proprioception

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24
Q

Classification - Special Visceral Afferent

A

Gustation and smell (olfaction). Includes:

Olfactory - I
Facial - VII
Glossopharyngeal - IX
Vagus - X

Special has very special receptors/cells
General is pain and touch

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25
Q

Autonomic Nervous System

A

When the cell is outside the central nervous system its called a ganglia

Vital organs

Additional ganglion

  • pre and post ganglionic positions
  • cranial nerve nuclei
  • corticonuclear tract

****Images clustered CN nuclei, coriconuclear tract

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26
Q

Innervation Pattern

HELP

A

** Image blue background white brain

Bilateral corticonuclear regulation of most CN LMNs

Exceptions:

  • Lower face (VII)
  • SCM/Trap muscles (XI)
  • Lingual muscles (XII)

Ocular muscles - the gaze center
Coordination of both eyes - left frontal cortex to right center

R gaze center - right and left recti contraction

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27
Q

Why are CN’s so Complex?

A

Shared nuclei
- salivatory, solitarius, ambiguus

Shared CN functions - some CNs are doing more than one thing

  • Ocular movement
    • there are 3 CNs for eye movement
  • Tongue sensation
    - there are 2 CNs for tongue sensation, 2 for taste

Look up Summary Table 17-3

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28
Q

Trigeminal Neuralgia

A

AKA Tic Doulaureux

Loss of sensation due to damage to the trigeminal nerve

Stabbing pain

Trigger Point

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29
Q

Herpes Zoster

A

Caused by damage to the trigeminal nerve

Painful disorder along the nerve

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30
Q

Masticator Palsy

A

Caused by damage to the trigeminal nerve

Paralysis of the muscles of mastication

Unilateral UMN = mild paresis because of bilateral innervations; mild effect on muscle strength

Unilateral LMN = twitching, muscle atrophy, and jaw deviation to the side of the lesion

Bilateral (UMN/LMN) lesions = profound impact on chewing,

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31
Q

Bell’s Palsy

A

Due to damage to the Facial nerve

Ipsilateral Facial Paralysis

Sagging face

Loss of taste on anterior ⅔ of tongue

32
Q

Cranial Nerve I

A

Olfactory

Function: Smell

Classification: SVA

Pathways:

Clinical Considerations:

  • Anosmia = unilateral and bilateral lesions
    • Caused by TBI, sinusitis, upper respiratory infections, orbital tumors

Assessment: Odor Identification

Speech Relevance: N/A

33
Q

Cranial Nerve II

A

Optic

Function: Vison

Classification: SVA

Pathways:

Clinical Considerations:

  • Blindness pattern
  • Field of loss patterns

Assessment: Reporting on finger moving from periphery; reflexes

Speech Relevance: N/A

34
Q

Cranial III

A

Oculomotor

Function: Eye Movement

Classification: GSE, GVE

Pathways:

Clinical Considerations:

  • External ophthalmoplegia (ex. recti muscles are paralyzed)
  • Diplopia
  • Internal ophthalmoplegia (pupil is permanently dilated)
  • Ptosis (droopy eyelid)

Assessment:

  • Ocular movement
  • Diplopia
  • Pupillary response to light

Speech Relevance: N/A

35
Q

Cranial Nerve IV

A

Trochlear

Function: Eye Movement

Classification: GSE

Pathways:

Clinical Considerations:

  • Diplopia
  • Peripheral Neuropathy

Assessment:
- Look for eyes moving in coordination

Speech Relevance: N/A

36
Q

Cranial Nerve V

A

Trigeminal

Function:

  • Receives pain/touch from skin and muscles in the face, orbit, nose, mouth, forehead, teeth, meninges, ant. ⅔ of tongue, ext. auditory meatus, and ext. surface of the tympanic membrane.
  • Proprioception of jaw
  • Controls jaw movement

Classification: GSA, SVE

Pathways:

Clinical Considerations:

  • Loss of sensation - Tic Doulaureux
  • Herpes Zoster
  • Masticator Palsy

Assessment:

  • Symmetry during rest and action
  • Jaw movements

Speech Relevance:

  • Dental sounds
  • Bilabial sounds
37
Q

Cranial Nerve VI

A

Abducens

Function:

  • Lateral Eye movements
  • Abducts eye via activation of the lateral rectus muscle

Classification: GSE

Pathways:

Clinical Considerations:

  • Medial Strabismus = no gaze to affected side
  • Diplopia

Assessment : Impaired Ocular movements

Speech Relevance: N/A

38
Q

Cranial Nerve VII

A

Facial

Function:

  • Regulates secretions from the lacrimal and mucosal glands of the nasopharynx and salivary secretion from sublingual and submaxillary glands
  • Mediates taste sensation from anterior ⅔ of tongue and palate
  • Innervates muscles of facial expression, scalp, and stapedius

Classification: GVE, SVA, SVE

Pathways:

Clinical Considerations:

  • Unilateral facial paresis
  • Secretions
  • Taste
  • Bell’s Palsy
  • Hyperacusia

Assessment:

  • Oral Secretion
  • Taste Sensation
  • Facial Symmetry
  • Ability to smile

Speech Relevance:

  • Bilabial Sounds
  • Labiodental sounds
  • Sagging face
  • Drooling of food
  • Loss of taste
39
Q

Cranial Nerve VIII

A

Auditory

Function: Hearing, Equilibrium

Classification: SSA

Pathways:

Clinical Considerations:

  • Hearing Impairments
  • Disequilibrium

Assessment:

  • Repetition of words with masking
  • Weber Test
  • Rinne (Mastoid Placement)

Speech Relevance: Hearing

40
Q

Cranial Nerve IX

A

Glossopharyngeal

Function:

  • Mediates gag and respiratory reflexes
  • Regulates salivary secretion
  • Transmits taste from posterior ⅓ of tongue
  • Contributes to swallowing reflex

Classification: GVE, SVA, SVE

Pathways:

Clinical Considerations:

  • Palatal sensation
  • Gag reflex (afferent)
  • Swallowing
  • Taste (posterior ⅓)
  • Cutaneous senation

Assessment:

Speech Relevance:

  • Can’t form bolus (swallowing)
  • Loss of taste
  • No gag reflex
41
Q

Cranial Nerve X

A

Vagus

Function:

  • Sensation from pharynx, larynx, thorax, carotid body, abdomen
  • Regulates Nausea, oxygen intake, and respiratory reflex
  • Innervates glands, cardiac muscles, trachea, bronchi, esophagus, stomach and intestine
  • Taste sensation
  • Controls muscles of larynx, pharynx, and soft palate

Classification: GVE, SVA, SVE

Clinical Considerations:

Assessment:

  • phonation
  • voice quality
  • swallowing quality
  • resonance quality

Speech Relevance:

  • Swallowing
  • Sensation
  • Dysarthria
  • Palatal Movement
  • Gag reflex
  • Pitch
42
Q

Cranial Nerve XI

A

Spinal Accessory

Function:
- Controls head position by controlling trapezius and sternocleidomastoid muscles

Classification: SVE

Pathways:

Clinical Considerations:

  • UMN - Contralateral Weakness
  • LMN - ipsilateral paralysis = dropped shoulders, deviated head

Assessment:

  • Shrugging/Shoulder movement
  • Head turn against resistance

Speech Relevance: N/A

43
Q

Cranial Nerve XII

A

Hypoglossal

Function: Controls motor movements of the tongue

Classification: GSE

Pathways:

Clinical Considerations:

  • Unilateral LMN = ipsilateral paralysis
  • Bilateral LMN = loss of speech, swallowing, chewing
  • Unilateral UMN = contralateral muscle weakness with gradual recovery
  • Bilateral UMN = complete paralysis

Assessment:

  • Visual appearance
  • Tongue movement against resistance
  • Alternate motion rate

Speech Relevance:

  • Lingual sounds
  • Dental sounds
  • Swallowing
44
Q

Multiple Nerve Innervation

A

Ocular Muscles

Lingual Muscles

Pharyngeal Muscles

45
Q

Cranial Nerve Mediated Reflexes

A

Pupillary Reflex

Corneal Reflex

Gag Reflex

Sneeze Reflex

46
Q

Pupillary Reflex

A

Constriction

Assess through:
Shining light in eye

CN III Efferent fibers
CN II afferent fibers

47
Q

Corneal Reflex

A

Eye blink

Assess through corneal touch

CN VII efferent fibers
CN V afferent fibers

48
Q

Gag Reflex

A

Effort to vomit

Assess through pharyngeal touch

CN X efferent fibers
CN IX, X afferent fibers

49
Q

Sneeze Reflex

A

Sneeze

Assess through nasal irritation

CN X efferent fibers
CN V afferent fibers

50
Q

Cranial Nerve Syndromes

A

Weber Syndrome

Millard-Gubler Syndrome

Locked-in Syndrome

Wallenberg Syndrome

Dejerine Syndrome

51
Q

Weber Syndrome

A

Midbrain

Structures = corticospinal fibers, Oculomotor nerve

Symptoms:

Contralateral hemiplegia

Ipsilateral ocular paralysis

Lateral eye deviation

dilated pupil

Possible ptosis

52
Q

Millard-Gubler Syndrome

A

Lower Pons

Coricospinal nerves, facial nerve, abducens,

Contralateral hemiplegia

Medial strabismus due to ocular paralysis

Ipsilateral facial paralysis

53
Q

Strabismus

A

Eyes don’t look in the same direction at the same time

54
Q

Locked-in Syndrome

A

Bilateral Basal Pons

Motor fibers and Cranial Nerve VI

Quadriplegia

Preserved vertical eye movements

Intact sensation and comprehension

55
Q

Wallenberg Syndrome

A

Lateral Medulla

Trigeminal spinal tract, nucleus ambiguous, spinal lemniscus

Ipsilateral pain sensation loss from face

Contralateral pain sensation loss from body

Dysarthria

56
Q

Dejerine Syndrome

A

Medial Medulla

Hypoglossal Nerve, pyramidal fibers

Contralateral hemiplegia

Contralateral hemianesthesia - loss of sensation

Dysarthria due to ipsilateral lingual paralysis

57
Q

Neurological Motor Speech Assessment - Purpose

A

Identify the following:

Nature of oral deficit

Facial adequacy for speech

Severity of disorder

Implications for treatment

58
Q

Neurological Motor Speech Assessment - Patient History

A

Ask:

Onset and course

Associated deficit:

  • dysphagia and dysarthria
  • fatigue
  • unintelligibility

Perception of deficit by self and/or others

Cognitive ability

59
Q

Neurological Motor Speech Assessment - Salient Motor Features

A

Muscle Strength

Movement speed

Movement range

Movement accuracy and steadiness

Muscle tone

60
Q

Assessment of Muscle Strength

A

Strength Dysfunction:

  • Failure to reach or sustain a level
  • Strength fall with sustained act
  • Inaccurate/excessive/lesser strength

Implications:

  • respiration (incompetence)
  • Laryngeal (incompetence)
  • Palatopharyngeal (emission)
  • Articulatory (precision)
61
Q

Assessment of Speed

A

Speed Dysfunction:

  • slow start
  • slow course & slow delay
  • slow movements with limited range

Implications for speech, prosody, and resonance

62
Q

Assessment of Range

A

Range Disturbance:

  • limited for single/repetitive movement
  • inaccurate and variable range

Implications for speech:

  • prosodic dysfunctions
  • weak articulation
63
Q

Assessment of Movement Accuracy

A

Accuracy Disturbance:
- Over/Under shooting

Implications:

  • random breakdown in speech
  • prosodic variations
64
Q

Assessment of Movement Steadiness

A

Steadiness Disturbance:

  • Tremor
  • Chorea
  • Involuntary Movements

Implications:

  • Articulatory fluctuation
  • Unsustained articulation
  • Premature articulations
  • Random Prosodic interruptions
65
Q

Assessment of Confirmatory Signs of Motor Dysfunction - Non-Speech Symptoms

A

Gait:

  • Clumsy - with wide-based gait
  • Standing - body swaggering from side to side
  • Not walking from heel to toe or in a straight line

Pathological Reflexes

Palsy:
- Single or multiple sets of muscles

Slow and awkward movement

Object dropping

Foot dropping while walking

Unexplained fatigue

66
Q

Assessment of Confirmatory Signs of Motor Dysfunction - Speech Symptoms

A

Sound distortions

Slurred and imprecise speech

Impaired resonance

Slow rate of speech:

  • articulatory duration
  • increased pauses

Reduced loudness

Altered phonation

67
Q

Examination of Motor Speech

A

Symmetry is very important in the brain

Testing Conditions:

  • Rest
  • Non-speech motor activity
  • Sensation
  • Speech activity
68
Q

Assessment - Face

A 
Rest Condition: 
Check for symmetry of
 - eyes
 - nasolabial fold
 - mouth angle
 - philtrum and its ridges
 - cheek curve
 - forehead wrinkles 
 - facial bulk
69
Q

Assessment of Facial Signs of Weakness

A

Masked face

Sagging face/lip

Lack of wrinkles

Absence of nasolabial fold

Wide pallbearer fissure

Flat philtrum

Asymmetric facial contours

70
Q

Assessment of Facial Muscles - MN Involvement

A

Facial muscles are needed for speech and non-speech tasks

Sensation of oral facial muscles

Unilateral UMN – no problem, the patient should be able to make expressions
(the other side will take over)

Bilateral UMN – nothing can do, expression less, very few movements

Unilateral LMN – one side is affected

Bilateral LMN (both facial nerves are damaged)– patient cannot do anything, both sides of the face are affected

**profound affects with bilateral

71
Q

Assessment of Mandibular Muscles

A

At rest condition:

  • manidble asymmetry and bulk
  • bilateral jaw sagging

Non-speech activities:

  • jaw opening/closing with or without resistance
  • lateral jaw movement against force
  • bulk during jaw clenching
  • holding tongue depressor

Sensation Assessment

Speech Tasks

LMN/UMN/Bilateral involvement
- Bilateral = big issue

72
Q

Assessment of Tongue

A

At rest condition:

  • Symmetry
  • Fibrillations at edges

Non-Speech Motor Activities:

  • Protrusion
  • Movements
  • Movements against resistance

Sensation:
- 3 CNs for tongue sensation =

Speech Tasks

UMN/LMN/Bilateral Involvement
UMN - unilateral = contralateral problem with tongue
LMN = ipsilateral problem with the tongue
Bilateral = devastating

73
Q

Assessment of Palatopharyngeal Port

A

At rest condition:

  • Symmetry of arch while saying “ah”
  • Unilateral palatal asymmetry (deviates to good side)
  • Bilateral palatal asymmetry (affects gag reflex because whole palate comes down

Sensation

Speech Tasks

  • Produce “ah” and “ga”
  • Deviation to good side
  • Lower excursions

LMN/UMN/Bilateral Involvement:

Unilateral UMN = asymmetry, but minimal
Unilateral LMN = vagus or trigeminal nerve; one side will go down, ipsilateral
Bilateral = whole thing comes down

74
Q

Assessment of Larynx

A

At rest condition:
- Position of head and shoulders

Sensation

Non-speech tasks:
- Coughing/Throat clearing

Speech tasks:
- Roughness, hoarseness, breathiness

UMN/LMN/Bilateral Involvement:

Unilateral UMN (ALWAYS CONTRALATERAL): no profound impact because of bilateral innervation

Bilateral UMN – profound impact on vocal folds (present the same as bilateral LMN)

Uni LMN = ipsilateral, LMN (ALWAYS IPSILATERAL): one vocal fold would be fixed in para-medium position (hoarseness, diplophonia, breathiness)

Bilateral LMN: both vocal folds would be fixed in para-medium position

75
Q

Assessment of Respiratory Capacity

A

At rest condition:

  • Posture - changed or abnormal posture
  • Shortness of breath
  • Abnormal breathing patterns - chest breathing

Speech tasks:
- Water glass manometer (bubble generation)

76
Q

Assessment of Speech Quality

A

Contextual Attributes of Spontaneous Speech:

  • Intelligibility
  • Intensity
  • Resonance characteristics
  • Naturalness

Intelligibility and naturalness go when there is any kind of dysarthria

77
Q

Additional Aspects of Assessment

A

Stress reading
- Need to read with lots of energy/stress

Vowel Prolongation
- Duration, steadiness, loudness

Sequential Motion Rate =
Alternate Motion Rate =

Speed and regularity of movements

Neuromuscular (2 decks)

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