Medicine

1

1. 10^th, 11^th, 12^th cranial nerves

2. Cervical plexus. Organ of taste

3. Preparation of brain and cranial nerves

Lesson No 23

Theme 1. 10^th, 11^th, 12^th cranial nerves

X Vagus nerve (mixed) contains motor fibers which start from nucleus ambiguus, parasympathetic (preganglionic) fibers form dorsal nucleus and sensory fibers from superior and inferior ganglia in jugular foramen.

·Cranial part of vagus nerve gives off the following branches:

Meningeal branch which starts from superior ganglion and passes to cranial dura mater in posterior cranial fossa;

Auricular branch, which starts from superior ganglion

, passes over mastoid canalicule of temporal bone and innervates the skin of external surface of auricle and posterior wall of external acoustic meatus.

The vagus nerve is composed of both motor and sensory fibers, and has a more extensive course and distribution than any of the other cranial nerves, since it passes through the neck and thorax to the abdomen.

Upper part of medulla spinalis and hind- and mid-brains; posterior aspect, exposed in situ

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. Some of the sensory fibers of the glossopharyngeal nerve have been seen to end in the upper part of this nucleus. 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, few in number, 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. The somatic motor fibers arise from the cells of the nucleus ambiguus, already referred to in connection with the motor root of the glossopharyngeal nerve.

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. In emerging through this opening, the vagus is accompanied by and contained in the same sheath of dura mater with the accessory nerve, a septum separating them from the glossopharyngeal which lies in front . In this situation the vagus presents a well-marked ganglionic enlargement, which is called the jugular ganglion (ganglion of the root); to it the accessory nerve is connected by one or two filaments. After its exit from the jugular foramen the vagus is joined by the cranial portion of the accessory nerve, and enlarges into a second gangliform swelling, called the ganglion nodosum (ganglion of the trunk); through this the fibers of the cranial portion of the accessory pass without interruption, being principally distributed to the pharyngeal and superior laryngeal branches of the vagus, but some of its fibers descend in the trunk of the vagus, to be distributed with the recurrent nerve and probably also with 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.

On the right side, the nerve passes across the subclavian artery between it and the right innominate vein, and descends by the side of the trachea to the back of the root of the lung, where it spreads out in the posterior pulmonary plexus. From the lower part of this plexus two cords descend on the esophagus, and divide to form, with branches from the opposite nerve, the esophageal plexus. Below, these branches are collected into a single cord, which runs along the back of the esophagus enters the abdomen, and is distributed to the postero-inferior surface of the stomach, joining the left side of the celiac plexus, and sending filaments to the lienal plexus.

Course and distribution of the glossopharyngeal, vagus, and accessory nerves

On the left side, the vagus enters the thorax between the left carotid and subclavian arteries, behind the left innominate vein. It crosses the left side of the arch of the aorta, and descends behind the root of the left lung, forming there the posterior pulmonary plexus. From this it runs along the anterior surface of the esophagus, where it unites with the nerve of the right side in the esophageal plexus, and is continued to the stomach, distributing branches over its anterosuperior surface; some of these extend over the fundus, and others along the lesser curvature. Filaments from these branches enter the lesser omentum, and join the hepatic plexus.

The Jugular Ganglion (ganglion jugulare; ganglion of the root) is of a grayish color, spherical in form, about 4 mm. in diameter.

Branches of Communication.—This ganglion is connected by several delicate filaments to the cranial portion of the accessory nerve; it also communicates by a twig with the petrous ganglion of the glossopharyngeal, with the facial nerve by means of its auricular branch, and with the sympathetic by means of an ascending filament from the superior cervical ganglion.

The Ganglion Nodosum (ganglion of the trunk; inferior ganglion) is cylindrical in form, of a reddish color, and 2.5 cm. in length. Passing through it is the cranial portion of the accessory nerve, which blends with the vagus below the ganglion.

Branches of Communication.—This ganglion is connected with the hypoglossal, the superior cervical ganglion of the sympathetic, and the loop between the first and second cervical nerves.

Branches of Distribution.—The branches of distribution of the vagus are:

In the Jugular Fossa…

Meningeal.

Auricular.

In the Neck…………

Pharyngeal.

Superior laryngeal.

Recurrent.

Superior cardiac.

In the Thorax……….

Inferior cardiac.

Anterior bronchial.

Posterior bronchial.

Esophageal.

In the Abdomen…….

Gastric.

Celiac.

Hepatic.

The Meningeal Branch (ramus meningeus; dural branch) is a recurrent filament given off from the jugular ganglion; it is distributed to the dura mater in the posterior fossa of the base of the skull.

The Auricular Branch (ramus auricularis; nerve of Arnold) arises from the jugular ganglion, and is joined soon after its origin by a filament from the petrous ganglion of the glossopharyngeal; it passes behind the internal jugular vein, and enters the mastoid canaliculus on the lateral wall of the jugular fossa. Traversing the substance of the temporal bone, it crosses the facial canal about 4 mm. above the stylomastoid foramen, and here it gives off an ascending branch which joins the facial nerve. The nerve reaches the surface by passing through the tympanomastoid fissure between the mastoid process and the tympanic part of the temporal bone, and divides into two branches: one joins the posterior auricular nerve, the other is distributed to the skin of the back of the auricula and to the posterior part of the external acoustic meatus.

The Pharyngeal Branch (ramus pharyngeus), the principal motor nerve of the pharynx, arises from the upper part of the ganglion nodosum, and consists principally of filaments from the cranial portion of the accessory nerve. It passes across the internal carotid artery to the upper border of the Constrictor pharyngis medius, where it divides into numerous filaments, which join with branches from the glossopharyngeal, sympathetic, and external laryngeal to form the pharyngeal plexus. From the plexus, branches are distributed to the muscles and mucous membrane of the pharynx and the muscles of the soft palate, except the Tensor veli palatini. A minute filament descends and joins the hypoglossal nerve as it winds around the occipital artery.

The Superior Laryngeal Nerve (n. laryngeus superior) larger than the preceding, arises from the middle of the ganglion nodosum and in its course receives a branch from the superior cervical ganglion of the sympathetic. It descends, by the side of the pharynx, behind the internal carotid artery, and divides into two branches, external and internal.

The external branch (ramus externus), the smaller, descends on the larynx, beneath the Sternothyreoideus, to supply the Cricothyreoideus. It gives branches to the pharyngeal plexus and the Constrictor pharyngis inferior, and communicates with the superior cardiac nerve, behind the common carotid artery.

The internal branch (ramus internus) descends to the hyothyroid membrane, pierces it in company with the superior laryngeal artery, and is distributed to the mucous membrane of the larynx. Of these branches some are distributed to the epiglottis, the base of the tongue, and the epiglottic glands; others pass backward, in the aryepiglottic fold, to supply the mucous membrane surrounding the entrance of the larynx, and that lining the cavity of the larynx as low down as the vocal folds. A filament descends beneath the mucous membrane on the inner surface of the thyroid cartilage and joins the recurrent nerve.

The Recurrent Nerve (n. recurrens; inferior or recurrent laryngeal nerve) arises, on the right side, in front of the subclavian artery; winds from before backward around that vessel, and ascends obliquely to the side of the trachea behind the common carotid artery, and either in front of or behind the inferior thyroid artery. On the left side, it arises on the left of the arch of the aorta, and winds below the aorta at the point where the ligamentum arteriosum is attached, and then ascends to the side of the trachea. The nerve on either side ascends in the groove between the trachea and esophagus, passes under the lower border of the Constrictor pharyngis inferior, and enters the larynx behind the articulation of the inferior cornu of the thyroid cartilage with the cricoid; it is distributed to all the muscles of the larynx, excepting the Cricothyreoideus. It communicates with the internal branch of the superior laryngeal nerve, and gives off a few filaments to the mucous membrane of the lower part of the larynx.

As the recurrent nerve hooks around the subclavian artery or aorta, it gives off several cardiac filaments to the deep part of the cardiac plexus. As it ascends in the neck it gives off branches, more numerous on the left than on the right side, to the mucous membrane and muscular coat of the esophagus; branches to the mucous membrane and muscular fibers of the trachea; and some pharyngeal filaments to the Constrictor pharyngis inferior.

The Superior Cardiac Branches (rami cardiaci superiores; cervical cardiac branches), two or three in number, arise from the vagus, at the upper and lower parts of the neck.

The upper branches are small, and communicate with the cardiac branches of the sympathetic. They can be traced to the deep part of the cardiac plexus.

The lower branch arises at the root of the neck, just above the first rib. That from the right vagus passes in front or by the side of the innominate artery, and proceeds to the deep part of the cardiac plexus; that from the left runs down across the left side of the arch of the aorta, and joins the superficial part of the cardiac plexus.

·Cervical part of vagus nerve gives off:

Pharyngeal branches with branches of Glossopharyngeal nerve and sympathetic trunk form pharyngeal plexus, that innervates mucous membrane and muscles of the throat (superior and middle constrictors; levator veli palatini, palatopharyngeus and palatoglossus, uvulae muscles).

Superior cervical cardiac branches pass downward along common carotid artery and communicate with sympathetic nerves, enter into cardiac plexus and supply the heart (sensory and parasympathetic innervating).

Superior laryngeal nerve originate from inferior ganglion and carry sensory, motor and parasympathetic preganglionic fibers. Motor fibers of the external branch innervate cricothyroid and inferior constrictor muscles, sensory fibers (internal branch) supply mucous membrane of the larynx over vocal fold, mucous membrane of the epiglottis and tongue root.

Recurrent laryngeal nerve passes upward between esophagus and trachea and sends a numerous twigs. Inferior laryngeal nerve supplies mucous membrane of the larynx below vocal fold and the rest of muscles (thyroarytenoid, lateral and posterior cricoarytenoid, transverse and oblique arytenoid, vocalis). Tracheal, esophageal and inferior cervical cardiac branches supply internal organs.

Thoracic part of vagus nerve gives off:

Thoracic cardiac branches which pass to cardiac plexus;

Bronchial branches with sympathetic nerves form pulmonary plexus. Last enters in lungs with bronchi.

Esophageal branches form esophageal plexus round this organ.

Abdominal part of vagus nerve is represented by anterior and posterior vagal trunks, which originate from esophageal plexus. Anterior vagal trunk located on front surface of the stomach and gives branches gives off the anterior gastric and hepatic branches. Posterior vagal trunk supplies back gastric wall, and gives off coeliac branches to reach coeliac plexus. Then fibers of vagus nerve with sympathetic fibers supply the liver, spleen, pancreas, kidneys, small and large intestine (including a upper department of descending colon).

Hypoglossal nerve, cervical plexus, and their branches

The accessory nerve consists of two parts: a cranial and a spinal.

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 lateralward to 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 uvulæ and Levator veli palatini. Some few filaments from it are continued into the trunk of the vagus below the ganglion, to be distributed with the recurrent nerve and probably also with the cardiac nerves.

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 of the medulla spinalis as low as the fifth cervical nerve. 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. As its exit from the jugular foramen, it runs backward in front of the internal jugular vein in 66.6 per cent. of cases, and behind in it 33.3 per cent. (Tandler). 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.

The Hypoglossal Nerve

(N. Hypoglossus; Twelfth Nerve)

The hypoglossal nerve is the motor nerve of the tongue.

Its fibers arise from the cells of the hypoglossal nucleus, which is an upward prolongation of the base of the anterior column of gray substance of the medulla spinalis. This nucleus is about 2 cm. in length, and its upper part corresponds with the trigonum hypoglossi, or lower portion of the medial eminence of the rhomboid fossa (page 779). The lower part of the nucleus extends downward into the closed part of the medulla oblongata, and there lies in relation to the ventro-lateral aspect of the central canal. The fibers run forward through the medulla oblongata, and emerge in the antero-lateral sulcus between the pyramid and the olive.

The rootlets of this nerve are collected into two bundles, which perforate the dura mater separately, opposite the hypoglossal canal in the occipital bone, and unite together after their passage through it; in some cases the canal is divided into two by a small bony spicule. The nerve descends almost vertically to a point corresponding with the angle of the mandible. It is at first deeply seated beneath the internal carotid artery and internal jugular vein, and intimately connected with the vagus nerve; it then passes forward between the vein and artery, and lower down in the neck becomes superficial below the Digastricus. The nerve then loops around the occipital artery, and crosses the external carotid and lingual arteries below the tendon of the Digastricus. It passes beneath the tendon of the Digastricus, the Stylohyoideus, and the Mylohyoideus, lying between the last-named muscle and the Hyoglossus, and communicates at the anterior border of the Hyoglossus with the lingual nerve; it is then continued forward in the fibers of the Genioglossus as far as the tip of the tongue, distributing branches to its muscular substance.

Branches of Communication.—Its branches of communication are, with the

Vagus. First and second cervical nerves.

Sympathetic. Lingual.

The communications with the vagus take place close to the skull, numerous filaments passing between the hypoglossal and the ganglion nodosum of the vagus through the mass of connective tissue which unites the two nerves. As the nerve winds around the occipital artery it gives off a filament to the pharyngeal plexus.

The communication with the sympathetic takes place opposite the atlas by branches derived from the superior cervical ganglion, and in the same situation the nerve is joined by a filament derived from the loop connecting the first and second cervical nerves.

The communications with the lingual take place near the anterior border of the Hyoglossus by numerous filaments which ascend upon the muscle.

Branches of Distribution.—The branches of distribution of the hypoglossal nerve are:

Meningeal. Thyrohyoid.

Descending. Muscular.

Of these branches, the meningeal, descending, thyrohyoid, and the muscular twig to the Geniohyoideus, are probably derived mainly from the branch which passes from the loop between the first and second cervical to join the hypoglossal

Meningeal Branches (dural branches).—As the hypoglossal nerve passes through the hypoglossal canal it gives off, according to Luschka, several filaments to the dura mater in the posterior fossa of the skull.

The Descending Ramus (ramus descendens; descendens hypoglossi), long and slender, quits the hypoglossal where it turns around the occipital artery and descends in front of or in the sheath of the carotid vessels; it gives a branch to the superior belly of the Omohyoideus, and then joins the communicantes cervicales from the second and third cervical nerves; just below the middle of the neck, to form a loop, the ansa hypoglossi. From the convexity of this loop branches pass to supply the Sternohyoideus, the Sternothyreoideus, and the inferior belly of the Omohyoideus. According to Arnold, another filament descends in front of the vessels into the thorax, and joins the cardiac and phrenic nerves.

The Thyrohyoid Branch (ramus thyreohyoideus) arises from the hypoglossal near the posterior border of the hyoglossus; it runs obliquely across the greater cornu of the hyoid bone, and supplies the Thyreohyoideus muscle.

The Muscular Branches are distributed to the Styloglossus, Hyoglossus, Geniohyoideus, and Genioglossus. At the under surface of the tongue numerous slender branches pass upward into the substance of the organ to supply its intrinsic muscles.

The Cervical plexus is formed from the ventral rami of the first four spinal nerves (C1-C4). It is located under sternocleidomastoid muscle. The motor, cutaneous and mixed nerves start from this plexus.

Short motor branches run directly to the deep cervical muscles: the anterior and lateral rectus capitis muscles, and the longus capitus and longus colli muscles of the head and neck, anterior, middle and posterior scalenus muscles, also sternocleidomastoid and trapezius muscles. Fibers associated with the hypoglossal nerve and form the ansa cervicalis that innervates the infrahyoid muscles: the omohyoid, sternothyroid and sternohyoid, thyrohyoid.

The sensory nerves of the plexus penetrate the fascia behind the sternocleidomastoid muscle:

· transverse cervical nerve of the neck (supplies the anterior cervical region)

· lesser occipital nerve (for lateral occipital region)

· greater auricular nerve (the region of the ear)

· supraclavlcular nerves (supply the supraclavicular region, the shoulder and the upper thoracic region)

The Phrenic nerve (mixed) enters the superior thoracic aperture and runs through the mediastinum to the diaphragm, giving off small branches for the sensory innervation of the pericardium. It divides on the surface of the diaphragm to supply all the diaphragmatic muscle. Branches provide the sensory fibers to the serous coverings of the diaphragm, the pleura cranially and caudally the peritoneum covering it and the liver and gallbladder.

Plan of hypoglossal nerve

TASTE ORGAN

In man gustatory buds (2000 in number) are situated in mucous membrane of the tongue, palatine, pharynx, epiglottis. Most of gustatory buds localised in vallatae, foliatae and fungiform papillae of the tongue. In front 2/3 part of tongue tasting impulses are perceived by fibres of chorda tympani (intermediate nerve), in back 1/3 portion of tongue – by glossopharyngeal nerve, in lingual root and epiglottis – by fibres of vagus nerve.

The central process of first neurons, that are situated in mouth cavity, pass in composition of VII, IX, X cranial nerves to tasting sensory nucleus that positioned in medulla oblongata - nucleus tractus solitarius. Axons of second neurons run to the thalamus, where the third neuron is situated. Axons of third neurons terminate in uncus (cortex of cerebrum), where is situated a cortical taste analyzer.

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Theme 3. preparations OF BRAIN AND CRANIAL NERVES

The inferior surface is concave, and is continuous posteriorly with the tentorial surface of the occipital lobe. It is traversed by the inferior temporal sulcus, which extends from near the occipital pole behind, to within a short distance of the temporal pole in front, but is frequently subdivided by bridging gyri. Lateral to this fissure is the narrow tentorial part of the inferior temporal gyrus, and medial to it the fusiform gyrus, which extends from the occipital to the temporal pole; this gyrus is limited medially by the collateral fissure, which separates it from the lingual gyrus behind and from the hippocampal gyrus in front.

The Insula (island of Reil; central lobe) lies deeply in the lateral or Sylvian fissure, and can only be seen when the lips of that fissure are widely separated, since it is overlapped and hidden by the gyri which bound the fissure. These gyri are termed the opercula of the insula; they are separated from each other by the three rami of the lateral fissure, and are named the orbital, frontal, frontoparietal, and temporal

opercula. The orbital operculum lies below the anterior horizontal ramus of the fissure, the frontal between this and the anterior ascending ramus, the parietal between the anterior ascending ramus and the upturned end of the posterior ramus, and the temporal below the posterior ramus. The frontal operculum is of small size in those cases where the anterior horizontal and ascending rami of the lateral fissure arise from a common stem. The insula is surrounded by a deep circular sulcus which separates it from the frontal, parietal, and temporal lobes. When the opercula have been removed, the insula is seen as a triangular eminence, the apex of which is directed toward the anterior perforated substance. It is divided into a larger anterior and a smaller posterior part by a deep sulcus, which runs backward and upward from the apex of the insula. The anterior part is subdivided by shallow sulci into three or four short gyri, while the posterior part is formed by one long gyrus, which is often bifurcated at its upper end. The cortical gray substance of the insula is continuous with that of the different opercula, while its deep surface corresponds with the lentiform nucleus of the corpus striatum.

The term limbic lobe was introduced by Broca, and under it he included the cingulate and hippocampal gyri, which together arch around the corpus callosum and the hippocampal fissure. These he separated on the morphological ground that they are well-developed in animals possessing a keen sense of smell (osmatic animals), such as the dog and fox. They were thus regarded as a part of the rhinencephalon, but it is now recognized that they belong to the neopallium; the cingulate gyrus is therefore sometimes described as a part of the frontal lobe, and the hippocampal as a part of the temporal lobe

The insula of the left side, exposed by removing the opercula.

The Thalamencephalon.—The thalamencephalon comprises: (1) the thalamus; (2) the metathalamus or corpora geniculata; and (3) the epithalamus, consisting of the

trigonum habenulæ, the pineal body, and the posterior commissure.

Dissection showing the ventricles of the brain.

Connections.—The thalamus may be regarded as a large ganglionic mass in which the ascending tracts of the tegmentum and a considerable proportion of the fibers of the optic tract end, and from the cells of which numerous fibers (thalamocortical) take origin, and radiate to almost every part of the cerebral cortex. The lemniscus, together with the other longitudinal strands of the tegmentum, enters its ventral part: the thalamomammillary fasciculus (bundle of Vicq d’Azyr), from the corpus mammillare, enters in its anterior tubercle, while many of the fibers of the optic tract terminate in its posterior end. The thalamus also receives numerous fibers (corticothalamic) from the cells of the cerebral cortex. The fibers that arise from the cells of the thalamus form four principal groups or stalks: (a) those of the anterior stalk pass through the frontal part of the internal capsule to the frontal lobe; (b) the fibers of the posterior stalk (optic radiations) arise in the pulvinar and are conveyed through the occipital part of the internal capsule to the occipital lobe; (c) the fibers of the inferior stalk leave the under and medial surfaces of the thalamus, and pass beneath the lentiform nucleus to the temporal lobe and insula; (d) those of the parietal stalk pass from the lateral nucleus of the thalamus to the parietal lobe. Fibers also extend from the thalamus into the corpus striatum—those destined for the caudate nucleus leave the lateral surface, and those for the lentiform nucleus, the inferior surface of the thalamus.

The Metathalamus comprises the geniculate bodies, which are two in number—a medial and a lateral—on each side.