1. Gross Anatomy: Review of Autonomics in the Head and Neck

2. General principles of autonomic innervation to the structures of the head and neck:

3. Cranial Nerves with Parasympathetic Functional Componenents
1. Olfactory CN I (SVA) Sensory
2. Optic CN II (SSA) Sensory
3. Oculomotor CN III (GSE, GVE-P) Motor
4. Trochlear CN IV (GSE) Motor
5. Trigeminal CN V (GSA, SVE) Both
6. Abducens CN VI (GSE) Motor
7. Facial CN VII (SVE, GSA, SVA, GVA, GVE-P) Both
8. Vestibulocochlear CN VIII (SSA, SSE) Sensory
9. Glossopharyngeal CN IX (SVE, GSA, SVA, GVA, GVE-P) Both
10. Vagus CN X (SVE, GSA, SVA, GVA, GVE-P) Both
11. Accessory CN XI (GSE) Motor
12. Hypoglossal CN XII (GSE) Motor

4. Head and Neck Parasympathetics – KEY Points
CN V is the great sensory nerve to structures of the head and provides a ready-made route to all structures which need to be innervated autonomically
The four parasympathetic ganglia [COPS] in the head are “associated” with CN V:
V1 (ciliary)
V2 (pterygopalatine)
V3 (submandibular and otic)
Autonomic fibers of CN III, VII, and IX “hitchhike” along these routes to gain their target organs

5. Head and Neck Sympathetics – KEY Points
Preganglionic sympathetic axons arise from the IML cell column at T1 – T4
Enter the sympathetic chain via white rami
Ascend in the sympathetic chain
All preganglionic fibers associate with viscera of the head and neck synapse in the superior cervical sympathetic ganglion
Therefore, THERE ARE NO PRE-GANGLIONIC SYMPATHETIC FIBERS IN THE HEAD

6. Sympathetic Pathways
T1 – T4

7. Postganglionics leave the Superior Cervical Ganglion as the:
External carotid nerve: located on the surface of the external carotid artery; distributes to superficial viscera of the head/neck via branches of this vessel
Internal carotid nerve: located on the surface of the internal carotid artery; forms a plexus that contributes branches to the:
Glands in the middle ear (caroticotympanic branches)
lacrimal gland and mucous glands of the nasal cavity, oral cavity, pharynx [deep petrosal nerve joins the nerve of the pterygoid canal which in turn distribute via branches of maxillary nerve].
Dilator pupillae muscle [cavernous plexus gives rise to the sympathetic root of the ciliary ganglion that distribute by short ciliary nerves].

8. Autonomic innervation of the ciliary and pupillary muscles:

9. Parasympathetic Innervation
The ciliary ganglion:
has sensory, sympathetic and motor roots
receives preganglionic parasympathetic axons (from the brainstem/CN III) via the motor root
gives rise to postsynaptic axons that travel in short ciliary nerves to the ciliary muscle and sphincter pupillae

10. Sympathetic Innervation
postganglionic sympathetic fibers arise from the superior cervical ganglion and travel along the cavernous plexus
reach the orbit on ophthalmic artery or CN III
traverse the ciliary ganglion without synapse
Innervates the dilator pupillae muscle and superior tarsal muscle

12. Autonomic innervation of the mucous glands of the head:

13. Parasympathetic Innervation
preganglionic parasympathetic fibers course in CN VII (greater petrosal nerve  nerve of the pterygoid canal)
synapse in the pterygopalatine ganglion
postganglionic parasympathetic fibers “hitchhike” along branches of CN V2 to reach the lacrimal, oral, palatal, nasal and pharyngeal mucous glands

14. Cranial Nerve VII

15. Sympathetic Innervation
postganglionic sympathetic fibers arise from the superior cervical ganglion and travel in the cavernous plexus
forms the deep petrosal nerve and joins the greater petrosal nerve to form the nerve of the pterygoid canal
fibers traverse the pterygopalatine ganglion without synapse
reach the viscera along branches of the maxillary artery and/or follow branches of CN V

16. Pterygopalatine Ganglion

17. Autonomic innervation of the salivary glands:

18. Parasympathetic Innervation
preganglionic parasympathetic fibers course in CN VII (chorda tympani)
joins the lingual nerve in the infratemporal fossa
synapse in the submandibular ganglion
postganglionic parasympathetic fibers innervate submandibular, sublingual and lingual salivary glands

19. Parasympathetic Innervation
preganglionic parasympathetic fibers course in CN IX (tympanic nerve lesser petrosal nerve)
synapse in the otic ganglion
postganglionic parasympathetic fibers travel along CN V3 (auriculotemporal nerve) to innervate the parotid gland

20. Parasympathetic Routes to the Salivary Glands

21. Sympathetic Innervation
postganglionic sympathetic fibers arise from the superior cervical ganglion and travel in the external carotid plexus
travel on the facial artery
reach the viscera along branches CN V3

22. Autonomic innervation of the smooth muscle and glands in the pharynx and larynx:

23. Parasympathetic Innervation
preganglionic parasympathetic fibers course in CN X (pharyngeal branches, internal laryngeal nerve, recurrent laryngeal nerve)
enter pharynx and larynx to synapse in intramural ganglia

24. Sympathetic Innervation
T1 – T4
Sympathetic Innervation
preganglionic sympathetic fibers arise in the IML cell column (T1 – 4)
synapse in the sympathetic chain
laryngopharyngeal branches

25. A 24-year-old female presents to the emergency room 5-days after a bar fight with the chief complaints of a “messed up hand and funny eye”. Physical examination reveals the images below.
Where is the injury?
What is the diagnosis?
What other signs would most likely be present on PE?

26. A 54-year-old male presents to the emergency room with the chief complaints of headache and hoarseness. Physical examination reveals a weak gag reflex and the image below.
Where is the injury?
What is the diagnosis?
Horner’s Syndrome also occurs in:
cervical spinal cord injury
Brainstem strokes
apical lung tumors