5 - Cranial Nerves

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Cranial nerves
Miss Mis a 37-year-old lady who has noticed a visual disturbance progressively worsening over the past three months. Please
examine her cranial nerves.
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Actor briefing
You are Miss M, a 37 year old lady who has recently noticed some
changes in her vision, being unable to see peripheral objects (Le. tunnel
vision). Do not offer any information to the candidate, but you may
respond to specific questions related to the examination, and be
responsive to their instructions.
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Cranial nerves
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Examiner briefing
The aim of this station is for the candidate to demonstrate that they are
able to clinically assess all cranial nerves in an ordered manner.
If they stop to say that they would do something but do not have the
necessary equipment (e.g smelling salts for the olfactory nerve, Snellen
chart for acuity), ask them to proceed as these can be discussed in the
viva at the end of the station.
Next question -.
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Cranial nerves
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On examination of the optic nerve the patient has:
Bitemporal hemianopia
Visual acuity and pupillary reflexes are normal.
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Cranial nerves
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On examination of the oculomotor, trochlear and abducent nerves the

patient has:
Normal eye movements and no nystagmus. The patient reports no

double vision.
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Cranial nerves
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On examination of the trigeminal nerve the patient has:
Normal sensation in the area supplied by the 3 branches.
Motor supply to the muscles of mastication is intact.
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Cranial nerves
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On examination of the facial nerve the patient has
Motor supply is intact from each of the 5 branches bilaterally.
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Cranial nerves
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On examination of the vestibulocochlear nerve the patient has:
Normal hearing.
Normal Weber's test and positive Rinne's test.
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Cranial nerves
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On examination of the glossopharyngeal and vagus nerves the patient has:
A normal cough and no deviation of the soft palate.
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Cranial nerves
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On examination of the accesory nerve the patient has:
Normal power to the trapezius and sternocleidomastoid muscles

bilaterally
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On examination of the hypoglossal nerve the patient has:
No obvious fasciculations of the tongue and normal tongue movements.
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Cranial nerves
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Please present your findings
Today in clinic I examined Miss M, a 37-year-old lady. Examination of

her optic nerve revealed a bitemporal hemianopia. I was unable to
formally assess the olfactory nerve or visual acuity, but found no other
abnormalities of any of the remaining cranial nerves.
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Cranial nerves
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What would you do to complete your examination?
To complete my examination I would
Formally assess the olfactory nerve with smelling salts.

Formally assess visual acuity using a Snellen chart.
Perform fundoscopy to check for papilloedema as a result of raised
intracranial pressure.
Check for corneal and gag reflexes
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Where might the lesion be to cause this lady's symptoms?
A bitemporal hemianopia is suggestive of a lesion affecting the optic

chiasm, where the more medial fibres cross over to the contralateral
eye. This may be either a lesion of the optic chiasm itself or a mass
pressing on it (e.g. a pituitary tumour).
If a mass arises from above the chiasm (e.g pituitary

craniopharyngioma), the initial symptoms may be of a bitemporal
inferior quadrantanopia, progressing to a bitemporal hemianopia.
Conversely, masses arising below the chiasm may present at first with
bitemporal superior quadrantanopia.
Lesions of optic nerve fibres between the eye and chiasm cause
unilateral blindness.
Lesions of fibres between the chiasm and visual cortex cause a
homonymous hemianopia.
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What else might you expect if a pituitary tumour were the cause of this
lady's bitemporal hemianopia?
The other signs and symptoms of a pituitary tumour can be general or

specfic to hormone production:
General - raised intracranial pressure may cause papilloedema (as

seen on fundoscopy) or headaches.
Specific - hyperpituitarism: this depends on the type of hormone

secreted. The most common are growth hormone and prolactin from
pituitary adenomas. The former causes acromegaly and the latter
hyperprolactinaemia.
Signs of acromegaly - prognathism, prominent brow, macroglossia,

thickening of the skin, enlargement of hands and feet, hyperhidrosis,
carpal tunnel syndrome
Signs of hyperprolactinaemia - increased lactation, loss of libido,

erectile dysfunction in males, amenorrhoea and infertility (anovulatory)
in females.
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Cranial nerves
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Key information
Here is a proforma that can be adapted to whatever cranial nerve

examination you are asked to perform
Initially
Wash your hands

Introduce yourself
Permission - may I examine you today please?
Exposure - full head and neck
Reposition - Patient sitting in a chair. Sit or kneel in front of them, with
your eye-line level with theirs.
General inspection
Look for any obvious facial asymmetry or scars on the head/scalp.
It is important to perform your examination in an ordered fashion - this

demonstrates knowledge of the anatomy and function of the cranial
nerves.
Cranial Nerve I
You will not have to perform this in the exam, but you would formally
assess with smelling salts.
Cranial Nerve II
Visual acuity - performed formally with a Snellen chart.
Colour vision - use Ishihara plates
Visual fields - check first for inattention by holding your fingers out at the
edge of the patient's vision and ask them which one you are wiggling.
Fields can be grossly tested by asking the patient to cover the eye
opposite the one you are covering and test fields in all four quadrants by
slowly moving a finger into view. This way you can compare the
patient's visual fields to your own.
Pupillary examination - first inspect for size and symmetry. Test pupil
reflexes to light and consensual light reflexes (shine light in one eye,
and the other pupil should also constrict).
Cranial Nerves Ill, IV and VI

Eye movements - asking the patient to keep their head still, get them to
follow your finger in a wide H shape. Look for nystagmus and ask the
patient if they experience any double vision at the peripheries.
Cranial Nerve V
Sensation - test all 3 branches bilaterally: Ophthalmic-forehead;
Maxillary-cheekbones and Mandibular-angle of jaw.
Motor supply to muscles of mastication - ask to clench jaw and open
jaw against resistance.
Cranial Nerve VII

Muscles of facial expression supplied by 5 branches:
Temporal - ask patient to raise eyebrows
Zygomatic- ask patient to screw up their eyes
Buccal- ask patient to puff out cheeks
Mandibular - ask patient to show you their teeth
Cervical - ask patient to grimace (platysma)
Cranial Nerve VIII

Weber's Test - Place tuning fork in the centre of the forehead (should be
same volume in both ears)
Rinne's Test - Tuning fork by external auditory meatus and on mastoid
bone (should be louder by auditory meatus = Rinne's positive)
Cranial Nerve IX and X

Ask patient to open mouth and say 'ah' - look for deviation of soft palate
(deviates TOWARDS normal side)
Ask patient to cough (assesses adduction of vocal cords as supplied by
the vagus nerve)
Cranial Nerve XI
Test power of:
Trapezius - ask patient to shrug shoulders against resistance
Sternocleidomastoid - ask patient to turn head to the side and feel SCM
bulk on side which the patient is facing away from
Cranial Nerve XII

Inspect tongue for fasciculations
Ask patient to stick tongue out and wiggle from side to side (tongue
deviates AWAY from normal side)
To complete my examination I would:

Forrmally assess the olfactory nerve with smelling salts.
Formally assess visual acuity using a Snellen chart.
Perform fundoscopy to check for papilloedema as a result of raised
intracranial pressure.
Formally assess taste.
Check for corneal and gag reflexes
Thank the patient, wash your hands, and turn to the examiner
"Today in clinic I examined Miss M, a 37 year old lady. Examination of

her optic nerve revealed a bitemporal hemianopia. I was unable to
formally assess the olfactory nerve or visual acuity, but found no other
abnormalities of any of the remaining cranial nerves."
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5 - Cranial Nerves

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PassTheMRCS x ;i, - ~

On examination of the optic nerve the patient has:

Visual acuity and pupillary reflexes are normal.

On examination of the oculomotor, trochlear and abducent nerves the

Normal eye movements and no nystagmus. The patient reports no

On examination of the trigeminal nerve the patient has:

Normal sensation in the area supplied by the 3 branches.

Motor supply to the muscles of mastication is intact.

On examination of the facial nerve the patient has

Motor supply is intact from each of the 5 branches bilaterally.

Next question <+

On examination of the vestibulocochlear nerve the patient has:

Normal Weber's test and positive Rinne's test.

On examination of the glossopharyngeal and vagus nerves the patient has:

A normal cough and no deviation of the soft palate.

Next question <+

On examination of the accesory nerve the patient has:

Normal power to the trapezius and sternocleidomastoid muscles

On examination of the hypoglossal nerve the patient has:

No obvious fasciculations of the tongue and normal tongue movements.

Next question <+

Please present your findings

Today in clinic I examined Miss M, a 37-year-old lady. Examination of

To complete my examination I would

Formally assess the olfactory nerve with smelling salts.

Next question <+

A bitemporal hemianopia is suggestive of a lesion affecting the optic

If a mass arises from above the chiasm (e.g pituitary

Next question <+

The other signs and symptoms of a pituitary tumour can be general or

General - raised intracranial pressure may cause papilloedema (as

Specific - hyperpituitarism: this depends on the type of hormone

Signs of acromegaly - prognathism, prominent brow, macroglossia,

Signs of hyperprolactinaemia - increased lactation, loss of libido,

Here is a proforma that can be adapted to whatever cranial nerve

Wash your hands

Look for any obvious facial asymmetry or scars on the head/scalp.

It is important to perform your examination in an ordered fashion - this

Cranial Nerves Ill, IV and VI

Cranial Nerve VII

Cranial Nerve VIII

Cranial Nerve IX and X

Cranial Nerve XII

To complete my examination I would:

"Today in clinic I examined Miss M, a 37 year old lady. Examination of

,. Return to module hst

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