EXAMINATION OF THE CRANIAL

NERVES
Before the procedure:
• Introduce yourself to the patient
• Identify the patient
• Give short description about the procedure
• Wash your hands

I Nerve (Olfactory Nerve)

• Ask your patient to close one of the nostrils and keep another one open, then to
close his/her eyes and smell some of the generally known smells (like orange,
lemon, coffee, etc.). The patient has to identify that smell.
• Repeat the procedure for the another nostril.
II Nerve (Optic Nerve)

• Check the Visual Acuity of the patient.

• Use the Snellen Chart
 Use Ishihara plate for color identification test:
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Check the visual field of the patient:

• Ask your patient to cover one eye with the hand while keep it open. The patient should
watch the top of your nose. Place your finger somewhere in the upper or lower quadrant
of the patients visual field and move the fingers. Patient need to tell you if he/she sees
any movement of your finger. Repeat the procedure for another eye.
Pupillary Light Reflex

• Place your hand over the patient’s nose and sharply fall
the light in the patient eye. The pupil should contract.
Repeat the test for another eye.

Extraocular movements
For the 3rd (ocolomotor), 4th (trochlear), and 6th (abducens) cranial nerves, eyes are observed
for symmetry of movement, globe position, asymmetry or droop of the eyelids (ptosis), and
twitches or flutters of globes or lids. Extraocular movements controlled by these nerves are tested
by asking the patient to follow a moving target (eg, examiner’s finger, penlight) to all 4 quadrants
(including across the midline) and toward the tip of the nose; this test can detect nystagmus and
palsies of ocular muscles. Brief fine amplitude nystagmus at end-lateral gaze is normal
 For the 5th (trigeminal) nerve, the 3 sensory divisions (ophthalmic, maxillary, mandibular)
are evaluated by using a pinprick to test facial sensation and by brushing a wisp of cotton against
the lower or lateral cornea to evaluate the corneal reflex. If facial sensation is lost, the angle of the
jaw should be examined; sparing of this area (innervated by spinal root C2) suggests a trigeminal
deficit. A weak blink due to facial weakness (eg, 7th cranial nerve paralysis) should be
distinguished from depressed or absent corneal sensation, which is common in contact lens
wearers. A patient with facial weakness feels the cotton wisp normally on both sides, even though
blink is decreased

Trigeminal motor function is tested by palpating the

masseter muscles while the patient clenches the
teeth and by asking the patient to open the mouth
against resistance. If a pterygoid muscle is weak,
the jaw deviates to that side when the mouth is
opened.

The 7th CN, facial nerve is tested by asking the patient to crease up their forehead (raise their
eyebrows), close their eyes and keep them closed against resistance, puff out their cheeks and
reveal their teeth
Asymmetry of facial
movements is often more
obvious during spontaneous
conversation, especially when
the patient smiles or, if
obtunded, grimaces at a
noxious stimulus.
8th Cranial nerve Webertest

Weber test: Place the base of a struck tuning fork on the Normal

bridge of the forehead, nose, or teeth. In a normal test, there Conductiveloss,sameear

or
is no lateralization of sound. With unilateral conductive loss, Sensorineuralloss,oppositeear

sound lateralizes toward affected ear. With unilateral

sensorineural loss, sound lateralizes to the normal or better-
hearing side. Rinnetest

Airconduction(AC)

Rinne test: Place the base of a struck tuning fork on the

Boneconduction(BC)
mastoid bone behind the ear. Have the patient indicate
when sound is no longer heard. Move fork (held at base)
beside ear and ask if now audible. In a normal test, AC > AC>BC=Normal
BC; patient can hear fork at ear. With conductive loss, BC > BC>AC=Conductiveloss

AC; patient will not hear fork at ear.

082

The 9th (glossopharyngeal) and 10th (vagus) cranial nerves are usually
evaluated together. Whether the palate elevates symmetrically when the patient says "ah" is
noted. If one side is paretic, the uvula is lifted away from the paretic side. A tongue blade can be
used to touch one side of the posterior pharynx, then the other, and symmetry of the gag reflex is
observed; bilateral absence of the gag reflex is common among healthy people and may not be
significant
 The 11th (spinal accessory) cranial nerve is evaluated by testing the muscles it
supplies:

• For the sternocleidomastoid, the patient is asked to turn the head against resistance
supplied by the examiner’s hand while the examiner palpates the active muscle (opposite
the turned head).
• For the upper trapezius, the patient is asked to elevate the shoulders against resistance
supplied by the examiner.

The 12th (hypoglossal) cranial nerve is evaluated by asking the patient to

extend the tongue and inspecting it for atrophy, fasciculations, and weakness (deviation is
toward the side of a lesion).
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