Common disorders of

cranial nerves

Thashi Chang
Department of Clinical Medicine
 Neurological diagnosis

1. Where is the lesion?

(neuroanatomical localisation)

2. What is the lesion?

(cause / aetiology )
 Examine the eyes neurologically

1. Inspection
2. Visual acuity (+ colour vision)
3. Visual fields
4. Eye movements
5. Pupils – size, reaction to light and accommodation
6. Funduscopy
 Horner syndrome
Where is the lesion? What is the lesion?

1. Lateral medullary syndrome

2. Glioma
1. Carotid dissection 3. Demyelination (MS)
2. Carotid aneurysm

1. Syringomyelia
2. Intramedullary tumours

1. Cervical rib
2. Pancoast tumour
 SR (IO) SR (IO)
SR IO IO SR

LR MR MR LR

IR SO SO IR
IR (SO) IR (SO)

SO4; LR6
Oculomotor nerve palsy
Where is the lesion? What is the lesion?

1. Stroke
2. Tumour
3. Demyelination
Oculomotor nerve palsy
Where is the lesion? What is the lesion?
Oculomotor nerve palsy
Where is the lesion? What is the lesion?

1. Cavernous sinus
thrombosis
2. Carotico-cavernous fistula
3. Carotid artery aneurysm
Oculomotor nerve palsy
Where is the lesion? What is the lesion?

LFT SONIA

1. Granulomatous
inflammation (Tolosa-
Hunt syndrome)
2. Tumour (meningioma)
3. Metastasis
Bilateral ptosis
Examine the motor cranial nerves
 Unilateral LMN facial nerve palsy
Where is the lesion? What is the lesion?
Geniculate ganglion
Herpes zoster (Ramsay
Hunt syndrome)
Pons

Cerebello-pontine angle
1. Acoustic neuroma
2. Meningioma
3. Metastasis

Facial canal
1. Bell palsy
2. Middle ear disease
3. Local trauma

Stylomastoid foramen
Parotid tumour / surgery
Examine the lower
cranial nerves
 Dysphagia and dysarthria

Bulbar palsy Pseudobulbar palsy

o LMN o UMN
o Flaccid tongue o Spastic tongue
o Tongue wasting o Brisk jaw jerk
o Tongue fasciculations o Emotional lability
 Bulbar palsy
o Muscle: myopathy or myositis

o NMJ: MG

o Nerve: GBS, NPC, basal meningitis (carcinomatous,

tuberculous, granulomatous),

o Medulla: lateral medullary syndrome (PICA

syndrome), MND
 Pseudobulbar palsy

1. Bilateral strokes

2. MND

3. Multiple sclerosis
 Summary
o Cranial nerve lesions are localised in relation to their
neuroanatomical course and their related structures
o Close proximity of cranial nerves at certain sites
results in combined lesions (cavernous sinus, SOF, CP
angle, base of the brain, jugular foramen)
o Intelligent INSPECTION (observation) remains a
powerful tool in clinical diagnosis
‘You see, but you do not observe’
Sir Arthur Conan Doyle (1859 – 1930)