The Cranial Nerves

08/12/21 © Peninsula Medical School, UK 1

 1st (Olfactory) Nerve
 Responsible for the sense of smell
 Sense of smell may be lost as a result of
 trauma
 infection
 ageing
 Smell is an important component of the appreciation
of taste (which may be the principal complaint of a
patient)
 Crude bed side test may be to identify the odour of
coffee or fresh orange
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 The 2nd (Optic) Nerve
 Various tests are possible which depend to
some extent (though not exclusively) on the
integrity of the optic nerve(s)
 These include
 pupillary reflexes
 visual acuity
 visual fields

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 The Pupils - Inspection
 Size and shape
 Regularity in outline and equality of both
sides
 Defects in iris
 Foreign bodies in anterior chamber

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 Pupillary Light Reflexes
 Patient should fix on a distant object
 Swing light beam in from the side
 Shield non-examining eye
 Direct - constriction of pupil to light shone
into that eye
 Consensual - constriction of pupil to light
shone in opposite eye

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 Pupillary Light Reflexes 2
 Shield the non-
examined eye
 Swing light beam in
from the side
Direct
 Direct reflex - ipsilateral
pupil constricts
 Consensual reflex -
contralateral pupil
Consensual
constricts
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 Pupillary Accommodation Reflex
Ask patient to fix on a distant object and
then to focus on finger held about 10cm
from face
 The eyes will converge
 The pupils will normally constrict equally

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 Accommodation
 The person fixes
on a distant object
 The person is
then asked to look
at a close object -
their eyes
converge and
pupils constrict
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 Visual Acuity Testing
 A series of different sized
letters on the chart
 Viewed at 6 metres (half
sized charts are viewed at 3
metres)
 Under each line is a number
that represents in metres
the distance from which that
size letter would be visible
in someone with normal
eyesight

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 Visual Acuity Test Results
 The result of the test is recorded
as the smallest set of letters that
can be read beneath the
distance from which the patient
was positioned
 6/6 (capable of reading letters
expected to be visible at 6
metres at 6 metres)
 6/4 (capable of reading letters
only expected to be visible at 4
metres at 6 metres)
 6/60 (only capable of reading
letters expected to be visible at
60 metres at 6 metres)

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 Visual Acuity Measurement
 Ask the patient to cover each eye in turn and determine the
smallest print size that can be read
 Record separately for each eye e.g. R = 6/6 L = 6/5
 For short-sighted patients glasses should be worn, but if not
available reading through a pin-hole will help to compensate
 For patient unable to read the 60 print size, move them
nearer to the chart (e.g. 3 metres) and record acuity as 3/xx
 For patients unable to read the chart as close as 1 metre
record acuity as:
CF Count fingers HM Hand movement
PL Perceives light NPL No perception of light
 For children and for the illiterate there are charts showing
shapes rather than letters

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 Visual Field Testing
 The “bedside” test is
undertaken facing the
patient at a distance of
about 1 metre
Fig 1 To test the right eye
 The patient should
close the left eye and
the examiner should
close the right eye
Fig 2
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 Visual Field Testing 2
 The patient and examiner
should fix the gaze of their
opened eye on each others
opened eye
 Visual fields are assessed by
bringing a white pin head
diagonally (along a plane
Fig 3 midway between patient and
examiner) into the lateral
quadrants of the patient’s
field of vision from the
extreme of vision (arm’s
length) and then into the
nasal quadrants (see Fig. 1-
Fig 4 4)
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 Visual Field Testing 3
 The patient is asked to indicate when they first
appreciate the white ball entering their visual field
 The examiner compares this to their own detection
 A more detailed “map” of a defect can be produced
by increasing the number of spokes used
 Superiorly the field is limited by the supra-orbital
ridge and medially by the nose
 A defect should be assessed formally

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 The Blind Spot
Sit approx. 1 metre apart, fix gaze on
each other’s open eyes (right to left).
Move the pin slowly across the axis of
fixation. The red pin will disappear when it
coincides with the optic disc.
08/12/21 © Peninsula Medical School, UK
To test for the blind spot (
optic disc)
 The patient should close 1
eye (e.g. right) and the
examiner the opposite eye
(e.g. left)
 Use a red pin (head  1cm
diameter), moving along a
horizontal line through the
axis of visual fixation from the
temporal aspect of the
patient’s visual field, ask the
patient to note the point at
which it briefly disappears
 Repeat for the other eye
15
 Visual Field Defects
 1 Monocular - occurs
ahead of optic chiasm
 2 Bitemporal loss -
occurs at chiasm affecting
fibres crossing over
 3 Homonymous
hemianopia - optic
radiation lesion
 4 Occipital cortex -
macula sparing

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 Eye Movements (3rd, 4th & 6th)

Inferior oblique Up Superior rectus

III III

Medial Lateral
rectus rectus
Medial Lateral
III VI

Superior oblique Down Inferior rectus

IV III

Left eye viewed from the front

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 Testing Eye Movements
 Hold a pen or similar object
vertically about 50cm from the
patient in the midline and on a
level with the patient’s eyes
 The patient is asked to follow
the object without moving their
head and to report any double
vision
 The object is moved slowly
 side to side
 up and down centrally
 up and down at extreme of
lateral gaze on each side

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 Eye Movements
 Observe
 range of eye movements
 smoothness of eye movements
 synchronous eye movement (moving together)
 any nystagmus
 If patient reports diplopia
 establish relative position of images (side-by-side, above and below or at
an angle)
 establish position where images are widest apart
 cover each eye in turn and establish which image disappears
Note:
 Double vision is maximal in the direction of gaze of the affected muscle
 False image in outermost
 False image arises in the affected eye

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 6th (Abducens) Nerve Palsy

R e s t in g p o s it io n

L o o k to L

O n c o m m a n d t o lo o k t o t h e le f t t h e a f f e c t e d e y e ( L E F T ) d o e s n o t
m ove

Affected eye

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 3rd (Occulomotor) Nerve Palsy
Ptosis
Resting

On lifting ptosis,
the eye deviated
laterally and
downwards

Affected eye

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 4th (Trochlea) Nerve Palsy

R e s tin g

L o o k in g to rig h t a n d
d o w n w a rd s

Affected eye

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 The Cover Test
R L  The test is intended to detect
latent squint
 The examiner asks the patient
to look with both eyes at his/her
right eye
 Cover patient’s left eye, then
uncover left eye and rapidly
cover right eye
 Observe to see if left eye has to
correct to fix on examiner’s eye
Example above:  Repeat for patient’s right eye
left latent squint

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 The 5th (Trigeminal) Nerve
The trigeminal nerve supplies
 Sensory divisions
 Ophthalmic (V1)
 Maxillary (V2)
 Mandibular (V3)
 Motor
 Muscles of mastication

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 Sensory Branches of 5th Nerve
 Ophthalmic

 Maxillary

 Mandibular

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 Testing 5th Nerve Motor Function
Testing the jaw reflex
08/12/21
 Clench teeth and feel
strength of masseter and
temporalis muscle
 Push jaw against a hand
held to the right and then
left side of mandible
 Jaw jerk
 ask the person to let their
mouth hang open loosely
 place a finger on the chin
 percuss the finger with the
head of the tendon hammer
 observe and feel jaw
movement
© Peninsula Medical School, UK 26
 Sensory Examination of 5th Nerve
 Using cotton wool create a wisp and demonstrate on the patients
hand what you are going to do
 Ask the patient to say when they can feel you touching their skin
 They should close their eyes and then you touch the skin with the
cotton wisp (a dab not a drag) of each division of the nerve
starting with ophthalmic division then maxillary then mandibular
 Compare right to left
 Repeat the test with neurotips, demonstrate on the patients hand
first - say this is blunt and this is sharp for the relevant ends
 Ask the patient to close their eyes and then assess ophthalmic,
maxillary and mandibular divisions comparing right to left
 Alternate between blunt and sharp whilst asking the patient to
indicate which it is
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 Corneal Reflex
 Sensation - trigeminal nerve
 Motor - facial nerve
 Ask the person to look up and
away
 A wisp of cotton wool twisted to a
point is touched to the lateral
aspect of the cornea
 Both eyes should blink
 Care should be taken to touch the
peripheral cornea and not the
conjunctiva
 The central cornea must be avoided.
 Cotton wool should not be dragged
across the cornea
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 The 7th (Facial) Nerve
 The facial nerve supplies
 Muscles of facial expression
 Stapedius muscle in the ear
 Taste to the anterior 2/3rds of the tongue
 Parasympathetic nerves to the lacrimal gland
 Lower motor neurone lesions affect all facial
muscles on that side
 Upper motor neurone lesions spare the
forehead
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 Tests of Facial Nerve Function
 Ask person to
 Show their teeth
 Purse lips
 Blow out cheeks
 Close eyes tightly
 Open eyes as wide as they can

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 Tests of Facial Nerve Power
 With eyes tightly shut
 attempt to gently pull the eyelids apart
 With eyebrows raised
 attempt to pull eyebrows downwards
 With lips pursed tightly
 attempt to pull lips apart
 With cheeks blown out
 press against the cheek to assess strength

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 The 8th (Acoustic) Nerve
 The 8th nerve has two functions
 Auditory (hearing)
 Vestibular (balance)

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 Tests of Auditory Function
 Test each ear, one at a time
 Block the opposite ear
 Use a watch or rubbing
fingers together (in a quiet
environment), judge how far
away the sound can be
detected
 If impaired in either ear
perform Rinne’s and Weber’s
test
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 Rinne’s Test 1
 Use a 516 Hz tuning fork,
set it vibrating by gently
tapping on your knee
 Set the fork vibrating and
place on mastoid process
(bone conduction)
 Ask the person to tell you
when they can no longer
“hear” the sound

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 Rinne’s Test 2
 Then place forks in
front of ear directly
over the auditory
meatus (air conduction)
 Ask the patient if they
can hear the sound
again (normal to do so
as air conduction is
better than bone
conduction)
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 Rinne’s Test 3
 Alternatively
 Place base of tuning fork
on mastoid process
 Confirm it can be heard
 Then immediately place
prongs in front of external
auditory meatus
 Ask patient which is louder
- “behind the ear or in
front? (the latter is normal)

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 Weber’s test
 The base of the 516
Hz tuning fork is
held on the vertex of
the head
 The person is asked
which ear hears
better (the good or
the deaf ear)

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 Interpreting Hearing Tests
Loss of hearing may be conductive (transmission of sound to the nerves
of hearing fails)
Sensorineural deafness reflects disorders of the nerve tissues)

Interpretation of Rinne and Weber tests

Normal Conductive Sensorineural
deafness deafness
Weber Equal in both Deaf ear > Good ear >
good ear deaf ear
Rinne Air conduction Bone Air conduction
> bone conduction > > bone
air
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 Vestibular Function of the 8th Nerve
 Gait
 Ask patient to walk heel to toe
 Gait veers to the affected side and is unsteady
 Nystagmus
 Nystagmus is a slow drift of eye position in one
direction with a fast correction in the opposite
direction.
 Tested during eye movement assessment
 At the limit of each direction hold the object steady
where it can be seen by both eyes
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 Points to Note if Nystagmus Present
 Pendular nystagmus - movement symmetrical
 Jerk nystagmus - movement fast in one direction and slow in the other
 Direction of the fast movement and plane - horizontal, vertical, rotatory
 The position of the eye when nystagmus occurs
 If the abducting eye is affected more than the adducting
 If it occurs in the direction of gaze in more than one direction
 Care: At the extreme of lateral gaze one or two jerks may normally be
seen, this will be especially the case if the object is outside the field of
binocular vision - ensure the object is visible to both eyes

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 Halpike’s Test
 Used in testing for positional vertigo
 Sit person up in a position so that when
(s)he lies down, the head will extend
over the end of couch
 Turn the head to one side, ask person to
look over the shoulder to that side.
 Lie the patient back quickly, so that head
extends supported by examiner
Hallpike’s
 Ensure continues to look over shoulder
test
(now towards floor)
 Observe for nystagmus in direction of
gaze, whether it fatigues with repeating
the test and sensation of vertigo
Examiner supports head
 Repeat for other side

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 Halpike’s Test Interpretation
 No nystagmus - normal
 Non-fatigable nystagmus - central vestibular
 Fatigable rotatory nystagmus with delay - peripheral vestibular

 The Turning Test

 Ask person to close their eyes and extend arms out in front of them.
 Ask them to walk on the spot and observe the person’s position
 Interpretation
 A positive test occurs when the patient gradually turns (towards the
side of the lesion)
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 9th (Glossopharyngeal) Nerve
 Sensory
 posterior 1/3rd of tongue, the pharynx and
middle ear
 Motor
 stylopharyngeus
 Autonomic
 parotid salivary gland

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 Testing the 9th Nerve
 Gag reflex (afferent glossopharyngeal - efferent
vagus) - not routinely done
 touch pharyngeal wall behind the pillars of the fauces
 Deviation to one side indicates weakness on the
other side
 upper or lower motor neurone lesion of vagus
 Does not move on saying “Ahh” or gag
 bilateral palatal muscle paresis
 Moves on saying “Ahh” but not on gag
 isolated 9th nerve palsy (rare)
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 The 10th (Vagus) Nerve
 Sensory
 tympanic membrane, external auditory canal,
external ear
 Motor
 muscles of palate, pharynx and larynx
 Autonomic
 afferents from carotid baroreceptors
 parasympathetic supply to and from thorax and
abdomen
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 Testing the 10th Nerve
 Look at the uvula (use tongue depressor if
necessary)
 Ask patient to say “Ahh”
 Deviation to one side indicates weakness on
the other side
 upper or lower motor neurone lesion
 Does not move on saying “Ahh” or gag
 bilateral palatal muscle paresis

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 11th (Accessory) Nerve
Purely Motor
 The relevant cerebral hemisphere
supplies
 The ipsilateral sternomastoid muscle
 The contralateral trapezius muscle

 Therefore, a lesion on one side can give

rise to signs on both sides

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 Testing the 11th Nerve
 Sternomastoid
 Ask the person to turn their head to one
side whilst pushing against the turn of the
head. Watch the opposite sternomastoid
 Trapezius
 Ask the patient to shrug shoulders, push
down against movement

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 Interpreting Tests of 11th Nerve
 Weakness of sternomastoid and
trapezius on the same side - ipsilateral
peripheral accessory nerve lesion
 Weakness of sternomastoid and
contralateral trapezius - upper motor
neurone lesion on the side of the
sternomastoid

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 Testing the 11th Nerve

Turning head - test

of contralateral
sternomastoid

Upward shrug
of shoulders -
test of trapezius

Inspect both
sternomastoid and
trapezius muscles for
wasting and fasciculation

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 12th (Hypoglossal) Nerve
 Motor intrinsic muscles of the tongue
 Testing the 12th nerve
 Put out tongue
 deviation to one side indicates weakness on
the same side
 wasting and fasciculation - lower motor
neurone
 normal bulk - upper motor neurone
 To test power - patient pushes tongue against
mucosa of the cheek and examiner presses
against skin - repeat for the other side
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 Useful Resources
 Neurological eye simulator –
http://cim.ucdavis.edu/eyes/

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