CRANIAL NERVE

EXAMINATION
Done by :
Dimah atmeh
Esraas nahleh
Shereen
AbuSaif
Introduction
• THE CRANIAL NERVES : are the nerves that
emerge
directly from the brain (including the brainstem)
• brainstem
– The 12Except the
pairs of olfactory
cranial ariseoptic
(I) and
nerves fromnerves
the
((II)-
• There are 4 cranial nerves in the medulla, 4 in
the
pons and 4 above the pons
• (2 in the midbrain )
Ooh, Ooh, Ooh,
to touch and feel
very good
velvet. A
 •The olfactory (I) nerve
• Test the sense of smell
• Rarely performed
• Hyposmia or (reduction or loss of the sense of smell) , result ear,
nose and throat
anosmia , after head injury or skull base
from
disease often also
• Patients tumours
hypogeusia/ (altered taste) with
note ageusia anosmia .
he optic
(II)
• The optic ( II ) nerve transmits all visual information, also responsible for
two
important neurological reflexes: the light reflex and the accommodation reflex.
• Examination sequence
• Visual acuity (Myopia (short-sightedness) , Hypermetropia (long-sightedness)
• Ask patients to put on their distance glasses, if they use them.
• Place a Snellen chart 6 meters from the
• patien
Ask the patient to cover one eye and to from the top down until he can no
distinguish the letters
read longer
• Repeat with the other eye.
• Snellen visual acuity is expressed as 6 (the distance at which the chart is read) over
the number corresponding to the lowest line read. This indicates the distance at
which someone with normal vision should be able to read that line, i.e. Snellen visual
acuity of 6/60 indicates that at 6 meters patients can only see letters they should be
able to read 60 meters away. Normal vision is 6/6.
Snellen
chart
• If the patient cannot read down to line 6 (6/6 vision), place a pinhole directly in front
of glasses . This allows only central rays of light to enter the eye
his
.
• If patients cannot see the top
of the chartline
at 6 meters (even
with pinhole) bring them
forward till they can and record
that vision, e.g. 1/60 – can see
top letter at 1 meter.
• If patients still cannot see the
top letter at 1 meter, check
whether they can count fingers,
see hand movements or just
see light.
• Visual fields (The normal visual field extends 160° horizontally and 130° vertically )
• test visual fields by
confrontation
•• Examination
Sit directly facingsequence
the patient, 1 away.
• about
Ask the patient to meter
looking at your
Homonymous defects
• keep eyes
• ■ Keep your eyes open and ask the patient to do the
•■ same . your hands out to their full extent. Wiggle a fingertip and ask the patient
Hold
point
to to it as soon as he sees it
• move.
■ Do this at 10 and 2 o’clock, and then 8 and 4 o’clock (to screen the four
outer
quadrants of the patient’s visual field )
Sensory
•• ■ inattention (visual neglect )
both eyes
• Test
■ Bothtogether.
you and the patient should keep your eyes open.
• ■ Test both left and right fields at the same time.
• ■ Note whether the patient reports seeing only one side
 • Peripheral visual fields

• 1. Ask the patient to cover their left eye with their left hand.
• 2. You should cover your right eye and be staring directly at the patient (mirroring the patient).
• 3. Ask the patient to look into your eye and not move their head or eyes during the assessment.
• 4. Ask the patient to tell you when they can see your fingertip wiggling.
• 5. Outstretch your arms, ensuring they are situated at an equal distance between yourself and the
patient.
• 6. Position your fingertip at the outer border of one of the quadrants of your visual field.
• 7. Slowly bring your fingertip inwards,
towards the centre of your visual field until the patient sees it.
• 8. Repeat this process for each quadrant –
at 10 o’clock /2 o’clock / 4 o’clock / 8 o’clock.
9. If you are able to see your fingertip but the patient cannot, this would suggest a visual field defect.
• Pupils
• Shape – pupils should be round .
• Symmetry – note any asymmetry ( Anisocoria is inequality of the pupil sizes.
)
• Pupillary reflexes
•• 1) light
Ask reflex
the patient to fix his eyes on a distant point straight .
• Bring a bright torchahead
light from the side to shine on the
• Direct pupillary reflex pupil.
• Shine a light into the pupil and observeconstriction of that pupil (miosis thereby allowing less light
• Consensual pupillary reflex in )
• Again shine a light into the pupil, but this time observe thecontralateral
• pupil.
A normal consensual response involves the contralateral pupil
constricting.
• 2) Accommodation reflex
•• 1. Ask the
2. Place patient
your to fix hisapproximately
finger/object 15cpointinstraight
eyes on a distant front ofahead
the
• eyes.
3. m the distant object to the nearby
Ask the patient to switch from looking at
• finger/object.
4. Observe the pupils, you should constriction and - inward movement of both eyes toward each
• Fundoscopy
see
( Just convergence
mention other
) : Assess the optic disc , the retinal vessels and the
The oculomotor (III), trochlear (IV) and abducens (VI) cranial
nerves
innervate the six external ocular muscles controlling eye
LR6 SO4 AO
movement
3 . This
superior oblique CNstands for lateral rectus
, All Others . cranial nerve (CN) 6,
4
Levator CN 3
palpebrae superioris (oculomotor (III) nerve )
muscle
the lid. open
• Examination sequence
• Sit directly facing the patient, 1 away.
about meter
Inspection
•• Note any evidence ptosis (drooping or falling of the
of upper
shine a)light into the patient’s eyes and ask the patient to look at
• eyelid.
• Inspect
it. the light in the corneas. They should be in
center of the
reflection. the
 Ocular movements

• Hold your finger vertically at least 50 cm away from the patient, and ask him
follow with his eyes, without moving his
to
•■it Move your
head.finger steadily to one side, then up and down, then to the other
and
• repeat, describing
■ Ask the the
patient to report H in diplopia
letterany the air. (double vision)
• ■ Observe restriction of eye and note nystagmus (a fine
for
rhythmic oscillation of the eyes - repetitive,any
movement uncontrolled movements
-)
•The trigeminal (V) nerve
• provides sensation to the face, mouth and motor supply to the muscles of
mastication (masseter, temporalis, medial and lateral pterygoid, accessory muscles)

• There are three major branches of the nerve:

• • ophthalmic (V1): sensory

• • maxillary (V2): sensory
• • mandibular (V3): sensory and motor.
• Examination sequence
• There are four functions: sensory, motor and two reflexes.
•Sensory
• Ask the patient to close his eyes and say ‘yes’ each time he feels you lightly
touch them using a cotton wool tip. Do this in the areas of V1, V2 and V3. The
ophthalmic division is tested by touching the forehead, the maxillary division is
tested by touching the cheeks, and the
mandibular division is tested by touching
the chin (in the circled areas in the Figure)
• Repeat using a fresh neurological pin,
e.g. Neurotip, to test superficial pain.
• Compare both sides
•Motor
• Inspect for wasting of the muscles of mastication
• Ask the patient to clench his teeth; feel the masseters, estimating their bulk.
• Place your hand under the jaw to provide resistance; ask the patient to open his
jaw. Note any deviation.
•Corneal reflex
• Explain to the patient what you are going to
do
• Gently depress the lower eyelid while the
patient looks upwards.
• Lightly touch the lateral edge of the cornea
with a wisp of damp cotton wool • Look for
both direct and consensual blinking
•Jaw jerk
• Ask the patient to let his mouth hang loosely open.
• Place your forefinger in the midline between lower lip and chin.
• Percuss your finger gently with the tendon hammer in a downwards direction
noting any reflex closing of the jaw. An absent, or just present, reflex is normal
•The facial (VII) nerve
• The facial nerve supplies the muscles of facial expression; it receives taste
sensation from the anterior two-thirds of the tongue

• Examination sequence
• Examination is usually confined to motor function; taste is rarely tested.

• Motor function
• Inspect the face for asymmetry or differences in blinking or eye closure on one side.
• Watch for spontaneous or involuntary movement.
• Ask the patient to raise the eyebrows and observe for symmetrical wrinkling of the
forehead
• Demonstrate baring your teeth (Show both upper and lower teeth) and ask the patient
to mimic you. Look for asymmetry
• Test power by saying:
• Closed eyes – “Close both eyes tightly and don’t let me open them”
• Blown out cheeks – “blow out your cheeks and don’t let me deflate them”
•The vestibulocochlear (VIII) nerve (Acoustic and Vestibular. )
•Testing hearing

•Whispered voice test

• Examination sequence • Stand behind the patient.
• ■ Explain to the patient that you’re going to say a word or number and you’d like them
to repeat it back to you.
• 2. With your mouth approximately 15cm from the ear, whisper a number or word.
• 3. Mask the ear not being tested by rubbing the tragus.
• 4. Ask the patient to repeat the number or word back to you.
• 5. If the patient repeats the correct word or number, repeat the test at an arm’s length
from the ear (normal hearing allows whispers to be perceived at 60cm).
•Tuning fork tests
• Use a tuning fork to help differentiate between conductive (sound waves are unable to
pass through the middle ear to the inner ear. ) and sensorineural (damage to any part of
the specialized nervous system of the ear. ) hearing loss

• Examination sequence
• Weber’s test
• Hit the prongs of the fork against a padded surface to make it vibrate.
• ■ Place the base of the vibrating tuning fork in the middle of the
patient’s forehead.
• ■ Ask: ‘Where do you hear the sound?’
• ■ Record which side Weber’s test lateralizes to if not central
.
• Normal findings The noise is heard in the middle or equally in both ears.
• Rinne’s test (evaluates hearing loss by comparing air conduction to bone
conduction)
• Place the vibrating prongs at the patient’s external auditory meatus; ask if he can
hear it.
• ■ Now place the still-vibrating base on the
mastoid process.
• Ask: ‘Is it louder in front, or behind your
ear?
• Normal findings The sound is louder at the
ear, that is, air conduction is better than bone
conduction.
• Abnormal findings
• If the sound is louder on the mastoid process, bone conduction is better than air
conduction.
This applies in conductive deafness
•Testing vestibular function
• Dix–Hallpike positional test
• Examination sequence
• Ask the patient to sit upright, close to the edge of the couch. Warn the patient
about what you are going to do.
• ■ Turn the patient’s head 45° to one side.
• ■ Rapidly lower him, so that the head is now 30° below the horizontal. Say:
‘Keep your eyes open even if you feel dizzy.’
• ■ Watch the eyes carefully for nystagmus. Repeat the test, turning the head to
the other side.
•The glossopharyngeal (IX) and vagus (X) nerves
• The glossopharyngeal (IX) nerve carries sensation from the pharynx and tonsils, and
sensation and taste from the posterior one-third of the tongue.
• The vagus (X) nerve innervates upper pharyngeal and laryngeal muscles.
• The main functions of IX and X are swallowing, phonation/articulation and sensation
from the pharynx/larynx.
• Examination sequence
• Listen to the patient’s voice. Is it hoarse, or does it have a nasal quality?
• Ask him to say ‘Ah’; look at the movements of the palate and uvula using a torch.
Normally, both sides of the palate elevate symmetrically and the uvula remains in the
midline.
• The glossopharyngeal (IX) and vagus (X) nerves
• The glossopharyngeal (IX) nerve emerge from anterior aspect of medulla oblongata exit
from jugular foramen ,carries sensation from pharynx and tonsils, and the sensation +
taste from posterior one third of the tongue.
• The vagus (X) nerve exit from medulla oblongata in the area between olive and ICP ,leave
the
cranium from jugular foramen,it innervates upper pharyngeal and laryngeal muscles.
• The main functions of IX and X are swallowing, phonation/articulation and sensation
from the
pharynx/larynx.
• Examination sequence
• Listen to the patient’s voice. Is it hoarse, or does it have a nasal quality?
• Ask him to say ‘Ah’; look at the movements of the palate and uvula using a torch.
Normally,
both sides of the palate elevate symmetrically and the uvula remains in the midline.
• Ask the patient to puff out his cheeks with the lips tightly closed. Listen for air escaping from
the nose. For the cheeks to puff out, the palate must elevate and occlude the nasopharynx.
If palatal movement is weak, air will escape audibly through the nose.
• The accessory (XI) nerve
• It has a double origin: spinal and cranial, exit through a jugular foramen.
• The spinal component of the accessory nerve provides motor control of
the the trapezius and the sternocleidomastoid muscles responsible for
elevating (shrugging) the shoulders, and head turning .
• Examination sequence
• Face the patient and inspect the sternocleidomastoid muscles for wasting
or
hypertrophy; palpate them to assess their bulk.
• Stand behind the patient to inspect the trapezius muscle for wasting or
asymmetry.
• Ask patient to shrug shoulders and resist you pushing down to assess the
power
• Test power in the left sternocleidomastoid
• The hypoglossal (XII) nerve
• This nerve arises from the hypoglossal nucleus in MO and exit through
hypoglossal canal of the occipital bone ,it Provides motor innervation to all
extrinsic and intrinsic muscle except for palatoglosuss muscle which is
innervated by the Vegus nerve
• Examination sequence
• Ask the patient to open his mouth. Look at the tongue at rest for wasting,
fasciculation
or involuntary movement.
• Ask the patient to put out his tongue. Look for deviation or involuntary movement.
• Ask the patient to move the tongue quickly from side to side.
• Test power by asking the patient to press the tongue against the inside of each
cheek in
turn while you press from the outside with your finger.