CRANIAL NERVES

EXAMINATION (1-6)
DR SACHIN K
FIRST YEAR POST GRADUTE
UNDER THE GUIDANCE OF UNIT 5
OLFACTORY NERVE
Olfactory nerve
Olfactory bipolar receptor nerve cells
(ln olfactory mucous membrane in upper part of the nasal cavity above
the level of the superior concha)
peripheral process that passes to the surface (about 20 fiber bundles)
• Short cilia /olfactory hairs
Olfactory Nerve Examination
• Examine each nostril separately while occluding the other.
• With patients eyes closed bring test substance near open one.
• Ask patient if he/she smells something ,if so identify it.
• Compare both sides(side that might be abnormal should be examined
first)
• Substances used: cloves, coffee ,cinnamon, wintergreen.
• At bedside use mouthwash ,toothpaste ,soap,alcohol etc.
IMPORTANT HISTORY POINTS
• Past head injury
• Smoking
• Recent upper respiratory tract infection
• Systemic illnesses
• Nutrition
• Exposure to toxins
OLFACTORY SYSTEM LESIONS
Loss of smell(anosmia) can be produced by a lesion anywhere along
olfactory pathway
• olfactory epitheliumff
• olfactory bulb
• olfactory tracts
• central structures(posterior orbitofrontal ,subcallosal ,anterior
temporal ,insular cortex)
• Unilateral anosmia- lesion proximal to piriform cortex(has bilateral
representation)
 CAUSES OF ANOSMIA
Normal aging (prevalence 50% above 65, 75% above 80). • Nutrition : deficiency
of vitamin b6, b12,A,zinc,copper.
• Traumatic: closed head injury with or without cribriform plate fracture. •
Infectious/Inflammatory
- Sinonasal Inflammatory disease (rhinitis, sinusitis ,sinonasal polyposis). – Viral
Infections (e.g.. Influenza) (due to mucosal edema). – Basilar meningitis. –
Neurosarcoidosis.
• Toxic –chronic smoking
-cadmium ,chromium, toluene ,herbicide ,pesticide –chemotherapeutic agents
• -
drugs:antihistamines ,propylthiouracil ,levodopa ,cocaine ,amphetamines ,general
anesthesia.
 OPTIC NERVE
CLINICAL EXAMINATION:
• Visual acuity
• Visual field
• Fundus examination
• Colour vision
VISUAL ACUITY
Snellen’s chart-distant vision –chart is placed 6m from patient
-patient covers one eye and is asked to read smallest line he can accurately –
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(recorded as a fraction ex.
6/24).
Jaeger chart- near vision –held 30 cm from patient’s eye
-similar test is carried out(average acuity between J1-J4)
• For patients unable to read the chart as close as 1 metre record acuity as: CF =Count
fingers(Hold hand 0.5 of a metre from the patient)
• HM = Hand movement
• PL= Perceives light
• NPL = No perception of light
• For children and illiterate patients there are charts showing shapes rather than letters
• Causes of loss of visual acuity: refractive errors ,cataracts ,vitreous opacities etc.
 VISUAL FIELD
• Purpose: -to chart periphery of visual field
-to detect size, shape, and position of blind spot –to detect any abnormal scotomas’s
-to compare any defect shown with those abnormalities known to be reproduced by
lesions at specific points in visual pathway.
• Methods: 1. Confrontation visual field exam: -face the patient at a distance of
about 1 metre
-examiner covers the right eye and patient covers left, either with a shield or his
fingers.
-ask patient to fix on examiner’s pupil while examiner moves test object’s of various
sizes (whole hand, moving finger, a white or red pin) inward’s in each of four
quadrant’s from just outside limits of his own field.
• -central area of vision tested in order to map out blind spot and any scotoma by
using a disc of white paper about 5mm in diameter attached to a rod or long pin, or
a white or red hat pin.
FUNDOSCOPY
Red reflex
• Focus on eye from cornea to fundus –
• Start at +20 & reduce towards 0. • Note cataracts. •Fundi
• Find optic disc-note colour ,clarity of edges, size of depression in
centre optic cup.
• Look at vessels as they leave and enter disc(veins are wider and
darker),check continuity, curves.
• Note exudates „haemorrhages, retina, tears
Papilledema
• Disc swelling due to increased intracranial pressure • Causes:
• -Bilateral:
• 1)Raised intra cranial pressure
• 2)Hypertension
• 3)Diabetic papillopathy
• 4)Grave’s Disease
• 5)Cavernous sinus thrombosis
• -Unilateral:
• 1)Optic neuritis
• 2)CRVO
• 3)Orbital tumours
• Normal vs. R-G Blindness
• Terminologies and other causes of defective color vision
• Protanopia or Deuteranopia: Red-Green blindness;
Tritanopia: Yellow Blue blindness; : Corresponding color weakness
• • Achromatopsia: Lack color vision (Parvo-cellular blob V4 cortex
lesion)
• • Dyschromatopsia: Defective color vision (Optic neuritis)
•
Oculomotor (Third cranial nerve)
The oculomotor nerve is entirely motor nerve.
Arises from oculomotor nuclear complex in the midbrain.
Supplies Levator palpabrae superioris and all extrinsic muscle of eye
except lateral rectus and superior oblique.
• Also parasympathetic fibres to sphincter pupillae and cilliary muscle.
Trochlear nerve
• It is purely motor nerve, Supplies to superior oblique muscle.
• It is crossed, most slender, smallest nerve and has longest intra cranial
course(7.5cm) of all cranial nerves.
• It is Only cranial nerve to emerge from dorsal aspect of brain.
• Nucleus :
• tegmentum of midbrain
• at the level of inferior colliculus.
• ventral to the periaqueductal grey matter –
• inferior to the oculomotor nucleus –superior to the medial longitudinal
bundle
ABDUCENT NERVE
Entirely motor nerve, supplies to lateral rectus muscle.
• Most vulnerable cranial nerve, to damage in trauma’s involving
cranium.
• Nucleus:
• - lies in mid to lower pons
• -in the gray matter of dorsal pontine tegmentum –in the floor of
fourth ventricle
• -encircled by looping fibres of facial nerve.
Clinical examination of 3rd, 4th and 6thnerves
Purpose of test:
1.Inspect pupils to rule out a local disease, peripheral lesion or a
nuclear involvement.
2.Examine eye movement & determine if defects is muscular origin or
neural involvement
• 3.To detect nystagmus
Methods
Inspection :
-note presence or absence of ptosis and squint. –unilateral or bilateral –
constant or variable
- compare size of palpebral fissure’s(normal 9-12 mm) –note if eyeballs’s are
protruded(exophthalmos) or recessed(enophthalmos).
-conjunctiva ( tortous blood vessels- carotid cavernous fistula)
subconjunctival haemorrahge –(following cranial trauma) –cornea (kf ring)
• -pupil (size, shape, equlity and regularity)
Causes of ptosis
• Acquired
• Neurogenic
• 1) horner’s syndrome (lid can be raised voluntarily)
• 2)3rd nerve palsy (permanent wrinkling of forehead)
• Myogenic (ptosis is fixed and head is often held extended)
• -mitochondrial myopathies
• –oculopharyngeal muscular dystrophy
• –myotonic dystrophy
• Neuromuscular junction –myasthenia gravis (fluctuating ptosis)
Reaction to light
• Reduce illumination of room & vision should focus on a far object
• A bright beam of light is shone from the side of one eye
• Repeat on the other side[the pupil should constrict briskly]
• Shield one eye & perform test on the other & see for consensual reaction
• Reaction to convergence & accommodation for near vision
• Fix vision on a distant object & instruct to look in a near object
• Place finger tip in front of the bridge of the nose (22 cm)
• Then return to the far object
• Observe pupillary reaction in both
Analyzing nystagmus
Watch the patients eye while talking
Ask to look at a definite point & move the point from left to right & up
to down
• Hold each end position for5 sec & assess nystagmus (direction, rate
amplitude
On inspection:
• Eye moves towards the muscles that still work
• Third nerve palsy:
• Down and outward deviation =Tramps Pupil
• Fourth nerve palsy:
• Subtle- Head tilted away from lesion
• Sixth nerve palsy:
• Inward deviation
• Inability to look out
3rd nerve lesion
PATHOLOGICAL FEATURES:
• -Ptosis caused by loss of levator palpebrae function
–Eye deviated laterally and down
–Diplopia
-Dilated non reactive pupil
–Loss of accommodation
• Syndromes of Fascicular lesion of 3rd nerve
• Weber syndrome- Ipsilateral 3rd nerve palsy and contralateral hemiparesis
• Benedikt syndrome- Ipsilateral 3rd nerve palsy and contralateral
extrapyramidal signs
• Nothnagel syndrome- Ipsilateral 3rd nerve palsy and cerebellar ataxia
• Claude syndrome- combination of benedict and nothnagel syndrome.
• 4th nerve lesion
• EXAMINATION: Ask patient to turn eye in and then try to look down
• PATHOLOGICAL FEATURES:
• -Inability to move eye downward and lateral
• –Diplopia
• -Patients tilt head toward unaffected eye to overcome inward rotation
of affected eye
6th nerve lesion
PATHOLOGICAL FEATURES:
-Inability to move eye laterally
-Diplopia on lateral gaze
AETIOLOGY:
-Tumour e.g. lesions in cerebellopontine angle –
-Cavernous sinus lesions e.g. vascular cause
• -Elevated intracranial pressure from any cause abduct
• Vascular
• -Metabolic (Wernicke-Korsakoff syndrome)
• Subarachnoid space lesions (haemorrhage, infection, inflammation,
tumour)
• -Inflammatory (post viral, demyelinating, giant cell arteritis)
Trigeminal nerve
• The largest cranial nerve
• It is mixed nerve
• (has 3 divisions ophthalmic ,maxillary, Mandibular)
• - Skin of face
• –Mucosa of cranial viscera(Except base
• of tongue and pharynx )
• Motor
• Muscles of Mastication
• Tensor ville palatini,
• Tensor tympany
• Anterior belly of digastric
• Mylohyoid
• Examination of trigeminal nerve
• 1- Sensation Function
• 2- Motor Function
• 3-Corneal reflex
• 4- Test jaw jerk
• Sensory function
• use sterile sharp item on forehead, cheek, and jaw
• If any abnormality present we test the thermal and light touch sensation.
Motor function
Inspect face of the subject
• Observe for any tremors or muscle atrophy
• Ask the subject to clench his teeth, the temporalis and masseter muscle
stand out with equal prominence on each side which can be confirmed by
palpation.
• Ask the subject to open his mouth. In case of paralysis, the jaw will deviate
towards the paralysed side because of push by healthy external pterygoid
muscle on the opposite side
Corneal reflex
Take a clean piece of cotton wool and ask the patient to look away ,genthy
touch the cornea with the cotton wool and the
• patient will blink.

Jaw jerk
• Patient is told to let his jaw sag open slightly.
• Doctor forefinger or little finger on below the lower lip, grip patellar
hammer halfway up shaft and tap finger lightly usually nothing happens, or
just a slight closure
Abnormal:
exaggerated reflex: lesion of upper motor neuron above pons.eg pseudobulbar
palsy. Motor neuron disease, multiple sclerosis.
Trigeminal Neuralgia
• Sudden, usually unilateral, severe, brief, stabbing lancinating,
recurring pain in the distribution of one or more branches of the 5 th
Nerve
• Most common cause is compression of sensory root by an ectatic arterial
loop of basilar artery, most commonly anterior inferior cerebellar or
superior cerebellar.
• TRIGEMINAL NEUROPATHY
• sensory loss of face or weakness of the jaw muscles
• Causes
• -sjogren syndrome –herpes zoster –leprosy –meningioma –schwanomma
HERPES ZOSTER OPHTHALMICUS
• Recurrent neurocutaneous infection In opth. Div. of trigeminal
dermatome, most freq. affecting nasociliary branch
HHV3 / varicella zoster affects Gasserian ganglion
ophthalmic nerve Supraorbital N Supratrochlear N.
Infratrochlear N. Nasal N.
• Infraorbital Nerve
Congenital
-congenital absence of olfactory epithelium
-kallmann syndrome- familial, anosmia with hypogonadotrophic
hypogonadism (due to agenesis of olfactory bulbs)
• • Neurodegenerative disease –Alzheimer disease –Huntington disease –
Parkinson disease –Down syndrome
• Parosmia-pervertion or distortion of smell
• Hyposmia-decrease in sense of smell
• Cacosmia-inappropriately disagreble odours
• Parosmia and cacosmia-seen in closed head injury psychiatric
disease,complex partial seizure
• Hyperosmia-seen in migraine adrenocortical insufficiency, substance
abuse
• Olfactory Hallucinations –seen in psychosis, temporal lobe seizures