PHYSICAL EVALUATION I (Dent 5121) Cranial Nerve Examination

Lecture Objectives
After todays lecture, the student will be able to: Describe how to examine the function of the cranial nerves Describe the more common abnormal findings associated with function of the cranial nerves Describe abnormal findings that may indicate a systemic disease

CRANIAL NERVE EXAMINATION

Objectives of the cranial nerve examination
Recognize signs and symptoms of cranial nerve disorders Recognize signs and symptoms of systemic diseases Distinguish between dental and neurological disorders

Referral to physician for evaluation

CRANIAL NERVE EXAMINATION

n Evaluate

function of the cranial nerves during interview and clinical examination test routinely

n Not

CN I Olfactory Nerve
n Assess

patency of nostrils

CN I Olfactory Nerve
n Present

aromatic substance should be able to identify the odor with each nostril

n Patient

CN I Olfactory Nerve
n Altered

smell or taste n Anosmia decrease or loss of smell

- Bilateral smoking, allergic rhinitis, cocaine, aging - Unilateral neurogenic, frontal lobe masses
n Phantom

smells

CN II Optic Nerve
n Visual

acuity - Usually assess during interview for far vision

Snellen chart

CN II Optic Nerve
n Visual

acuity - Usually assess during interview

CN II Optic Nerve
n Visual

acuity - Rosenbaum near vision chart - Over 40 yrs old

CN II Optic Nerve
n Visual

acuity - Health History

CN II Optic Nerve
n Visual

acuity

- Myopia - nearsightedness - Hyperopia - farsightedness - Presbyopia loss of accommodation

CN II Optic Nerve
n Visual

acuity

- Diabetic retinopathy

CN II Optic Nerve
n Visual

fields - Confrontation test

CN II Optic Nerve
n Pupillary

light reflex

- direct light reflex - consensual light reflex

CN II Optic Nerve
n Pupillary

light reflex

- direct light reflex - consensual light reflex Absent or delayed pupillary light reflex CNS trauma, Increased intracranial pressure

CN III Oculomotor Nerve

n Accommodation

Contraction of ciliary ms increases curvature of lens Contraction of pupillary constrictor ms Contraction of medial rectus ms causes convergence

CN III Oculomotor Nerve

n Extraocular
z

movements

Innervates levator palpebrae superioris ms Oculomotor nerve elevates upper eyelid Ptosis drooping upper eyelid z Myasthenia gravis z Horners syndrome

CN III, IV, and VI Oculomotor, Trochlear, and Abducens nerves

n Extraocular

movements

- Cardinal fields of gaze

CN III Oculomotor Nerve

n Extraocular

movements

- Cardinal fields of gaze

z

Innervates superior rectus ms medial rectus ms inferior rectus ms inferior oblique ms Oculomotor nerve turns eye up, down and medially.

CN IV Trochlear Nerve
n Extraocular

movements

- Cardinal fields of gaze

z

Innervates superior oblique ms Trochlear nerve turns the eye downward and inward.

CN VI Abducens Nerve
n Extraocular

movements

- Cardinal fields of gaze

z

Innervates lateral rectus ms

Abducens nerve turns the eye laterally

CN III, IV, and VI Oculomotor, Trochlear, and Abducens Nerves

n Nystagmus

- fine oscillation (tremor) of

the eyes
- Multiples etiologies
Vision impairment as child Vestibular disorders Cerebellar disorders Drug toxicity (sedatives, anticonvulsants, alcohol)

n Diplopia

double vision

CN V Trigeminal Nerve
n

Sensory - Patients eyes closed, test light touch on face with cotton wisp
Test forehead,

cheeks, and chin

Assess patients

ability to detect sharp, dull, light pressure, hot and cold

CN V Trigeminal Nerve
n Sensory

- Corneal reflex - Intra-oral: mucosa teeth

CN V Trigeminal Nerve
n

Motor
- Muscles of mastication - Have patient bite against resistance - Have patient protrude mandible against resistance - Have patient go into lateral excursive movements against resistance

CN V Trigeminal Nerve
n Motor

- Rare
n Sensory

- Paresthesia following oral surgery - Trigeminal neuralgia

CN VII Facial Nerve

n Motor

- Muscles of facial expression

CN VII Facial Nerve

n Motor

- Damage to the peripheral nerve presents as paralysis to the entire side of face - A central lesion (e.g., stroke) on one side affects mainly the lower face on the side of the lesion - Bells palsy

CN VII Facial Nerve

n Sensory

- Taste to the anterior 2/3 of the tongue - Loss or altered taste following a stroke or damage to the lingual nerve (local anesthetic injection, laceration of tongue)

CN VIII Vestibulocochlear Nerve

- Observe if the patient turns one ear towards you - Evaluate hearing using a ticking watch, rub fingers together, whisper.

CN VIII Vestibulocochlear Nerve

- Observe equilibrium as patient walks or stands

CN VIII Vestibulocochlear Nerve

n Deafness

complete or partial, unilateral or bilateral of vestibular apparatus (e.g., Mnire Syndrome)

Dizziness Falling Abnormal eye movements Nausea and vomiting

n Dysfunction

CN IX Glossopharyngeal Nerve
n Sensory

- Sensation to the posterior 1/3 of the tongue including taste and to the mucous membranes of the pharynx - Sensory part of gag reflex

CN IX Glossopharyngeal Nerve n Motor

- Middle constrictor muscle of pharynx - Stylopharyngeus muscle

CN X Vagus Nerve
n Sensory Sensation to the inferior pharynx, larynx, heart, lungs, and gut. Not tested

CN X Vagus Nerve
n Motor

- Soft palate, pharynx, and larynx - Patient say Aah and watch soft palate rise

CN X Vagus Nerve
n Motor

dysfunction

- Recurrent laryngeal nerve hoarseness or weakness in the voice inability to cough voluntarily - Dysphagia difficulty swallowing

CN XI Accessory Nerve
n

Sternocleidomastoid ms

CN XI Accessory Nerve
n Trapezius

muscles

CN XII Hypoglossal Nerve

n Motor

- Muscles of tongue - Geniohyoid and thyrohyoid muscles

CN XII Hypoglossal Nerve

n Have

patient stick out tongue. Should be symmetrical. No tremors or wasting. will deviate toward side of lesion when tongue protruded.

n Tongue