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• Step approach to cranial nerve examination : clinically oriented • Anatomy of cranial nerves : 12 nerves • How to examine fast & accurate (tip & trick) • Practice !!
• Visual abnormality (blurred vision, visual loss, diplopia, shaking vision, narrow field) • Facial numbness, weakness • Deafness, dizziness, imbalance • Dysphagia, dysarthria • Neck weakness • Odorless
• Associated neurological deficit Motor weakness Body numbness Horner’s syndrome Autonomic disturbance Cortical lobe sign • Associated organ involvement Vascular bruit Lymphadenopathy Skin rash Proptosis
Cranial Nerves Anatomy .
Base of Skull & CN .
Eye problems • • • • • Visual failure Blurred vision Double vision Shaking vision Narrow field .
Cranial Nerves • II visual acuity. tract. cerebellum nystagmus . IV. occipital lobe visual field defect • Brainstem. field • III. radiation. VI double vision • Optic chiasm.
Visual acuity : Macular function • Jaeger chart • Glasses must be worn or pinhole • Read the smallest typed paragraph hand movement directing the light light perception .
Visual field : Confrontation test .
• Start at the edge of the field • Test both upper & lower field • Test simultaneous stimuli detect inattention field • Incorporate patient make a center of the line (Need to check further regarding inattention field) .Confrontation test tips • Do not test with your fingers on the equatorial line.
Blind spot • Optic nerve head location • Fix the eye move object from temporal field on the equator Macula field Macula. ON head location Visual field Blind spot .
Fundoscopic examination • Retinal arteries : pale strip at the center • Retinal veins : dusky red. larger. no white strip. macula & fovea . pulsation • Optic nerve head or disc • Physiologic cup • Posterior pole.
not pale Papilledema: blurred disc. ↓ VA. pale disc. ↓ VA. hemorrhage Ischemic ON: blurred disc. ↔ VA. no hemorrhage. hemorrhage .Normal Disc Papillitis: blurred disc .
Double vision Neurologic cause: binocular diplopia Ophthalmologic cause: monocular diplopia Horizontal & vertical diplopia Diplopia worsening if the eyes axis points to defected ocular muscle axis • Left 6th nerve palsy: horizontal diplopia worsening on left lateral gaze & far vision • Right 3rd nerve palsy: horizontal diplopia worsening on left lateral gaze & near vision • • • • .
Normal ocular movement .
SR. IO innervation • Miosis of pupil Pupil dilatation.3rd nerve palsy Function • MR. IR. lateral deviation due to unopposed lateral rectus & slightly downward due to unopposed superior oblique .
tumor . VI. V2 • Orbit : trauma.3rd nerve pathway • Midbrain : hemiparesis or hemianesthesia. progressive drowsiness • Cavernous sinus : carotid aneurysm. infiltrative tumor CN III. thrombosis. IV. ataxia & tremor • Interpeduncular (P Com aneurysm) • Edge of tentorium : uncal herniation contralateral UMN signs. granulomatous. V1.
head-tilt to opposite side .4th nerve palsy • Normal function: Intorsion & downward • Maximum function when eye move inward and down • Deficit cause hypertropia on affected eye.
Head-tilt to correct false image .
inflammation • Localization : cavernous & orbit part .4th nerve palsy • Most common cause is trauma • Others : nerve ischemia (DM).
6th nerve pathway 6th nerve Abducen nucleus & nerve .
cross sensory loss): demyelination. Contralateral hemiparesis. gaze palsy. infarction. orbit : same as 3rd nerve • DM. 8th nerve palsy) : meningitis. 7th. tumor • Cavernous. glioma. Horner’s syndrome. CA nasopharynx • Petrous part of temporal bone (pain. ↑ICP (false localizing sign) . ataxia .6th nerve palsy • Pons (Ipsilateral 7th nerve palsy. fracture. paresthesia of same side of face & deafness) : infection. Wernicke encephalopathy • Base of brain (5th.
5th nerve palsy Peripheral trigeminal nerve lesion Central trigeminal nerve lesion .
Ophthalmic branch (V1) • Corneal reflex • Sensory upper face .
pass cavernous • V3 : both sensory & motor Test masseter muscle .Maxillary (V2) & Mandibular (V3) • V1 & V2 : sensory branch.
MS • Jaw movement abnormality : foramen ovale lesion jaw is pushed to paretic side by normal contralateral pterygoid • Unilateral UMN lesion : jaw movement is normal due to dual innervation .5th nerve palsy • Facial pain : trigeminal neuralgia (V2 or V3) if V1 involvement always R/O secondary cause • Facial numbness : CP-angle tumor.
7th nerve palsy • UMN lesion : preserve upper facial. talking. to show their teeth . weakness of contralateral lower facial muscles • LMN lesion : ipsilateral weakness of both upper & lower facial muscles • Observe patients: at rest. blinking (not cover the entire eye) • Ask patients to close their eyes tightly.
Facial muscles • Upper facial muscles : dual innervation • Lower facial muscles : contralateral cortex .
hyperacusis on the same side. infectious mononucleosis. granulomatous disease • CP-angle tumor : deafness or trigeminal nerve signs • Herpes zoster infection (zoster external ear canal) . absence taste ipsilateral 2/3 anterior • Guillain-Barre syndrome • Parotid gland tumor.Cause of 7th nerve palsy • Bell’s palsy : pain behind the ear.
8th nerve palsy • • • • Vestibulocochlear nerve Vestibular : balance Cochlear : hearing Tuning fork 256 Hz (128 Hz for vibration) .
Weber & Rinne test : Cochlear nerve Weber test Rinne test Normally AC > BC .
warm water enhances it • Cold water = acute labyrinthine disease eyes deviate to irrigate side first then nystagmus away to opposite side • COWS (cold-opposite. warm-same) nystagmus • Check tympanic membrane first!!!! .Caloric test : Vestibular nerve • Cold water inhibits semicircular canal function.
Caloric test • Head on pillow 300 • Remove ear wax. check intacted tympanic membrane • Slowly & gently inject 20 mL of cold tap water (20-25 C over 20 sec) • Wait 10 mins to do on another side .
9th nerve palsy • Motor : stylopharyngeus muscle (could not be tested clinically) • Sensory : post aspect of soft palate response of gag reflex .
do not use uvula as the reference • Absent bilateral gag reflex may be normal. listen to voice • Palate : paretic of palate lower & straighten. absent unilateral is abnormal • Bilateral palatal weakness nasal voice .10th nerve palsy • Test palate movement.
Paresis of left palatal muscle .
10th nerve palsy • Pharyngeal muscle weakness food will not go down • Vocal cord paralysis hoarseness of voice • Bilateral distal lesions of vagus n stridor • Bilateral proximal lesions palatal weakness. weak voice without stridor .
long tract signs) or extracranial disease (cervical sympathetic & 12th CN palsy) metastatic tumor of skull base. glomus jugulare tumor .9th & 10th nerve palsy • Central lesion : brainstem infarction or glioma • Glossopharyngeal neuralgia severe throat & ear lancinating pain induced by swallowing • Jugular foramen syndrome (9th. 10th & 11th) : intracranial disease (BS compression.
11th nerve palsy • Innervate sternocleidomastoid & upper trapizius • Ask pt to turn the head to one side first without resistance then try to move pt’s head back to normal position • Jugular foramen lesion. foramen magnum lesion .
11th nerve palsy Wrong way to test sternocleidomastoid Correct way to test sternocleidomastoid .
fasciculation • Observe the protruding tongue tongue deviate to the weak side .12th nerve palsy • Motor : tongue muscle • Observe for tongue at rest: atrophy.
12th nerve palsy Right hypoglossal nerve palsy : atrophy on the right side with deviate to right side .
sugar and coffee .CN I • Use non-irritative substance!!! • Salt.
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