CRANIAL NERVE EXAMINATION Jaw Jerk – mouth slightly open, eyes closed (Fig.

I Olfactory Do you have any problems with Macleod 10th P 205)

smelling things
II Optic VII Facial – Look up wrinkle your face with finger
dewrinkle the face
VISUAL ACUITY – Snellen Chart reading with glass on. Close your eyes tight, don’t let me open them
checking distant vision Can you give me a grin? Show me your teeth –
Cover one eye with one hand and read see asymmetry or give me a smile
with the open eye – please read the bottom line Drooping side is affected side
Repeat with the other eye Can you puff your cheeks – cannot puff it

Then glasses off VIII Vestibulo-cochlear Hearing and balance

VISUAL FIELD: red head pin – cover one eye of patient
Cover your eye opposite the patient’s eye
(so if the patient covers her right eye, cover your
left eye)
distance should be an arm’s length
patient should look at examiner’s nose
Red head should be first to see by the
patient
Change hand to check other side
Whisper Test (Go behind the patient arm
length from the ear, because they may read your lips
and give a different 2 digit number, cover the other ear)
Hair rubbing test (low frequency20-40 hertz)
It’s a rough test,
If there is anything abnormal – do Rinne’s or Weber’s
test
You don’t test the balance

FUNDI - need a dark room, ask the examiner that I IX Glossopharyngeal, X Vagus – tested together – ask
would like to do fundus exam the patient to open their mouth – Open wide
If not asking you’ll fail Uvular deviation – deviated towards the good
side
III, IV, VI Oculomotor, Trochlear, Abducent – main AAAH (movement of the palate to see if there is
involving eye movement symmetry
1st check Pupil – look equal in size, shape, +/- GAG – touch the palate – be very careful with
ptosis- eyelid drops, Horner syndrome this, adults are very sensitive
Light reaction with pen torch – check response Speech – hoarseness (due to paralysis of
Direct, Consensual – other pupil response with one recurrent laryngeal nerve (X)
pupil is reflected light Glass of water – swallow (Lateral Medullary
Accommodation – look above my shoulder at Syndrome – Cerebellum V, IX, X PICA?)
distance – dilated pupil
And near to red pin – constricted pupil XII Hypoglossal – the reason you do XII before XI –
Eye Movement: Focus a pin because it involves the mouth
Don’t move head In charge of the tongue
H – shape movement Inspection – look for wasting of the tongue or
Stop outside ask for Diplopia, fasciculation
check for nystagmus Can you please show me your tongue?
V Trigeminal Mixed Nerve – sensory/motor/reflex jaw (Protrude the tongue)
jerk - deviation to the affected side –
weak side
Sensory
1. Corneal Reflex – Approach from side, pt XI Accessory – Go behind the role player and shrug
looks to opposite direction, very light touch corner of the shoulders – resisted movement
eyes – Blinking eye is + Check for weakness of the muscles
2. Facial Sensation – frontal, maxillary,
mandibular Turn your head towards your right. Don’t let me
Ask for Sharp and dull push it
3. Light touch – close eye
Do Summary at the End
Motor part – According to my examination of the Cranial Nerves
Clench their teeth – feel masseter, ?pterygoid I could not find any findings
Or there is an abnormality in cranial nerves….
Open your mouth do not let me close your mouth
Feel Pterygoid muscle – near Temporomanibular joint
NECK PAIN (Red Flags) – shooting pain, radiated pain,
tender spine on palpation, numbness or tingling
sensation
Common Abnormalities
I. Olfactory
Causes of anosmia
Obstruction of nasal passage (commonest)
Head injury causing shearing damage to the olfactory
filaments (commonest neurological cause)
II. Optic
Abnormal pupillary reflexes
Afferent - defect of retina or optic nerve. No direct light
reflex. But constricts when light shone into the opposite
eye (consensual reflex preserved)
 Optic nerve damage on one side: (Example
in parens.: Left optic nerve lesion)
o The ipsilateral direct reflex is lost
(Example: when the left eye is
stimulated, neither pupil constricts,
as no signals reach the brain from
the left eye due to its damaged optic
nerve)
o The ipsilateral consensual reflex is
INTACT (because light shone into
the right eye can signal to the brain,
causing constriction of both pupils
via the normal oculomotor nerves)
o The contralateral direct reflex is
intact (because light shone into the
right eye can signal to the brain,
causing constriction of both pupils
via the normal oculomotor nerves)
o The contralateral consensual reflex
is lost (because light shone into the
eye on the damaged side cannot
signal to the brain; therefore, despite
the right eye's motor pathway
(oculomotor nerve) being intact, no
signals from the left eye are able to
stimulate it due to the damage to the
sensory pathway (optic nerve) of the
left eye)
Efferent – defect of oculomotor nerve, ciliary
ganglion
 Oculomotor nerve damage on one side:
(Example in parens: Left oculomotor
lesion)
o The ipsilateral direct reflex is lost
(Example: when the left eye is
stimulated, only the right pupil
constricts)
o The ipsilateral consensual reflex is
lost (Example: when the right eye is
stimulated, only the right pupil
constricts)
o The contralateral direct reflex is
intact (because light shone into both
eyes can still signal to the brain, and
the pupil on the undamaged side
will still be able to constrict via its
normal oculomotor nerve)
o The contralateral consensual reflex
is intact (because light shone into
the left eye can still signal to the
brain via the normal optic nerve,
causing attempted constriction of
both pupils; the contralateral pupil
constricts via its normal oculomotor
nerve, but the ipsilateral pupil is
unable to constrict due to its
damaged oculomotor nerve)
Holmes-Adie Syndrome – Myotonic pupil + absent
ankle jerks + absent other deep tendon reflexes
Abnormalities of papillary size
B/L constriction – Pontine hge, Neostigmine, Morphine
U/L miosis (constriction) + ptosis + impaired sweating +
enophthalmos – Horner’s syndrome
B/L symmetri dilation – Anxiety, Atropine, Amphetamine
Impaired visual field
Due to damage of optic nerve (U/L), chiasma
(Bitemporal), Homonymous defects (distal to
chiasma)
III. Oculomotor
C/F- Superior, medial & inferior eye movements,
pupil dilatation, absent reflex
Cause – diabetic mononeuropathy, tumour
IV. Trochlear
C/F – Diplopia when looking down & reading,
compensatory head tilt.
Cause – Ischaemic mononeuropathy (DM, HTN)
VI. Abducent
C/F – Diplopia when looking towards the side of VIII. Vestibulocochlear nerve
paretic LR. Rinnie’s test
Casus – DM, Suppurative Otitis Media BC>AC = conductive deafness

V. Trigeminal Weber’s lateralization test

C/F – reduction in corneal reflex Normally midline
Cause – Lesions within the cavernous sinus. Frequently Lateralisation => Sensorineural deafness of opposite
with dysfunction of III, IV or VI. ear

C/F – Sensory impairment of one or more branches

Cause – Neoplasms of the base of the middle cranial IX. Glossopharyngeal & X. Vagus nerve
fossa. Dysphagia, loss of gag reflex, dysphonia
IX – Post 1/3 of tongue sensation
VII. Facial X- Asymmetrical elevation of soft palate, deviation of
UMNL – Uvula to healthy side, Hoarseness of voice (Rec Lar
Stroke – nerve br of Vagus)
1. Cortical,
2. Brain stem XII. Hypoglossal nerve
LMNL – U/L atrophy of the tongue, wrinkled, thinner affected
1. Bell’s palsy, side
2. # Petrous temporal bone, Tongue deviates towards the affected side.
3. Cerebello – Pontine tumour any, XI. Accessory nerve
4. Ramsay Hunt syndrome (Herpes zoster), Wasting/weakness of Trapezius
5. Parotid tumour paresis of Sternomastoid

Clinical feature UMNL LMNL

Forehead wrinkling Preserved Lost in
affected
side
Angle of mouth Droop of Droop of
affected affected
side side
Nasolabial fold Lost in Lost in
affected affected
side side
Ability to close eye & blinking Preserved Lost in
affected
side
Bell's phenomenon (Upward Absent Present
rolling of eye when try to close
eyes
Taste in Ant 2/3 rd of tongue Preserved absent

Pathology at Petrous Temporal bone level

Facial weakness + Loss of Ant 2/3 taste sensation +
Hyperacusis (Sound louder than normal) =>
D/D
1. #,
2. Bell’s palsy

Pathology at the level of Parotid gland (distal to

stylomastoid foramen)
Taste + Lacrimation preserved only facial weakness
D/D
Tumour of Parotid Gland