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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 Whisper Test (Go behind the patient arm
Cover your eye opposite the patient’s eye length from the ear, because they may read your lips
(so if the patient covers her right eye, cover your and give a different 2 digit number, cover the other ear)
left eye) Hair rubbing test (low frequency20-40 hertz)
distance should be an arm’s length It’s a rough test,
patient should look at examiner’s nose If there is anything abnormal – do Rinne’s or Weber’s
Red head should be first to see by the test
patient
Change hand to check other side 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,  Oculomotor nerve damage on one side:
tender spine on palpation, numbness or tingling (Example in parens: Left oculomotor
sensation
lesion)
o The ipsilateral direct reflex is lost
(Example: when the left eye is
Common Abnormalities stimulated, only the right pupil
I. Olfactory constricts)
Causes of anosmia
Obstruction of nasal passage (commonest) o The ipsilateral consensual reflex is
Head injury causing shearing damage to the olfactory lost (Example: when the right eye is
filaments (commonest neurological cause) stimulated, only the right pupil
constricts)
II. Optic o The contralateral direct reflex is
Abnormal pupillary reflexes
intact (because light shone into both
Afferent - defect of retina or optic nerve. No direct light eyes can still signal to the brain, and
reflex. But constricts when light shone into the opposite the pupil on the undamaged side
eye (consensual reflex preserved) will still be able to constrict via its
 Optic nerve damage on one side: (Example normal oculomotor nerve)
in parens.: Left optic nerve lesion) o The contralateral consensual reflex
o The ipsilateral direct reflex is lost is intact (because light shone into
(Example: when the left eye is the left eye can still signal to the
stimulated, neither pupil constricts, brain via the normal optic nerve,
as no signals reach the brain from causing attempted constriction of
the left eye due to its damaged optic both pupils; the contralateral pupil
nerve) constricts via its normal oculomotor
o The ipsilateral consensual reflex is nerve, but the ipsilateral pupil is
INTACT (because light shone into unable to constrict due to its
the right eye can signal to the brain, damaged oculomotor nerve)
causing constriction of both pupils
via the normal oculomotor nerves) Holmes-Adie Syndrome – Myotonic pupil + absent
o The contralateral direct reflex is ankle jerks + absent other deep tendon reflexes
intact (because light shone into the
Abnormalities of papillary size
right eye can signal to the brain, B/L constriction – Pontine hge, Neostigmine, Morphine
causing constriction of both pupils U/L miosis (constriction) + ptosis + impaired sweating +
via the normal oculomotor nerves) enophthalmos – Horner’s syndrome
o The contralateral consensual reflex B/L symmetri dilation – Anxiety, Atropine, Amphetamine
is lost (because light shone into the
Impaired visual field
eye on the damaged side cannot Due to damage of optic nerve (U/L), chiasma
signal to the brain; therefore, despite (Bitemporal), Homonymous defects (distal to
the right eye's motor pathway chiasma)
(oculomotor nerve) being intact, no
signals from the left eye are able to
III. Oculomotor
stimulate it due to the damage to the C/F- Superior, medial & inferior eye movements,
sensory pathway (optic nerve) of the pupil dilatation, absent reflex
left eye) Cause – diabetic mononeuropathy, tumour

IV. Trochlear
C/F – Diplopia when looking down & reading,
Efferent – defect of oculomotor nerve, ciliary compensatory head tilt.
ganglion 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