EXAMINATION OF

CRANIAL NERVES

PRAVEEN RK

NO: 75
CRANIAL NERVES

• I. Olfactory • VII Facial

• II. Optic • VIII Vestibulocochlear
• III. Oculomotor • IX Glossopharyngeal
• IV. Trochlear • X Vagus
• V. Trigeminal • XI Accessory
• VI. Abducent • XII Hypoglossal
• The olfactory, optic and vestibulocochlear nerves are entirely sensory
• The occulomotor, trochlear, abducent, accessory and hypoglossal nerves are
entirely motor
• The remaining nerves are mixed nerves.
1. OLFACTORY NERVE

• Function – sense of smell

• Test each nostril separately with other nostril and eye closed. Use familiar
materials like orange peel, coffee powder, soap, toothpaste, asafoetida, etc.
• For infants and retarded children note the behavioral response
11. OPTIC NERVE

• Function – vision
• Components of examination - Acuity of vision
Field of vision
Color vision
Fundus examination
VISUAL ACUITY

• Above 3 years – vision screened by use of E chart or Snellens picture charts

• Visual acuity recorded according to formula V=d/D, where d is distance at which
patient can read the letter and D is the distance at which letters are readable by a
person with normal vision.
• In infants – vision tested by checking blinking response to bright light, turning of
head towards diffuse light or following red moving ball or ring
• Visual acuity in a term newborn baby is 6/45, 6/18 at one year, 6/6 at 6to7 years.
VISUAL FIELD

• Confrontation test in older children, and in younger children by moving a

light/toy
• Confrontation test- examiner sits one meter away facing the patient whose right
eye is tested with examiners left eye and vice versa.
• The other eye is kept covered self by the corresponding hands of the examiner
and the patient. Differing numbers of fingers of examiner are presented in
different quadrants of visual field from extreme periphery.
• Child is asked to mimic the number of fingers in each field as soon as it is seen
• For small children move a light or red ball into the visual field from behind
forwards and observe the response
• Visual induced refixation - infant’s attention is directed elsewhere while the
examiner flashes light in various field of vision. Normal response is the infant
turning and looking to light
COLOR VISION

• Test whether child is able to appreciate 3 primary colors- red, green, blue by
showing toys
• Ishihara pseudoisochromatic eye plates are used in older children. Child is asked
to identify the number produced by virtue of different colors.
PUPIL EXAMINATION

• Size, shape and pupillary reflexes

• Test – patient should be looking into distance. Bring the light beam directed to
pupil from periphery. Sudden constriction of pupil occurs (direct response).
Repeat the test , this time looking at the contralateral pupil, which will normally
constrict (consensual response)
• Accomodation reaction – hold up a pen close to patients nose. Ask patient to
look away and then quickly at the pen. As eyes converge, pupils constrict.
111.OCCULOMOTOR, 1V.TROCHLEAR,
V1.ABDUCENT NERVES
• Function – eye movements
• Diplopia is the most reliable symptom of its involvement
• Test – observe the eye movements when a colored object is moved in various
directions of visual field.
• Above age of 4 years child is asked to look at a red pen as it is moved in direction
of action of extraocular muscles
• Doll’s eye movement phenomenon is used to test ocular movements in infants
• Extraocular muscles
• 4 Recti and 2 Obliques
• Superior rectus
• Inferior rectus
• Medial rectus
• Lateral rectus
• Superior oblique
• Inferior oblique
• Squint ‐ paralytic ‐range of eye movements impaired, diplopia present and is
sudden in onset.

‐ nonparalytic /concomitant – range of eye movements normal

V. TRIGEMINAL NERVE

• Function – sensory to face and eyes, motor to muscles of mastication

• Corneal and conjunctival reflex

• Sensory ‐test sensations over forehead, cheeks and chin ( ophthalmic, maxillary
and mandibular divisions)

• Motor ‐ ask to clench the teeth and palpate over the cheek and temple
(masseters & temporalis )

‐ ask to open the mouth wide ‐ jaw deviates to the paralyzed side
(pterygoid)
VII. FACIAL NERVE

• Function – Motor to facial muscles, Taste sensation to anterior 2/3 of tongue

• Motor ‐ raise the eyebrows (frontalis) –wrinkling

‐ try to open tightly closed eyes ( orbicularis oculi )
‐ obliteration of nasolabial fold on paralyzed side
‐ look for deviation of angle of mouth
‐ blowing of air ( buccinators)
• Sensory ‐ test for taste in the anterior 2/3 rd of tongue
• Lower motor neuron lesion of 7th nerve results in complete lack of
ipsilateral facial movements
• Upper motor neuron lesion – only lower half of the face is affected
(upper part of the face has bilateral cortical innervation )
VIII. VESTIBULOCOCHLEAR NERVE

• Function – sound perception and maintenance of body balance

• Hearing assessment
Ask for tinnitus
Rinne’s test
Weber ‘s test
Audiometry from 3 yrs onwards
• In infants – assess for blinking of eyes, sudden change or cessation of activity,
change in heart rate, turning of head towards the sound stimulus of a bell,
whistle, etc
• Vestibular nerve
Vertigo, giddiness and dizziness – complaints
Caloric test – child’s head is kept in semireclining position. 10 ml cold water
(30oC) or warm water (44oC) is injected into ear canal
and nystagmus recorded on electromyography. Cold
caloric test produce slow deviation of eye towards side of injection
and opposite effect in hot caloric test. No nystagmus occur in case
of vestibular damage.
IX & X ‐ GLOSSOPHARYNGEAL AND
VAGUS NERVE

• Function – IXth: motor for stylopharyngeus muscle and middle pharyngeal

sphinctor, sensory to posterior 1/3 of tongue
Xth: Motor for soft palate,pharynx,larynx , sensory and motor for
respiraory passage, heart and most of abdominal viscera
• Nasal regurgitation of fluids and nasal twang of voice
• Position of uvula moves to normal side in Xth nerve palsy
• Palatal movement - no movement on the affected side ; pulled to normal side
- palate immobile if bilateral palatal palsy
• Gag reflex – tickle the posterior pharyngeal wall and look for contraction of
pharynx‐afferent is IX and efferent is X
• Sensory – taste in posterior 1/3 of tongue
XI. ACCESSORY NERVE

• Trapezius muscle

‐ Tested by shoulder shrugging against resistance

‐ Drooping of shoulder on paralyzed side and scapula drop to lower level
• Sternomastoid

‐ ask the child to turn his head to one side or other against resistance
X11. HYPOGLOSSAL NERVE

• Ask the child to protrude the tongue‐ it deviates to the paralyzed side
• Fasciculation of tongue in Wernig –Hoffman disease
• Atrophy of tongue on affected side in LMN palsy
• In UMN palsy ,tongue is spastic , thin and pointed
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