NEU • MOD 3 Trans 4 • 12/13/22

EXAMINATION OF THE CRANIAL

NERVES
DR. NICO PAULO M. DIMAL M.D. F.P.N.A.
OUTLINE (Arial, 10 Bold)
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b. Subtopic
c. Subtopic
II. Main Topic
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b. Subtopic
c. Subtopic
 In the instance that there are plenty of topics included in the trans, the
outline table can be divided into two (2) columns
 Maintain alignment between boxes and headings. Use the View Gridlines
when necessary

LEGEND
⭐ ❓ 🖊️ 📖 📝 📺
Must Good Lecture Book Prev. Presentation
Know to [lec] [bk] Trans [ppt]
Know [tn]
 ⭐ Please put the legend before the text
 Please do not change legends to maintain uniformity in all batch transes.

I. ANATOMIC REVIEW OF THE 12 PAIRS OF

CRANIAL NERVES
 CNs must exit one of the major foramina in the base of the skull.
 Optic nerve and olfactory nerve are closer to each other, a lesion
in one of these nerves will affect both nerves. Figure 1. Anterior=Green; Middle=Red; Posterior=Blue
o 🖊️ Pt who have cognitive impairment and (Source: © Dr. Dimal’s PPT)
behavioral changes with visual complains,
olfactory nerve must be check.
 🖊️ CN XI – before it exit to the Jugular foramen, it arises at the
upper cervical cord and the rootlets unite and enter the Foramen
Magnum which eventually joined by the cranial roots of the spinal
accessory nerves.
 Only CNs I and II attach to the brain rostral to the midbrain. They
do not emerge from the brainstem but rather connect directly to the
forebrain.
o 🖊️ CN I and CN II do not attached to the
brainstem.
 CN I – synapses directly to the olfactory
bulb
 CN II – an evagination from the
diencephalon
o 🖊️ CN XI mainly comes from the cervical cord

📺 Exit Foramina for the Cranial Nerves in the Base of the Skull

nterior fossa I Perforations in cribriform plate

Middle fossa II Optic foramen
III, IV, VI and Ophthalmic division of V Superior orbital fissure
Maxillary division of V Foramen rotundum
Mandibular division of V Foramen ovale
osterior fossa VII and VIII Internal auditory meatus
IX, X, and XI Jugular foramen
XII Hypoglossal foramen

Figure 2. Foramina of the Cranial Nerves

(Source: © Dr. Dimal’s PPT)

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Figure 5. POSTERIOR VIEW

(Source: © Dr. Dimal’s PPT)

Figure 3. Cranial Nerves

(Source: © Dr. Dimal’s PPT)

Figure 6. LATERAL VIEW

(Source: © Dr. Dimal’s PPT)

Figure 4.
(Source: © Dr. Dimal’s PPT)

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 The CNs name conveys at least something about the components,

function, or distribution of the nerve.
 Three Sets of Cranial Nerves
o Solely Special Sensory set
 I (smell), II (vision), and VIII (hearing
and equilibrium)
o Somite set
 III, IV, VI, and XII
o Branchial set
 V, VII, IX, X, and XI

II. GENERAL REMINDERS FOR EXAMINATION OF

CNs

Use simple instructions as minimally as possible

For examination of senses:
o Demonstrate the stimulus first
o Isolate the chosen modality through eye closure
(except for CN II), avoiding noxious substance
o Periodically remove the stimulus to test for
suggestibility and attentiveness
o Check for asymmetry
Figure 7. NUCLEI OF THE CRANIAL NERVES
(Source: © Dr. Dimal’s PPT)  For examination of motor function:
o Check for asymmetry
 🖊️ Do not assume normal result, always
Cranial Nerve check for asymmetry (abnormal
findings).
ber Name Functional or Anatomic significance of name
o Have the Pt perform the muscle action being
OLFACTORY It smells. tested before applying resistance

OPTIC It sees.
III. CRANIAL NERVE I (OLFACTORY NERVE)
I OCULOMOTOR Its muscles move the eyeball.  Functional category:
TROCHLEAR Its muscle moves the eyeball after running through a o special somatic sensory
trochlea.  Function:
TRIGEMINAL It has three large sensory branches to the face. o olfaction (smell)
 📝 Arise from the olfactory receptor nerve cells in the
ABDUCENS It abducts the eye. olfactory mucous membrane.
I FACIAL It moves the muscles of all facial orifices.  📝 Olfactory hairs: short cilia from peripheral process,
project to mucus covering the surface of the mucous
I VESTIBULOCOCHLEAR It equilibrates, hears. membrane. It reacts to odors in the air and stimulate the
olfactory cells.
GLOSSOPHARYNGEAL It supplies taste fibers to the tongue and activates the  📝 Olfactory bulb: possesses several types of nerve cells.
pharynx during swallowing. Mitral cell is the largest. Incoming olfactory nerve fibers
VAGUS It is a vagrant, wandering from the pharynx to the splenic synapse with the dendrites of the mitral cells and form
flexure of the colon. rounded areas- synaptic glomeruli.
SPINAL ACCESSORY It arises from neuronal cell bodies in the cervical spinal cord,
 Needs:
runs into the skull, out again, and conveys accessory fibers to o aromatic substance like coffee in an opaque vial
the vagus. o Penlight
I HYPOGLOSSAL It runs under the tongue.
 Technique:
o Check nostrils
Function of the Cranial Nerves o Test one nostril at a time by compressing the other
o Ask Pt to close eyes and sniff
Number Function
o Pt identifies the substance or not
I Smells  📝 You can use 2 different stimuli so
that you’re sure that the patient isn’t just
II Sees saying the same response as in the
other side.
III, IV, and VI Move eyes; III constricts pupil
 📝 Sometimes, some people would do
V Chews and feels the front of the head fake testing and put an empty bottle
close to the open nostril and ask if
VII Moves the face, tears, snots, tastes, salivates he/she smells anything, just to make
sure that the patient is attentive and
VIII Hears, equilibrate actually responding honestly.
IX Tastes, salivates, swallows, monitors carotid body and sinus 
Sample abnormal findings
o Pt is unable to identify the substance on one/both
X Tastes, swallows, lifts palate, phonates, afferent and parasympathetic side/s (anosmia)
efferent to thoracicoabdominal viscera
XI Turns head, shrugs shoulders

XII Moves tongue

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 Light projection: use a

penlight and have the patient
point which direction the light
is coming from

 May test for response to visual threat or
for visual tracking

Figure 8. CN I EXAMINATION
(Source: © Dr. Dimal’s PPT)
Figure 9. CN II EXAMINATION
(Source: © Dr. Dimal’s PPT)
IV. CRANIAL NERVE II (OPTIC NERVE)
 Functional category: o Visual fields: confrontation testing
o special somatic sensory  Position yourself 50 cm away from the
 Function: patient
o vision  Test one ye at a time, one hemifield at a
 📝 conveys the afferent axons for both vision and time, one quadrant at a time
pupilloconstriction.  Patient should look into Examiner’s eye
 📝 (Patient’s right eye to Examiner’s left
 Needs: eye)
o Snellen chart or Pocket vision chart (aka  Patient should identify Examiner’s
Rosenbaum chart) finger/s per quadrant
o Ophthalmoscope  Map out field defect, if any
o Penlight  Test for visual attention
 ⭐ Components:
o Visual acuity
o Visual fields
o Ophthalmoscopy
o “Always start with visual acuity, you don’t go
straight to visual field nor ophthalmoscopy
because want to ensure that the patient can see
before asking about visual field and etc.”
 Technique:
o Visual acuity
 Pocket near vision chart should be 14
inches away from the pt’s eyes
 Have the pt read each
number from the chart,
beginning from the biggest
row to the smallest
Figure 10. CN II EXAMINATION
 Pt must be able to read
(Source: © Dr. Dimal’s PPT)
majority of the numbers
 Test each eye separately w/ correction
 Remind the pt to squint lightly
because if the pt squint’s too
much the pt will have a
difficulty with the following
examinations
 If the patient have glasses, let
them wear it
 If unable to read the tool, test counting
fingers à light projection à light
reception
 Counting fingers: usually
done 5 feet away from the pt
and tell the pt to respond how
many fingers are shown by
the ex

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Figure 11. CN II EXAMINATION

(Source: © Dr. Dimal’s PPT)

o Direct Opthalmoscopy
 Instruct patient to fixate ahead
 Examine patient’s right eye w/
examiner’s right eye, patient’s right eye
w/ examiner’s left eye
 Maintain a proprioceptive link
 Check ROR, clarity of media, disc
margins, artery to vein ration (2:3), cup
to disc ratio (<0.5), exudates

Figure 14. CN II & III EXAMINATION

(Source: © Dr. Dimal’s PPT)

Figure 12. CN II EXAMINATION

(Source: © Dr. Dimal’s PPT)

 Sample abnormal findings

o VA: 20/200 OU with correction
o VF: right homonymous hemianopia
Figure 15. CN II & III EXAMINATION
o Fundoscopy: (+) ROR, clear media, distinct (Source: © Dr. Dimal’s PPT)
borders, no exudates or hemorrhages

VI. CRANIAL NERVE III, IV, VI (TROCHLEAR,

TRIGEMINAL & ABDUCENS NERVE)
 EOM3SO4LR6
 Functional category:
o CN III
 Somatic motor: Levator palpebrae
superioris and all extraocular motor
muscles, except for superior oblique and
Figure 13. CN II EXAMINATION lateral rectus
(Source: © Dr. Dimal’s PPT)  Parasympathetic: Parasympathetics to
pupil constrictor and ciliary muscles for
near vision
V. CRANIAL NERVE II & III (OPTIC & TROCHLEAR o CN IV
 Somatic motor: Superior oblique
NERVE) muscle; causes depression motor and
 Functional category: intorsion of the eye
o special somatic sensory o CN VI
 Function:  Somatic motor: Lateral rectus muscle:
o Vision (pupillary light reflex) causes abduction of the eye
 Needs:  Needs:
o Penlight o Penlight
o Ideally, ability to darken ambient light  Technique:
 Technique: o Assess palpebral fissures for ptosis
o Patient should fixate ahead o Assess primary gaze by checking corneal light
o Shine a light from below at the midline to check for reflection
pupil size with ambient light o Assess for spontaneous eye movement
o Shine a light on each eye, checking direct and (nystagmus, intrusions)
consensual response on each eye; note pupil size, o Assess pursuit in all directions of gaze
shape and briskness of response o Assess smoothness and range of motion
o Check for relative afferent pupillary defect (RAPD) o Keep patient’s head steady
with swinging flashlight test at 3-5 second intervals o Test for accommodation: towards the patient’s
 Sample abnormal findings nose
o Pupils 3mm/3mm equal and brisky reactive to  Sample abnormal findings
direct and consensual stimulation, no RAPD
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o No ptosis bilaterally, midline primary gaze, EOMs

full in all directions

VII. CRANIAL NERVE V (TRIGEMINAL NERVE)

SENSORY
 Functional category:
o general somatic sensory
 Function:
o Sensations of touch, pain, temperature, joint
position, and vibration for the face, mouth, anterior
two-thirds of tongue, nasal sinuses, and
meninges.
 Needs:
o Cotton wisp for light touch and corneal reflex,
o broken tongue depressor for pain MOTOR
o tuning fork for cold or finger for warm  Functional category:
 Technique: o Muscles of mastication and tensor tympani muscle
o Sensory:  masseter
• Use cotton wisp, broken tongue  temporalis
depressor, or tip of tuning fork to test each  medial pterygoid
trigeminal division excluding the angle of  lateral pterygoid
the mandible (C2 dermatome)  Needs:
• Ask Pt to inform Ex once the stimulus o none
is felt
• Compare right versus left, quantify by
 Technique:
percentage
o Inspect temporalis and masseter for atrophy
 Corneal reflex: o Ask Pt to clench jaw/bite down, and palpate
• Lightly touch lower outer quadrant of temporalis and masseter; check for asymmetry
the cornea with cotton o Press heel of palm down on Pt’s chin.
• Check for symmetry and speed of o Move jaw side to side, push to one side against
blinking response heel of Ex’s palm with Ex’s other hand on Pt’s
 Sample findings contralateral cheekbone.
o Intact V1 to V3 bilaterally to pain and light touch,  Sample findings
brisk corneals bilaterally o no temporalis/masseter atrophy, intact muscles of
mastication bilaterally

A. FIGURES AND TABLES

 Useful tools to supplement the information. Only include what’s
necessary
 Table and figure alignment: center
 Use the view > tick “Gridlines” to place the figures in the center of
the column if necessary
 Tables and figures can be placed in the appendix or in between
texts
o If the table or figure can be placed in the appendix,
please mention in the content (e.g., (See
Appendix _ )

FIGURES
 Do not use pixelated photos
 As much as possible, avoid taking photos at an angle
 For figure-heavy subjects like anatomy, label them as much as
possible

FORMAT
 Details: Arial, 8, Bold, Centered
3 Sensory Divisions of the trigeminal nerve:  ⭐In the picture format: go to picture styles > border. Use ¼
V1- Opthalmic weight, black outline to distinguish it from the next
V2- Maxillary
 Use “top and bottom” wrapping
V3- Mandibular

CITATION
 Details: Arial, 7, in between parentheses
 If it came from the professor or a classmate, put alt + 0169 to
insert ©
o Example: (Source: © LN, FN)

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 Paste the designated link in the address bar > ok

Figure X. School Logo

(Source: © Flaviano, Angel Mykhelle)
o If it came from a link, do not paste the entire link.
Insert hyperlink to avoid excessive characters

Figure X. School Logo

(Source: Sample link)
o If a reference from a book or lecture is used, use
superscript. The # is to denote the number in the
reference portion of the trans.
 Example: Figure 1. Figure Name# FIGURE 3. Inserting Hyperlink

VIII. IX. GLOSSOPHARYNGEAL, VAGUS NERVE

 📺 Glossopharyngeal
o Functional category: function
o Branchial motor: Stylopharyngeus muscle
Figure X. School Logo1 o Parasympathetic: Parasympathetics to parotid
gland
o General somatic sensory: Sensation from middle
TABLES ear, region near the external auditory meatus,
 Concise and straight to the point; to summarize a topic pharynx, and posterior one-third of tongue
 Tables that may come from the lecturer, presentation, other o Visceral sensory (special): Taste from posterior
trances, books, other resources should be manually typewritten one-third of tongue
 For the taste portion, we are not testing it
for easier searching
clinically
o Visceral sensory (general): Chemoreceptors and
FORMAT baroreceptors of carotid body
 Details: Arial, 8  📺 Vagus
o Branchial motor: Pharyngeal muscles (swallowing)
 Use superscript at the end of the table title to cite reference listed
and laryngeal muscles (voice box)
in the reference section fo the trans o Parasympathetic: Parasympathetics to heart,
 Title of the table lungs, and digestive tract down to the splenic
o Table 1. Title# (reference) flexure
 Size 8, Bold, Center o General somatic sensory: Sensation from pharynx,
 Cell color is the trans’ main color meninges, and a small region near the external
o Categories/Must know: cell color is the trans’ sub auditory meatus
color o Visceral sensory (special): Taste from epiglottis
and pharynx
Table 2. How to Cite from Book/Lecture2  We don’t test
o Visceral sensory (general): Chemoreceptors and
Arial, 8, Bold,
Category Notes baroreceptors of the aortic arch
Center
 📺 Cranial Nerves IX, X
Sample information Arial, 8, Left Sample text o Needs: Tongue depressor
here  To check for palatal elevation
1. Info may be Please continue to Keep them always o Technique:
numbered follow proper format indented at the left  Have Pt say kuh kuh kuh; check for
dysphonia
Table 3. How to cite from Website/not from book  Have Pt say ah while inspecting palatal
Verdana, 8, Bold, elevation and uvula position
Category Note o See picture
Center
Sample information Verdana, 7, Bold, Note that there is no o the palate on the left side is not
here Left superscript at the elevated equally as the right (left
table title palatal weakness), report as there is
uvula deviation slightly to the right
1. Information The citation will be Do not paste the
and there is weak palatal elevation on
from below and the entire link length.
the left, so you are expecting a
cite shall be linked Insert hyperlink problem in the left CN 9 or 10 or a
with the title. instead problem in the corticobulbar fibers on
(Source: Sample link) the other side

CREATING HYPERLINK  Gag reflex: warn Pt, gently touch

tonsillar pillar with tongue depressor
 Highlight the word/s
 Right click > link > insert link
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and check for choking response and o Have Pt turn head to either side, apply hand on side of Pt’s
symmetry of palatal elevation head while the other hand is on Pt’s shoulder; palpate SCM
o Not routinely done only when you tone during contraction
expect a LMN problem o Have Pt push forehead against Ex’s hand while the other
hand is on Pt’s nape
o Sample findings: Uvula is midline, palatal o Have Pt raise both shoulders; Ex then pushes
elevation is symmetric, good gutturals, no shoulders downwards
dysphonia o Key here is where to place your hand
 If intubated: (+) gag on endotracheal o The SCM turns the head to the other side, same side if tilting
tube tugging or suctioning (right tilts to the right side)
 📝 The Glossopharyngeal nerve (CN IX) supplies the stylopharyngeus muscle o Trapezius elevates the shoulder on that side
and sends secretomotor fibers to the parotid gland. Sensory fibers o Also palpate the bone – press neck then feel the SCM bone
innvervate the posteror 1/3 of the tongue for general sensation o Forward movement – SCM bilaterally – tulak po ang aking
and taste. kamay paganito (palpate bone)
 📝 Isolated lesions of CN IX are rare and usually involve the vagus o Lingon kayo sa kaliwa, tutulak ko labanan nyo (hawak sa
nerve (CN X)
balikat and check tone)
 📝 To test for gag reflex use cotton swab and stimulate the back
o Akyat balikat patenga
of the throat (do it on both sides, not in the midline) that will
o Angat muna before tulak
cause the patient to gag ☤ (pharyngeal muscles will contract)
o Sample Findings: GOOD SCM tone bilaterally, good head
o 📝 Gag reflex is often impaired in patients with stroke –
turn and shoulder elevation bilaterally
supratentorial or infratentorial, especially when multiple
o Always compare left vs right
strokes are present
 📝 Unilateral lesions of the vagus nerve will show little or no gag
reflex on that side. 🕮
 Observe palatal elevation patient says “aaah” ☤
o Normally the soft palate rises and the uvula moves backward
in the midline 🕮
 Reminder: check for palatal elevation, NOT uvula deviation
o Should be symmetric (both should elevate)
 Also test for swallowing reflex☤
 To check for laryngeal and pharyngeal dysarthria ☤
o Ask the patient to say “mi-mi-mi" (for laryngeal)
o Ask the patient to say “ka-ka-ka" (for pharyngeal)
o Slurring is a sign of lesion in these nerves
 All muscles of the larynx are supplied by the recurrent laryngeal
branch of vagus, except the cricothyroid muscle which is supplied
by the external laryngeal branch of the vagus.
 Hoarseness or absence of voice may occur as a symptom of vagal
nerve palsy.
 Lesions involving the vagus nerve in the posterior cranial fossa
commonly involve CN IX, XI and XII.

📺
📺 UPCM Neuro OSCE

📺 Testing for Gag Reflex:

IX. CRANIAL NERVE XI (SPINAL ACCESSORY)

o 📺 Functional category: function
o Brachial motor: sternocleidomastoid and upper part of
trapezius
o Needs: None
o Technique:

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📺 Doc Dimal Lecture: You can see downward displacement of the

📺 Doc Dimal Lecture: palpate the bone scapula and some emptiness, trapezius lag of the left, shoulder
asymmetry, CN11 problem on the left

X. CRANIAL NERVE XII (HYPOGLOSSAL NERVE)

 Functional category:
o somatic motor
 Function:
o intrinsic muscles of the tongue
 Needs:
o Penlight
 Technique:
o Inspect tongue inside the mouth: check for
atrophy and fasciculations
o Have Pt protrude tongue (testing for bilateral
genioglossus muscle), check if the tongue
is midline
o Have Pt push tongue against each cheek from
inside the mouth, push on each cheek
alternately
o
 Sample findings:
o Tongue is midline, with no atrophy or
fasciculations

 Sample abnormal findings:

o Dysarthria: arises from faulty articulation. Test
labials (CN VII), gutturals (CN IX and X), linguals
(CN XII).
o Dysphonia: arises from faulty sound production
(problem with CN X or its branches)

TAKE HOME POINTS

 CN I and II arise above the
brainstem; CN III and IV
nuclei are in the midbrain; CN
V, VI, VII, and VIII (partly)
nuclei are in the pons; CN
VIII (partly), IX, X, and XII
nuclei are in the medulla; CN
XI nucleus is in the cervical
cord
 Remember 3 sets of cranial
nerves: SSS set, somite set,
branchial set
 Look for abnormal findings
using knowledge on functions
of each cranial nerve
 When examining sensation,
isolate the modality and
periodically remove the
stimulus

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 Always check for asymmetry
 Examination must be driven
by hypotheses (based on
history and findings during
the examination)
 Check CN I in those with
history of trauma, cognitive
impairment, and visual issues
 For CN III, IV, and VI:
determine which EOMs are
involved
 For CN VII: determine pattern
of facial weakness
 Check taste if suspecting
peripheral CN VII lesion
 For CN VIII: determine if
sensorineural or conductive
hearing loss
 Do not test gag reflex
routinely
 Always assess for tongue
atrophy
ANSWER: Choice A (Arial, 7, main color, justified)
 Insert a 1x1 table. Insert a bullet before the explanation
 If there is a figure or table included in the answer, insert it in the
appendix and cite it the rationale
o See Appendix _
 Follow correct bullet and numbering
3. Question 1
a. Choice A
b. Choice B
c. Choice C
d. Choice D
RATIONALE (Arial, 7, Bold, main color, justified)
ANSWER: Choice A (Arial, 7, main color, justified)
 Insert a 1x1 table. Insert a bullet before the explanation
 If there is a figure or table included in the answer, insert it in the
appendix and cite it the rationale
o See Appendix _
 Follow correct bullet and numbering

XI. REFERENCES
1. Question 1  Follow proper APA citations
 Arial, 6, justified
a. Choice A  You may use a website citation generator
b. Choice B  Book
c. Choice C o Author, A. (Year). Title of work (edition). Place of publication:
Publisher
d. Choice D
 Journal article
o Author, A. (Publication year). Article title. Periodical title, Volume
(Issue), pp-pp
RATIONALE (Arial, 7, Bold, main color, justified)  Online book
ANSWER: Choice A (Arial, 7, main color, justified) o Author, A. (Year). Title of article. Retrieved from URL
 Website
 Insert a 1x1 table. Insert a bullet before the explanation o With author
 If there is a figure or table included in the answer, insert it in the  Author, A. (Year). Title of article. Retrieved from URL
appendix and cite it the rationale o Without author
 Article title (Year). Title of work (edition). Retrieved
o See Appendix _ from URL
 Follow correct bullet and numbering  Photo
o Photographer, A. (Photographer). (Year). Title of Photograph
[digital image]. Retrieved from URL
2. Question 1  Previous trans
a. Choice A o Batch year COM-Transcription
b. Choice B  Example: 2025COM-Transcription
c. Choice C  Lecturer’s PowerPoint
o Lecturer, A. (Year). PowerPoint title [Lecture PPT]
d. Choice D

RATIONALE (Arial, 7, Bold, main color, justified)

APPENDIX

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 To prevent any changes in the format, please leave the blank space above the appendix.
 If there is no appendix, do not delete this portion.
o Instead, you may write No appendices
 All appendices in any trans should be in one column
 Figures and tables that’s large in size should be placed here
 Includes figures and tables used to rationalize the answers in the review questions
 Table for the abbreviations used must be included in the appendix

Note:
You may insert meme and any motivation quotes in the trans. Please place them accordingly, suggested area is at the end of the trans.

Let us work together as a batch. Please treat the transes as your own reviewers
and keep its content informative and helpful.
One for All, All for One.
Let’s go Batch 2026! Walang iwanan!

[NEU] Nassir Surname 1, Surname 2, Surname 3 (alphabetical order) TH Regala Page 11 of 11