CRANIAL NERVE STEPS

First gather your testing devices:

Penlight
Visual acuity card/ newspaper
Red hatpin
Red/ Green tool
Cotton ball
Tongue depressor
Tuning forks: 512Hz

1. Introduce yourself to the patient

“Hello, my name is your name. I am a your position and I would like to examine the nerves of
your face. Is that ok? What is your name and age?”

2. Expose and position the patient

“Patient’s name, I want to be able to see your face, neck and shoulders. Can you sit upright
please?”
Patient should be exposed to level of upper shoulders.

3. General inspection from the foot of the bed:

General body habitus; facial asymmetry/ body asymmetry- slumping to one side, deviation of
the eyes etc.
Pay attention to speech!
Are there adjuncts: glasses, hearing aids, nasogastric tubes, NPO designation etc.

4. Move to the right side for closer inspection of the face and shoulders:
Look for asymmetry, scars, abnormal skin findings, deviation of eyes

5. Assess Cranial Nerve I:

Ask the patient if they have had any blocked nostrils or runny nose.
“I want you to close your eyes and block a nostril. I am going to put something by your nose, I
want you to tell me if you smell anything and what it smells like.”
Once patient has eyes closed and nostril blocked, introduce an aromatic e.g. coffee beans.
Ask the patient to block the other nostril and use a different aromatic e.g. peppermint

6. Assess Cranial Nerve II (5 steps):

1) Acuity: “Do you have any problems seeing? If you have glasses, you can put them on now.”
If you have the handheld Snellen chart, hold it 2ft away from the patient, ask them to cover one
eye and read from top to bottom. Note the visual acuity. Repeat with the other eye.
Alternatively: use a newspaper and ask the patient to read the title font, section font and article
font similarly comparing to the other eye.

If the patient cannot read printed text, downgrade your assessment to visualization of fingers.
Stand an arm’s length in front the patient and hold up fingers in either ‘single index (one),
peace sign (two) or open palm (five)’, in any order asking the patient to tell you how many
fingers you are holding up with one eye covered, then the other.

If the patient cannot visualize fingers, downgrade to hand movements:

“I’m going to be moving my hand sometimes and keeping it still others. I want you to cover one
eye and tell me when you think it is moving or when it is not.”
Using the open palm, wave the hand side to side and ask the patient to tell you whether it’s
moving or not with one eye covered. Compare to the other side.

If the patient cannot visualize hand movements, downgrade to light movement:

Repeat the instructions for hand movement but using the penlight. Compare eyes.

2) Colour vision: Say you would assess colour vision of each eye, using an Ichihara chart.
3) Visual Fields:
Sit an arm’s length across from the patient at the same height level.
“Sir/Miss, I want you to focus looking at my nose and cover one eye. I am going to be coming in
from outside moving my finger. While you keep looking at my nose, I want you to say “see it”
as soon as you see my finger moving out of the corner of your eye. OK?”
Cover your eye to mirror the patient and outstretch the hand in front of you along an imaginary
vertical plane mid- spaced between you and the patient.
While wagging your finger, move from the upper outer corner, diagonally to the middle,
listening for the patient’s “see it” and comparing it to when you are seeing it.
Repeat from the lower outer corner.
Switch your hand to cover the same eye and then go again from upper outer corner in, followed
by lower out corner.
Instruct the patient to cover the other eye and repeat making sure to do each corner.
4) Pupillary Light Reflexes:
Ask for the light to be dimmed in the room.
“Sir/Miss, I want you to look straight ahead. I am going to shine a light into your eyes, just keep
looking straight ahead.”
Elicit the direct light reflex by introducing the light from lateral into each eye.
Then, elicit the consensual light reflex by introducing the light from the lateral eye and then
quickly dipping across to look into the contralateral eye; for each eye.
Then, check for the relative afferent pupillary defect by swinging the light from eye to eye to
look for inappropriate dilatation of either pupil.
5) Fundoscopy (will always be its own station)
7. Examine Cranial Nerves III, IV and VI:
“OK sir/Miss, I want you to follow my finger with your eyes with your eyes only, don’t move
your head. Let me know if you are seeing more than 1 finger at any time.”
(You can stabilize the patient’s forehead if you find they are moving around.
Elicit the extraocular eye movements by drawing the “H” making sure to bury the pupil in each
direction and looking for any nystagmus.

8. Examine Cranial Nerve V

Sensory: “I’d like to test the sensation in your face. I am going to ask you to close your eyes
and I’m going to touch you with this cotton. I want you to close your eyes and tell me “yes”
when you feel it and if it feels the same on both sides”
Dab the cotton in the bilateral dermatomes for V1, V2 and V3 distribution- forehead, cheeks
and chin, comparing sensation in sides.
Motor: place your fingertips over the temporalis muscles bilaterally and ask the patient to bite
down then place your fingertips over the temporomandibular joint and ask the patient to bite
down again. Compare the tone of the muscles.
Ask the patient to do open the mouth and not let you close it’ push up from mentum and assess
the strength.
Corneal reflex:
“Now sir/ miss, I want you keep your head straight but to look away from me. I am going lightly
touch your eye with this cotton, it won’t hurt.”
Have the patient look ahead and away and touch the wisp of cotton to the cornea (white part
of the eye lateral to the iris) look for the direct and consensual blink. Repeat with the opposite
eye.

9. Examine Cranial Nerve VII (3 aspects):

Motor: give the patient the following instructions:
“Lift your eyebrows up like you’re surprised”
“Close your eyes as tightly as you can and don’t let me open them”
“Puff out your cheeks and don’t let me push the air out”
“Show me your teeth”
Sensory:
Say “I would also like to assess taste on the anterior 2/3 of the tongue.”
Ask if the patient has any sensitivity to sounds where one ear is louder than the other (i.e.
hyperacusis)

10. Assess Cranial Nerve VIII (2 steps):

“Do you have any problems hearing?”
Rub your fingers together close to the auditory canal and ask if the patient can hear a sound.
Repeat with the other ear.
Weber’s: Instruct the patient “sir/miss, I am going to place something on your forehead that
will make a sound…” - Using the 512Hz tuning fork, strike it and place it in the midline on the
frontal bone – “can you hear the sound? Does it sound lounder in either ear?”
Rinne’s: Instruct the patient “sir/miss, I am going to now place something behind the ear…” –
using the 512Hz tuning fork, strike it and place it on the mastoid process – “do you hear the
sound? Tell me when it stops.”
When the patient tells you it has stopped, move the fork such that the prongs are at the
auditory canal “can you hear the sound again?”
Repeat on the other side.

11. Assess Cranial Nerves IX, X and XII:

AS if the patient has any problems speaking of swallowing.
Ask the patient to open their mouth and say “ahhhh”. You can utilize a tongue depressor to
assist with visualization. Observe the palate to look for elevation and symmetry by looking at
the uvula to move up and for any deviation to one side.
Say you would assess gag by touching the posterior oropharynx on each side.
Ask the patient to protrude the tongue. Observe for wasting, or deviation away from one side.
Additionally you can ask the patient to put their tongue in their cheek on either side and
palpate for equal strength.

10. Assess Crania Nerve XI:

Step back and inspect the patient’s neck and shoulders, looking for head tilt, shoulder
asymmetry, wasting of neck muscles.
Instruct the patient: “shrug your shoulders” and push down to compare strength.
Instruct the patient: “turn your head away from me and push your face against my hand”.
Place you hand against their contralateral cheek and resist them, while using the other hand to
palpate the strap muscles of the neck closest to you.
Repeat on other side.

11. Thank the patient and cover them with the sheet.

To Do:
1. Predict the expected visual disturbances at different points in the diagram of the visual tract
below and list a cause for each pathology.
2. Describe the resultant clinical features from the conditions listed below:
a. Cranial nerve III palsy
b. Cavernous sinus thrombosis
c. UMN cranial nerve VII palsy
d. LMN cranial nerve VII palsy
- list 3 -5 causes
e. Bulbar syndrome
f. Pseudobulbar syndrome
g. Internuclear ophthalmoplegia
3. Describe the following pupillary abnormalities:
a. RAPD
b. Holmes- Adie pupil
c. Argyll- Roberts pupil
4. Causes of
a. Conduction hearing loss
b. Sensorineural hearing loss