Cranial Nerve Examination

General Procedure
Introduction Introduces self, explains process and obtains consent, uses plain language
Structure Organised, efficient time management, transitions smoothly between tasks
Professionalism Confident, efficient examination, uses plain language, interacts appropriately with pt
Equipment Brings all equipment in order to complete the assessment (not borrowed)
CN I (Olfactory)
smell 2 random stuff differential
1. Ask pt if they have had any changes in smell.
Olfaction Procedure 2. (Verbalise only) Check nasal patency, then check sense of smell in each nostril separately (block one nostril at a time, use two
different widely recognised scents e.g. coffee, citrus peel).
CN II (Optic)
chartwigglefrom side
Procedure
wiggle from U quadrantlose
Ask pt to stand 6m/20ft away from Snellen chart andone
eyedwiggle from covered
eye
read aloud the letters of the smallest row to
across unlovered
they can read. eye
Visual Acuity
Explanation Pt should be wearing glasses or contacts if used. Explain interpretation of Snellen chart.
1. Stand in front of pt and ask them to look in your eyes. Starting from past the ears and on one side at a time, wiggle your fingers
and bring hand forward gradually until pt can see your fingers, comparing sides.
Visual Fields Procedure 2. Repeat this in upper and lower temporal quadrants.
3. If a defect is noted, check nasal fields: have pt cover one eye at a time, while you cover your contralateral eye. Start from in
front of the ear on the side with the covered eye, wiggle fingers and move across toward opposite ear.
CN II (Optic) & CN III (Oculomotor)
Inspection Procedure
shine lightseeobjectinfront look I
Inspect size and shape of pupils for asymmetry. away
Pupillary Light Procedure Shine light into one eye while checking for pupil changes in ipsilateral, then contralateral, eye.
Reflex Explanation Afferent: CN II, Efferent: CN III. Normal response: constriction of pupil (ipsilateral - direct, contralateral - consensual).
Hold finger or pencil ~10 cm from pt’s eyes, and ask them to look alternately at the object and then into distance directly behind it,
Accommodation Procedure
observing for changes in pupil size in each eye.
Reflex
Explanation Afferent: CN II, Efferent: CN III. Normal response: constriction of pupil when gazing at near object.
CN III (Oculomotor), CN IV (Trochlear), & CN VI (Abducens)
Inspection Procedure
H only
Inspect for eye alignment, eyelid ptosis, and nystagmus.
Instruct pt to keep head still and move eyes only. Draw a large H shape in air to lead pt’s gaze. Test convergence by asking pt to
Procedure
Extraocular Eye follow your finger to his/her nose.
Movements CN IV: superior oblique (infero-medial movement). CN VI: lateral rectus (lateral movement). Rest are CN III. Also inspecting for
Explanation
nystagmus during eye movements.
CN V (Trigeminal)
cotton touh
hadLight sharp dull palpate inchteethtapchin
touch testing in each division, comparing sides. Pt’s eyes must be closed, with a cotton wisp touch the skin lightly, ask pt to
Light Touch Procedure
respond each time a touch is felt.
Sharp/dull testing in each division, comparing sides. Show pt what sharp and dull feel like on sternum first, pt’s eyes must be closed,
Sharp/dull Procedure
ask pt to indicate if each touch is sharp or dull, randomly alternating between the two.
Motor Procedure Palpate temporal and masseter muscles, then ask pt to clench teeth, noting strength of contraction.
Pt’s jaw is relaxed with mouth slightly open. Place a thumb or finger on the pt’s chin and briskly tap downwards with a reflex
Procedure
Jaw Jerk Reflex hammer.
Explanation Normal response: no/slight jaw contraction. Abnormal: pronounced jaw contraction (suggests UMNL).
CN VII (Facial)
facial expression
Inspection Procedure Inspect at rest and during conversation for asymmetry, e.g. drooping corner of mouth or lower eyelid.
Motor Procedure Ask pt to demonstrate the following facial expressions: raise eyebrows, frown, close eyes tightly, show teeth, puff out cheeks.
Sensory Procedure Ask about any alterations in taste.
CN V (Trigeminal) & VII (Facial)
look one side touch corma
Procedure Ask if pt has been more sensitive to sound (e.g. chewing or voices heard louder).
Motor
Explanation CN V: tensor tympani muscle, CN VII: stapedius muscle.
Procedure Ask pt to look to one side, lightly touch cornea with cotton wisp.
Corneal Reflex
Explanation Afferent: CN V, Efferent: CN VII. Abnormal response: no blink reflex.

whisper middle head mastoidthis bring to ear

CN VIII (Vestibulocochlear)
rub
Stand behind pt and finger rub one ear at a time and ask pt to point to the side OR ask pt to occlude one ear with finger then
Procedure
Hearing whisper a word and ask pt to repeat it.
Explanation If abnormal/asymmetrical, move on to Weber and Rinne tests.
Procedure Weber test: place 256 or 512Hz tuning fork at vertex of head and ask pt in which ear the sound is best heard or if it is equal.
Rinne test: place base of tuning fork on mastoid until pt cannot hear sound, then immediately hold tuning fork (U facing forward)
Weber and Rinne Procedure
next to the ear canal and ask pt if the sound is heard again.
Tests
Sensorineural loss causes lateralisation to normal ear, and air > bone conduction. Conduction loss causes lateralisation to affected
Explanation
ear, and bone > air conduction.
either art conduction
lost sensory hearing loston eitherside
CN IX (Glossopharyngeal) & CN X (Vagus)
Voice Quality Procedure sayahh
Listen for the quality of gag
reflex
the pt’s voice (e.g. nasal, hoarse, whisper)
Procedure Have the pt open their mouth and say “Ahh” while you look (with a light) for soft palate and pharynx movement.
Motor
Explanation Abnormal: as palate lifts, uvula deviates to one side (points toward normal side).
Procedure (Verbalise only) Lightly touch back of throat on each side with tongue depressor.
Gag Reflex
Explanation Afferent: CN IX, Efferent: CN X.
CN XI (Spinal Accessory) rotate head
Inspection Procedure Inspect upper trapezius and SCMs for asymmetry, wasting and fasciculations.
Motor Procedure Upper trapezius: test ipsilateral shoulder shrug strength. SCMs: test contralateral cervical rotation strength.
CN XII (Hypoglossal)
tongue touch cheek
Inspection Procedure Check tongue at rest for asymmetry, wasting and fasciculations.
Ask pt to stick out their tongue, again inspecting for symmetry, then ask pt to push their tongue into their cheek on each side and
Procedure
Motor check strength.
Explanation Abnormal: tongue deviates to one side when protruded (points toward abnormal side).