Cranial Nerve Exam Routine

I:

Examination:

• It is important to know if the pt has previously noticed decreased ability to smell.

• If there has been trauma, fractures or surgery.

• If there has been unexpected / abnormal sense of smell at unexpected times.

• At the time of exam is the pt suffering from increased mucus production (rhinitis, flue, allergies…).

Explain to pt what you are going to do and what assistance you require from them.

Ask pt to close mouth, compress one side of the nose and breathe in and then repeat with the other side of
the nose – this ensures each nasal passage is open.

Ask the patient to close their eyes and repeat the process whilst you;

Pass a container of? coffee / vanilla essence / lemon …. under the side of the nose that is not compressed and
ask if they can smell something - can they recognise and name the smell.

When doing the other side use a different odour.

II:

Snellen – visual acuity test

Ophthalmoscopy

Visual fields

Blind spot

Accommodation (II/III),

Pupil Light reflex (II,III)

III / IV / VI:

Light Reflex Test: Cr.N. II & III

Assessing – the integrity of the pupillary light reflex pathway

How:
 • Dim the light

• Ask pt to fixate vision on a distant target

• Shine right eye from right side and left from left side – do not stand in front of pt as pupils will
accommodate for you standing there –

• Observe for direct pupillary response = constriction of pupil in eye into which light is being shone

• Observe for consensual light response = constriction of pupil in contralateral eye

• Repeat from the other side.

Some insist that the bridge of the nose is covered so as to isolate each eye

Normal:

– a brisk, simultaneous equal response of both pupils to the light being shone / taken away

– should be same not matter what eye light is shone into

Swinging flashlight test: Assessing for an afferent pupillary defect

Assessing – a comparison of direct and consensual responses of each eye

(rather that assessing the light reflex i.e. if they are present)

How:

Conditions as per light reflex test but here you are in front of pt

 Move beam swiftly and rhythmically from one eye to the other, ensuring same amount of light into
each eye, from same angle on each side and for equal amount of time
(?count 1-2-3 then swap and count again – repeat)

 Check if one pupil constrict less, which will make it appear to dilated

when a bright light is swing from the unaffected eye to the affected one

Eye movement – H Test

 Pt is asked to keep head still and to fix eyes on object held in front at eye level (pencil,

clinicians finger..)

Pt is asked to follow the movement generated by examiner, without moving their head.

Movements should involve all ranges of motion of the eyes – once done move finger toward nose thereby
encouraging the pt to bring both eyes inward = converge - and also refocusing the pupils (constrict) =
accommodation. Unilateral testing L and R may also be appropriate to double check that nothing has been
missed, particularly if there is a complaint of diplopia.

Cover-Uncover test

Cover up one eye and observe:

You may notice that the non-covered eye adjusts in order to fix on light

You may notice that when you move the cover, the eye underneath readjusts in order to fix on light.

Testing for Supra- and intra-nuclear coordination:

- Observe for well coordinated eye movement during the following movements

- May show if there is supra-nuclear disorders (can easily be missed)

 Saccadic movements (alternate fixation of vision from one side to the other)

Saccades are eye movements used to rapidly re-fixate from one object to another.
The examiner can test saccades by holding two widely spaced targets in front of the patient (such as the
examiner's thumb on one hand and index finger on the other) and asking the patient to look back and forth
between the targets

 Pursuit movement (follow a finger moving in various directions)

 Convergence movement (following a finger in an axis toward and away from the pt)

 Oculocephalic reflex (move head in various directions)

Some terminology:

Conjugate eye movement: eye movements in which the two eyes move in the same direction

Convergence: simultaneous inward movement of both eyes toward each other, usually in an effort to maintain
single binocular vision when viewing an object

Midriasis : dilation of pupil

Miosis: constriction of pupil

Nystagmus: a repetitive, involuntary, to-and-fro oscillation of the eyes. It may be physiological or pathological
and may be congenital or acquired. It can be described according to: The direction of movement: this may be
horizontal, vertical, torsional or nonspecific.

Ptosis: intrapalpebrae fissure (distance between upper and lower eyelid )= N = 10mm? and equal in both eyes.
If difference is lager than 2mm then consider Ptosis.

 To detect ptosis observe position of the inferior margin of upper lid relative to the superior border of
the iris – N = the upper lid covers 1-2mm of the iris.

 Ptosis is present when the upper eyelid is less than 2 mm from midpupil

 Abnormal eyelid retraction is seen in Hyperthyroidism and with tumor in the pineal region (Parinaud
syndrome)

Squint: not having the visual axes parallel

Strabismus: inability of one eye to attain binocular vision with the other because of imbalance of the muscles
of the eyeball—called also heterotropia or squint.

V:

Testing:

Soft and pinprick: Ensure you base-line on other part of body first.
As on rest of body - one side, then the other, then both. Soft, pinprick, mixture. Must do multiple times in
outline of each branch so as to be able to evaluate that if a problem exists does if follow the pattern of a
branch or ‘onion ring’.

Temperature: Place cold tuning

fork / container with warm water on face as above, determine if they can feel it, what they can feel and is it
the same on both sides.

Corneal Reflex: wisp of cotton wool swept lightly across /touch cornea – check that both eyes blink – same
speed and degree – check bilaterally. Approach lateral to medial, having asked pt to look lateral
If neither blinks = V, if unilateral loss = VII

Motor: Observe opening and closing of mouth, as closing observe if once side appears to move faster during
this movement if so the other side = weak. Also once closed
ask pt to clench teeth together and attempt to open – should not be able to do so, assess jaw in L and R lateral
hold for muscle strength.

Reflex: Use triangular hammer? – ask pt to close mouth with tongue behind teeth. Then ask pt to relax jaw
leaving it slightly open. Place one thumb over the tip of the chin and with other hand tap with reflex hammer
in a downward fashion. Often there will be no response which is within normal, small upward movement of
jaw as if closing will be observe, but if fast and snap like = UMNL

VII:

Examination:
Muscle

Ask pt to – do all facial expressions

raise eyebrows, frown, open eyes widely, closed eyes tightly, smile, blow out cheeks

bring edge of mouth downward, purse lips, show teeth,

Ensure that you observe that they can do it and also that you test they can hold the position against resistance
…

Look for symmetry of muscle action / flattening of facial lines and nasolabial fold

Sensory

As other sensory testing – soft and pinprick – around outer ear

Base line else where

Corneal Reflex:

wisp of cotton wool swept lightly across / touch cornea – check that both eyes blink – same speed and degree
– check bilaterally. If neither blinks = V, if unilateral loss = VII

Consider doing the Glabella Tap here – checking for Parkinsonian response = blinking

Taste

Ask if pt has noticed any difference in taste – possible examine with sweet, sour, salt

Parasympathetic

Ask if pt has experienced decrease / lack / increase in tear and saliva production

VIII:

Vestibular component: normally not tested unless pt history is indicative thereof

Dix-Halpike
 Remember to turn to other side afterwards

To treat hold each position for 30 seconds

Cochlear division - Examination:

Ensure that you have understood if there is an existing hearing loss and / or history of any trauma to either ear
– head area

Prior to testing – check for wax, blood, foreign body with use of Otoscope

Cochlear component:

Rub fingers together / use watch / whisper ...whilst slowly pulling away from the ear – can they hear/ and for
what distance – compare L and R

If there is a difference – establish if lack of hearing is due to bone or neuronal conduction loss

using a 256Hz / 512Hz tuning fork

- air conduction tested by tuning fork held by external ear - testing conduction and sensory neural

- bone conduction tuning fork held on mastoid process – testing sensory neural

In conductive hearing loss – bone > air – as bone conduction bypasses problems in the external or middle
ear

In sensorineural hearing loss – air > bone – in both ears as in normal hearing, with decreased hearing in the
affected ear

Rinne Test: (considered to be + if normal)

Tuning fork (high-pitched) on mastoid until not heard and then immediately brought to the external auditory
canal – can it still be heard? If still able to hear = Normal / Sensorineural loss If both lost = sensorineural loss

Bing Test:

Tuning fork (high-pitched) on mastoid and examiner or pt alternately occludes the external meatus.
If N / sensorineural loss pt will notice a change with the occlusion, but not so in conductive hearing loss.

Weber Test:

Tuning fork (high-pitched) is placed on the forehead (top of head anterior to vertex) – can they hear it equally
or more to one side ? In conductive hearing loss it is heard louder in the affected ear.
In sensorineural hearing loss it is heard louder in the normal ear

IX + X:

Examination:

Explain to pt what you are going to do - ascertain if there is anything in the mouth such like gum that
needs to be thrown away and also consider if there may be ill fitting dentures that could fall out and
get damaged.
Have they had any problems with swallowing?
Any change to tone of voice or ability to speak?

Ask pt to open mouth widely and observe the oral cavity – look for smooth healthy tissue

(be mindful of white spots on back of throat: DDX thrush, strep infect, oral leukoplakia, mononucleosis - can
just be due to dry air, post nasal drip)

– ask pt to say ‘ah’ – observe for movement of palate – full and symmetrical, uvula remains in midline
and each posterior pharynx moves medially (like a curtain)

Unilateral weakness - lesion will be on ipsilateral – also uvula shift to normal side

No movement - lesion is bilateral X

Palate weakness may cause dysarthria (?esp. noticeable on the sound of K), or a nasal voice

Hoarse voice could indicate vocal cord involvement

Sensory function is tested by the gag reflex -

(tongue depressor to lower tongue?) - cotton-tipped applicator to stimulate back of the throat -
sensory = IX motor = X
(remember pt may not ‘gag’ and still be normal )
XI:

Muscle test

SCM – rotation of head as well as F/Flex

Traps – shoulder elevation

XII:

Innervates all intrinsic and all extrinsic muscles of the tongue except one extrinsic (palatoglossus - X)

Normally: the genioglossus muscle causes protrusion of the tongue when contracted bilaterally and
simultaneously.
If only unilateral contraction - right side muscles cause tongue to stick out to left and vice versa