Cranial Nerve Examination

Oleh dr. Shabrina Narasati

PPDS Ilmu Kedokteran Fisik dan Rehabilitasi FKUB RSSA
Pembimbing: Dr. Dwi Indriani, SpKFR
Nervus Cranialis
I. Olfactorius
II. Opticus
III. Occulomotorius
IV. Trochlearis
V. Trigeminus
VI. Abducens
VII. Facialis
VIII. Vestibulocochlearis
IX. Glossofaringeal
X. Vagus
XI. Accessorius
XII. Hypoglossus
 Nervus I – Olfactorius
 Function: smell
 Type: sensory
 Sensory examination
1. Examination of smell

The most common cause of permanent anosmia is head injury.

 Nervus I – Olfactorius (sensorik)
Sensory : examinations of smell

Purpose & • Detect disturbance in smell

Terms • Terms : patient is aware and communicate

• Do not use substances (eg, ammonia) that irritate the nasal mucosa.
• Use granulated coffee, oil of peppermint, or oil of camphor / tembakau
• Hole is cleared. Holes are examined one by one. Ask the patient to close his
Examination
eyes. Move the test substance to- ward him, under his nose, and then away
from him.
• Ask him in advance to tell you when he smells something.

Abnormality • Hiposmia, anosmia, parosmia, cacosmia

Results
Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus II – Opticus
 Function: Visual Acuity
 Type: Sensory
 Sensory Examination
Vision is discussed here in two parts—central, or macular, vision and peripheral vision.
1. Central: Visual Acuity
2. Peripheral: Confontration test
 Nervus II – Opticus (sensorik)
Sensorik : 1. Visual Acuity

Purpose and • Asses the visual acuity / visus

terms • Requirements: conscious & cooperative

• Inspection tool: snellen chart, penlight

• Snellen chart: If the patient can read the 20-ft (or 6-m) line when the card is 20 ft (or 6
m) away, her vision is 20/20 (or 6/6) and she has normal macular function.
• Finger > Normal fingers can be seen at a distance of 60 meters > people who can see a
distance of 2 m but cannot see a distance of 3 m is 2/60
Examination • Hand movements > Normal hand movements can be seen at a distance of 300>
Visibility of people can see a distance of 1 m but can not see a distance of 2 m is 1/300
• Light beam > The light beam can be seen at an infinite distance > recorded as LP (light
perception) only
• If the light beam cannot see then the vision is a sightless eye

Abnormalities • Miopia, hipermetropia, or any other visual disease

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus II – Opticus (sensorik)
Sensorik : 1. Visual Acuity

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus II – Opticus (sensorik)
Sensorik : 1. Visual Acuity

 The results of the examination

were confirmed by a pinhole
examination to distinguish nerve
abnormalities from refractive
abnormalities
 If vision becomes clearer means
visual impairment due to refractive
abnormalities

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus II – Opticus (sensorik)
Sensorik : 2. Confrontation test

Purpose and • Testing the visual fields

Terms • Requirements: conscious & cooperative, doctor’s visual field is normal

• Tools: -
• Doctor – Patient : 60-100 cm
• To test visual fields by confrontation, seat the patient facing you with his
Examination glasses off. Ask him to cover his right eye with his hand and to stare at your
right eye with his left eye. Hold your arms out to either side so that your
fingers are at the edges of his visual fields
• Objects are moved from the lateral and medial field of view, up and down

Abnormalities • Limitation in visual fields

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus II – Opticus (sensorik)
Sensorik : 2. tes konfrontasi
Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus III, IV, VI
Occulomotorius
Trochlearis
Abducens

 Function: Ocular Motility

 Type: Motoric
 Motoric Examination
1. Ocular motility
2. Pupillary light reflex
 N. III, IV, VI - Occulomotor, Trochlear, Abducens (motorik)
Motorik : 1. examine the occular motility

Purpose and • Examine the ocular motility

Terms • Requirements: conscious & cooperative

• Tools: -
• Examination of the extraocular muscles involves assessing the alignment
Examination of the patient’s eyes while the eyes are at rest and when the eyes are
following an object or finger held at an arm’s length. The examiner should
observe the full range of horizontal and vertical eye movements in the six
cardinal directions

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 N. III, IV, VI - Occulomotor, Trochlear, Abducens (motorik)
Motorik : 1. Occular Motility

 The primary action of the medial

rectus is adduction (looking in)
and that of the lateral rectus is
abduction (looking out). The
superior rectus and inferior
oblique primarily elevate the
eye, whereas the inferior rectus
and superior oblique depress the
eye. The superior oblique muscle
controls gaze looking down,
especially in adduction.
 N. III, IV, VI - Occulomotor, Trochlear, Abducens (motorik)
Motorik : 2. Pupillary light reflex

Purpose and • Examine the pupillary light reflex

Terms • Requirements: conscious & cooperative

• Inspection tool: penlight

• Examination of pupillary state: diameter (normal 3 mm), isocorous /
anisocorous, pupillary shape: regular or not
Examination • Examination of pupil light reflexes:
• Direct: the light is directed entirely towards the pupil (normal: the pupil will
shrink
• Indirect: light is directed at one pupil and looks at another pupil

Abnormalities • Loss of reflexes, abnormality of the pupil

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus V – Trigeminus
 The fifth cranial (trigeminal) nerve is a mixed nerve. It
contains motor and sensory fibers
 Type: Sensory dan motoric
 Sensory Examination
1. Facial Sensory
2. Cornea Reflex
 Motoric Examination
1. Examination of mastication muscle
 Nervus V – Trigeminus (sensorik & motorik)
Sensorik : examination of facial sensory function

Purpose and • Examination of facial sensory function

Terms • Requirements: conscious & cooperative

• Examination tools: cotton, toothpicks

• Check the sensory state of the face area
which is innervated with the trigeminal
Alat & Cara nerve light touch (using cotton) and the
Pemeriksaan prick pin (using a toothpick)
• Determine the area of sensory deficit
(ophthalmicus / maxillary / mandibular)

Abnormalities • Hipoesthesia, anesthesia, hiperesthesia

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus V – Trigeminus (sensorik & motorik)
Sensory: corneal reflex

Purpose and • Assest the corneal reflex

Terms • Requirements: conscious & cooperative

• Tools: tissue/cottonAsk the patient to look straight ahead; touch the cornea with a
piece of tissue or cotton wool.
• If the patient will not let you touch his cornea, ask him to look up and to the left when
you test his right corneal reflex (Figure 8-3). It is flien quite simple to touch his cornea
from below wifliout startling him. To test the left cornea, have him look up and to the
Examination right.
• The response to corneal stimulation is bilateral blinking.
• Pathological:
• There is no response: ipsilateral parese N V
• One eye does not blink: parese N VII

Abnormalities • Sensory defisit of the cornea

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus V – Trigeminus (sensorik & motorik)
Sensorik : reflex kornea

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus V – Trigeminus (sensorik & motorik)
Motorik : Examination of mastication muscle

Purpose and • Examination of mastication muscle

Terms • Requirements: conscious & cooperative

• Test tool: tongue spattle

• Check strength m. masetter & m. Temporalis: Requests the patient to close
his teeth, then the examiner feels great, contraction and shape m.
masetter & m. Temporalist; Asking the patient to bite the wooden spattle
Examination tongue  assess the depth of the bite or try to pull it while the patient tries
to maintain it
• Check for parese: compare the position of the patient's mouth when
opening and closing

Abnormalities • Weakness of mastication muscle

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus V – Trigeminus (sensorik & motorik)
Motorik : penilaian kekuatan otot mastikasi

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus VII – N. Facialis
 Fungsi :The seventh cranial (facial) nerve is a great nerve—with
it we can laugh, frown, cry, taste, and spit!
 Tipe : Senoric, Motoric, Autonomy
 Sensoric
1. Tes schimmer (lacrimation)
2. Taste function on the anterior 2/3 of the tongue
 Motoric
1. Facial muscle strenght
Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus VII – Facialis (motorik)
Motorik : facial muscle strenght examination

Purpose and • Detect facial muscle strenght

Terms • Requirements: conscious & cooperative

• Check the condition of the patient's

face in still condition> symmetrical or
Examination not symmetrical
• Check the presence of the patient's
face in movements> symmetrical or
not symmetrical

Abnormalities • Weakness of the facial muscle

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
How to Examine the Seventh Cranial Nerve

 Look at the patient when she is at rest

and while she is talking, smiling, and
blinking.
 Ask her to wrinkle her forehead quickly
two or three. Watch the rate and extent
of the movement of the two eyebrows.
 When the patient is relaxed, put your
finger on her eyebrows and ask her to
wrinkle her forehead against this gentle
resistance.
 Ask her to close her eyes gently, then
tightly. Try to open them while the
patient resists you.

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Now compare the lower right side of the
face with the left side and look for
relative weakness on one side, as in
facial weakness resulting from an upper
motor neuron lesion.
 Ask the patient to close her eyes as
tightly as she can.
 Ask the patient to show her teeth
 Ask the patient to whistle.
 Ask the patient to open her mouth as
wide as she can.
 Clench your teeth and pull the corners of
your mouth forcefully downward with a
grimace, revealing your platysma.

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus VII – Facialis (motoric)
Motoric : facial muscle examination

Penilaian kondisi wajah saat bergerak

M. Frontalis • Mengangkat alis

M. Corrugator supercilli • Mengerutkan dahi

M. Nasalis • Melebarkan cuping hidung

M. Orbicularis occuli • Menutup mata

M. Orbicularis oris • ‘mencucu’

M. Zygomaticus mayor • tersenyum

M. Risorius • menyeringai

M. Mentalis • Menekan bibir kebawah

 Nervus VII– Facialis (sensorik & motorik)
Motorik : Schimmer Test

Purpose and • Detects a lacrimation function disorder

Terms • Requirements: there is no conjunctivitis

• Red litmus paper is inserted in the

conjunctival sach
Examination • Let stand 5 minutes with your eyes closed.
• Normal: tears will moisturize the 20-30mm
long litmus and change color (blue)

Abnormalities • Disturbance in lacrimation

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus VII – Facialis (sensorik & motorik)
Sensorik : tasting function on the anterior 2/3 of the tongue

• Assessing the presence of a tasting function deficit on the anterior 2/3 of the
Purpose and tongue
Terms • Requirements: conscious & cooperative patient

• Examination equipment: cotton bud,

salt / sugar
• Patients are asked to stick out their
tongues. Then on the right and left
Examination are placed sugar, acid, salt or
something bitter using a cotton
stick.
• Patient simply write down what is
felt on a piece of paper

Abnormalities • Disturbance in tasting funtion

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus VIII – Vestibulocochlearis
 Function: The eighth (acoustic) nerve is really two nerves—the
cochlear (meaning “snail shell”), which is concerned with hearing,
and the vestibular (meaning “cavity at a canal entrance”), which is
concerned with movement, position, and balance.
 Type: Sensory
 Sensory Examination
1. Cochlear Nerve: Pemeriksaan pendengaran
2. Vestibular Nerve: Tes kalorik & Manuver Dix-Hallpike
 Nervus VIII – Vestibulocochlearis (sensorik)
Sensorik : 1. Examine Hearing

Purpose and • Examine hearing

Terms • Requirements: conscious & cooperative

• Tools: vibrating 256 tuning fork

• A formal test is awareness of whispered speech at 6 ft: A person with
normal hearing can hear and repeat nine out of 10 whispered numbers at
Examination this distance.
• If the patient is deaf in one or both ears, do the following to establish
whether the deafness is caused by a defect in the conducting system of the
ear or in the nerve leading from the ear.  Rinne test and weber test

• Nerve deafness results in decreased bone conduction and loss of high-tone

Abnormalities appreciation; conduction deafness results in decreased air con- duction and loss of
low-tone appreciation. Total hearing loss always means nerve deafness.
Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus VIII – Vestibulocochlearis (sensorik)
Sensorik : 1. Examine Hearing
 Nervus VIII – Vestibulocochlearis (sensorik)
Sensorik : 2. tes kalorik

Purpose and • Examine the balance

Terms • Requirements: conscious & cooperative, no tympany membrane perforation

• Sit the patient with her head in extension, occiput supported, looking at the ceiling, or have her lie on
her back with her head on a pillow 30 de- grees from the horizontal. Her horizontal semicircular canal
is now vertical.
• Look in the external ear with an otoscope. Remove any wax in the external canal. If the tympanic
membrane is perforated or red and bulging, stop now.
• Put a large kidney basin under the ear, with the concave side against the neck. Put a folded towel
Examination under the basin, and slowly and gently inject 20 mL of cold (20°C) tap water over 20–30 s.
• Time the onset, duration, and direction of nystagmus. Wait 10 min and do the same to the other ear
(check first for wax, perforation, and so on).
• The interval and duration should be approximately the same, right and left, as should the degree of
discomfort, nausea, spinning sensation, or vom iting.
• Repeat the irrigations after an interval using warm (42°C) water in first one and then the other ear.

Abnormalities • See on the next slide

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus VIII – Vestibulocochlearis (sensorik)
Sensorik : 2. tes kalorik

 Principle of the test

 COWS: Cold–Opposite–Warm–Same
 Cold water inhibits the function of the semicircular
canals, whereas warm water enhances it.
 Cold-water stimulation of the external ear canal
simulates acute destructive labyrinthine dis- ease,
that is, eyes to the irrigated side, nystagmus away
from the irrigated side.
Joel S. Glaser’s Neurophthalmology (Harper & Row, Hagerstown, Maryland, 1978)
Nervus VIII – Vestibulocochlearis (sensorik)
Sensorik : 2. tes kalorik
 Nervus VIII – Vestibulocochlearis (sensorik)
Sensorik : 3. Manuve Dix-Hallpike

Purpose and • Examination balance

Terms • Requirements: conscious & cooperative

• Patients are asked to sit on a bed

• The head is allowed right / left around 30-40 degrees
• Then lay down until your head hangs on the edge of
Examination the bed
• See the presence of nystagmus, and in patients also
asked for the emergence of vertigo.

Abnormalities • Benign paroxyximal positional vertigo

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus IX & X
Vagus & Glossopharyngeus
 Functions: muscle & sensory in the larynx & pharynx,
parasympathetic function, tasting function on 1/3
posterior tongue
 Type: Sensory & Motoric
 Sensory examination: Gag reflex
 Motoric examination: Assessment of pharyngeal &
uvula arch
 Nervus IX, X – Vagus & Glossopharyngeus
Sensorik : gag reflex

Purpose and • Assest the sensory funtion: gag reflex

Terms • Requirements: conscious & cooperative

• Examination: tongue spatel

• The patient is asked to open his mouth
• The gag reflex can be tested by depressing the patient’s tongue with a
Examination tongue depressor and touching the pharyngeal wall with a cotton tip
applicator until the patient gags. The examiner should compare the
sensitivity of each side (afferent: glossopharyngeal nerve) and observe the
symmetry of the palatal contraction (efferent: vagus nerve).

• The absence of a gag reflex indicates loss of sensation and/or loss of motor contraction. The presence
Abnormalities of a gag reflex does not imply the ability to swallow without risk of aspiration.
 Nervus IX, X – Vagus & Glossopharyngeus
Motorik : Assessment of pharyngeal & uvula arch

Purpose & • Assessment of pharyngeal & uvula arch

Terms • Requirements: conscious & cooperative

• Tools: tongue spatel, penlight

• The patient is asked to open the mouth and say “ah.” The examiner should
Examination
inspect the soft palate, which should elevate symmetrically with the uvula
in midline.

• In an LMN vagus nerve lesion, the uvula will deviate to the side that is
Abnormality
contralateral to the lesion. A UMN lesion presents with the uvula deviating
Results toward the side of the lesion
Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Things to Remember About Cranial Nerves 9
and 10

 Can the patient swallow liquids and solids?

 Is there nasal regurgitation or coughing when
he swallows?
 Is the voice different in any way?
 Can the patient cough forcefully?
 An absent gag reflex (bilateral) is often normal;
a unilaterally absent gag reflex is not normal.
 Nervus XI - Accessorius
 Function: sternocleidomastoideus & trapezius muscles
 Type: Motoric
 Motoric Examination
 Test the strenght of sternocleidomastoideus & trapezius
muscles
 Nervus XI – Accessorius (motoric)
Motoric : test the strenght of sternocleidomastoideus and
trapezius muscles

Purpose & • Test the strenght of sternocleidomastoideus & trapezius muscles

Terms • Requirements: conscious & cooperative

• Inspection tools: -
• Examination m. sternocleidomastoid: The patient decides to look to one
Alat & Cara side while being held prisoner by the examiner's hand, while papasi on m.
Pemeriksaan the sternocleidomastoid is performed on the opposite side.
• Examination m. trappezius: The patient decides to hold his shoulder
against pleading from the examiner

Abnormalities • Weakness of sternocleidomastoideus & trapezius muscles

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
Nervus XI – Accessorius (motorik)
Motorik : sternocleidomastoid

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus XII - Hipoglossus
 Function: muscle of the tounge
 Type: Motoric
 Motorik Examination
 test the strength of the tongue
 Nervus XII – Hipoglossus (motorik)
Motorik : : test the strength of the tongue

Purpose & • Assess tongue muscles

Terms • Requirements: conscious & cooperative

• Examination tool: tongue spatel, penlight

• At rest
• is there atrophy and fasciculation the tongue slants to the healthy side
Examination • On the move
• the patient is asked to stick out the tongue  tilting to the side of the lesion.
• the patient is asked to press the inner cheek with his tongue and the
examiner detains from the outside, compare right-left operative

Abnormalities • Weakness of the tounge muscle

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Nervus XII – Hipoglossus (motorik)
Motorik : test the strength of the tongue

Ross RT. How to Examine the Nervous System. 4 th ed. New Jersey: Humana Press. 2006
 Sinopsis
Name Type Clinical function
I Olfactory Sensory Smell

II Optic Sensory Vision

Movement of eyeball, with N IV & VI

III Oculomotor Motor Parasympathetic : cilliary muscle, accomodation of lens, iris muscle,
pupil constriction

Movement of eyeball : m. Obliquus Superior

IV Trochlear Motor With N III & VI

Trigeminal Sensation  eyeball, anterior scalp, upper face

V1 : Ophtalmic Sensory Sensation  nasal cavity & sinuses, palate, midface, maxillary teeth
V V2 : Maxillary Sensory Muscle of mastication, tensor tympani
Sensation  chin, temple, oral cavity, TMJ, mandibular teeth, ear,
V3 : Mandibular Mixed proprioceptive mastication

Movements of eyeball : m. Rectus Lateral

VI Abducens Motor With N III & IV
 Sinopsis
Name Type Clinical function

Muscles of facial expression, stapedius (middle ear)

VII Facial Mixed (parasympathetic: lacrimal, nasal, palatine, submandibular,
sublingual glands) (taste: anterior tongue)

VIII Vestibulocochlear Sensory Hearing, balance

Sensation from oropharynx, posterior tongue, carotid body and sinus

(taste: posterior tongue)
IX Glossopharyngeal Mixed (muscle: stylopharyngeus)
(parasympathetic: parotid gland)

Muscles of larynx, pharynx (phonation, swallowing)

Sensation from larynx, hypopharynx, heart, lungs, abdominal viscera
X Vagus Mixed (taste: epiglottic region, hypopharynx)
(parasympathetic: cardiac muscle; muscles and glands of foregut and
midgut: intestinal activity)

XI Accessory Motor Muscles: sternocleidomastoid, trapezius

XII Hypoglossal Motor Tongue muscles and movements
References
 Ross RT. How to Examine the Nervous
System. 4th ed. New Jersey: Humana Press.
2006
 Cifu D. Braddom’s Physical Medicine And
Rehabilitation. Philadelphia: Elsevier. 2016