ALL Cranial Nerves Examination

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CRANIAL NERVES EXAMINATION

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Before Examination The patient should be fully relaxed. Cooperation. Explain the procedure to the patient. Examination ONLY if indicated. Findings should be recorded one by one. Negatives are as important as positives. Full equipments for the different tests. The Anatomy should be reviewed.

During Examination Examine both sides (Right and Left). Remind yourself whether the nerve is:

i. Motor – muscle supplied- , ii. sensory – areas covered- , iii. mixed, iv. contains parasympathetic fibers – 3rd, 7th,

9th, 10th , v. involved in reflex as afferent or afferent.

General Strategy Higher cerebral functions. Meningeal irritation. Cranial nerve examination. Motor system. Autonomic system. Sensory system.

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OlfactoryI

TrigeminalV

GlossopharyngealIX

OcculomotorIII

Facial VII

AccessoryXI

OpticII

AbduscensVI

VagusX

TrochlearIV

VestibulochoclearVIII

HypoglossalXII

5 6 7 8

9 10 11 12

Olfactory nerve (I) Ask the subject to recognize

a common type of smell e.g. oil of peppermint.

Loss of sense of smell is called anosmia.

Optic nerve (II)

Investigate the following tests: Acuity of vision. Color vision. Field of vision (confrontation test). Fundoscopy (examination of the

optic disc by ophthalmoscope).

Oculomotor (III), Trochlear (IV) and Abduscens (VI):

The three nerves are examined together.

They innervate the extrinsic muscles of the eye.

The recti muscles act as elevators and depressors alone when the eye is in abduction, and the obliques act similarly when the eye is in adduction.

Oculomotor (III), Trochlear (IV) and Abduscens (VI):

In (VI) nerve paralysis, there is inability to move the eye ball outwards (squint), the eye turns medially due to unopposed action of the medial rectus.

Paralysis of medial rectus causes lateral deviation of the eye.

In (IV) nerve paralysis there is inability to look down and outwards

Oculomotor (III), Trochlear (IV) and Abduscens (VI): 3/

Oculomotor (III), Trochlear (IV) and Abduscens (VI): 4/

Trigeminal nerve (V)a. Sensory division: Test for the sense of touch, pain and

temperature in the face, keeping in mind the

regions supplied by ophthalmic, maxillary & mandibular divisions of the nerve.

Reflex function: Test for corneal reflex (afferent fibers are through 5th nerve and

efferent fibers through the 7th nerve).

Trigeminal nerve (V)b. Motor division: - Ask the subject to clench his teeth and feel the

prominence of temporal and masseter muscles. The muscles would remain soft on the paralyzed side.

- To test the function of pterygoid muscles ask the subject to open the mouth, the lower

jaw moves towards the paralyzed side due to unopposed action of the opposite

healthy pterygoid muscle.

The facial nerve (VII)

A- Sensory division: Test the anterior 2/3rd of the

tongue for the sense of taste using

strong solutions of sugar, salt, and quinine.

The facial nerve (VII)b. Motor division: This is responsible for facial

expression, it is tested as follows: Ask the subject to wrinkle the forehead.

Wrinkles do not appear on the paralyzed side. Ask the subject to close his eyes forcibly

and you try to open them forcibly. In case of paralysis, the eyes remain open or if

can be closed, they can be opened with minimal force.

The facial nerve (VII)b. Motor division: Ask the subject to show his teeth & observe the

nasolabial folds and the angles of the mouth. On the paralyzed side the nasolabial folds

are flattened and the angle of the mouth seems to be drawn towards the healthy side. Ask him to whistle. It is not possible in case of 7th

nerve paralysis. Ask him to inflate the cheeks with air. Tap each cheek

lightly with a finger. On the paralyzed side air escapes from the mouth.

The vestibulocochlear (VIII)

This is responsible for hearing and balance. Rinne’s test: Set a tuning fork into vibration and hold

it opposite the ear. When it can no more be heard, put its base over the mastoid process. Normally it would not be heard at this point also. In middle ear disease the vibration will be heard over the bone after it could no more be heard through the ear.

In middle ear disease the bone conduction remains normal when air conduction is diminished. In nerve deafness, air conduction and bone conduction are equally diminished.

The vestibulocochlear (VIII)

Weber’s test: A vibrating tuning fork is set against the middle of the forehead of the subject. He would hear better on the side with middle ear deafness.

The glossopharyngeal (IX) Tickle the posterior wall of

pharynx and observe the pharyngeal reflex. The afferent & efferent fibers of this reflex lay in the 9th cranial nerve. The sense of taste may also be tested over the posterior 1/3rd of the tongue.

The vagus nerve (X) Ask the subject to open his

mouth and say A-H-H-H- and observe the elevation of the soft palate. On the side of lesion, the soft palate is not elevated.

The accessory nerve (XI) Ask the subject to rotate the chin

to one side against resistance. Examine sternomastoid and trapezius

muscles for bulk and power of contraction. Paralysis of stemomastoid will produce failure to rotate the chin to opposite side.

Hypoglossal nerve (XII) Ask the subject to protrude his

tongue out. The tongue would be pushed

towards the paralyzed side.

Examine the eye

MR MR LRLR

IRIR SO

Optic Nerve

inflammed

Optic Chiasma

Optic Tract

Post L. geniculate

Occipital Region

Optic Nerve cut

Temporal fibers

Post L geniculate

Post L. geniculate

Fascial Nerve paralysis

ALL Cranial Nerves Examination

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