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    Cranial Nerve Examination

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    Kartu Krishnan
    The document outlines how to examine the 12 pairs of cranial nerves, beginning with introducing yourself to the patient and positioning them appropriately. It describes how to inspect the head and neck, then test each cranial nerve's motor and sensory functions. This includes testing eye movements, visual acuity, smell, hearing, facial expressions, tongue movement, and more. The goal is to systematically examine each nerve's function to locate any neurological lesions.

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    Cranial Nerve Examination

    Uploaded by

    Kartu Krishnan
    31 views46 pages
    The document outlines how to examine the 12 pairs of cranial nerves, beginning with introducing yourself to the patient and positioning them appropriately. It describes how to inspect the head and neck, then test each cranial nerve's motor and sensory functions. This includes testing eye movements, visual acuity, smell, hearing, facial expressions, tongue movement, and more. The goal is to systematically examine each nerve's function to locate any neurological lesions.

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    The document outlines how to examine the 12 pairs of cranial nerves, beginning with introducing yourself to the patient and positioning them appropriately. It describes how to inspect the head and neck, then test each cranial nerve's motor and sensory functions. This includes testing eye movements, visual acuity, smell, hearing, facial expressions, tongue movement, and more. The goal is to systematically examine each nerve's function to locate any neurological lesions.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    31 views46 pages

    Cranial Nerve Examination

    Uploaded by

    Kartu Krishnan
    The document outlines how to examine the 12 pairs of cranial nerves, beginning with introducing yourself to the patient and positioning them appropriately. It describes how to inspect the head and neck, then test each cranial nerve's motor and sensory functions. This includes testing eye movements, visual acuity, smell, hearing, facial expressions, tongue movement, and more. The goal is to systematically examine each nerve's function to locate any neurological lesions.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 46

    Cranial Nerve Examination

    Dr Will Ricketts
    Clinical Teaching Fellow, Bart’s Health NHS
    Trust
    Honorary Lecturer, QMUL
    thanks to
    Kate Breckenridge
    BACKGROUND
    CRANIAL NERVE EXAMINATION
    • 12 pairs of cranial nerves:
    ▫ CN1 Olfactory
    ▫ CN2 Optic
    ▫ CN3 Oculomotor
    ▫ CN4 Trochlear
    ▫ CN5 Trigeminal
    ▫ CN6 Abducens
    ▫ CN7 Facial
    ▫ CN8 Vestibulocochlear
    ▫ CN9 Glossopharyngeal
    ▫ CN10 Vagus
    ▫ CN11 Accessory
    ▫ CN12 Hypoglossal
    CRANIAL NERVE EXAMINATION
    • Assessing motor and/or
    sensory function

    • Can be a tough
    examination:
    ▫ Requires patient cooperation
    ▫ Communication skills are key

    • Where is the lesion?


    BASIC STRUCTURE
    STARTING THE EXAMINATION
    • WASH HANDS
    • INTRODUCE & CONSENT
    ▫ “Hello, my name is **. I am a medical student. I
    would like to examine your eyes and the movement
    and feeling in your face today. Would that be OK?”
    • POSITION
    ▫ Sitting (in bed/on couch/on chair)
    • EXPOSE
    ▫ Head and neck
    • RETREAT to end of bed to observe
    INSPECTION – END OF THE BED
    AROUND THE BED:
    • Sensory aids – Including Spectacles
    • Mobility aids
    • Special Diet
    • Catheter

    THE PATIENT:
    • Well/Unwell?
    • Level of Consciousness
    • Obvious Neurological Signs?
    CLOSER INSPECTION
    • Face:
    ▫ Asymmetry

    • Eyes:
    ▫ Deviation
    ▫ Ptosis
    ▫ Pupil size

    • Skin:
    ▫ Scars
    ▫ Neurofibromas
    ▫ Rashes
    CLOSER INSPECTION
    • Face:
    ▫ Symmetry

    • Eyes:
    ▫ Deviation
    ▫ Ptosis
    ▫ Unequal Pupils (Anisocoria)

    • Skin:
    ▫ Scars
    ▫ Neurofibroma
    ▫ Rashes
    CLOSER INSPECTION
    • Face:
    ▫ Symmetry

    • Eyes:
    ▫ Deviation
    ▫ Ptosis
    ▫ Pupil size

    • Skin:
    ▫ Scars
    ▫ Neurofibromas
    ▫ Rashes
    CRANIAL NERVE
    EXAMINATION
    BASIC STRUCTURE
    CN1 - OLFACTORY
    • SENSORY only

    • Smell sensation
    CN1 - OLFACTORY
    • Ask patient:
    ▫ Any problems with sense of
    smell?
    ▫ Does food/drink taste
    normal?

    • Formal testing:
    ▫ Test each nostril separately
    with familiar smells (e.g.
    coffee)
    ▫ Scratch and sniff (Upsit)
    cards available for this
    ▫ Not routinely done
    CN2 - OPTIC
    • SENSORY only

    • Visual acuity

    • Visual fields

    • Reflexes:
    ▫ Pupillary light reflex
    ▫ Accommodation reflex

    • Colour vision

    • Fundoscopy
    CN2 - OPTIC
    • Visual Acuity
    ▫ Snellen chart at 6 metres (bring
    them closer if they cannot read
    top letter)
    ▫ One eye at a time
    ▫ With normal correction
    ▫ Establish smallest line patient
    can read

    ▫ If acuity too poor for Snellen


    chart, try:
     Finger counting at 20cm
     Hand movement
     Perception of light
    CN2 - OPTIC
    • Documented as:
    R L
    x/y x/y

    x=Distance from Chart (m)


    y = Text Size
    Larger Number =
    Larger Font

    • Normal = 6/6
    Historically 20/20
    CN2 - OPTIC
    • Visual fields:
    ▫ Ask patient to look at your
    eye
    ▫ Test one eye at a time
    ▫ Cover your eye that is
    opposite the patient’s
    covered eye
    ▫ Ask patient to report
    finger movements on both
    sides, move inwards until
    they are able to see them
    ▫ Compare with your own
    visual field
    CN2 - OPTIC
    • Visual fields:
    ▫ Consider whether any
    field defect is:
     Unilateral field loss (i.e.
    all vision in one eye)
     One side of the visual
    field in each eye
    (hemianopia):
     Bitemporal
     Homonymous
     Or even one quadrant
    only (quadrantanopia)
    CN2 - OPTIC
    • Central fields:
    ▫ Use red pin
    ▫ Assess central fields:
     Ask patient to report
    when the pin appears red
     Fovea has more cones to
    detect colour
    ▫ Assess blind spot:
     Ask patient to report
    when pin disappears
     Normally 15 degrees
    lateral to centre of vision
    CN2 - OPTIC
    • Reflexes:

    ▫ Pupillary light reflex


     Ask patient to fixate on a
    distant point
     Shine light into one eye
     Look for constriction of that
    pupil (direct reflex) and the
    other pupil (consensual
    reflex)

    ▫ Swinging light test


    ▫ Accommodation reflex
    CN2 - OPTIC
    • Reflexes:

    ▫ Pupillary light reflex

    ▫ Swinging light test


     Swing light between the eyes
     If optic nerve intact, both stay
    constricted
     If optic nerve damaged, pupils
    appear to dilate when light
    shone directly into it
     Relative afferent pupillary defect

    ▫ Accommodation reflex
    CN2 - OPTIC
    • Reflexes:

    ▫ Pupillary light reflex

    ▫ Swinging light test

    PEARLA
    ▫ Accommodation reflex Pupils Equal And
     Ask patient to fixate on Reactive to Light
    distant object and
     Present an object around 6 Accommodation
    inches from their face and
    ask them to focus on it
     Look for pupil constriction
    CN2 - OPTIC
    • Colour vision:
    ▫ Ishihara plates – ask
    patient to read out the
    numbers
    ▫ Not always available
    (unless you have the
    iPhone app!)
    CN2 - OPTIC
    • Fundoscopy

    This involves looking into the


    back of the patient’s eye with an
    ophthalmoscope to visualise the
    retina and optic disc.

    We will not be covering this in


    today’s session, but you should
    be aware that it forms part of the
    CN examination.
    CN3 (OCULOMOTOR)
    CN4 (TROCHLEAR)
    CN6 (ABDUCENS)

    • MOTOR ONLY

    • Eye movements:
    ▫ CN3 – Superior rectus,
    Inferior rectus, Medial
    Oblique, Inferior oblique
    ▫ CN4 – Superior Oblique
    ▫ CN6 – Lateral Rectus

    LR6 SO4
    CN3 (OCULOMOTOR)
    CN4 (TROCHLEAR)
    CN6 (ABDUCENS)

    • On inspection:
    ▫ Eye moves towards the
    muscles that still work
    • Third nerve palsy:
    ▫ Down and outward deviation
    = Tramps Pupil
    • Fourth nerve palsy:
    ▫ Subtle – Head tilted away
    from lesion
    • Sixth nerve palsy:
    ▫ Inward deviation
    ▫ Inability to look out
    ▫ “False Localising Sign”
    CN3 (OCULOMOTOR)
    CN4 (TROCHLEAR)
    CN6 (ABDUCENS)

    • Ask patient to keep their head


    still and follow your finger
    with their eyes

    • Ask patient to report any


    double vision in neutral
    position or during test

    • Move your finger slowly


    through a large double letter
    HH
    • Observe for full eye
    movements
    CN5 - TRIGEMINAL
    • SENSORY & MOTOR

    • Sensory – 3 divisions:
    ▫ Ophthalmic
    ▫ Maxillary
    ▫ Mandibular

    • Motor:
    ▫ Muscles of mastication:
    ▫ Jaw jerk reflex
    CN5 - TRIGEMINAL
    • Sensory:
    ▫ Test light touch sensation in
    each of the areas shown
     Demonstrate on sternum
     Ask patient to close their
    eyes and report when they
    feel it and if it feels normal

    ▫ Corneal reflex – touch cornea


    lightly with cotton wool and
    look for blink in both eyes
     Not done in exam setting
    CN5 - TRIGEMINAL
    • Motor:

    ▫ Muscles of mastication:
     Inspect for wasting
     Palpate on jaw clenching
     Resisted mouth opening

    ▫ Jaw jerk reflex:


     Mouth slightly open, jaw
    relaxed
     Place finger on chin and tap
    with tendon hammer
     Normally absent or small
     Brisk in UMN lesions
    CN7 - FACIAL
    • SENSORY & MOTOR

    • Sensory:
    ▫ Taste sensation to anterior
    2/3 of tongue

    • Motor:
    ▫ Muscles of facial expression
    CN7 - FACIAL
    • Sensory:
    ▫ Not routinely tested

    • Motor:
    ▫ Muscles of facial expression –
    ask patient to:
     Raise eyebrows
     Close their eyes and don’t let
    you open them
     Smile
     Puff out their cheeks
    CN8 - VESTIBULOCOCHLEAR
    • SENSORY only

    • Carries hearing and balance


    input from ear
    CN8 - VESTIBULOCOCHLEAR
    • Crudely test hearing:
    ▫ Whisper a number into each ear whilst making a
    distracting sound in the other ear
    ▫ Ask patient to repeat the number

    • If concerned, perform Weber’s and Rinne’s tests


    CN8 - VESTIBULOCOCHLEAR
    • Weber’s test:
    ▫ Tuning fork in centre of
    forehead – in which ear does
    it sound louder?
    ▫ Normally equal in both ears.

    ▫ Conductive hearing loss:


     Lateralises to affected side
    ▫ Sensorineural hearing loss:
     Lateralises to non-affected
    side
     How do you know which?
     Rinne’s Test
    CN8 - VESTIBULOCOCHLEAR
    • Rinne’s test:
    1. Tuning fork on Mastoid
    2. When sound stops move
    next to ear
    3. Ask if can now hear it?
    ▫ Yes = Normal
    or Equally affected =
    Sensorineural Deafness

    ▫ No = Conductive deficit
    CN9 & 10 – GLOSSOPHARYNGEAL &
    VAGUS
    • SENSORY & MOTOR
    • CN9 Sensory
    ▫ Nasopharynx
    ▫ Posterior 1/3 Tongue
    ▫ Middle + Inner Ear
    • CN10 Sensory
    ▫ Pharynx + Larynx
    • CN10 Motor
    ▫ Pharynx + Larynx
    ▫ Palate
    CN9 & 10 – GLOSSOPHARYNGEAL &
    VAGUS
    • Observe for any dysphonia

    • Ask patient to open mouth


    wide and say “aah”
    ▫ Observe for any deviation of
    the uvula
    ▫ Deviation would be AWAY
    from the side of the lesion

    • Gag reflex
    ▫ Not routinely done
    CN11 - ACCESSORY
    • MOTOR only

    • Trapezius muscle

    • Sternocleidomastoid muscle
    CN11 - ACCESSORY
    • Trapezius muscle
    ▫ Ask patient to shrug their
    shoulders against resistance

    • Sternocleidomastoid muscle
    ▫ Ask patient to turn their head
    to each side against resistance
    CN 12 - HYPOGLOSSAL
    • MOTOR only

    • Muscles of the tongue


    CN 12 - HYPOGLOSSAL
    • Muscles of the tongue
    ▫ Observe for fasciculations

    ▫ Ask patient to stick out their


    tongue
     Observe for deviation
     Deviation would be TOWARDS
    the side of the lesion

    ▫ Check power of muscles by


    asking patient to push their
    tongue into the side of their
    cheek and pressing on it from
    the outside
    COMPLETING THE EXAMINATION

    • THANK PATIENT
    • ENSURE COMFORT
    • WASH HANDS

    “To complete my examination I would like to perform the


    reflexes mentioned, plus a full peripheral nerve
    examination.”
    TYING IT ALL TOGETHER
    Cranial Nerves and the Brain Stem

    II
    Midbrain III & IV
    Pons
    Cb
    V - VIII
    Medulla IX - XII cerebellum
    or ‘Bulb’
    CPA

    Feather’s Cartoon Version


    Thanks to Dr Adam Feather

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