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Cranial Nerve
Examination
Samantha Harrison
MBBS 3
King’s College London
What are Cranial Nerves?
 Definition: Nerves that emerge directly from the
brain
There are 12 of them
I.Olfactory II.Optic III.Oculomotor IV. Trochlear
V.Trigeminal VI.Abducens VII.Facial VIII.
Vestibulocochlear IX.Glossopharyngeal
X.Vagus XI.Spinal Accessory XII.Hypoglossal
Where do they come from?
 1 & 2 from the cerebrum
 3-12 from the brainstem
Olfactory – Telencephalon
Optic –Diencephalon
Oculomotor – Ant. Midbrain
Trochlear – Dorsal Midbrain
Trigeminal - Pons
Abducens – Pons (under
floor of the fourth ventricle)
Facial – Pons –
cerebellopontine angle
Vestibulo-cochlear –
cerebellopontine angle
(lat to CVII)
Glossopharyngeal -Medulla
Vagus –Medulla
Spinal Accessory –
cranial and spinal roots
Hypoglossal – Medulla
Efferent and Afferent Cranial Nerves
Some
Say
Money
Matters
But
My
Brother
Says
Big
….Brains
Matter
More
Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Spinal Accessory
Hypoglossal
I: Olfactory
Efferent or Afferent: Afferent (sensory)
Function: Smell
Examination: Block one nostril. Get patient
to smell strong distinctive smell (coffee, lemon, cinnamon).
Normal: If patient can smell/identify smell with both nostrils –
olfactory nerve intact
Palsy/Lesion: Unilateral loss of smell – lesion. Generally
from trauma, meningitis, tumour. WILL NOT AFFECT
SENSATION.
Optic Nerve
Efferent or Afferent: Afferent
Function: Visual transmission – eye to brain
Examination: 1. Visual Acuity: Read progressively smaller writing on the
snellen chart.
2. Visual fields – finger wiggle, fingers/ red hat pin in from the periphery (for
each eye)
3. Pupillary light reflex and Swinging light reflex
Normal: Consensual response to both pupillary light and swinging light reflex
Palsy: 1, visual acuity is reduced in one or both eyes 2. Peripheral vision is
reduced compared to yours 3. non –consensual pupillary light reflex, swinging
light reflex – pupil dilates when light shining on it – the consensual response is
stronger than the direct
Oculomotor
Efferent or Afferent: Efferent
Function: Innervates all but two muscles for eye movement.
Examination: 1. Look for ptosis, eye position and nystagmus,
inspect pupil for PERRLA
2. Test Ocular Movement ‘H’. Ask about diplopia
3. Accommodation reflex
Normal: Consensual pupil responses
No diplopia or nystagmus
Palsy: obvious ptosis, lateral rectus
And superior oblique acting unnopposed
Trochlear
Efferent or Afferent: Efferent
Function: Innervates Superior Oblique
Examination: Examination: 1. Look for ptosis, eye position
and nystagmus, inspect pupil for PERRLA
2. Test Ocular Movement ‘H’. Ask about diplopia
3. Accommodation reflex
Palsy: Intorsion
(same plane
as face). Eye points supero-
Medially
Abducens
Efferent or Afferent: Efferent
Function: Innervates Lateral Rectus
Examination: 1. Look for ptosis, eye position and nystagmus,
inspect pupil for PERRLA
2. Test Ocular Movement ‘H’. Ask about diplopia
3. Accommodation reflex
Palsy: lack of innervation of lateral
Rectus, eye cannot be abducted
Trigeminal: V1, 2, 3
Efferent or Afferent: Both
Function:
Sensory to the face: V1 – ophthalmic, V2- maxillary, V3 –
mandibular
Motor: Muscles of mastication
Examination: S: Point touch with cotton wool/tissue, pain using a sharp point,
temperature – cold tuning fork
Corneal reflex: rapid blinking of the eye lids from a sudden stimulus
Motor: Inspect. Palpate temporalis and masseter as patient clenches the jaw,
pterygoids – mouth open against resistance, jaw jerk
Normal: even feeling of sensation, both eyelids respond to corneal reflex, able to
clench jaw, no jaw jerk
Palsy: wasting of temporalis or masseter, unable to resist pressure to close mouth
Facial
Efferent or Afferent: Both
Function: Sensory - Taste (Anterior 2/3 of the tongue); Motor – Muscles
of facial expression
Examination:
Sensory: Test Taste of distinctive flavours (similar to the
smell test of olfactory).
Motor: 1) raise both eyebrows 2) screw eyes up, try to pull
open to test muscular strength 3) frown 4) smile 5) bare teeth (show
both upper and lower teeth) 6) puff out cheeks
Palsy: Bell’s Palsy (central/peripheral)
Ramsay-Hunt Syndrome
Vestibulo-cochlear
Efferent or Afferent: Afferent
Function: Hearing
Examination: 1) Whisper a number into patient’s ears. One at a time.
Ask the patient to repeat the numbers
2) Rinne Test 3) Weber Test
Normal: 1. Correct number 2. Air conduction louder than bone 3. Hear
the tuning fork in both ears equally
Palsy: Rinne normal (both ears). Weber lateralisation = contralateral
sensorineural hearing loss. Rinne – BC>AC in left, weber normal or left
lateralisation = conductive loss left. Rinne BC>AC left, weber lateralises
right = conductive and sensorineural loss left
Glossopharyngeal
Efferent or Afferent: Both
Function: Swallowing, Gag Reflex
Examination: Gag response :/, palatal articulation –
KA or guttural articulation GO
Palsy: Abnormal Cough on swallowing
Vagus
Efferent or Afferent: Both
Function: Swallowing, gag reflex
Examination: Test in the same way as the
glossopharyngeal
Palsy: Abnormal Cough on swallowing
Spinal Accessory
Efferent or Afferent: Efferent
Function: Innervation to SCM and Trapezius
Examination: Ask patient to turn head, shrug shoulders
(against resistance).
Normal: Symmetrical movements performed. Able to resist
pressure
Palsy: Muscle wasting, unable to resist pressure
Hypoglossal
Efferent or Afferent: Efferent
Function: innervation to genioglossus. NOT to palatoglossus
(innervated by vagus nerve)
Examination: Inspect for tongue fasciculations, asymmetry
or atrophy. Ask patient to poke out their tongue
Normal: No deviation of the tongue on protrusion
Palsy: Will deviate ipsilateral to the paralysis and
contralateral to the lesion
References
 Crossman and Neary
 Oxford Clinical Handbook

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Cranial Nerves

  • 2. What are Cranial Nerves?  Definition: Nerves that emerge directly from the brain There are 12 of them I.Olfactory II.Optic III.Oculomotor IV. Trochlear V.Trigeminal VI.Abducens VII.Facial VIII. Vestibulocochlear IX.Glossopharyngeal X.Vagus XI.Spinal Accessory XII.Hypoglossal
  • 3. Where do they come from?  1 & 2 from the cerebrum  3-12 from the brainstem Olfactory – Telencephalon Optic –Diencephalon Oculomotor – Ant. Midbrain Trochlear – Dorsal Midbrain Trigeminal - Pons Abducens – Pons (under floor of the fourth ventricle) Facial – Pons – cerebellopontine angle Vestibulo-cochlear – cerebellopontine angle (lat to CVII) Glossopharyngeal -Medulla Vagus –Medulla Spinal Accessory – cranial and spinal roots Hypoglossal – Medulla
  • 4. Efferent and Afferent Cranial Nerves Some Say Money Matters But My Brother Says Big ….Brains Matter More Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Spinal Accessory Hypoglossal
  • 5. I: Olfactory Efferent or Afferent: Afferent (sensory) Function: Smell Examination: Block one nostril. Get patient to smell strong distinctive smell (coffee, lemon, cinnamon). Normal: If patient can smell/identify smell with both nostrils – olfactory nerve intact Palsy/Lesion: Unilateral loss of smell – lesion. Generally from trauma, meningitis, tumour. WILL NOT AFFECT SENSATION.
  • 6. Optic Nerve Efferent or Afferent: Afferent Function: Visual transmission – eye to brain Examination: 1. Visual Acuity: Read progressively smaller writing on the snellen chart. 2. Visual fields – finger wiggle, fingers/ red hat pin in from the periphery (for each eye) 3. Pupillary light reflex and Swinging light reflex Normal: Consensual response to both pupillary light and swinging light reflex Palsy: 1, visual acuity is reduced in one or both eyes 2. Peripheral vision is reduced compared to yours 3. non –consensual pupillary light reflex, swinging light reflex – pupil dilates when light shining on it – the consensual response is stronger than the direct
  • 7. Oculomotor Efferent or Afferent: Efferent Function: Innervates all but two muscles for eye movement. Examination: 1. Look for ptosis, eye position and nystagmus, inspect pupil for PERRLA 2. Test Ocular Movement ‘H’. Ask about diplopia 3. Accommodation reflex Normal: Consensual pupil responses No diplopia or nystagmus Palsy: obvious ptosis, lateral rectus And superior oblique acting unnopposed
  • 8. Trochlear Efferent or Afferent: Efferent Function: Innervates Superior Oblique Examination: Examination: 1. Look for ptosis, eye position and nystagmus, inspect pupil for PERRLA 2. Test Ocular Movement ‘H’. Ask about diplopia 3. Accommodation reflex Palsy: Intorsion (same plane as face). Eye points supero- Medially
  • 9. Abducens Efferent or Afferent: Efferent Function: Innervates Lateral Rectus Examination: 1. Look for ptosis, eye position and nystagmus, inspect pupil for PERRLA 2. Test Ocular Movement ‘H’. Ask about diplopia 3. Accommodation reflex Palsy: lack of innervation of lateral Rectus, eye cannot be abducted
  • 10. Trigeminal: V1, 2, 3 Efferent or Afferent: Both Function: Sensory to the face: V1 – ophthalmic, V2- maxillary, V3 – mandibular Motor: Muscles of mastication Examination: S: Point touch with cotton wool/tissue, pain using a sharp point, temperature – cold tuning fork Corneal reflex: rapid blinking of the eye lids from a sudden stimulus Motor: Inspect. Palpate temporalis and masseter as patient clenches the jaw, pterygoids – mouth open against resistance, jaw jerk Normal: even feeling of sensation, both eyelids respond to corneal reflex, able to clench jaw, no jaw jerk Palsy: wasting of temporalis or masseter, unable to resist pressure to close mouth
  • 11. Facial Efferent or Afferent: Both Function: Sensory - Taste (Anterior 2/3 of the tongue); Motor – Muscles of facial expression Examination: Sensory: Test Taste of distinctive flavours (similar to the smell test of olfactory). Motor: 1) raise both eyebrows 2) screw eyes up, try to pull open to test muscular strength 3) frown 4) smile 5) bare teeth (show both upper and lower teeth) 6) puff out cheeks Palsy: Bell’s Palsy (central/peripheral) Ramsay-Hunt Syndrome
  • 12. Vestibulo-cochlear Efferent or Afferent: Afferent Function: Hearing Examination: 1) Whisper a number into patient’s ears. One at a time. Ask the patient to repeat the numbers 2) Rinne Test 3) Weber Test Normal: 1. Correct number 2. Air conduction louder than bone 3. Hear the tuning fork in both ears equally Palsy: Rinne normal (both ears). Weber lateralisation = contralateral sensorineural hearing loss. Rinne – BC>AC in left, weber normal or left lateralisation = conductive loss left. Rinne BC>AC left, weber lateralises right = conductive and sensorineural loss left
  • 13. Glossopharyngeal Efferent or Afferent: Both Function: Swallowing, Gag Reflex Examination: Gag response :/, palatal articulation – KA or guttural articulation GO Palsy: Abnormal Cough on swallowing
  • 14. Vagus Efferent or Afferent: Both Function: Swallowing, gag reflex Examination: Test in the same way as the glossopharyngeal Palsy: Abnormal Cough on swallowing
  • 15. Spinal Accessory Efferent or Afferent: Efferent Function: Innervation to SCM and Trapezius Examination: Ask patient to turn head, shrug shoulders (against resistance). Normal: Symmetrical movements performed. Able to resist pressure Palsy: Muscle wasting, unable to resist pressure
  • 16. Hypoglossal Efferent or Afferent: Efferent Function: innervation to genioglossus. NOT to palatoglossus (innervated by vagus nerve) Examination: Inspect for tongue fasciculations, asymmetry or atrophy. Ask patient to poke out their tongue Normal: No deviation of the tongue on protrusion Palsy: Will deviate ipsilateral to the paralysis and contralateral to the lesion
  • 17. References  Crossman and Neary  Oxford Clinical Handbook