EXAMINATION OF THE CRANIAL NERVES

Anwar Wardy W

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Cranial Nerves: Motor and Sensory Functions

Figure 28.4 Dorsal aspect of brain with cranial nerves noted.

Components of the Neurological Examination (Cranial Nerves)

Olfactory Nerve (I) perception (recognition, hallucinations) Optic Nerve (II) visual acuity (unaccommodated / accommodated) visual fields color vision pupils visual reflexes light reflexes (direct / indirect) accommodation reflex funduscopic exam

Ocular Motor Nerves (III,IV,VI)

Components of the Neurological Examination (Cranial Nerves)

inspection palpebral fissures (ptosis, proptosis) ocular position (strabismus, gaze shifts) head position (compensation) spontaneous movements (nystagmus) common complaints diplopia blurred vision ocular movements (monocular and binocular) tracking (pursuit) volitional ocular motor testing cover testing (heterotropia/heterophoria) red glass test corneal light reflection test

Components of the Neurological Examination Cranial Nerves Trigeminal Nerve (V)

sensory (ophthalmic, maxillary, mandibular) threshold and symmetry to tactile (and thermal) stimuli (corneal reflex) motor masseter and temporalis strength reflex jaw jerk

Facial Nerve (VI)

inspection forehead, palpebral fissures, nasolabial fold, corner of mouth motor upper face (frontalis, orbicularis oculi) lower face (zygomaticus, orbicularis oris) enunciation labial sounds M (autonomic) (lacrimation) (sensory) (taste anterior 2/3 of tongue)

Components of the Neurological Examination Cranial Nerves Vestibulocochlear Nerve (VIII)

cochlear division screening test finger rub (auditory threshold) deficit characterization (sensorineural vs. conduction) Weber Rinne vestibular division inspection nystagmus tests of function past pointing marching in place vestibulo-ocular reflexes oculocephalic reflex (dolls head maneuver) head thrust and head shake tests oculovestibular reflex (caloric testing) walking (oscillopsia) provocative tests Dix-Hallpike maneuver (Nylen-Barany )

Components of the Neurological Examination Cranial Nerves

Glossopharyngeal (IX) and Vagus (X) Nerves inspection position of uvula and soft palate at rest movement of uvula and soft palate with AAHH (glottis - position of the vocal folds) auscultation hoarseness stridor enunciation pharyngeal sounds K (pharyngeal ((gag)) reflex) (observe swallowing)

Components of the Neurological Examination Cranial Nerves

Spinal Accessory Nerve (XI) inspection atrophy, head tilt strength testing (upper) trapezius shoulder shrug sternocleidomastoid head turning

Hypoglossal Nerve (XII) inspection (tongue in floor of mouth) atrophy/furrowing fasciculations inspection (on protrusion) midline/deviation enunciation lingual sounds - L

OLFACTORY NERVE (I)

Test with alcowipes, coffee etc. Unilateral anosmia may be significant Bilateral anosmia: commonest cause viral Classical pathology:olfactory groove meningioma Basal skull fractures another potential cause (unilateral or bilateral)
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OPTIC NERVE (II)

Visual acuity Visual fields to confrontation Pupillary reflexes (II and III) Fundoscopy (papilloedema, optic atrophy, retinitis pigmentosa)

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VISUAL ACUITY
CORRECTED (ie brain not lens) Each eye separately Snellen charts for distance and near vision reading charts for near vision Best approximation: small print (or equivalent) at normal reading distance If unable, finger counting, hand movements, perception of light
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VISUAL FIELDS
Often forgotten but very important First do a bilateral screening test: will uncover the majority of significant visual field defects immediately Go on to check each eye separately, ask about scotomata Mention checking for blind spot enlargement
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COMMON FIELD DEFECTS

HOMONOMOUS HEMIANOPIA: lesion posterior to the optic chiasm (eg posterior cerebral artery territory infarction) BITEMPORAL HEMIANOPIA: lesion at the optic chiasm (eg pituitary tumour) BLINDNESS ONE EYE: lesion in eye, retina or optic nerve
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PUPILLARY RESPONSES
Light reflex is the clinically significant one Afferent limb = II, efferent limb = III Look at pupillary sizes Direct and consensual response Look for afferent pupillary defect (optic nerve lesion)
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PUPILLARY ABNORMALITIES
One large pupil: IIIrd nerve palsy, iris problem (eg traumatic midriasis), unilateral dilator eye drops Small pupil: Horners syndrome, ArgyllRoberston pupil (small, irregular, reacts to accommodation but not to light) Bilateral small pupils: drugs (opiates), pontine lesion (haemorrhage)
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HORNERS SYNDROME
Oculosympathetic paralysis A good lateralising sign but a poor localising sign Ptosis, miosis and sometimes unilateral anhydrosis of face Look especially at neck, supraclavicular fossa and hand (Pancoasts tumour)
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Eye movements (III, IV and VI)

IV: TROCHLEAR NERVE (supplies superior oblique muscle) VI: ABDUCENT NERVE (supplies lateral rectus muscle) III: OCULOMOTOR NERVE: all other extraocular muscles, also carries parasympathetic (constrictor) fibres to pupil, and fibres to levator palpebrae superioris
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EYE MOVEMENTS
Look at eyes in primary position of gaze IIIrd nerve palsy: eye often down and out VI nerve palsy: often eyes convergent (unopposed medial rectus) Look at pupils Look for ptosis
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EYE MOVEMENTS
Follow a moving object (finger, end of tendon hammer) and ask for any symptomatic diplopia Determine position/s causing maximum diplopia Ask about separation of images (horizontal or oblique) Check diplopia is BINOCULAR
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TYPICAL EXAM CASES

IIIrd nerve palsy: ptosis, eye down and out, diplopia in all except one direction of gaze, may have dilated pupil ( a surgical IIIrd nerve palsy VI nerve palsy: eye convergent, diplopia on lateral gaze only, horizontally separated images
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CAUSES OF COMPLEX OPTHALMOPLEGIA

Dysthyroid eye disease Myasthenia gravis (look for fatiguability of diplopia and ptosis) Mitochondrial disorders

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INTERNUCLEAR OPHTHALMOPLEGIA
Nystagmus in the abducting eye Failure of adduction of the other eye Both eyes move normally when tested individually Lesion in the MEDIAL LONGITUDINAL FASICULUS (on the side WITHOUT nystagmus Can be bilateral
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TRIGEMINAL NERVE (V)

Most important function is sensory Ophthalmic, maxillary and mandibular divisions Test with light touch and pinprick in all 3 divisions, comparing each side Corneal reflexes (afferent limb V, efferent limb VII) Know something about trigeminal neuralgia (examination is normal in these cases)
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FACIAL NERVE (VII)

Supplies the muscles of the face DIFFERENTIATE AN UPPER MOTOR NEURON FROM A LOWER MOTOR NEURON LESION Upper motor neuron lesion: milder, spares the forehead, no Bells phenomenon

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VESTIBULOCOCHLEAR NERVE (VIII)

For clinical examination purposes, forget the vestibular element Check hearing approximately in each ear If reduced, determine whether conductive (BC >AC) or sensorineural (AC>BC) deafness

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GLOSSOPHARYNGEAL (IX) AND VAGUS (X)

Tested together Speech, palate, cough, swallow, (gag reflex) Bulbar palsy: bilateral LMN lesions of IX and X: poor palatal movement, nasal speech, nasal regurgitation of fluids Pseudobulbar palsy: bilateral UMN lesions: hot potato speech, no nasal regurgitation, additional frontal lobe signs
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ACCESSORY NERVE (XI)

Cranial and spinal roots Cranial roots: sternocleidomastoid (note direction of head turn) Spinal roots: trapezius (shoulder shrug)

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HYPOGLOSSAL NERVE
Movement of the tongue Look for wasting and fasiculation of the tongue Deviation of tongue on protrusion Tongue movements including power

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