Cranial Nerves Examination

BLOCK

16

Dr. Janet Arcenal-Beltran

MODULE

August 5, 2015 | 8-10 am

LECTURE

07

Objectives
I. Objectives:
1. To review the cranial nerves
-its origin
-its motor and sensory distribution
-its function (Functional Neuroanatomy)
-the associated disorders
2. To demonstrate how to test the Cranial Nerves
Audio- italicized
DeMeyers The Neurological Examination, 6th edition- blue green box
Internet- red font

Overview

FUNCTIONS OF CRANIAL NERVES

I
Smell
II
Visual acuity, visual fields and ocular fundi
II, III
Pupillary Reactions
III, IV, VI
Extra-ocular movements, opening of the
eyes; pure motor to the eyes
V
Facial sensation, movements of the jaw and
corneal reflexes/blink reflex; mastication
VII
Facial movements and gustation (anterior 2/3
of the tongue; taste); eyelid closure
VIII
Hearing and Balance
IX, X
Swallowing, elevation of the palate, gag reflex
and gustation
V, VII, X, XII Voice and Speech
XI
Shrugging of shoulders and turning of head
XII
Movement and protrusion of tongue (look for
any atrophy or fasciculation)
CN II- afferent to pupillary reaction
CN III- efferent to pupillary reaction; opening of
eyelid
CN VII- closing of eyelid; defect=ptosis
CN IX- tongue
CN X- pharyngeal muscles
Weakness on one side of shoulder (Stroke)/ gross
weakness- doesnt mean defect on CN XI; problem
may be on the cortex of the brain
CN I OLFACTORY NERVE
Parts:

Olfactory Receptor
Olfactory Bulb
Olfactory Tract
Olfactory Lobe

1. Olfactory Receptors
Olfactory Membrane
- yellowish-brown specialized epithelium in
the upper posterior part of the nasal cavity
III III IV VVI VII VIII IX XXI XII -

Cranial Nerves
Sensory
Sensory
Motor
Motor
Mixed
Motor
Mixed
Sensory
Mixed
Mixed
Motor
Motor

Origin
-frontal lobe/rhinencephalon
-occipital bone
midbrain
pons

medulla

Page 1 of 13

CN II OPTIC NERVE

Optic Nerve
Optic Chiasm
Optic Tract
Optic Radiations (Geniculocalcarine tract)
Visual Cortex at the occipital lobe

2. Olfactory Tract
- located at the orbital surface of the frontal lobe;
adjacent to the temporal lobe
3. Olfactory Lobe
-Pyriform lobe
Primary Olfactory Cortex
Pyriform
Periamygdaloid
Secondary Olfactory Cortex
Entorhinal areas
TEST OF THE OLFACTORY NERVE
Assess patency of nasal passages
Occlusion of a single nostril (eyes are closed) and
demonstrate that air passes freely
The patient inhales thru the open nostril to a common
odorant:
Vanilla
Ground Coffee
Peppermint
Fresh Orange
Soap
EACH NOSTRIL IS TESTED SEPARATELY
Caution: AMMONIA stimulates CN V
Dont use volatile substances because they can
stimulate CN V instead of CN I
Its okay if the patient could not identify as long as he
can smell it (true in the elderly and those with
Parkinsonian disorders)
BILATERAL ANOSMIA
Blocked nasal
passage
Trauma

Aging (>70)
Parkinsons Dse

UNILATERAL ANOSMIA
Blocked nostril
FRONTAL brain
lesion

KEY TO FUNCTION
V1: Primary visual cortex: receives all visual input.
Begins processing of color, motion and shape. Cells in
this area have the smallest receptive fields
V2, V3,VP: Continue processing: cells of each area have
progressively larger receptive fields
V3A: Biased for perceiving motion
V4v: Function unknown
V5/MT: Detects motion
V7: Function unknown
V*: Processes color vision
LO: Plays a role in recognizing large-scale objects
Note: A V6 region has been identified only in monkeys
Areas in the occipital lobe:
a. Small scale images
b. Pursuit/motion
c. Vision/color

Page 2 of 13

TESTS OF THE OPTIC NERVE

A. Visual acuity measurement
B. Color vision testing
C. Pupil evaluation
D. Visual field testing
E. Optic nerve evaluation via ophthalmoscopy

Optic Neuropathy:
Inflammation, Ischemic,
Compressive
Bilateral Occipital Lesions:
Cortical Blindness
B. Color vision testing

A. Testing the Visual Acuity

Standardized test: reading of a Wall-mounted or
pocket Snellen Eye Chart
Cover one eye under favorable lighting
Patient may use their glasses if needed to obtain
best corrected vision
Hold the pocket chart at focal length: 14 inches
Have them read the line with the smallest letters
st
TEST ONE EYE AT A TIME; examine 1 the eye with
defect
Record smallest size read
Acuity testing by:
Snellens Chart
Near Vision Chart
Bedside Material
IF UNABLE TO READ LARGEST LETTERS, see if patient
can: (in sequence)
Count Fingers
Hand Movements*
Perceive Light*
(*3 correct answers out of 5 means satisfactory)
Does visual acuity improve with PINHOLE TEST?
Test if error of refraction is considered
o

Pinhole Testing: The pinhole testing device can determine if a

problem with acuity is the result of refractive error (and thus
correctable with glasses) or due to another process. The
pinholes only allow the passage of light which is
perpendicular to the lens, and thus does not need to be bent
prior to being focused onto the retina. The patient is
instructed to view the Snellen chart with the pinholes up
(below right) and then again with them in the down position
(below left). If the deficit corrects with the pinholes in place,
the acuity issue is related to a refractive problem.

Corrected by pinhole:
Not corrected:

C. Testing the Pupillary Light Reflex

Ensure that patient is looking into the distance
Dim the room and make sure to use good light;
preferably yellow and strong light to elicit papillary
contraction
Look at the pupils
Before checking for reflex, make sure to ask the
patient if he/she had previous eye surgeries, i.e.,
cataract extraction= pupils are irregular, some pupils
do not react at all
o Are they equal in size (estimate)?
o Are they irregular in size?
Check for direct or consensual light reflex
o Direct reflex Ipsilateral eye constricts
o Consensual reflex contralateral eye constricts

Findings: equal, large, small (size in mm) pupils, +/reaction to light (brisk, sluggish, non-reactive), +/accommodation

Pupillary Light Reflex Pathway (study the pathway)

Error of Refraction
Ophthalmologic Problems:
Cataract, Corneal lesion,
Retinal Hemorrhage/ infarct,
Macular Degeneration
Page 3 of 13

Review of the Visual Pathway

When both eyes focus on the arrow, the real images fall on
corresponding parts of the retina. Then proceed through the
retinal rods and cones; bipolar layer; multipolar layer, optic
nerve, optic chiasm; optic tract; geniculate body synapse; and
geniculocalcarine tract to the primary visual cortex around
the calcarine fissure.
PUPILLARY LIGHT REFLEX
Normal
Both pupils constrict
CN II Lesion
Loss of direct papillary light reflex
CN III Lesion
Loss of consensual papillary light reflex
Anisocoria: Left or Right? (Name after the pupil that
is bigger)
Pupils equal and normally reacting: normal variant
Senile Miosis: Normal age-related change; not so
much in accommodation
10% of normal patients have unequal eye dilatation
Know reactions whether briskly reactive, reactive or
non-reactive(problem with CN II and III mostly in
coma patients)
HORNERS SYNDROME TRIAD
Miosis small-sized eye
Partial Ptosis
Enopthalmos and loss of hemifacial sweating

Visual Field Defects (study this)

Monocular Field Defects

(scotoma)
Bitemporal Field Defects
Homonymous Field Defect
Congruous Homonymous
Field Defect

Optic Chiasm
Behind Optic Chiasm
Behind Lateral Geniculate
Bodies

E. Optic nerve evaluation via ophthalmoscopy (Fundoscopy)

Central cause: Stroke (Wallenberg), demyelination

Peripheral cause: Pancoasts tumor (apical bronchial Ca),
trauma, carotid dissection

CORTICAL BLINDNESS
a blind patient with briskly reactive pupils
occipital or post-geniculate ganglion
D. Visual Field Testing
Test each eye individually
Use your fingers in the four quadrants of the visual
field. Ask the patient to count fingers held up or
point to the hand when a finger wiggles.
To test the extraocular muscles (CN III, IV, VI), have
the patient follow a target through the 6 principal
positions of gaze (H pattern)
Patient identifies the moving finger/fingers
Distance between the examiner and examinee should
be equal (about 14-15 inches)
Use peripheral vision

Anterior to Optic Chiasm

Observe the optic disc, physiological cup, retinal

vessels and fovea
Note for the:
o Pulsations of the optic vessels
o Blurring of the optic disc margin
o Change in the optic discs color
(normal: yellowish-orange)
Possible Findings:
o Red orange reflex
o Media clear, hazy
o Disc borders distinct, blurred
o Cup disc ration = 0.4 to 0.5
o Arteriole/ Venule Ratio (AVR) = 2:3
If more veins, consider malformations like AVM
o Note for hemorrhage, exudates, papilledema

CN III, IV, VI OCULOMOTOR, TROCHLEAR, ABDUCENS

Formed by diverging fibers of the medial longitudinal
fasciculus (MLF)
MLF is one of a pair of crossed fiber tracts (group
of axons), on each side of the brainstem. These bundles
of axons are situated near the midline of
the brainstem and are composed of both ascending and
descending fibers that arise from a number of sources
and terminate in different areas. MLF is the main central
connection for the oculomotor nerve, trochlear nerve,
and abducens nerve.

Page 4 of 13

You will meet this MLF in eye movement problems

(related to CN III)
Lies ventral to periaqueductal gray
V-shaped trough
To test for extraocular muscles, let the patient look
on extremes
o Conjugate movement detects muscle palsy
st
Aneurysm- 1 sign is ptosis/anisocoria
CN III palsy secondary to compression of aneurysmpresents with dilatation
CN III palsy secondary to stroke/ischemia- presents
with exaggerated constriction with slight ptosis

Curve dorsolaterally and caudally, decussate in the

superior medullary velum
Supplies the SUPERIOR OBLIQUE
-Downward, inward movement of eyes
CN VI ABDUCENS NERVE

Innervates the LATERAL RECTUS muscle

CN III OCULOMOTOR NERVE

Functions:
Superior Division
Inferior Division

Levator palpebrae
Superior rectus
Inferior rectus
Medial rectus
Inferior Oblique
For pupillary constriction and
accommodation

Abduct or lateral deviation of the eyes

Defect- cant look laterally
Inferior oblique- upward and inward
Superior oblique- downward and inward
Superior rectus- upward (and opening of eyelid)
Inferior rectus- downward
Medial rectus- medially
Lateral rectus- laterally
All eye muscles supplied by CN III
except Lateral rectus (CN VI) and
Superior Oblique (CN IV)
CN IV- TROCHLEAR NERVE

Test of Oculomotor, Trochlear, and Abducens Nerves

Inspect the eyes. Note for ptosis (lagging of an eyelid).
Check for ocular alignment.
Versions
- Test extraocular range of motion with both eyes
open and following the target (conjugate gaze) if eyes
have the same movement
- Follow a target trough the H pattern six
principle positions of gaze
- Note for misalignment of eyes and complaint of
diplopia (double vision)

Small cell group at ventral border of Periaqueductal gray

Ductions
- If there is any misalignment of the eyes or diplopia
on versions then examine each eye with the other covered
(ductions)
-done one eye at a time if with complains of diplopia
Page 5 of 13

 Vestibulo-ocular reflex (Dolls eye movement)

- Have the patient visually fixate on an object
straight ahead, then rapidly turning the patients head from
side to side and up and down
- The eyes should stay fixed on the object and turn in
the opposite direction of the head movement
-usually done on coma patients
Vergeance
- Eye movements occur when the eyes move
simultaneously inward (convergence) or outward
(divergence)
- When the patient is asked to follow an object that
is brought from a distance to the tip of their nose the eyes
converge, the pupil will constrict and the lens will round up
(accommodation)

Motor-wise, cranial nerve V only chews. Its motor axons

innervate all and, for clinical purposes, only the chewing
muscles: masseter, temporal, and lateral and medial
pterygoids. CN V conveys no efferents to glands or smooth
muscle and no special sensory afferents.

Unilateral destruction of the perikarya or axons of

CN V causes complete paralysis of all ipsilateral
chewing muscles.
Atrophy and paralysis are the two outstanding signs
of lower motoneuron (LMN) lesions of CN V.
Masseter is the most readily palpable muscle to
check for atrophy.
Many proximal (axial) muscles that ordinarily
contract symmetrically have bilateral upper motor
neuron innervation.
The distal muscles that contract unilaterally have
mainly contralateral upper motor innervation.

Misalignment of Eyes
If there is paralysis of 1 of the eye muscle, the opposite
muscle pulls the eye into its direction. Ex. Medial rectus
palsy of the right eye (paralysis of medial rectus, the right
eye is pulled by lateral rectus and goes laterally)
Control of Eye Movements
Type of Eye Movement
Site of Control
Saccadic (command) (fast
Frontal Lobe
phase, awareness)
Pursuit/motion
Occipital Lobe
Ex. Seeing a moving car
Vestibular-Positional
Cerebellar, Vestibular Nuclei
Convergence, divergence
Midbrain
*Eye field- eye gazes to the direction of the lesion
CN V TRIGEMINAL NERVE
V, VII, X and XII nerves responsible for speech production.

Largest cranial nerve

Sensory and motor components

Sensory
- Exteroceptive pain, thermal, tactile sensation
from face, forehead, mucous membranes of the
nose and mouth, teeth, large parts of cranial dura
- Proprioceptive deep pressure and kinesthesis
from the teeth, periodontium, hard palate and
temporomandibular joint
Motor muscle of mastication

Page 6 of 13

 Reaches the face by infraorbital foramen

Palatine nerves
Alveolar Nerves
Inferior Paplpebral branch
Nasal branch
Superior labial branch
Zygomaticofacial branch

Lower lid
Side of the nose
Upper lip
Cheek

Mandibular Division (V3)

Lower gums and papillae and
mucous membrane of the
anterior 2/3 of tongue
Inferior dental branch
Lower gums, teeth and
mandible
Mental branch
Skin, mucous membrane of
the lower lip
Lingual nerve

TEST FOR TRIGEMINAL NERVE

Ophthalmic Division (V1) Branches
Dura of cavernous sinus, sphenoid wing,
anterior fossa, petrous ridge, Meckels
cave, tentorium cerebella, post falx cerebri
and dural venous sinuses
Lacrimal
Conjunctiva and skin at area of lacrimal
gland; reflex lacrimation
Frontal Medial upper lid and conjunctiva, frontal
Supraorbital
sinuses, forehead and scalp
Frontal Conjunctiva, medial upper lid, forehead and
Supratrochlear side of nose
Nasociliary
Nasal nerves- mucosa of nasal septum,
lateral nasal wall, inferior and mid
turbinates, top of nose
Infratrochlear branch- lacrimal sac,
caruncle, conjunctiva, and skin of medial
canthus
Ciliary nerves- ciliary body, iris and cornea,
papillary dilator
Tentorial

Maxillary Division (V2)

Sensory
Test for both light touch (cotton tip applicator, finger) and
pain (sharp object ex. toothpick) in the sensory divisions:
o Forehead - ophthalmic
o Cheek - maxillary
o Jaw or chin- mandibular
Corneal reflex
Limbal junction of the cornea is lightly touched with
a cotton observing the reflex blink
Sensory or afferent limb ophthalmic division (V1)
of CN V
Motor or efferent limb branch of CN VII to the
orbicularis oculi muscle
Motor

Palpate the temporalis and masseter muscles as

the patient bites down hard
Have the patient open their mouth and resist the
examiners attempt to close the mouth
If there is weakness of the pterygoids, the jaw will
deviate towards the side of the weakness
Muscles of mastication (temporalis, masseters,
and pterygoids
JAW JERK
o A stretch reflex
o Tested by placing a finger over the
patients chin and then tapping the finger
with a reflex hammer
o Normal: the jaw moves minimally
o Most prominent is patients with
parkinsonism

Leaves the skull through the foramen rotumdum and enter

the sphenopalatine fossa
Page 7 of 13

CN VII FACIAL NERVE

Except for the mandible and eyelid elevation, CN
VII innervates every other movement that the face
can make.

The pontine tegmentum contains motor nuclei for

three CNs: V, VI and VII.
Through the basis of the pons run the corticospinal
(pyramidal tract) to the lower motor neurons of the
spinal cord.
Before exiting from the pons, the VII nerve fibers
loop around the nucleus of the CN VI.
Three CrNs exit at the pontomedullary sulcus. In
ventrodorsal order, these nerves are VI, VII, and VIII.
As typifies peripheral nerves, the VII nerves do not
cross the midline.
If a lesion destroys the VII nerve nucleus, the intraaxial course of the axons, or the peripheral nerve
trunk, the result is paralysis of all facial muscles
ipsilaterally.
The only sensory function of CrN VII tested clinically
is taste
Remember that, in addition to moving the face, CN
VII innervates: (A) Tasting: taste from the anterior
two-thirds of the tongue via the geniculate ganglion;
(B) Snotting: parasympathetic axons to the nasal
mucosa via the pterygopalatine ganglion, (C)
Tearing: parasympathetic axons to the lacrimal
gland via the pterygopalatine ganglion and (D)
Salivating: parasympathetic axons via the
submandibular ganglion.
Mnemonic summary of the clinically important
functions of CrN VII: It tears, snots, tastes, salivates,
moves the face, and dampens sounds.
Cranial Nerve Seven
This is the nerve that lets you cry
And wets your mouth when it is dry
Dampens noise when you are young
Tastes on two-thirds of your tongue
And lastlynow, just let me think
Lets you give a smileand wink!
Meredith Rose Golomb,MD

The freest unilateral facial movement normally is lip

retraction.
The least free unilateral facial movement normally is
forehead elevation.

4 COMPONENTS AND FUNCTIONS

Branchial
Muscles of facial expression: digastrics,
Motor
stylohyoid and stapedius
Test: frontal, buccinators, oris, ocular
Visceral
Motor
Special
Sensory
General
Sensory

Lacrimal, submandibular and sublingual

glands and mucous membranes of
nasopharynx, hard and soft palate
Taste sensation anterior 2/3 of tongue;
hard and soft palates
Concha of the auricle and small area behind
the ear

Diagram of the complete distribution of cranial nerve VII.

(Reprinted with permission from DeMyer W.Neuroanatomy, 2nd
ed. Baltimore: Williams & Wilkins, 1998.)

Page 8 of 13

TEST FOR FACIAL NERVE

Inspect the face during conversation noting any
facial asymmetry including drooping, sagging or
smoothing of normal facial creases
-be discrete that you are observing
Motor division. It supplies the muscles of facial
expression
o Wrinkle forehead frontalis muscle
o Close eyes tight - orbicularis oculi
o Smile and Show teeth buccinators
o Purse lips or blow a kiss orbicularis oris
Should not give way when you
poke the puffed cheek
Sensory division: Taste
o Use a cotton tip applicator dipped in a
solution that is sweet, salty, sour or bitter
o Apply to one side then the other side of the
extended tongue and have the patient decide
on the taste
Use salt, sugar, vinegar, and
bitter gourd/coffee

CN VIII VESTIBULOCOCHLEAR NERVE

CrN VIII consists of cochlear (auditory) and vestibular
divisions. Each division has its own specialized receptors,
its own bundle within the trunk of VIII, and its own
brainstem nuclei and central pathways.
The cochlear division mediates hearing only. It detects
sound vibrations between 20 and 20,000 cps. By its
design, the ear is the most sensitive vibration detector in
the human body.

Bells Palsy

Pxs left face is abnormal

Several times ER residents get this wrong; they admit
Bells palsy patients because they thought it was stroke
Differentiate bells palsy from stroke
Bells palsy- is a peripheral Cranial nerve 7 palsy;
from forehead-eyelid-down to the face; unable to
close eyes full; no forehead crease;
facial
asymmetry; We dont admit bells palsy px vs.
Stroke- only the cheek part (paralysis); able to close
eyes fully, nasolabial flattening, intact forehead
crease L&R; we admit

TEST FOR VESTIBULOCOCHLEAR NERVE

Screen Hearing:
1. Face the patient and hold your arms with your
fingers near each ear
- Px eyes should be closed so that there will
be no visual clue
2. Rub your fingers together on one side while moving
the finger noiselessly on the other
3. Increase intensity as needed and note any
asymmetry
4. If abnormal, proceed with the Weber and Rinnes
tests.
Weber Test
o Test for lateralization
o Place vibrating tuning fork on the middle of the head
and ask if the patient feels or hears it beast on one
side or the other
o Use tuning fork with ears (256 Hz)
Page 9 of 13

o
o
o

Normal: the same in both ears

Unilateral neurosensory hearing loss: hear best in
the normal ear
Unilateral conductive hearing loss: hear best in the
abnormal ear

TYPE OF DEAFNESS
RINNES TEST

WEBERS TEST
WHAT IT MEANS

Rinne test
A tuning fork is held against the mastoid process
until it can no longer be heard.
It is then brought to the ear to evaluate patient
response.
Consists of comparing bone conduction versus air
conduction

CONDUCTIVE
Bone
Conduction >
Air Conduction
Deaf Ear
External ear
obstruction
Middle ear
disease

SENSORINEURAL
AC > BC

Good Ear
Cochlear lesion:
Otosclerosis,
Menieres, drug,
noise-induced,
damage
Auditory nerve
lesion: meningitis,
CPA, tumor, trauma
Pontine lesion

CN IX, X GLOSSOPHARYNGEAL AND VAGUS NERVES

CN IX GLOSSOPHARYNGEAL NERVE

Supplies motor fibers: parotid gland and pharynx

Carries sensory fibers: from carotid body and taste
fibers from the posterior third of tongue
Motor: gag reflex
Sensory: taste posterior 1/3 of tongue

- Normal: AC > BC
- Neurosensory hearing loss: AC> BC
- Conduction Hearing Loss: BC > AC

Page 10 of 13

CN X VAGUS NERVE
Test: performed by the gag reflex and ahh test
Unilateral lesion: produce hoarseness and difficulty
swallowing due to loss of laryngeal function

Skeletal muscle innervated by CN X: It innervates the palatal

muscles, aided by CN V, the pharyngeal constrictors, aided by
CN IX, and the laryngeal muscles unaided: the palate,
pharynx, and larynx, in rostrocaudal order.

Unilateral weakness, the uvula will deviate toward the

normal side (side of the palate is pulled up higher)
Bilateral weakness neither side of the palate will
elevate and there will be marked nasal air escape
Ask the patient to swallow and note any difficulty
Note the quality and sound of the patients voice
Sensory and Motor
Gag reflex
This involuntary reflex is done by touching the back of
the pharynx with the tongue depressor and watch for
the elevation of the palate
1. Speech
2. Dysphagia
3. Examine Palate and Larynx
4. Hoarseness
5. Rhythm, force (dysprosody), and timber of voice
CN XI SPINAL ACCESSORY NERVE

TEST FOR GLOSSOPHARYNGEAL AND VAGUS NERVES

Motor
Ask the patient to say ah or kah
The palate should rise symmetrically and there should
be little nasal air escape

CN XI has two parts, spinal and accessory.

The spinal part supplies the sternocleidomastoid
(SCM) and rostral portions of the trapezius muscles.
The accessory part is accessory to the vagus. The
accessory fibers arise in the nucleus ambiguous of the
medulla and merely hitchhike along the proximal part
of CN XI before joining CN X for distribution to the
pharynx and larynx.

TEST FOR SPINAL ACCESSORY NERVE

Patient is instructed to shrug shoulders against
resistance. For Trapezius
Patient is instructed to turn head against the examiners
hand while the sternocleidomastoid muscle is palpated.
The muscle tone on both sides is compared.
1. Inspect the SCM and trapezius muscles for size and
asymmetry.
2. Next palpate the muscles at rest and as they exert their
actions.
3. To test the strength of SCM and trapezius muscles,

Page 11 of 13

CN XII HYPOGLOSSAL NERVE

References:
SGD notes
Audio- italicized
th
DeMeyers The Neurological Examination, 6 edition- blue
green box
Internet- red font

CATOLICO |DAVIS | DE GUZMAN | DOMINADO

TEST FOR HYPOGLOSSAL NERVE

Patient is instructed to stick out the tongue as far
out as possible, and then move it laterally against
resistance.
Have the patient stick out their tongue and move it
side to side
Further strength testing: have the patient push the
tongue against a tongue blade
Inspect the tongue for atrophy and fasciculation
Unilateral weakness: the protruded tongue will
deviate towards the weak side; uvula will deviate
towards normal side
By having the patient say lah-pah-kah, the examiner
is testing the motor components of CN 7, 9, 10 and
12

Motor examination of all of the cranial nerves in 45 seconds

The formal examination of CrN motor function begins with
the eyes. The NE outline at the beginning of the text lists
motility last in the ocular sequence for a reason. The Ex can
then flow smoothly through the entire CrN motor
examination, yes, III to XII, in just 45 seconds, in a normal
cooperative Pt. No, the 45 seconds is not a misprint.

Lower motor neuron lesion of CNs XI to XII is termed

bulbar paralysis.
Paralysis of speech and swallowing after UMN (upper
motor neuron) lesions pseudobulbar, or false
bulbar paralysis, because the lesion was not truly in
the bulb (medulla) or its nerves.
1.
2.
3.
4.
5.

Inspect tongue at rest

Testing tongue motility and deviation
Tongue strength
Involuntary movements
Dysarthria

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