Cranial nerve examination.

Position: Sitting on the side of the bed or in chair.

General inspection of head and neck: scars, neurofibromas, facial asymmetry, ptosis,
proptosis, deviation of the eyes, equality of the pupils.
The first nerve (olfactory).
1. Ask the patient if he can smell normally.
2. If there is a problem with a smell, with the eyes closed test one nostril at a time with a
different aromatic materials.
The second nerve (optic).
1. Ask whether the patient normally wears spectacles?
2. Visual acuity with Snellen chart. Consider pin-hole do differentiate refractory error.
3. Visual field. (Always remove patients spectacles first. Examiners head should be
level with the patients head. Do it slowly! The doctor will close the same side, not the
same eye)
4. Fundoscopy (Do red reflex first, use the right eye to look in the patients right eye,
and vice versa.)
The third, fourth, sixth nerves (oculomotor, trochlear, abducens).
1. Look at the pupil (shape, size, associated ptosis)
2. Test direct and consensual response to light, check for afferent pupillary defect.
(Bring the light from the site.)
3. Test accommodation (look at the distance focus on the object -30cm distance from
the nose)
4. Assess the eye movements (start from the centre follow H pattern, ask about
diplopia, look for nystagmus and failure of movement). Lateral rectus (6th nerve)
can only move eyes horizontally outwards; while medial rectus (3d nerve) can only
move eyes horizontally inwards.
The fifth nerve (trigeminal).
1. Cornel reflex - light touch cornea, not conjunctiva; (sensory 5th nerve, motor 7th)
2. Test sensory: light touch and pain in 3 divisions (ophthalmic, maxillary, mandibular).
3. 3 motor functions: ask to clench teeth + feel masseter muscles; open mouth against
resistance; jaw jerk.
The seventh nerve (facial)
1. Look up + wrinkle forehead push down against the corrugation on each side (spared
in UMN lesions)
2. Close eyes tightly - try to open.
3. Puff out cheeks with mouth closed.
4. Show teeth compare nasolabial folds.
The eighth nerve (acoustic).
1. Softly whisper a number 60cm away from each ear.
2. Otoscopy if indicated.
3. Perform Rinners (conduction deafness no note is audible at the external meatus)
and Webers tests (conduction deafness the sound is louder in the abnormal ear)
with 256 Hz tuning fork if partial deafness is suspected.

The ninth and tenth nerves (glossopharyngeal + vagus)

1. Note any displacement of the uvular (unilateral 10th nerve palsy - uvula is drawn
towards the normal side).
2. Look for symmetrical movements of soft palate as the patient says Ah.
3. Assess gag reflex.
4. Assess for voice hoarseness and cough.
The twelfth nerve (hypoglossal).
1. Inspect the tongue for wasting and fasciculation (Deviate towards the weaker side if
there is a unilateral LMN lesion).
2. Ask patient to protrude tongue and look for deviation.
The eleventh nerve (accessory).
1. Ask the patient to shrug shoulders and feel trapezius as you push down.
2. Ask the patient to turn head against resistance and feel bulk of sternocleidomastoid
muscle. (Right sternocleidomastoid muscle turns the head to the left!)

Reference: N. Talley and S. OConnor Clinical examination 6th edition