CRANIAL NERVES Normal ABNORMALITY

Smell  Different aromas Absence of smell  aging,

Cover one nostril, breathe smoking, nasal disease
(Pts eyes closed)
in with other
CN I - Olfactory Patency Absence of sniff = obstruction
Septum  Check both Mucosa slightly redder than Perforation – trauma, cocaine
nostrils oral mucosa use; Deviation, Epistaxis
Visual acuity (hand held 20/20  20/40 – person Myopia: nearsighted; Hyperopia:
card @ 14”) sees at 20 feet what’s farsighted; Presbiopia: aging
normally seen at 40
Visual Fields by N = 50° upward, 90° Pituitary tumor - Peripheral field
confrontation (peripheral temporal, 70° down, 60° lost Glaucoma, optic neuritis,
CN II – Optic vision) nasal papilledema - enlarged blind
N= blind spot at 15 deg spot
Ophthalmoscope Red reflex Retina should appear to be Opaque black areas with
Dark room (to red. “Orange glow” cataracts or detached retina
maintain large
Retina Red / orange Hypertension - flame shaped
pupil)!
hemorrhages
Start negative (ppl w
Diabetes – deep retinal
myopia) and move to
hemorrhage (red blots)
positive
Med intense, med Optic disc (should be Follow blood vessels to Papilledema—blurred margins &
size creamy yellow/orange and optic disc elevation of disc (inflammation)
Start 15 deg lat, once round or oval) Glaucoma – looks very white &
see optic disk, ask pt Margins  distinct atrophy may be seen
to look into light – this Blood vessels Veins - bigger, darker ones Hypertension - Copperwire and
will change view to Arteries -smaller, brighter narrow arteries
their macula/fovea red structures
Your left/their left Macula, fovea centralis Macula - lateral to the optic Clumped pigment with retinal
Pt look up and disc, looks somewhat detachment
straight darker then the rest of the
retina
fovea centralis – center of
macula
Glaucoma—optic nerve atrophy
Neovascularization—cancer

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 Eyelids for drooping
Pupil size for equality
Direct & Consensual
response to light
CN III – Oculomotor
Accommodation – follow
finger to bridge of nose
H test: CN III
• upward/out movt: superior rectus
• upward/in: inferior oblique
• inward: medial rectus
• downward/out: inferior rectus
H test:
CN IV - Trochlear Downward/inward eye
movement
H test:
CN VI (6)- Abducens
Lateral eye movement
• Inspect for muscle
atrophy, tremors
• Palpate jaw mms:
temporal & masseter
for tone & strength on
clenching teeth
• Facial sensation in each
branch:
CN V – Trigeminal o Forehead:
ophthalmic
o Cheeks: maxillary
o Chin: mandibular
• Corneal reflex: Whisp
test: tearing & blinking
CN VII – Facial Inspect symmetry of
facial features:
• Smiling
• Frowning
• Closes eyes tightly
Symmetry – both sides
Pupil reactions should be
equal.
A) Direct light reflex
Pupil constricts to direct
light
B)Consensual light reflex
Pupil constricts to light
shining on opposite pupil
Converge (cross eyed)
Superior Oblique (SO4)
Lateral Rectus (LR6)
Equal muscle bulk, tone &
strength
Equal sensation on both
sides
Blinking and tearing
Symmetry of patient’s face.
Ptosis— droopy eyelids (CN III
damage) seen in Myastenia gravis
and Horner’s syndrome
Glaucoma – fixed dilation
Aniscoria – unequal pupil
constriction
Failure of convergence with CN
damage
H Test:
- Extraocular muscle
movements
Nystigmus - eye tremor seen is
MS, brain lesion, CN palsy
- Lateral & vertical mov’t
disorder (look at magnitude &
direction)
ABN = weak or absent contraction
suggests lesion of CN 5
Afferent: CN V
Efferent: CN VII
Trigeminal nerve palsy - unable
to feel touch of cotton wool (no
blinking)
Facial nerve palsy - patient can
feel the touch of the cotton wool -
no reflex blink & tear (CN7)
Bell’s Palsy – Asymmetry of face.
2
 w/ Drs attempt to
open
• Shows teeth
• Puffs cheeks w/
resistance
• Wrinkles forehead
• Lifts eyebrows
Whisper test: Hearing N = patient can repeat back ABN = unable to repeat word
whispered word
Weber: Lateralization N = sound is heard midline, CHL: sound lateralizes to
or equally in both ears. impaired ear (causes are acute
OM, perforation, obstruction,
otosclerosis)
SHL: sound lateralizes to good
ear (long-term exposure to loud
CN VIII – Acoustic noises, drugs, infections of the
inner ear, trauma, tumours…)
Rinne: Air & Bone Normal AC>BC CHL: AC=BC or BC>AC
conduction SHL: AC>BC
Otoscopic: TM is pinkish grey, oblique Otitis media: inflamed/red TM
membrane held inward at Perforation of TM
Tympanic membrane its centre by the handle of
the malleus.
Cone of light should point toward jaw
Swallowing
Gag reflex (don’t need to
CN IX –
Glossopharyngeal
do)
Taste post 1/3 tongue sour
& bitter (just explain)
Inspect palate for symmetry Patients says “ahhhh” – CN 10 paralysis – soft palate fails
(say AH) note rise of soft palate to rise and uvula deviates to
CN X – Vagus (symmetry and uvula opposite side (good side)
Uvula rise
centered) & gag reflex
Oral inspection: elicited
(tongue depressor) Swallowing ABN = dysphagia
Speech sounds Talking: note Hoarseness, Nasal
sounds
Sternocleidomastoid mms ABN = pain or difficulty performing
strength actions  paralysis of muscle
• Pt turns head to each
CN XI – Spinal side against resistance
Accessory
Trapezius mms strength
• Pt shrugs shoulders
against resistance

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 Inspection - Tremor
• Tongue in mouth & - Atrophy
while protruding - Deviation towards affected
side
• Tongue mvt toward
nose & chin
CN XII -
Hypoglossal Test Strength
• Test index finger when
tongue is pressed
against cheek
Evaluate - Presence of lisp
Quality of lingual speech