Indy Karpha

LOCAS

Helps to start EARLY! Nicest exam

Pastest books
F1s classic cases on the wards Test and time each other

How to examine all 12 cranial nerves in 8 minutes....?!

Examination

Introduce, ID, explain, consent :

Hello, my name is...
Im a 4th year medical student Can I check your name and DOB? Thanks.

As part of my medical training Ive been asked to

examine your cranial nerves. This will involve checking your eyes and facial muscles, and I will have to touch your face to check the sensation. Is that ok with you? Wash hands

INSPECT!
Clues in the room!!! Look at patient

Eyes ptosis, nystagmus, III,IV,VI nerve palsies Face weakness

Ask about pain!

CN I: Olfactory Nerve

Not routinely done

Any change in sense of smell or taste?

Or
Occlude one nostril Test the other (coffee, orange) Eyes closed

Ammonia doesnt require olfactory tracts

CN II: Optic Nerve

Pupils PERLA Acuity Fundoscopy Visual fields

CNII: Optic Nerve

Inspect eye:
Compare R and L eyes Eyelid complete/partial ptosis, lid retraction Position of eye Nerve palsies Exopthalmos (hyperthyroid look from above the head) Enopthalmos (Horners syndrome) Pupils equal?

CN II: Optic Nerve

Pupils
R and L pupils equal? Direct and consensual response Look straight ahead at this point on the wall. Im going to shine a light in your eyes, but try not to look directly into the light, just keep looking at this point on the wall. Direct response shine light into eye and

ipsilateral pupil constricts Consensual response shine light into eye and contralateral pupil constricts

CN II:

Pupillary Defects

Marcus Gunn pupil (RAPD)

Shine light into normal eye both eyes constrict Shine light into abnormal eye both eyes dilate Swinging light test MS

Argyll Robertson pupil

Tertiary syphilis Small irregular pupil Accommodates but does not respond...!

Holmes-Adie pupil
Large, slowly reacting pupil With absent reflexes = Holmes-Adie syndrome

CN II: Optic Nerve

Accommodation
Please look at a point on the wall behind me.

When I say now, please look at my finger

Pupils constrict Eyes converge

CN II: Optic Nerve

Acuity
Snellen chart Know how to record results: If they can read a 6m line at 6m, then 6/6 If they the smallest they can read at 6m away is the 60m line, then 0/60 Near vision chart Hold 30cm from face Bedside test e.g. your name badge/newspaper Count fingers/perceives light/movement Use glasses/pinhole

CN II: Optic Nerve

Fundoscopy
Probably wont be asked to do this

CN II: Optic Nerve

Visual fields
Position patient: Sitting on a chair/edge of bed Same level 1m apart

Ask patient to cover eye & you cover your corresponding eye Use hat pin/wiggle fingers

Ask patient which finger you are moving

CN II: Optic Nerve

Blind spot with red pin

Move it out laterally
Also shows central scotomas

Visual fields

CN III, IV, VI
Occulomotor, trochlear, abducens Make sure they keep their head still! Any double vision? Any pain? optic neuritis Watch for:

Nystagmus cerebellar/brainstrem/INO

Internuclear opthalmoplegia

INO
Median longitudinal fasciculus Median rectus paralysis

So on lateral gaze, eye cannot adduct Abducting eye - nystagmus Commonest cause: MS

Nerve Palsies
Occulomotor nerve

Horners Syndrome
Ptosis Miosis Anhydrosis Enopthalmos

Lesion to cervical/sympathetic chain EXAMS: Horners syndrome = pancoast tumour BUT ptosis does not = horners Could be CN III lesion

Trochlear Nerve Palsy

Innervates Sup Oblique

Moves eye down and in (look at your nose)

Vertical diplopia on downward gaze

Tucked in chin

Eye position slightly upwards and outwards (extorsion)

Abducens Nerve Palsy

Lateral rectus
Lateral gaze

Diplopia on abduction
Move head to compensate

CN V: Trigeminal Nerve
Sensory and motor 3 divisions

Ophthalmic branch (V1) Maxillary branch (V2) Mandibular branch (V3)

CN V: Trigeminal Nerve

Sensory

Patient eyes closed Cotton wool Touch each division left and right Compare each side Corneal reflex not normally done!

Motor
Ask patient to clench teeth Temporalis masseter

Jaw jerk
Not normally done! Checking for UMN lesion (brisk reflex)

CN VII: Facial Nerve

Inspect:

Obvious asymmetry Loss of nasolabial folds/forehead wrinkles on one side Drooling from one side Watch movements smiling, talking etc

Raise your eyebrows Tightly close your eyes Bells Phenomenon Purse your lips Blow out your cheeks Show me your teeth Best to demonstrate movements too

J Smith, locum registrar, B Henderson,consultant, department of neurology, Pinderfields Hospital, Wakefield WF1 4DG, UK

BMJ 2003;327:E154

Copyright 2003 BMJ Publishing Group Ltd.

CN VII: Facial Nerve - Anatomy

UMN Vs LMN
UMN contralateral facial weakness with forehead sparing LMN ipsilateral facial weakness with no forehead sparing

Bells Palsy

Acute LMN nerve palsy Unilateral Worth learning a differential for facial weakness: Inflamed facial nerve within petrous temporal bone neuroma Acoustic Bells Palsy 24 hx ear ache Middle ear infection Ramsay-Hunt syndrome No sensory loss Parotid gland tumours Idiopathic Mumps Guillain-Barre ?HSV acyclovir multiplex inconclusive evidence Mononeuritis MS ?short course high dose steroids
MND

CN VIII: Vestibulo-cochlear
noticed any change in hearing? Hearing:

Block other ear Rubbing fingers together, see when they can no

longer hear it

Rinnes tuning fork louder in front or behind? Webers is it louder in one ear?

CN IX: Glossopharyngeal
Sensory: post 1/3rd of tongue (facial nerve ant 2/3rd) Motor: stylopharyngeus Autonomic: salivary glands Inspect:

Position of uvula

say aahh
See if the uvula deviates to one side (away from

abnormal side)

CN X: Vagus
Sensory: tympanic membrane, ext auditory canal, ext ear Motor: muscles of palate, pharynx, larynx Autonomic: thorax and abdomen! Gag reflex dont do it

CN XI: Accessory Nerve

Inspect neck:
Sternomastoid wasting/fasciculation Shoulders equal?

Put you hand on side of face and say push against my hand Test each shoulder separately:

Shrug your shoulder against my hand

UMN: ipsilateral sternomastoid and contralateral trapezius wasting LMN: ipsilateral sternomastoid and trapezius wasting

CN XII: Hypoglossal Nerve

Inspect tongue (resting inside mouth)

Wasting, fasciculations

Stick your tongue out:

Watch if is deviates to one side: Weakness on the side it deviates to

Bulbar/Pseudobulbar Palsy
CN 9-12 Pseudo-bulbar = UMN Bulbar = LMN

Any questions....?
GOOD LUCK!