Cranial Nerve Examination

Irfan Ziad MD UCD

drkupe.blogspot.com
 Anterior aspect
CN1 :Olfactory of midbrain
Dorsal aspect of
CN2 :Optic midbrain
CN3 :Oculomotor
midbrain
CN4 :Trochlear

CN5: Trigeminal

CN6 :Abducens
pons
CN7 :Facial

CN8: Vestibulocochlear

CN9: Glossoparyngeal

CN10: Vagus
medulla
CN11: Accessory

CN12: Hypoglossal
 Inspection
Position the patient sitting over the
edge of the bed

Look for : Scars (eg. craniotomy),

pupil equality, facial asymmetry,
ptosis, proptosis, neurofibromas
Hi, my name is _____.
Can I examine you?
CN 1 Olfactory Nerve
CN I
CN 1 Olfactory Nerve
CN I
Smell
You ask the patient
Have you ever noticed any change in
sense and smell?
If the answer is NO, proceed to the
Have you ever noticed next CN
any change in sense and
smell?
CN 1 Olfactory Nerve
CN I
Smell
If the answer is YES, Test: occlude
one nostril, close eyes, identify smell
(mint, coffee)
Anosmia- loss of the sense of smell
Can you tell me what (eg. flu, nasal polyps)
smell is this? Lesion- nose, cribiform plate of the
eythmoid bone, base of skull- eg
meningioma, early sign of parkinson.
CN 2 Optic Nerve
CN II

Optic canal
CN 2 Optic Nerve
CN II
Visual Acuity
Ask patient do they have any difficulty
with their vision.

Can you see the clock on the wall?

Can you see Can you read the newspaper?
the clock on
the wall? Ask the pt whether shes myopic
(nearsighted) or hyperopic(farsighted)
CN 2 Optic Nerve
CN II
Test acuity with her
glasses on. Pinhole if
she forgets her glasses
Snellen chart is hold at
arm-length
Visual Acuity
A portable Snellens chart will enable
you to perform a more formal test
A patient who is having visual
problems should be asked to count
fingers held up in front of each eye in
turn, and if this is not possible then
perception of hand movement should
be assessed. Failing this, light
perception only may be present
CN 2 Optic Nerve
CN II
Visual Field
Confrontation test: ask the pt to
look into your eyes while you place
our index finger just outside the outer
limits of your temporal fields. Move
Point to the the fingers in turn and then together.
moving finger
Point to the moving finger

In visual inattention (parietal lobe

lesions) the patient will only point to
one finger when you move both
simultaneously.
CN 2 Optic Nerve
CN II
Visual Field
Test her peripheral field on each eye
separately.

Can you see the whole of my face?

Can you see
the whole of
my face?
CN 2 Optic Nerve
CN II
Visual Field
Test her left temporal vision against
your right temporal vision by moving
your wagging finger from the
Keep looking at my periphery towards the centre
nose, tell me when
you see my finger Tell me when you see my finger
moves moves

The temporal field should be tested in

the horizontal plane and in the upper
and lower temporal quadrants.
Change hands and repeat on the
nasal side
CN 2 Optic Nerve
CN II

1 Right optic nerve lesion

Visual Field
2 Bitemporal hemianopia:
Level of lesions causes: optic chiasm lesion,
pituitary tumour,
craniopharyngioma
2b

2a+2b Binasal hemianopia: Very rare

2+2a
2a 2b

3 Left Homonymous hemianopia

4 Left Superior Quadrantanopia

5 Left Inferior Quadrantanopia

6 Left Homonymous hemianopia

with macular sparing

7 Left homonymous scotoma

CN 2 Optic Nerve
CN II

Visual Field

Lesions at the level of the retina

These affect one eye only

Arcuate scotoma- Unilateral defect found with Central scotoma-

moderate glaucoma arterial occlusion, branch retinal macular degeneration or
vein thrombosis and inferior macular oedema
retinal detachment
CN 2 Optic Nerve
CN II
Blind Spot
Tell the pt to look at the tip of your
nose. Move the red-headed pin
from the temporal periphery
tell me when the through the central field to the
red pin disappears nasal periphery, asking the patient
and reappears.
tell me when the red pin
disappears, and reappears.
The blind spot enlarges with
papilloedema e.g. raised
intracranial pressure with brain
tumour. Demyelination of the optic
nerve in multiple sclerosis can
cause loss of central vision
CN 2 Optic Nerve
CN II
Colour Vision
Test is done with an Ishihara plate

This is affected in colour blindness

and optic neuritis (loss red colour
first).
CN 2 Optic Nerve
CN II
Fundoscopy
Turn on, set diopters to zero, focus on
specific distance, look for red reflex, adjust if
pt wear glass, look for blood vessels, follow,
look at optic disc- clear or blurred?

- Hypertensive, diabetic, papillodema, optic

neuropathy, pigmentation (mithocondrial
disorder, retinotitis pigmentosa)
CN 3,4.6 Oculomotor, Trochlear, Abducens Nerve
CN III, IV, VI

Extraocular movements
From oculomotor nucleus
CN 3 Oculomotor Nerve
CN III Pupillary light reflex

Direct and Consensual:

Put your hand in between the
patients eyes.
With a pocket torch shine the light
from the side. Do a swinging-light
test.

Normally, the pupil into which the

light is shone constricts rapidly
(Direct light reflex)
Simultaneously the other pupil
constricts in the same way,
(Consensual light reflex)
Repeat this procedure on the other
side

RAPD (Relative Afferent Pupillary

Defect) previous optic neuritis)-
swinging light test- damaged nerve
dilate in response to light
Causes: eg previous optic neuritis
CN 3 Oculomotor Nerve
CN III
Accommodation reflex
Look at that mark on the wall, now
look at my finger

Look at that mark Examine the pupils for size, shape,

on the wall, now look equality and regularity
at my finger
PERRLA : Pupils Equal, Round,
Reactive to Light and
Accommodation

Pathology
Unilateral dilated pupil
- drugs- cocaine, eye drops
(mydriatic)
- 3rd nerve palsy- any associated
ptosis, strabismus
- Holes-Adie pupil- pupil reacts
sluggishly, associated with syphilis
-Absent light reflex with an intact
accommodation reflex occurs in
Argyll Robertson pupil in
neurosyphilis
CN 3,4.6 Oculomotor, Trochlear, Abducens Nerve

Extraocular movements
Assess for eye movement, diplopia
Without moving your [double vision] and nystagmus
head, follow the pin with
your eye. Tell me if you Ask the patient to look laterally left
see double and right, continue moving the
finger to complete H pattern.
Tell the patient to inform you if they
see double images [diplopia]

Diplopia is an early sign of ocular

muscle weakness
CN 3,4.6 Oculomotor, Trochlear, Abducens Nerve

Extraocular movements

LR Lateral Rectus
MR Medial Rectus
SR- Superior Rectus
IR- Inferior Rectus
IO- Inferior Oblique
SR SR SO- Superior Oblique
IO CN IV supplies SO
CN VI supplies LR
LR MR CN III supplies all others + levator
LR palpebrae superioris (which
elevates the superior eyelids)
SO
IR IR
CN 3,4.6 Oculomotor, Trochlear, Abducens Nerve
Extraocular movements
3rd nerve palsy 4th nerve palsy 6th nerve palsy

Double vision going down stairs Failure of lateral movement

Complete ptosis
Eye down and out
Dilated pupil which is not
responsive to light and
accommodation.
or reading books Nystagmus.
Ask patient to turn the eye in
and then to look down- may
cause vertical hypertropia (pic)

Nystagmus
The direction of nystagmus is defined as that of the fast [correcting] movement
Vestibular lesion nystagmus away from the side of the lesion
Cerebellar lesion nystagmus to the side of the lesion

Internuclear ophthalmoplegia
Abducting eye has greater nystagmus than the adducting eye. Problems btw nuclear, 3rd
n 6th connected by medial longitudinal fasciculus (MLF) - MS
CN 5 Trigeminal Nerve
CN V

Sensory Ophthalmic (V1)

branch
Trigeminal Nerve

Maxillary (V2)

Mandibular (V3)

Temporalis
All involved in
Masseter
biting, chewing,
Motor Muscle of
Medial pterygoid swallowing
mastication
Lateral pterygoid except for tensor
tympani which
Tensor veli palatini acts to dampen
sound produced
mylohyoid
from chewing
Temporalis Others Anterior belly of digastric
Masseter Tensor tympani
CN 5 Trigeminal Nerve
CN V
Facial Sensory
Test for soft touch using cotton wool -
sternum first, close eyes
in the 3 divisions of the nerve
V1- ophthalmic- forehead up to the top of
the head
Say yes if you feel this
V2- maxillary
V3- mandibular (up to angle of the jaw)

The patient should be instructed to say yes

each time the touch of the cotton wool is felt.
Do not stroke the skin touch it.
Test for pain using sharp object.
Ask patient does it feel sharp or dull

Causes of sensory problems

- MS- MS plaque in the brainstem in young
people
- Sjogren- dry eyes, dry mouth
-Trigeminal neuralgia- older people
CN 5 Trigeminal Nerve
CN V
Corneal Reflex
Ask the pt to look up and away, touch the
corneal. Reflex blinking of both eyes is a
normal response.
Im going to gently touch
your eye with a cotton bud. Pathology
Bells palsy- unable to blink due to damage to
the efferent limb (CNVII)
CNV forms the afferent limb
CN 5 Trigeminal Nerve
CN V
Motor
Inspect for wasting of the temporal and
masseter muscles
Ask patient to clench their teeth and palpate
for contraction of the temporal and masseter
Can you grit your teeth, muscles
please?
CN 5 Trigeminal Nerve
CN V
Open up your mouth
and hold it for me
Motor
Ask patient to open their mouth and hold it
open while the examiner attempts to force it
shut [pterygoid muscles].
A unilateral weakness of the motor division
causes the jaw to deviate towards the weak
side.If weakness is suspected patients
should be asked to move the jaw laterally
against resistance. The jaw can be moved
towards the affected muscle but cannot move
towards the normal side.
CN 5 Trigeminal Nerve
CN V
The Jaw Jerk
Ask the pt to open her mouth fully, and
close halfway, , place index finger on her
chin and tap with a patella hammer, if jaw
jerk is highly exaggerated.
Im going to gently tap
your jaw Help to distinguish btw pseudobulbar palsy
(UMN lesion of lower cranial nerve 9,
10,11,12) and a bulbar palsy (LMN lesion
of lower cranial nerve 9,10,11,12)
CN 7 Facial Nerve
CN VII The facial nerve has four components:
From facial nerve nucleus
1. BRANCHIAL MOTOR Petrous
temporal bone
Greater petrosal to Lacrimal
gland, sphenoid sinus, frontal From Nevus Intermedius
Internal auditory
sinus, frontal sinus, maxillary meatus
sinus, eithmoid sinus, nasal 2. PARASYMPATHETIC
cavity, Geniculate
3. SENSORY ganglion
Small contribution to external
acoustic meatus
4. TASTE Facial canal
(tortuous course)
Palate via greater petrosal
Ant 2/3 tongue via chorda
tympani
Stylomastoid foramen
Stapedius
Inside Skull
Outside skull Major facial
Frontalis, orbicularis oculi Temporal branches Other
Z1: Eye & around orbit Posterior auricular nerve
Z2: Mid face & smile Zygomatic controls scalp muscles around
the ear
Buccinator, upper lip Buccal

Lower lip, orbicularis oris Mandibular Posterior belly of Digastric

Platisma Cervical Stylohyoid muscle

CN 7 Facial Nerve
CN VII
Motor
Ask the patient to shut the eyes tightly
Observe and try to force open each eye.

If a lower motor neuron lesion is detected

Shut your eyes tightly and [weakness on one side of face], check for ear
dont let me open them and palatal vesicles of herpes zoster of the
geniculate ganglion the Ramsay Hunt
syndrome
CN 7 Facial Nerve
CN VII
Motor
Ask patient to look up and wrinkle her
forehead. Feel for muscle strength by
pushing down on forehead.

Wrinkle your forehead for This movement is preserved on the side

me please of an upper motor neurone lesion [a
lesion which occurs above the level of
the brainstem nucleus], because of
bilateral supranuclear innervation giving
some compensation to the upper face
which is not the case in LMN lesion (Bells
palsy/Ramsay Hunt- Herpes Zoster)

The remaining muscles of facial

expression are usually affected on the
side of an UMN lesion.
In a LMN lesion all muscles of facial
expression are affected on the side of the
lesion.
CN 7 Facial Nerve
CN VII
Motor
Ask the patient to show their teeth

Compare the nasolabial grooves which are

smooth on the weak side.

Show me your teeth Left upper motor neuron seventh nerve

lesion leads to drooping of the corner of
the mouth, flattened nasolabial fold, and
sparing of the forehead on the left side**
CN 7 Facial Nerve
CN VII
Motor
Ask the patient blow out her cheeks

Blow out your cheeks

CN 7 Facial Nerve
CN VII
Upper Motor Neurone
Pathway Rt motor cortex-corona-radiata-
internal capsule-brainstem
(midbrain-pons-medula)-crosses-
anterior horn cell-
Presentation increased tone, reflex, clonus,
upgoing(extensor) plantar
Cerebrovascular accident
stroke! most common
Intracranial tumour
Cervical spine injury
Lower Motor Neurone
Anterior horn cell, intervertebral
foramen, lumbar sacral(lower
limb)/brachial plexus(upperl imb
plexus, runs in peripheral nerve-
stop at NMJ
- wasting, fasciculation, lose of tone,
reflex, flexor plantar
Motor neuron disease
Peripheral nerve neuropathy
Diabetic neuropathy?
Poliomyelitis
anterior horn cell affected
Spinal cord injury
with nerve root compression
CN 8 Vestibulo-Cochlear Nerve
CN VIII

Cochlear division-
Hearing
From organ to Corti in
cochlea
Hair cells to cell bodies
in spiral ganglion (in
modiolus)
To 2 cochlear nuclei
(ventral & dorsal)

Vestibular division
Balance
From semicircular
canals, utricle & saccule
Cell bodies in vestibular
ganglion in outer part of
internal acoustic meatus
To 4 vestibular nuclei
(medial, lateral, superior,
inferior)
CN 8 Vestibulo-Cochlear Nerve
CN VIII

Im going to whisper a
number. I want you to
repeat it.
Hearing+Balance
Any problem with hearing? Hearing aids?
Mask- cover the tragus of the ear and
whisper a number, ask pt to repeat
If deafness is suspected perform Rinnes
test and Webers test
CN 8 Vestibulo-Cochlear Nerve
CN VIII
Rinnes Test
Rinne- base of tuning fork on the mastoid
process,
tell me when it stops,
then bring it to the ear,
Can you hear it? Can hear it?

With nerve deafness the note is audible

at the external meatus, as air and bone
conduction are reduced equally, so that
air conduction is better as is normal. This
is termed Rinne-positive.
With conduction [middle ear] deafness no
note is audible at the external meatus.
This is termed Rinne-negative.
CN 8 Vestibulo-Cochlear Nerve
CN VIII
Webers Test
A vibrating tuning fork is placed on the
centre of the forehead. Normally the
sound is heard in the centre of the
forehead. With nerve deafness the sound
Can you hear it? is transmitted to the normal ear. With
conduction deafness the sound is heard
louder in the abnormal ear.

Patients with defective hearing should be

referred for audiometry. This measures
the degree of hearing loss at different
sound frequencies.
CN 9 Glossopharyngeal Nerve
CN IX
CN 10 Vagus Nerve
CN X
CN 9, 10 Glossopharyngeal and Vagus Nerve
CN IX, X
CN 9, 10 Glossopharyngeal and Vagus Nerve
CN IX, X
Uvula + Gag Reflex
Uvula
Get the patient to open their mouth and
inspect the palate with a torch. Note
any displacement of the uvula.
Open your mouth Ask the patient to say Ah. If the uvula
and say ah is drawn to one side this indicates a
unilateral tenth nerve palsy. The uvula
is pulled towards the normal side.
Now test gently for the gag reflex
Ninth is the sensory component
Tenth is the motor component

Gag Reflex
Touch the back of the pharynx on each
side with a spatula. Ask the patient if
the touch of the spatula is felt each
time. Normally there is reflex
contraction of the soft palate.

The ninth nerve supplies taste from the

posterior two-thirds of the tongue this is
not routinely tested for.
CN 12 Hypoglossal Nerve
CN XII

Its nucleus receive Corticonuclear fibers

from both cerebral hemispheres, but the
cells supplying the genioglossus muscle
receives corticonuclear fibers only from
the opposite cerebral hemisphere
It supplies
1. All the intrinsic muscles of the tongue
2. Styloglossus
3. Hyoglossus
4. Genioglossus
5. Doesnt supply Palatoglossus
Supplied by the vagus
Function is to control the movement of the
tongue
In the upper part, the Hypoglossal nerve is
supplied by the C1 fibers
CN 12 Hypoglossal Nerve
CN XII
Motor Nerve of Tongue
Observe the tongue at rest- wasting? on
one side? fasciculation?
Stick out tongue straight- deviate to one
side?
Wiggle your tongue
Tongue deviate to the side of a lesion of
side-to-side
CNXII

Wiggle tongue side-to-side -

(coordination)altered in cerebellar
disorder
CN 11 Accessory Nerve
CN XI Cranial Root Spinal Root

Receives corticonuclear fibers from both cerebral

hemispheres

It joins the spinal root Situated in the anterior grey

& leaves the skull column of the spinal cord in the
through jugular upper 5 cervical segments
foramen
Nerve fibers emerge from the
Then the roots spinal cord & form a nerve trunk
separate again, cranial that ascends into the skull
root joins the vagus through the foramen magnum
Spinal part joins the cranial part
& pas through the jugular
foramen
Then they separate again

Supply the muscles of: Supplies the SCM muscle &

Soft palate (Except trapezius muscle
tensor veli palatini)
Pharynx (Except
stylopharyngeus)
Larynx (Except
cricothyroid)
CN 11 Accessory Nerve
CN XI
Trapezius
Ask the patient to shrug their shoulders
and feel the bulk of the trapezius
muscles and attempt to push the
shoulders down.
Shrug your shoulder,
push up against my
hand
CN 11 Accessory Nerve
CN XI
Sternocleidomastoid
Ask the patient to turn their head
against resistance and feel the bulk of
the sternomastoids. Feel for the
Turn your head sternomastoid on the side opposite to
against my hand the turned head. There will be
weakness on turning the head away
from the side of a muscle whose
strength is impaired.

(Optional)Test neck flexors if suspect

myasthenia gravis, MND-
put chin on chest, Ill put my hand
onto your forehead, push up against
my hand
Thank
You