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08 Sept
2014

CRANIAL NERVES
Alfredo Guzman, M.D.
What makes earth feel like hell is our expectation that it should feel like heaven
Chuck Pahlaniuk, Damned
TOPIC OUTLINE
Paulo Coelho
I. Cranial Nerves isang malaking joke ang topic outline since puro
cranial nerves lang naman :D
This trans came from upper batch trans + transcibers notes + Master
Bates :D

CRANIAL NERVE
12 pairs of specialized nerves within the skull or cranium
o
CN I and II fiber tracts emerging from the brain
o
CN III XII from the diencephalon and brainstem (midbrain,
pons, medulla)
Remember!

Jan 28, 1975

Jan 28 stands for cranial nerve I, II and VIII which are


all sensory

1975 means cranial nerves V, VII, IX and X which are


all both sensory and motor.

The rest are motor.

CN

Name

Function

I
II

Olfactory
Optic

Sensory
Sensory

III

Oculomotor

Motor

IV

Trochlear

Motor

Trigeminal

Both

VI

Abducens

Motor

VII
VIII

Both
Sensory

IX

Facial
Vestibulocochlear
or Auditory
(Acoustic)
Glossopharyngeal

Vagus

Both

XI
XII

Accessory or
Spinal Accessory
Hypoglossal

Both

Motor
Motor

Examinations
Used
Smell
Visual Acuity
Visual Fields
Ocular Fundi
Pupillary Reactions
Pupillary Reactions
Extraocular
Movements
Extraocular
Movements
Corneal Reflexes
Facial Sensation
Jaw Movements
Voice and Speech
Extraocular
Movements
Facial Movements
Hearing
Voice and Speech

Swallowing and
Rise of the Palate
Gag Reflex
Swallowing and
Rise of the Palate
Gag Reflex
Voice and Speech
Shoulder and Neck
Movements
Tongue Symmetry
and Position

American Academy of Neurology : Guidelines for Screening


Neurologic Examination
o Cranial Nerves
Visual Acuity
Pupillary Light Reflex
Eye Movement
Hearing
Facial Strength smile, eye closure
CRANIAL NERVE I OLFACTORY NERVE
Special afferent cranial nerve composed of sensory fibers only
Sole function: To discern smells
Olfaction depends on:
o
Integrity of the olfactory neurons in the roof of the nasal cavity
o
Their connections through the olfactory bulb, tract, and stria to
the olfactory cortex of the medial frontal and temporal lobes.
Olfaction is frequently not tested because of unreliable patient
responses and lack of objective signs.
TEST FOR OLFACTION
Present familiar and non-irritating odors
First be sure that each nasal passage is open by compressing of the
nose and asking to sniff through the other
Commonly used odorants:
o
Concentrated vanilla
o
Perfume
o
Coffee
o
Soap
o
Cloves
Patient should close both eyes

Occlude one nostril and test smell on the other using the odorants

Ask if the patient smells anything and, if so what

Test the other nostril

Figure 1. Testing for Olfaction


Avoid noxious triggers (ammonia) that can stimulate CN V
A person normally perceives odor on each side and can often identify
it.
DISORDERS/DISTURBANCES CN I (OLFACTION)
Uncommon in neurological practice
Alteration of taste and smell
o Recognized complication of head injury and can follow an upper
respiratory tract infection
o Sinus conditions
o Smoking
o Use of cocaine
Unilateral Anosmia
o Rare presenting complaint in subfrontal meningioma
Dulling of olfaction occurs in the:
o Elderly
o Parkinsons disease
o Early feature of Alzheimers disease
QUIZ TIME!
So what is the most common cause of BILATERAL ANOSMIA?
ANSWER: MARAMING LAMIG. HAHAHAHAHAHA! Ang corny! :D

Summary of CN Examination (from bates 11th Ed.)

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Page 1 of 8

CRANIAL NERVES

CRANIAL NERVE II OPTIC NERVE


Contains special sensory afferent fibers that convey visual
information from the retina to the occipital lobe via the visual pathway.

Figure 2. Visual Pathway


Evaluation gives important information about the
o Nerves
o Optic chiasm
o Optic tracts
o Thalamus
o Optic radiations
o Visual cortex
CN II is also the afferent limb of the pupillary light reflex
The optic nerve is tested by:
o Visual acuity,
o Color vision testing for males using Ishihara Test
o Pupil evaluation
o Visual field testing
o Optic nerve evaluation ophthalmoscopy and/or stereo
biomicroscopy

PUPILLARY REACTION TO LIGHT* (CN II & CN III)


Dim the room lights as necessary

Ask the patient to look into the distance

Shine a bright light obliquely into each pupil in turn

Look for both the direct (same eye) and consensual (other eye)
reactions

Record pupil size in mm and any asymmetry or irregularity

If abnormal, proceed with the test for accommodation.

PUPILLARY REACTION TO ACCOMODATION* (CN II & CN III)


Hold your finger about 10cm from the patient's nose

As the patient to alternately look into the distance and at your finger

Observe the pupillary response in each eye


Inspect the size and shape of the pupils, and compare one side with
the other.
o
Anisocoria, or a difference of >0.4 mm in the diameter
of one pupil compared to the other.
OPTIC NERVE EVALUATION
Inspect optic fundi using an ophthalmoscope
Pay special attention to the optic disc
DISORDERS/DISTURBANCES IN CN II

TEST FOR VISUAL ACUITY


Allow the patient to use their glasses if available
You are interested in the patient's best corrected vision

Position the patient 20 feet in front of the Snellen eye chart (or hold
a Rosenbaum pocket card at a 14 inch "reading" distance)

Have the patient cover one eye at a time with a card

Ask the patient to read progressively smaller letters until they can
go no further

Record the smallest line the patient read successfully (20/20, 20/30,
etc.)

Repeat with the other eye


There are hand held cards that look like Snellen Charts but are
positioned 14 inches from the patient
o
Used simply for convenience
o
Testing and interpretation are as described for the Snellen.

DISORDERS
Optic Atrophy
Papilledema
Glaucoma
Retinal Emboli
Optic Neuritis
Pituitary Tumor (defect at
optic chiasm)
Stroke, Postciasmal Lesions
(usually parietal lobe)

MANIFESTATION
Disc pallor
Disc bulging
Poor visual acuity
Bitemporal hemianopsia
Homonymous hemianopsia
Quadrantanopsia
Normal Visual Acuity

CRANIAL III, IV, VI


Function: Extraocular movements
o CN IV Superior Oblique
o CN VI Lateral Rectus
o CN III Superior Rectus, Inferior Rectus, Medial rectus, Inferior
Oblique
Remember!
SO 4 LR 6
the remaining EOM are innervated by CN III
TEST FOR EXTRAOCULAR MOVEMENT
Test the EOM in the six cardinal directions of gaze (H pattern)

Figure 3. Rosenbaum pocket


card - hand held visual acuity
card (held at 14 inches from the
patient)
VISUAL FIELD TEST VIA CONFRONTATION
Stand 2 feet in front of the patient and have them look into your eyes

Hold your hands about one foot away from the patient's ears, and
wiggle a finger on one hand

Ask the patient to indicate which side they see the finger move

Repeat two or three times to test both temporal fields

If an abnormality is suspected, test the four quadrants of each eye while


asking the patient to cover the opposite eye with a card

TRANSCRIBED BY: KYU, RYU, KINTA, MEGUMI, KAZUMA

Stand or sit 3 to 6 feet in front of the patient

Ask the patient to follow your finger with their eyes without moving
their head

Check gaze in the six cardinal directions using a cross or "H"


pattern

Pause during upward and lateral gaze to check for nystagmus

Check convergence by moving your finger toward the bridge of the


patient's nose
Look for loss of conjugate movements in any of the six directions
which causes diplopia
o Ask which direction makes the diplopia worse
o Inspect the eye for asymmetric deviation of movement
o Do a cover-uncover test or ask the patient to cover one eye
Determines if diplopia is monocular or binocular
Identify any nystagmus (Nystagmus is named for the direction of the
quick component)
o Note direction of gaze in which it appears
o Note plane of nystagmus
Horizontal
Vertical
Rotary

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CRANIAL NERVES

Mixed
o Direction of quick and slow components
Ask patient to fix his/her vision on a distant object and observe if
nystagmus increases or decreases
Look for ptosis
PUPILLARY REACTION TO LIGHT
Discussed earlier in CN II
DISORDERS/DISTURBANCES IN CN III, IV & VI
DISORDERS
Local Problems with glasses
or contact lenses
Cataracts
Astigmatism
Ptosis
CN III, IV, VI Neuropathy
Myasthenia Gravis
Cerebellar Disease
Vestibular Disease

CN III Palsy
Horners syndrome

MANIFESTATIONS
Monocular diplopia

Binocular diplopia (40% of


patients)
Ptosis
Weakness of extraocular muscles
Nystagmus
Gait ataxia
Dysarthria
Cerebellar Disease, increases with
retinal fixation
Vestibular Disease, decreases
with retinal fixation
Ptosis
Ptosis
Meiosis
Anhidrosis

o characteristic alternating hyperdeviation depending on the


direction of gaze
CN VI ABDUCENS NERVE
CN VI Lesions
o Abducens muscle paralysis
o Weakness of lateral or outward movement as well as a crossing
of the visual axes
o The affected eye deviates medially
Incomplete CN VI palsies
o Turning the head toward the side of the paretic muscle
overcomes the diplopia
ANALYSIS OF DIPLOPIA
Almost all instances of diplopia (seeing a single object as double) are
the result of an acquired paralysis or paresis of one or more
extraocular muscles.
The signs of oculomotor palsies are manifest in various degrees of
completeness.
Noting the relative positions of the corneal light reflections and having
the patient perform common versional movements will usually
disclose the faulty muscle(s) as the eyes are turned into the field of
action of the paretic muscle.
QUIZ TIME!!

CLINICAL EFFECTS OF LESIONS OF THE THIRD, FOURTH AND


SIXTH OCULAR NERVE
CRANIAL NERVE III-OCULOMOTOR
Complete CN III Lesion
o Ptosis (drooping of upper eyelid)
Levator palpebrae supplied by CN III
o Inability to rotate the eye (weakness of the extraocular muscles)
Upward SR, IO
Downward IR
Inward MR
o Down and Out position of the eye due to the remaining action
of CN IV and CN VI
When the lid is passively elevated
o Eye is deviated outward and slightly downward
Unopposed actions of intact LR and SO
o Iridoplegia (dilated nonreactive pupil) and Cycloplegia (paralysis
of accommodation)
Interruption of PSNS in CN III (no PSNS)
However, extrinsic and intrinsic eye muscles may be affected
separately
o Infarction of central portion of CN III spares the pupil
Since the PSNS preganglionic pupilloconstrictor fibers lie near
the surface
Occurs in Diabetic ophthalmoplegia
Conversely, compressive lesions of CN III usually dilate the pupil as
an early manifestation
After injury, regeneration of CN III fibers may be aberrant
o Some of the fibers that originally moved the eye in a particular
direction now reach another muscle or the iris
o If it reaches the iris, the pupil, which is unreactive to light, may
constrict when the eye is turned up and in
CN IV TROCHLEAR NERVE
Lesion of CN IV causes paralysis of SO muscle
o Most common cause of isolated symptomatic vertical diplopia
o Paralysis of SO muscle results in:
Weakness of downward movement of the affected eye
(most marked when the eye is turned inward)
Patient complains on difficulty in reading or going down
stairs
Affected eye tends to deviate slightly upward
This defect may be overlooked in the presence of a third
nerve palsy if the examiner fails to note the absence of an
expected intorsion as the patient tries to move the paretic
eye downward
Bielchowsky Sign head tilting to the opposite shoulder
o Characteristic of CN IV lesions
o this maneuver causes a compensatory intorsion of the
unaffected eye and ameliorates the double vision
Unilateral Trochlear Palsies
o More common
Bilateral Trochlear Palsies
o Occur rarely after head trauma
TRANSCRIBED BY: KYU, RYU, KINTA, MEGUMI, KAZUMA

What cranial nerve is involved? Right or Left?


Figure 4. Note patient's right eye is deviated
laterally and there is ptosis of the lid.

Right CN3 Lesion: The right pupil (upper left picture)


is more dilated than the left pupil.
o

Disorders of the extra ocular muscles themselves (and not the


CN which innervate them) can also lead to impaired eye
movement.

o An example is a patient who has suffered a traumatic left orbital


injury. The inferior rectus muscle has become entrapped within the
resulting fracture, preventing the left eye from being able to look
downward.
CN V TRIGEMINAL NERVE
Both motor and sensory components
o Sensory limb has 3 major branches, each covering roughly 1/3 of
the face
Ophthalmic (V1)
Maxillary (V2)
Mandibular (V3)

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CRANIAL NERVES

Blinking also requires that CN VII function normally, as it controls eye


lid closure
Sensory is via CN V, and Motor is via CN VII
Use of contact lenses frequently diminish this reflex
cotton wisp must touch the cornea not the sclera

Figure 6. Test for Corneal Reflex

SENSORY COMPARTMENT TESTING


TEST FOR PAIN SENSATION
Explain to the patient what you plan to do
Test the forehead, cheeks, and jaw on each side
Use a sharp implement (e.g. broken wooden handle of a cotton tipped
applicator)

Ask the patient to close their eyes so that they receive no visual cues

Touch the sharp tip of the stick to the right and left side of the forehead,
assessing the Ophthalmic branch

Touch the tip to the right and left side of the cheek area, assessing the
Maxillary branch

Touch the tip to the right and left side of the jaw area, assessing the
Mandibular branch

The patient should be able to clearly identify when the sharp end
touches their face

MOTOR COMPARTMENT TESTING


The motor limb of CN V innervates the Temporalis and Masseter
muscles, both important for closing the jaw.
Place your hand on both Temporalis muscles, located on the lateral
aspects of the forehead

Ask the patient to tightly close their jaw, causing the muscles beneath
your fingers to become taught

Then place your hands on both Masseter muscles, located just in front
of the Temporo-Mandibular joints (point where lower jaw articulates with
skull)

Ask the patient to tightly close their jaw, which should again cause the
muscles beneath your fingers to become taught

Then ask them to move their jaw from side to side, another function of
the Masseter.

Make sure that you do not push too hard as the face is normally quite
sensitive.
You may also use a sharp and blunt object, asking the patient to
identify if it is sharp or dull.
Test both sides of the face
If there is an abnormality, confirm by performing temperature
sensation test
Figure 7. Palpation of Temporal and Masseter Muscles
DISORDERS/DISTURBANCES IN CN V
DISORDERS
Masseter Weakness
Lateral Pterygoid Weakness

Figure 5. Suggested areas for Sensory Testing


TEMPERATURE SENSATION TEST
Two test tube with hot and ice cold water are commonly used
Tuning fork may also be used
Touch the skin of the patient using the objects and ask if it is hot or
cold
TEST FOR LIGHT TOUCH
Use a fine wisp of cotton
Ask the patient to respond whenever you touch the skin
TEST FOR CORNEAL REFLEX
The Ophthalmic branch of CN V also receives sensory input from the
surface of the eye
Ask the patient to look up and away from you
Avoid touching the eyelashes
If patient is apprehensive, touching the conjunctiva first may allay fear
Pull out a wisp of cotton.

While the patient is looking straight ahead, gently brush the wisp
against the lateral aspect of the sclera (outer white area of the eye ball).

This should cause the patient to blink.


TRANSCRIBED BY: KYU, RYU, KINTA, MEGUMI, KAZUMA

CN V Pontine Lesions
Cerebral Hemispheric
Disease
Contralateral Cortical or
Thalamic lesion
Brainstem Lesion
Peripheral Nerve Disorders
(Trigeminal Neuralgia)
CN V or CN VII Lesion
Acoustic Neuroma

MANIFESTATIONS
Difficulty clenching the jaw
Difficulty moving the jaw to the
opposite side
Unilateral weakness
Bilateral weakness
Facial and body sensory loss on the
same side
Ipsilateral face but contralateral body
sensory loss
Isolated facial sensory loss
Absent blinking
Absent blinking
Sensorineural hearing loss

CRANIAL NERVE VII FACIAL NERVE


Has both motor and sensory function
o Motor innervates many of the muscles of facial expression
o Sensory Chorda tympani branch contains fibers from anterior
2/3 of the tongue, along with secretomotor fibers to
the submaxillary and submandibular glands
MOTOR COMPARTMENT TESTING
First look at the patients face
It should appear symmetric:
o The same amount of wrinkles apparent on either side of the
forehead
o The nasolabial folds should be equal
o The corners of the mouth should be at the same height
Inspect both at rest and during conversation
Observe any tics or abnormal movements

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CRANIAL NERVES

If there is any question as to whether an apparent asymmetry is


new or old, ask the patient for a picture for comparison

Ask the patient to wrinkle their eyebrows and then close their eyes
tightly
You should not be able to open the patients eyelids with the
application of gentle upwards pressure
CN 7 controls the muscles that close the eye lids
CN 3 controls the muscles which open the eye lids

Ask the patient to smile.


Corners of the mouth should rise to the same height
Equal amounts of teeth should be visible on either side

Ask the patient to puff out their cheeks.


Both sides should puff equally and air should not leak from the
mouth
SENSORY COMPARTMENT TESTING
Apply sugar, salt, or lemon juice on a cotton swab to the lateral
aspect of each side of the tongue

Have the patient identify the taste


CN VII is responsible for taste sensation on anterior 2/3 of the tongue
Taste is often tested only when specific pathology of the facial nerve
is suspected
DISORDERS IN CN VII & INTERPRETATION
CN 7 has a precise pattern of innervation, which has important
clinical implications.
o Right and Left Upper Motor Neurons (UMNs)
Each innervate both the right and left lower motor neurons
(LMNs) that
Allow the forehead to move up and down
o Right and Left Lower Motor Neurons (LMNs)
Control the muscles of the lower face
Innervated by the UMN from the opposite side of the face
In the setting of CN VII dysfunction pattern of weakness or paralysis
observed will differ on whether the UMN or LMN is affected

nasolabial fold is slightly less pronounced compared


with right
LMN Dysfunction
o Occur most commonly in Bells Palsy an idiopathic acute CN
VII peripheral nerve palsy
o Right CN VII LMN (Peripheral) Dysfunction
Affects same side
Patient would not be able to wrinkle their forehead (right
side)
Patient cant close eyes (right side)
Patient cant raise the corner of their mouth (right side)
Left side function would be normal

Figure 10. Left CN VII LMN (Peripheral) Dysfunction.


Note loss of: a.) forehead wrinkle; b.) ability to close
eye; c.) ability to raise corner of mouth; d.)
decreased nasolabial fold prominence on left
Clue!
Always check first if patient can wrinkle the forehead:
o
If yes then it is not a LMN dysfunction
o
If no
- then it is a LMN dysfunction
- the cranial nerve involved is on the same side.
- eg. if patient cant wrinkle his forehead and has
weakness on the left side of the face, then it is a
case left LMN dysfunction.

DISORDERS
Facial Weakness
Peripheral Injury to CN 7
(Bells Palsy)

Unilateral Facial Paralysis

MANIFESTATIONS
Flattening of the nasolabial fold
Drooping of the lower eyelid
Affects both the upper and lower
face
Central lesion affects mainly the
lower face
Hyperacusis
Loss of taste
Increased or decreased tearing
Mouth droops on the paralyzed
side when the patient smiles or
grimaces

QUIZ TIME!

Figure 8. Innervation of CN VII - UMN and LMN

What cranial nerve is affected? Is this an upper or lower motor neuron


dysfunction? Right or left?

UMN Dysfunction
o Occur with a central nervous event (eg. Stroke)
o Right CN VII UMN Dysfunction
Patient is able to wrinkle their forehead on both sides of
their face
Because the Left CN VII UMN cross innervates the
Right CN VII LMN that also controls the movement of
the forehead
However, patient would be unable to effectively close their
left eye or raise the left corner of their mouth
Because the Left CN VII LMN that innervates the face
below the forehead is innervated by Right CN VII
UMN (has dysfunction)

Figure 10. A man with inability to wrinkle the area above the right
eyebrow area and right facial weakness below eyebrow area.
Answers:
Review yourself No. 1: Right CN III
Review yourself No. 2: Right CN VII LMN dysfunction
CRANIAL NERVE VIII VESTIBULOCOCHLEAR NERVE
Figure 9. Right CN VII UMN Dysfunction. Note: a.)
preserved ability to wrinkle forehead; b.) left corner
of mouth is slightly lower than right; c.) left

TRANSCRIBED BY: KYU, RYU, KINTA, MEGUMI, KAZUMA

CN 8 carries sound impulses from the cochlea to the brain.


Prior to reaching the cochlea, the sound must first traverse the
external canal and middle ear

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CRANIAL NERVES

ASSESSMENT
1. Stand behind the patient and ask them to close their eyes
2. Whisper a few words from just behind one ear. The patient should
be able to repeat these back accurately. Then perform the same test
for the other ear.
3. Alternatively, place your fingers approximately 5 cm from one ear
and rub them together. The patient should be able to hear the sound
generated. Repeat for the other ear
4. These tests are rather crude. Precise quantification, generally
necessary whenever there is a subjective decline in acuity, requires
special equipment and training
5. The cause of subjective hearing loss can be assessed with bedside
testing.

Thus, regardless of the means (bone or air) by which the impulse gets
to CN 8, there will still be a marked hearing decrement in the affected
ear. As AC is normally better then BC, this will still be the case.
Bates:

The whispered voice test is both sensitive (>90%) and specific


(>80%) when assessing presence or absence of hearing loss.
Excess cerumen, otosclerosis, otitis media in conductive hearing
loss; presbyacusis from aging, most commonly in sensorineural
hearing loss
Vertigo with hearing loss and nystagmus in Meniere's disease
Hoarseness in vocal cord paralysis; nasal voice in paralysis of
the palate Pharyngeal or palatal weakness The palate fails to
rise with a bilaterallesion of the vagus nerve. In unilateral
paralysis, one side of the palate fails to rise and, together with
the uvula, is pulled toward the normal side

Hearing is broken into 2 phases:


1. Conductive
Refers to the passage of sound from the outside to the level of
CN 8.
This includes the transmission of sound through the external
canal and middle ear
2. Sensorineural
Refers to the transmission of sound via CN 8 to the brain.
Identification of conductive (a much more common problem in the
general population) defects is determined as follows:
WEBER TEST
1. Grasp the 512 Hz tuning fork by the stem and strike it against the
bony edge of your palm, generating a continuous tone. Alternatively
you can get the fork to vibrate by "snapping" the ends between your
thumb and index finger
2. Hold the stem against the patients skull, along an imaginary line
that is equidistant from either ear.
3. The bones of the skull will carry the sound equally to both the R and
L CN 8. Both CN 8s, in turn, will transmit the impulse to the brain
4. The patient should report whether the sound was heard equally in
both ears or better on one side then the other (referred to as
lateralizing to a side)

CRANIAL NERVES IX, X GLOSSOPHARYNGEAL AND VAGUS


NERVE
These nerves are responsible for raising the soft palate of the mouth
and the gag reflex, a protective mechanism which prevents food or
liquid from traveling into the lungs. As both CNs contribute to these
functions, they are tested together.
IX GLOSSOPHARYNGEAL
CN IX is also responsible for taste originating on the posterior 1/3 of the
tongue.
X - VAGUS
CN X also provides parasympathetic innervation to the heart, though
this cannot be easily tested on physical examination.
Bates:

RINNE TEST
1. Grasp the 512 Hz tuning fork by the stem and strike it against the
bony edge of your palm, generating a continuous tone.
2. Place the stem of the tuning fork on the mastoid bone, the bony
prominence located immediately behind the lower part of the ear.
The vibrations travel via the bones of the skull to CN 8, allowing the
patient to hear the sound.
3. Ask the patient to inform you when they can no longer appreciate
the sound. When this occurs, move the tuning fork such that the
tines are placed right next to (but not touching) the opening of the
ear. At this point, the patient should be able to again hear the sound.
This is because air is a better conducting medium then bone.

Listen to the voice


o Is it hoarse?
Hoarseness suggests vocal cord paralysis
o Does it have a nasal quality?
Paralysis of the palate
Is there difficulty in swallowing?
Pharyngeal or palatal weakness

TESTING FOR ELEVATION OF THE SOFT PALATE


1. Ask the patient to open their mouth and say, ahhhh, causing the
soft palate to rise upward.
2. Look at the uvula, a midline structure hanging down from the palate.
o If the tongue obscures your view, take a tongue depressor and
gently push it down and out of the way.
o The uvula should rise up straight and in the midline.

Interpretation:
o The above testing is reserved for those instances when a patient
complains of a deficit in hearing.
o Thus, on the basis of history, there should be a complaint of
hearing decline in one or both ears.
Conductive Hearing Loss

The Weber test will lateralize (i.e. sound will be heard better) in the
ear that has the subjective decline in hearing.
o Competing sounds from the outside cannot reach CN 8 via
the external canal
o Sound generated by the vibrating tuning fork and traveling to
CN 8 by means of bony conduction is better heard as it has
no outside competition.
In the Rinne Test, bone conduction (BC) > air conduction (AC)
o If there is a blockage in the passageway (e.g. wax) that
carries sound from the outside to CN 8, then sound will be
better heard when it travels via the bones of the skull.

Sensorineural Hearing Loss

The Weber test will lateralize to the ear which does not have the
subjective decline in hearing.
o This is because CN 8 is the final pathway through which
sound is carried to the brain.
o Even though the bones of the skull will successfully transmit
the sound to CN 8, it cannot then be carried to the brain due
to the underlying nerve dysfunction.
Air conduction > bone conduction (normal).

TRANSCRIBED BY: KYU, RYU, KINTA, MEGUMI, KAZUMA

Normal Oropharynx
TESTING FOR GAG REFLEX
1. Ask the patient to widely open their mouth.
a. If you are unable to see the posterior pharynx (i.e. the back of
their throat), gently push down with a tongue depressor.
b. In some patients, the tongue depressor alone will elicit a gag.
In most others, additional stimulation is required. Take a
cotton-tipped applicator and gently brush it against the
posterior pharynx or uvula. This should generate a gag in most
patients.
2. A small but measurable percent of the normal population has either
a minimal or non-existent gag reflex. Presumably, they make use of
other mechanisms to prevent aspiration.
Perform this test when there is reasonable suspicion that
pathology exists.
This would include two major clinical situations:
i.

If you suspect that the patient has suffered acute dysfunction,


most commonly in the setting of a stroke.
These patients may complain of cough when they swallow.
They may suffer from recurrent pneumonia. Both of these

Page 6 of 8

CRANIAL NERVES

events are signs of aspiration of food contents into the


passageways of the lungs. These patients may also have
other cranial nerve abnormalities as lesions affecting CN 9
and 10 often affect CNs 11 and 12, which are anatomically
nearby.
Patients suffering from sudden decreased level of
consciousness. In this setting, the absence of a gag might
indicate that the patient is no longer able to reflexively protect
their airway from aspiration. Strong consideration should be given
to intubating the patient, providing them with a secure mechanical
airway until their general condition improves.

ii.

BATES!

BILATERAL LESION of CN X palate fails to rise

UNILATERAL LESION of CN X one side of palate fails to


rise and (with uvula) is pulled toward the NORMAL side
CRANIAL NERVE XI ACCESSORY NERVE
CN XI innervates the ff muscles:

Trapezius which permit shrugging of the shoulders


SCM which turns the head laterally
ASSESSMENT

Trapezius Paralysis shoulder droops and scapula is


displaced downward and laterally
Supine
Patient with BILATERAL
weakness
of
Sternomastoids- presents with difficulty raising head of
pillow
CRANIAL NERVE XII HYPOGLOSSAL NERVE

Each CN XII is responsible for tongue movement of of the


tongue.

ASSESSMENT
1. Ask the patient to stick their tongue straight out of their mouth.
2. If there is any suggestion of deviation to one side/weakness, direct
them to push the tip of their tongue into either cheek while you
provide counter pressure from the outside.
Or, alternatively,
1. Instruct the patient to stick out the tongue and then move it laterally
against resistance.

Bates:

Look for atrophy or fasciculations (fine flickering irregular


movements in small groups of muscle fibers) in the trapezius
o Suggests peripheral nerve disorder
Compare one side with the other
o Trapezius paralysis: The shoulder droops and the scapula
is displaced downward and laterally

1. Place your hands on top of either shoulder


2. Ask the patient to shrug while you provide resistance. Dysfunction
will cause weakness/absence of movement on the affected side.
(Tests the trapezius)

Interpretation:
The tongue deviates to the side of the CN XII with lesion.

Kasi the tongues action is pushing.


For example, if the right CN 12 is dysfunctional, the tongue
will deviate to the right.
The normally functioning left half will dominate as it no longer
has opposition from the right. Similarly, the tongue would have
limited or absent ability to resist against pressure applied from
outside the left cheek.

3. Place your open left hand against the patients right cheek
4. Ask them to turn into your hand while you provide resistance. Then
repeat on the other side. (Tests the SCM)

Bates:

The right Sternocleidomastoid muscle causes the head to turn to


the left, and vice versa.

Trapezius Weakness with Atrophy and Fasciculations


Peripheral Nerve Disorder

TRANSCRIBED BY: KYU, RYU, KINTA, MEGUMI, KAZUMA

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CRANIAL NERVES

CRANIAL NERVE
Olfactory

INNERVATION
Sensory

Smell

Identify odors

Optic

Sensory

Vision

Visual acuity, fields, color, nerve head

Oculomotor

Motor

Trochlear

Motor

Motor

Muscles of mastication

Corneal reflex

Sensory

Scalp, conjunctiva, teeth

Clench jaw/palpate
Light touch comparison

Abducens

Motor

Lateral rectus muscle

Abduction, physiologic "H"

Facial

Motor

Muscles of facial expression

Smile, puff cheeks, wrinkle forehead,


pry open closed lids

Vestibulocochlear

Sensory
Sensory

Taste-anterior two thirds of tongue


Hearing and balance

Glossopharyngeal

Motor

Tongue and pharynx

Vagus

Sensory
Motor

Accessory
Hypoglossal

Sensory
Motor
Motor

Taste-posterior one third of tongue


Pharynx, tongue, larynx, thoracic and
abdominal viscera
Larynx, trachea, esophagus
Sternomastoid and trapezius muscles
Muscles of tongue

Trigeminal

PRIMARY FXN(S)

Upper lid elevation


extraocular eye movement
pupil constriction, accommodation
Superior oblique muscle

TEST(S)

Physiologic "H"
Near point response
Physiologic "H"

Rinne test for hearing


Weber test for balance
Gag reflex

Gag reflex

Shrug, head turn against resistance


Tongue deviation

REMEMBER IT! Oh Oh Oh! To Touch And Feel Vivacious Girls Vaginas Ah Heaven! :D
SING IT! Se-Se-Mo-Mo-Mi-Mo-Mi-Se-Mi-Mi-Mo-Mo
QUIZ TIME!!
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TRANSCRIBED BY: KYU, RYU, KINTA, MEGUMI, KAZUMA

Page 8 of 8