Professional Documents
Culture Documents
6
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!
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
Occlude one nostril and test smell on the other using the odorants
Page 1 of 8
CRANIAL NERVES
Look for both the direct (same eye) and consensual (other eye)
reactions
As the patient to alternately look into the distance and at your finger
Position the patient 20 feet in front of the Snellen eye chart (or hold
a Rosenbaum pocket card at a 14 inch "reading" distance)
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.)
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
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
Ask the patient to follow your finger with their eyes without moving
their head
Page 2 of 8
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
Page 3 of 8
CRANIAL NERVES
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
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
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).
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
Page 4 of 8
CRANIAL NERVES
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
DISORDERS
Facial Weakness
Peripheral Injury to CN 7
(Bells Palsy)
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!
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
Page 5 of 8
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:
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.
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.
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).
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.
Page 6 of 8
CRANIAL NERVES
ii.
BATES!
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:
Interpretation:
The tongue deviates to the side of the CN XII with lesion.
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:
Page 7 of 8
CRANIAL NERVES
CRANIAL NERVE
Olfactory
INNERVATION
Sensory
Smell
Identify odors
Optic
Sensory
Vision
Oculomotor
Motor
Trochlear
Motor
Motor
Muscles of mastication
Corneal reflex
Sensory
Clench jaw/palpate
Light touch comparison
Abducens
Motor
Facial
Motor
Vestibulocochlear
Sensory
Sensory
Glossopharyngeal
Motor
Vagus
Sensory
Motor
Accessory
Hypoglossal
Sensory
Motor
Motor
Trigeminal
PRIMARY FXN(S)
TEST(S)
Physiologic "H"
Near point response
Physiologic "H"
Gag reflex
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!!
Ang unang makapagsabi ng anime na kinabibilangan ng mga characters sa baba ay bibigyan ko ng chocnut sa Tuesday! :D
Page 8 of 8