Cranial Nerves
- Make I------I shape, starting in middle
“if you get any double vision, tell me when you do”
Exam Trigeminal: CN V
- Sensation – cotton (light touch) and pain
May present with: (neurotip) in 3 areas, on each side
Change in smell, visual defect, double vision, facial drop, - Motor – (mandibular nerve)
numbness, hearing loss, dysphagia, change in speech, prev. Clench teeth - fingers on temporalis
surgery, prev. accident/trauma Open mouth, don’t let me close it (masseter muscle)
W.I.P.E.E Offer to test corneal reflex
Explain what you will do, have them sat in front of you
Examine: Facial: CN VII
- Visible GCS - Facial movements
- Scars
1. Raise eyebrows, don’t let me push them down
- Skin (neurofibromas, café au lait)
2. Close eyes, don’t let me open them
- Muscular wasting
3. Puff out cheeks, don’t let me push them in
- Facial symmetry/drooping
4. Smile
- Fasciculations
- Walking aids
- Ptosis = eyelid droop Vestibulocochlear: CN VIII
- Tremor Have you noticed any problems with your hearing/balance?
- Pupil – symmetry and size - Rinne’s = louder behind ear or in front?
- Weber’s = middle of forehead, louder in either ear or
the same?
Olfactory: CN I - Whisper = cover ear not testing, whisper into test ear 2
Have you noticed a change to your sense of smell? number at different distances
- Balance = march on spot with eyes closed
pathological = turns towards side of lesion
Optic: CN II – ensure they wear glasses if they have them
1. Pupillary reflexes
Glossopharyngeal: CN IX
- Direct (constricts when light on it)
‘Open your mouth and say ahhh’
- Consensual (constricts when light on other)
Assess soft palate and uvula position/symmetry
- Swinging light: positive = dilates when swing
- Offer to test gag reflex
back to pupil
= relative afferent pupillary defect = caused by glaucoma/MS,
which cause optic nerve lesion Vagus: CN X
2. Accommodation - Same as above with uvula, except ensure it doesn’t
deviate to one side – deviates away from affected side
- Look at where wall meets ceiling
- Any change in your voice?
- Then look at my finger
= testing for constriction and convergence - Cough reflex
- Swallow reflex
3. Offer to perform fundoscopy
4. Test visual acuity (test both eyes individually) Accessory: CN XI
- Snellen chart (letters) – read at 6m, unable = 3m/1m Trapezius – lift shoulders, don’t let me push them down
- Ishihara plates (colour with numbers) Sternocleidomastoid – turn head, don’t let me push you back
5. Visual fields (test both eyes individually)
- Cover same eye as patient Hypoglossal: CN XII
- Wiggle & move finger into field from corners
Ask patient to say ‘now’ or ‘yes’ when they see it - Stick your tongue out – look for deviations (deviates
to same side as lesion), fasciculations (bulbar palsy =
LMN, pseudobulbar palsy = UMN)
- Move tongue from side to side
Oculomotor, Trochlear and Abducens: CN III, IV, VI
Testing eye movements
- Make I------I shape, starting in middle
“if you get any double vision, tell me when you do”
Exam Trigeminal: CN V
- Sensation – cotton (light touch) and pain
May present with: (neurotip) in 3 areas, on each side
Change in smell, visual defect, double vision, facial drop, - Motor – (mandibular nerve)
numbness, hearing loss, dysphagia, change in speech, prev. Clench teeth - fingers on temporalis
surgery, prev. accident/trauma Open mouth, don’t let me close it (masseter muscle)
W.I.P.E.E Offer to test corneal reflex
Explain what you will do, have them sat in front of you
Examine: Facial: CN VII
- Visible GCS - Facial movements
- Scars
1. Raise eyebrows, don’t let me push them down
- Skin (neurofibromas, café au lait)
2. Close eyes, don’t let me open them
- Muscular wasting
3. Puff out cheeks, don’t let me push them in
- Facial symmetry/drooping
4. Smile
- Fasciculations
- Walking aids
- Ptosis = eyelid droop Vestibulocochlear: CN VIII
- Tremor Have you noticed any problems with your hearing/balance?
- Pupil – symmetry and size - Rinne’s = louder behind ear or in front?
- Weber’s = middle of forehead, louder in either ear or
the same?
Olfactory: CN I - Whisper = cover ear not testing, whisper into test ear 2
Have you noticed a change to your sense of smell? number at different distances
- Balance = march on spot with eyes closed
pathological = turns towards side of lesion
Optic: CN II – ensure they wear glasses if they have them
1. Pupillary reflexes
Glossopharyngeal: CN IX
- Direct (constricts when light on it)
‘Open your mouth and say ahhh’
- Consensual (constricts when light on other)
Assess soft palate and uvula position/symmetry
- Swinging light: positive = dilates when swing
- Offer to test gag reflex
back to pupil
= relative afferent pupillary defect = caused by glaucoma/MS,
which cause optic nerve lesion Vagus: CN X
2. Accommodation - Same as above with uvula, except ensure it doesn’t
deviate to one side – deviates away from affected side
- Look at where wall meets ceiling
- Any change in your voice?
- Then look at my finger
= testing for constriction and convergence - Cough reflex
- Swallow reflex
3. Offer to perform fundoscopy
4. Test visual acuity (test both eyes individually) Accessory: CN XI
- Snellen chart (letters) – read at 6m, unable = 3m/1m Trapezius – lift shoulders, don’t let me push them down
- Ishihara plates (colour with numbers) Sternocleidomastoid – turn head, don’t let me push you back
5. Visual fields (test both eyes individually)
- Cover same eye as patient Hypoglossal: CN XII
- Wiggle & move finger into field from corners
Ask patient to say ‘now’ or ‘yes’ when they see it - Stick your tongue out – look for deviations (deviates
to same side as lesion), fasciculations (bulbar palsy =
LMN, pseudobulbar palsy = UMN)
- Move tongue from side to side
Oculomotor, Trochlear and Abducens: CN III, IV, VI
Testing eye movements
