BASIC CRANIAL NERVE EXAMINATION NERVES CN I: OLFACTORY CN II: OPTIC Consensual pupil light reflex Accommodation (also CN III,

IV, VI) Acuity Visual fields Ophthalmoscopy PROCEDURE Ask the patient to block one nostril and identify a familiar smell. Coffee, soap, vanilla are all suitable. Do not use ammonia or smelling salts as these can stimulate a pain response. General observation of eyes, eyelids, conjunctiva. Patient places the side of their hand along their nose. Shine a pen torch into one eye, looking for papillary constriction, then repeat observing for the same in the other eye. Using a pen or Medipin, ask the patient to follow it with their eyes and slowly bring it toward the bridge of their nose. Snellen chart. Should be recorded at 6m from patient. Check eyes individually at smallest print. Looking through a pin hole in a card: if sharper, this confirms it is due to refractive error. Use a Medipin to map out the blind spot. A simple test for fields: stand behind the patient and bring your fingers in from each corner. Patient indicates when the pin appears. Dim the lights. Examine their R eye with your R eye. Check red reflex by shining the light into the eye obliquely. Set opthalmoscope to +10 to examine anterior part of eye, gradually reducing it until retina comes into focus. Examine the optic disc and any vessels you can see. Make sure to keep contact between your forehead and the oscope and get close to the patient. Observe for ptosis, position and symmetry of eyes and any head tilt in a long term attempt to compensate. Holding a Medipin with the sphere end uppermost, ask the patient to follow it with their eyes (no head movement). Draw an H shape in the air, but keep the shape within their shoulder width. Ask the patient to tell you if they have diplopia at any point. If so, try to determine which movements induce it. Tested along with CN III and VI. Innervates superior oblique muscle. Observe for asymmetry and deviation in jaw movement (which can also be caused by TMJ dysfunction). Protrude and retract jaw, move mandible from side to side. Palpate masseter as patient bites. Mandibular, maxillary and ophthalmic divisions. Test for light touch first and be very careful testing for pin prick sensation! Approaching from the side, touch the cornea with a wisp of cotton wool. A normal reflex is to blink. Tested along with CN VI and III. Innervates lateral rectus muscle. Ask the patient about any change in taste sensation .

CN III: OCULOMOTOR Watching the H

CN IV: TROCHLEAR CN V: TRIGEMINAL Muscles of mastication (fake eating) Test for sensation in the divisions Corneal reflex (optional) CN VI: ABDUCENS CN VII: FACIAL

BASIC CRANIAL NERVE EXAMINATION Pulling faces CN VIII: VESTIBULOCOCHLEAR The finger rustle (simple cochlear test) Tuning fork on mastoid (Rinnes test) screens for presence of conduction hearing loss Tuning fork on head (Webers test) for detecting conductive and sensorineural hearing loss. Standing Balance (vestibular) Hallpike Manouevre (for Benign Positional Paroxysmal Vertigo)

Ask the patient to raise their eyebrows, puff out the cheeks with the lips sealed, show their teeth and keep eyes closed against resistance. There are various tuning fork methods for testing hearing and caloric testing for vestibular component (the latter is usually done in a lab). Stand behind the patient and rub your thumb against your fingers from arms length away. The patient should indicate when they can hear a sound. Use a 512Hz fork. Twang the fork and place the base on the pts mastoid process. When they can no longer hear it, bring it to beside the ear hole, where they should hear it ringing again. Time the periods the pt can hear the sounds for: if normal, air conduction = twice as long as bone conduction. Place a vibrating 512Hz fork in the middle of the forehead. Pt reports in which ear it sounds louder, if any. Conductive loss = louder in affected ear. Sensorineural = louder in non-affected ear. Ask the patient to stand with feet together and eyes closed. Observe for sway. Try to move them a little and observe response. Explain this to the patient beforehand! Set up: pt sitting uright on a flat plinth, 2 pillows directly behind them. Rotate pts head 40 toward you and ask them to focus on your eyes. Quickly bring them into a supine position with the neck slightly extended. Observe for nystagmus for 30 seconds. Test bilaterally. Observe the palate for asymmetry. Having the patient say aaahh helps. Ask the patient to puff out the cheeks with the lips occluded: if air escapes from the nose, this is a sign that the soft palate cannot elevate. With a tongue depressor, touch the arches of the pharynx/uvula. Test sensation of outer ear. Speech gives a good indication of the motor supply to the pharynx. Also observe any deviation of the uvula. Ask the patient to shrug their shoulders and to turn the head against resistance. Observe the tongue for fasciculations or deviation. Speech may also be impeded.

CN IX: GLOSSOPHARYNGEAL Leaky puffer fish Gag reflex (unreliable and unpleasant) Sensation CN X: VAGUS CN XI: ACCESSORY CN XII: HYPOGLOSSAL

N.B. CN IV and VI could be examined individually, but once youve done the H-shape you know if they are working anyway. THINGS TO REMEMBER: 2, 2, 4, 4: forebrain, mid-brain, pons, medulla. CN I and II emerge from the cerebrum, the rest from the brainstem.

BASIC CRANIAL NERVE EXAMINATION - To recall whether theyre motor (M), sensory (S) or both (B): Some Say Money Matters But My Brother Says Big Boobs Matter Most. - Bulbar Palsy is due to LMN impairment of CN IX, X, XI, XII either in the medulla or in the CN outside the brainstem. There are many causes, and symptoms include dysarthria, dysphagia, dribbling, slow tongue movements, absent gag reflex. - Pseudobulbar Palsy is similar but due to UMN impairment, so between cerebral cortex and the motor nuclei in the medulla. This is common after stroke. - Loss of visual field should be recorded accurately. Good vocabulary to remember: hemianopia, homonymous, bilateral, (bi)temporal, nasal, macular sparing, scotomaa combination of those should describe most changes.