CRANIAL NERVE

ASSESSMENT
Dr. PAWAN SHARMA (PT)
M.P.T. (NEURO)
ASSISTANT PROFESSOR,
SHRI U.S.B. COLLEGE OF PHYSIOTHERAPY
ABU-ROAD, RAJASTAHAN
Email- pawan.physio2011@gmail.com
Contact- 07727989353
CRANIAL NERVES I Olfactory CEREBRAL
II Optic HEMISPHERE
III Oculomotor
IV Trochlear MIDBRAIN

V Trigeminal
VI Abducens
PONS
VII Facial
VIII Vestibulo-
cochlear

MEDULLA
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal
2
CRANIAL NERVES
 CRANIAL NERVES
General Characteristics:
The 12 pairs of cranial nerves are part of the
peripheral nervous system.

The Roman numeral is based on descending

order of the cranial nerve's attachment to the
CNS.

As a rule, cranial nerves do not cross in the

brain.

Cranial nerves may be sensory, motor both

somatic or parasympathetic, or have mixed
function.
3
CRANIAL NERVES
 REMEMBER ME
SOME
SAYS
S-SENSORY
MONEY M- MOTOR
MATTERS
BUT
B- BOTH
MY
BROTHER
SAYS All in
BIG
BRAIN
sequence
MATTERS
MOST
4
CRANIAL NERVES
 CN I - OLFACTORY
ORIGIN: Cerebral hemisphere
INNERVATION: Nasal mucous
membranes.
FUNCTION: Sense of smell
DYSFUNCTION: Anosmia

CLINICAL EVALUATION
Use non-noxious aromatic
substances, i.e. coffee, lemon,
garlic, etc.
Test each nostril separately.
Mark if any abnormality noted

5
CRANIAL NERVES
 CN II OPTIC NERVE
VISUAL ACUITY: Snellen
chart for distant vision,
Jaegers chart, newspaper or
fingers for near vision.

VISUAL FIELDS:
Confrontation.

FUNDI AND OPTIC DISCS:

Visualization of the termination
of the optic nerve by looking
through pupil with
ophthalmoscope.

CRANIAL NERVES 6
 CN II OPTIC NERVE(cont..)
Tested by- Near field
1. Visual acuity Far field
Color
2. Color vision
matching

3. Visual field
Confrontation
test

7
CRANIAL NERVES
 CN II OPTIC NERVE(cont..)
Visual acuity-
Snellen chart(Far vision)
Chart is placed at 20 feet or 6
meter and patient is asked to
read it
The formula is d/D
Where d is 6 meter and D is
the distance from which he can
read it clearly
Normal is 6/6 or 20/20
Jaegers chart(Near vision)
Paragraphs are printed in
successive coarser type with
0 is finest and 7 is biggest
Patient is asked to read
through the hole

8
CRANIAL NERVES
 CN II OPTIC NERVE(cont..)
Color vision-
Checked by asking to
match different colors
Day or night blindness
can be assessed

Visual field-
Confrontation test

Peripheral visual fields-

Goldmann Perimeter

CRANIAL NERVES 9
 SPECIFIC DYSFUNCTIONS
Blurred vision or complete blindness.
Ipsilateral vision loss - Optic atrophy, retinal/optic
nerve lesions, trauma.
Visual loss (one or both eyes) - Optic chiasm or
occipital lobe lesions.
Hemianopia - (loss of half of visual field in one or
both eyes) - Lesions of optic chiasm, tracts, or
radiations.
Cortical blindness - Lesion of occipital cortex
bilaterally, pupil reflexes intact.
Papilledema - Optic nerve tumor, venous
obstruction, chronic increased ICP.
Optic atrophy - MS, optic neuritis, increased ICP.
Scotomas- (Abnormal blind spots on visual fields)
- optic neuritis or atrophy.

10
CRANIAL NERVES
CN III OCULOMOTOR NERVE
ORIGIN: Midbrain
INNERVATION: EOM's;
eyelid; ciliary; and sphincter of
iris.
FUNCTION: Eye movement
inward (medially), upward,
downward, and outward; pupil
Constriction, shape and
equality; elevates upper eyelid;
accommodation reflex.
DYSFUNCTION: Unable to
look up, down, or medial
(dysconjugate gaze); ptosis,
pupil dilatation - bilateral or
ipsilateral, and loss of
accommodation reflex.
CRANIAL NERVES
11
 CN III OCULOMOTOR
NERVE(cont..)
Observe for eye opening and
symmetry.

Direct light response - brisk,

sluggish, or non-reactive.

Consensual response -
present or absent.

Pupil size and shape.

Accommodation.

Extra ocular movement

(EOM's) (Abducens).
12
CRANIAL NERVES
 CRANIAL NERVE FUNCTION & MUSCLE
INNERVATION
RELATIVE TO EYE MOVEMENT
Superior rectus Inferior oblique
CN III CN III

Lateral rectus Medial rectus

CN VI CN III

Inferior rectus Superior oblique

CN III CN IV
CN IV TROCHLEAR NERVE
ORIGIN: Midbrain
INNERVATION: Superior
oblique muscle.
FUNCTION: Down and
inward movement of the
eye.
DYSFUNCTION: Loss of
downward, inner
movement of eye,
dysconjugate gaze.

SUPERIOR OBLIQUE MUSCLE

CRANIAL NERVES 14
CN VI ABDUCENS NERVE
ORIGIN: Pons
INNERVATION: Lateral
rectus muscle.
FUNCTION: Outward,
lateral movement of eye.
DYSFUNCTION: Loss of
lateral eye movement,
dysconjugate gaze.
LATERAL RECTUS
MUSCLE
Clinical evaluation of CN III, IV, VI
Extraocular movements (EOM's)

CN IV (Trochlear) and CN VI tested with CN III (Oculomotor)

CRANIAL NERVES 15
CN V TRIGEMINAL NERVE
ORIGIN: Pons. The sensory
nucleus extends from the
pons to the midbrain, and also
to the medulla and spinal
cord.
INNERVATION: Three
branches of CN V:
Ophthalmic, maxillary, &
mandibular.
Motor innervation to
masseter & temporal
muscles.
Sensory innervation to skin &
mucous membranes in head;
teeth, tongue, external
auditory canal, and cornea.
16
CRANIAL NERVES
CN V TRIGEMINAL NERVE(cont..)
FUNCTION: Sensation of
pain, touch, hot, & cold; motor
movement of masseter &
temporal muscles.
DYSFUNCTION: Loss of
sensation - if affecting all
three branches, indicative of
peripheral injury.
Brainstem or upper cervical
cord injury may result in loss
of sensation to one or more
branches of the trigeminal
nerve.
Loss of corneal reflex.

17
CRANIAL NERVES
CN V TRIGEMINAL NERVE(cont..)
Paresthesia and/or severe
pain indicative of nerve
compression or irritation
(Trigeminal neuralgia)
Deviation of jaw towards the
same side, loss of sensation.
Inability to bite down and
chew, inability to close jaw.
Chewing, speaking, washing
face, cold water, may
precipitate the
attackTRIGGER POINT

18
CRANIAL NERVES
 CN V TRIGEMINAL
NERVE(cont..)
Tic douloureux or
trigeminal neuralgia
Paroxysmal attacks of
severe, short, sharp, stabbing
pain affecting one or more
branch of the nerve.
Most excruciating pain
known (?)
Caused by inflammation of
nerve
In severe cases, nerve is cut;
relieves agony but results in
loss of sensation on that side
of the face

CRANIAL NERVES 19
 TESTING TRIGEMINAL NERVE
o Sensation-
o Checked by extroceptive
modalities like superficial pain,
thermal, light touch over jaw,
cheeks, and forehead.
o Motor examination-
o Muscle power of masticatory
muscle namely the masseter
and temporalis.
o Inability to raise, depress,
protrude, retract and deviate
the mandible
o Jaw deflected toward same
side

20
CRANIAL NERVES
 TESTING TRIGEMINAL NERVE
Jaw jerk-
o Ask the patient to relax
jaw. Place finger on the
chin and tap it with
hammer.
o closing of mouth is the
response
o Brisk is normal
o Exaggerated is
pathological
Corneal reflex-
o Cornea is touched with wisp
of wet cotton
o Response is closing of both
eyes
o Afferent- ophthalmic div of
VI nerve
21
o Efferent- Facial nerve CRANIAL NERVES
 CN VII- FACIAL NERVE
ORIGIN: Pons & medulla.
INNERVATION: Anterior
two-thirds of tongue; facial
muscles, scalp, ear, and
neck.
FUNCTION:
Control of facial muscles
(expressions)
Motor limb of blink &
corneal reflex
Secretion of salivary &
lacrimal glands
Sensation of taste, anterior
two-thirds tongue.

22
CRANIAL NERVES
 CN VII- FACIAL NERVE(cont..)
Motor-
Facial asymmetry - Ipsilateral weakness/paralysis, right or left,
indicative of damage to motor nucleus or peripheral component
(lower motor neuron lesion) EX: Bell's palsy
Contralateral weakness/paralysis of lower face indicative of
Contralateral motor cortex damage (upper motor neuron lesion)
or hemispheric lesion, i.e. massive CVA.
Bilateral weakness or paralysis , E.g. myasthenia gravis or
Guillian Barre.
Parasympathetic-
Loss or excessive tearing or salivation
Sensory-
Loss of taste from anterior 2/3
Combined problem-
speech difficulty and drooling/difficulty handling food

23
CRANIAL NERVES
 CN VII- FACIAL NERVE(cont..)
CLINICAL EVALUATION
o MOTOR FUNCTION:
o Observe for facial symmetry
o Flattening of nasolabial fold
o Ask patient to wrinkle
forehead, puff cheeks, smile,
show teeth, close eyes
against resistance, and
whistle.
o Wrinkle forehead- Frontalis
o Close eye- orbi oculi
o Purse lip- Buccinator
o Show teeth- Orbi oris

24
CRANIAL NERVES
 CN VII- FACIAL NERVE(cont..)
SENSORY FUNCTION:
Test each side of tongue
separately.
Test for sweet (tip of
tongue); sour (sides of
tongue); salty (over most of
tongue, but concentrated on
sides).
Give sip of water between
tastes.
Prevent flowing it to the
posterior aspect of tongue
Reflex-
Corneal reflex
Glabellar reflex- Parkinson's
disease

25
CRANIAL NERVES
CN VII- FACIAL NERVE(cont..)

Guess your
observation

CRANIAL NERVES 26
 BELLS PALSY
Bells palsy: paralysis of
facial muscles on affected
side and loss of taste
sensation
Caused by herpes simplex
I virus, trauma,
Lower eyelid droops
Corner of mouth sags
Eye cannot be completely
closed (dry eye may occur)
CRANIAL NERVES
Lacrimation is seldom
affected
Condition my disappear
spontaneously without
treatment
Bells phenomenon-
Upward and outward
movement of eye
27
 CN VIII VESTIBULOCOCHLEAR
NERVE
ORIGIN: Pons and medulla
INNERVATION:
Cochlear - ear
Vestibular - ear
FUNCTION:
Cochlear - Hearing
Vestibular - Balance,
maintenance of body
position, and proprioception.
Rule out for presence of
wax, pus, blood or foreign
body Before testing

28
CRANIAL NERVES
 COCHLEAR NERVE
Rinnes test-
For comparing bone and air
conduction
Tuning fork placed at the
mastoid till the sound stop
being heard
Then is placed in front of
ear to be tested
+ve Rinne test i.e. air and
bone both are retained
-ve Rinne test i.e. air is lost
but bone is
retained(conductive
deafness)
If both are lost i.e.
sensorineural deafness
BERA TEST CRANIAL NERVES 29
 COCHLEAR NERVE(cont..)
Weber's test-
Evaluates lateralization
Use vibrating tuning fork on
top of patient's head, ask
patient where he hears it
(one or both sides).
Normally heard equally on
both the sides
If one ear is occluded then
it acts like a resonating
chamber and hear more on
that side
Conductive deafness-
involved side
Sensorineural- Uninvolved
side

30
CRANIAL NERVES
 VESTIBULAR NERVE
Look for Vertigo,
Nystagmus, loss of balance
NYLEN-BARANY
MANEUVER
Patient lie down supine
with head off the bed
45 degree extended
Lateral flexion to the
same side produces
Nystagmus
Other tests are
caloric test(cows)
Galvanic test
Rotation test
31
CRANIAL NERVES
CN VIII VESTIBULOCOCHLEAR
NERVE
DYSFUNCTION (Cochlear)
Unilateral deafness
Loss of sound appreciation
Tinnitus
(Rinne Test) AC >BC is
normal
both diminished
indicative of nerve
damage
BC> AC middle ear
disease.
(Weber Test)
Lateralization to good
ear is nerve damage,
lateralization to bad
ear is, middle ear
CRANIAL NERVES 32
CN VIII VESTIBULOCOCHLEAR
NERVE
DYSFUNCTION
(VESTIBULAR)
Vertigo
Balance disturbances
Vestibular branch normally
not tested unless patient
gives history of vertigo or
balance Disturbance
history is positive, caloric
testing is done by
physician.

CRANIAL NERVES 33
 CN IX- GLOSSOPHARYNGEAL
NERVE
ORIGIN-
Medulla
INNERVATION:
Mucous membranes of
tonsils, pharynx, posterior
one-third of tongue,
pharyngeal muscles,
carotid sinus and carotid
body
FUNCTION:
Taste from posterior one-
third of tongue - Afferent
limb of gag, swallow, and
cardiac reflexes.
DYSFUNCTION:
Loss of taste; Neuralgia

34
CRANIAL NERVES
 ORIGIN-
CN X VAGUS NERVE
Medulla
INNERVATION:
Muscles of larynx, pharynx, and
soft palate.
Parasympathetic innervation of
thoracic and abdominal viscera.
FUNCTION:
Muscles of larynx, pharynx, and
soft palate
Sensation conveyed from the
heart, lungs, digestive tract,
carotid sinus, & carotid body
Efferent limb of gag and swallow
reflex
DYSFUNCTION:
Loss of gag & swallow reflex
Loss of carotid sinus
CRANIAL NERVES 35
oculocardiac reflex; Dysphagia
 CN IX- GLOSSOPHARYNGEAL
and CN X - VAGUS
CN IX and X considered jointly, actions are seldom compared separately; they
are always tested together.

POSSITIVE FINDINGS-
Evaluate voice quality
(hoarseness or dysarthria)
Ask patient to open mouth,
say "ah", observe for
elevation of soft palate,
midline position of uvula.
Gag reflex, bilaterally
Swallowing
Taste (bitter) posterior one-
third tongue

CRANIAL NERVES 36
 CN IX- GLOSSOPHARYNGEAL
and CN X - VAGUS
Negative Findings
Loss of voice quality,
(dysarthria or hoarseness)

Deviation of uvula toward

non-paralyzed side

Swallowing difficulty or
nasal regurgitation

Vagal irritation
(bradycardia)

CRANIAL NERVES 37
 CN XI - SPINAL ACCESSORY
NERVE
ORIGIN: Medulla
INNERVATION:
Sternocleidomastoid &
trapezius muscles
FUNCTION: Motor
function
Sternocleidomastoid &
trapezius
DYSFUNCTION: Muscle
weakness.

CRANIAL NERVES 38
 CN XI - SPINAL ACCESSORY
NERVE
CLINICAL EVALUATION
Palpate trapezius muscle as
patient shrugs shoulders
against resistance; evaluate
strength.
Ask patient to turn head to
one side and push against
examiners hand or ask to flex
head against resistance,
palpate and evaluate strength
of sternocleidomastoid
muscle.
Evaluate both right and left
side, compare for symmetry.

39
CRANIAL NERVES
 CN XII HYPOGLOSSAL
ORIGIN: Medulla
NERVE
INNERVATION: Muscles of the
tongue except palatoglossus
FUNCTION: Movement of the
tongue
DYSFUNCTION:
Unilateral lesions can cause
paresis, atrophy, furrowing,
fibrillation and fasciculation on
the affected half
On protrusion tongue deviates
towards the affected side due to
unopposed action of the
Contralateral GENIOGLOSSUS

Flaccid paralysis
Dysphagia
Dysarthria
Dyspnea
Difficulty chewing food
40
CRANIAL NERVES
 PUPILLARY REFLEX
Afferent- Optic
Efferent-
Oculomotor Normal
Testing side- A and E = +nt
Yes(T) Opposite side- E +nt

Yes(O)
No(T) Probable lesion in A of eye
being checked
No(O)
Yes(T)
Probable lesion in E of
No(O) Opposite eye

No(T)
Yes(O) Lesion of E on same side and
E of opposite eye is normal
CRANIAL NERVES 41
 CORNEAL REFLEX
Afferent- Trigeminal
Efferent- Facial
Yes(T) Normal
Testing side- A and E = +nt
Yes(O) Opposite side- E +nt

No(T)
No(O) Probable lesion in A of eye
being checked
Yes(T)
No(O) Probable lesion in E of
No(T) Opposite eye

Yes(O)
Lesion of E on same side and
E of opposite eye is normal
CRANIAL NERVES 42