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CHAPTER 2

Examination

Cranial nerves
The dental surgeon should be adept in examining the cranial nerves.
Their main functions, the technique of their examination, possible causes
and sites of damage and abnormal findings are listed below.

Olfactory (I)
Function: Smell.
Examination: Substances such as coffee or peppermint are passed before
each nostril in turn.
Lesions: Obstruction; tumours; fracture of cribriform plate (head injury).
Abnormal finding: Anosmia.

Optic (II)
Function: Vision.
Examination: Visual acuity; pupillary reflexes; visual fields; fundoscopy
Lesions: Trauma to the orbit; brain tumours; vascular accidents.
Abnormal findings: Impaired visual acuity; loss of the direct and consensual pupillary responses (when shining a light at the affected eye, neither
eye will react); visual field defects; abnormalities on fundoscopy.

Oculomotor (III)
Function: Motor for most extraocular muscles (medial, superior and
inferior recti, inferior oblique, and levator palpebrae superioris); visceral
motor (parasympathetic fibres) for pupillary sphincter and ciliary muscle
(lens accommodation).
Examination: Check eye movements (page 43); test focusing of lens.
Lesions: Any neuropathy (although muscle trauma or disease is usually
the culprit of eye movement abnormalities).
Abnormal findings: Eye looks down and out (from IV and VI nerve
action); impaired eye movements; diplopia; ptosis (of upper eyelid); dilated
pupils; loss of direct pupillary response (consensual response is preserved,
i.e. the opposite eye will react while shining light at the affected eye).

Trochlear (IV)
Function: Motor for superior oblique muscle.
Examination: Check inferolateral eye movement.
Lesions: As for III.
Abnormal findings: Difficulty looking down (particularly from the
adducted position); strabismus; diplopia.

Trigeminal (V)
Function: Sensation from head; motor (muscles of mastication, mylohyoid, anterior belly of digastric, tensor veli palatini and tensor tympani).
Examination: Test light touch (with cotton wool) 9 pain (with pin prick);
corneal reflex (touch the cornea with a wisp of cotton wool); open and
close jaw against resistance; jaw jerk.
Lesions: Brain lesions; facial bone fractures (orbital floor, mandible, etc.).
Abnormal findings: Facial hypoaesthesia or paraesthesia; abnormal
reflexes; weakness and wasting of masticatory muscles.

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Abducens (VI)
Function: Motor for lateral rectus muscle.
Examination: Check lateral eye movement.
Lesions: As for III.
Abnormal findings: Impaired eye movement to affected side; diplopia.

Facial (VII)
Function: Motor (muscles of facial expression, stylohyoid, posterior belly
of digastric and stapedius); secretomotor (parasympathetic fibres to
lacrimal, submandibular and sublingual salivary, nasal and palatine glands);
taste (from anterior two-thirds of tongue through chorda tympani).
Examination: Test facial movements (eye shutting, smiling, etc.);
Schirmers test (lacrimation); check for xerostomia; test taste sensation
(applying salty, sweet, sour and bitter substances on the tongue).
Lesions: UMN lesions (brain lesions); LMN lesions (e.g. Bells palsy, parotid surgery, etc.).
Abnormal findings: Contralateral facial weakness with partial sparing of
the upper face (bilateral innervation) in UMN lesions; ipsilateral facial
weakness 9 impaired lacrimation, salivation and taste in LMN lesions.

Vestibulo-cochlear (VIII)
Function: Balance and hearing.
Examination: Nystagmus tests; Rinnes and Webbers tests (page 43).
Lesions: Acoustic neuroma.
Abnormal findings: Impaired balance; nystagmus; impaired hearing (tests
will differentiate from conduction deficit); tinnitus.

Glossopharyngeal (IX) and Vagus (X)

Function: IX serves motor (stylopharyngeus); secretomotor (parasympathetic fibres to parotid gland); sensory (pharynx); taste (posterior third of
tongue). X serves motor (pharynx, palate and larynx); taste (palate and
epiglottis) autonomic innervation of heart, lungs and intestines.
Examination: Inspect the palate while patient says aah; gag reflex.
Lesions: Brainstem lesions or injury (bulbar palsy).
Abnormal findings: Deviation of uvula to unaffected side; impairment of
gag reflex, taste, speech and cough.

Accessory (XI)
Function: Motor (sternocleidomastoid and trapezius).
Examination: Test head flexion/rotation and shoulder elevation.
Lesions: Neck lacerations; radical neck dissection.
Abnormal findings: Weakness and wasting of muscles; shoulder drop.

Hypoglossal (XII)
Function: Motor (intrinsic and extrinsic muscles of tongue).
Examination: Test tongue protrusion.
Lesions: Neck lacerations; other neurological disorders.
Abnormal findings: Wasting; fasciculation; dysarthria; deviation of protruded tongue towards affected side.

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