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Cranial Nerve Assessment

Summary of Function of Cranial Nerves

Figure 13.5b

Cranial Nerve I: Olfactory


Arises from the olfactory epithelium Passes through the cribriform plate of the ethmoid bone Fibers run through the olfactory bulb and terminate in the primary olfactory cortex Functions solely by carrying afferent impulses for the sense of smell

Cranial Nerve I: Olfactory

Figure I from Table 13.2

Olfactory nerve (CN I)


Located in the nose, cranial nerve (CN) I controls the sense of smell. This nerve isnt frequently tested, even by neurologists. However, suspect an abnormality in a neurologic patient who has a poor appetite. To assess the nerve, use soap and coffeeboth are easy to find on a unit. Or take a trip to the kitchen for cloves and vanilla. Dont use a substance with a harsh odor, such as ammonia, because it will stimulate the intranasal pain endings of CN V. Have the patient close both eyes, close one nostril, and gently inhale to smell the scent. Remember to do both nostrils.

Clinical notes
Smells and the responses they can provoke Evidence of olfactory connections to the limbic system are: smells can trigger memories; smells can provoke emotional responses; smells have a role in sexual arousal. Anosmia Head injuries which fracture the cribriform plate may tear olfactory nerves resulting in post-traumatic anosmia. Anosmia can also be caused by blockage of the nasal cavities, for example a nasal polyp or malignancy.
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Cranial Nerve II: Optic


Arises from the retina of the eye Optic nerves pass through the optic canals and converge at the optic chiasm They continue to the thalamus where they synapse From there, the optic radiation fibers run to the visual cortex Functions solely by carrying afferent impulses for vision

Cranial Nerve II: Optic

Figure II Table 13.2

Optic nerve (CN II)


Located in and behind the eyes, CN II controls central and peripheral vision. The fovea in the center of the retina is responsible for visual acuity in our central vision. Test one eye at a time. Ask the patient to read his I.V. bag. Then have him count how many fingers you are holding up 6 inches in front of him. Test peripheral vision one eye at a time, too. Cover one eye and instruct the patient to look at your nose. Move your index fingers to check the superior and inferior fields one at a time. Ask the patient to note any movement in the peripheral visual fields

Lesions of optic pathway


Optic nerve Section of one optic nerve causes blindness in one eye.

Crossing fibres in chiasma


Destruction of crossing fibres in chiasma (e.g. pituitary tumour) causes blindness in the nasal retina of both eyes. This gives a bitemporal hemianopia (field loss).

Pressure on lateral aspect of chiasma


Pressure on the lateral aspect of the chiasma (e.g. internal carotid aneurysm) affects fibres from the temporal retina of the ipsilateral eye, giving an ipsilateral nasal hemianopia. This is uncommon. Bilateral internal carotid artery aneurysms would cause a binasal hemianopia even more uncommon

Optic tract or geniculate body


Destruction of the right optic tract or LGB would interrupt pathways from the temporal retina of the right eye and the nasal retina of the left eye. This would cause blindness in the left side of both visual fields. This is a homonymous hemianopia. Thus, destruction of the right optic tract would cause a left homonymous hemianopia

Oculomotor nerve (CN III)


Also positioned in and behind the eyes, CN III controls pupillary constriction. To test the patients pupils, dim the lights, bring the light of the penlight from the outside periphery to the center of each eye, and note the response. Use the mm chart to describe pupil size; descriptions such as small, medium, and large are too subjective. Also, check where the eyelid falls on the pupil. If it droops, note that the patient has ptosis. Its easy to check cranial nerves III, IV, and VI together

3rd , 4th ,6th nerve


Functions: Control of all the external muscles and elevators of the lid Purpose of the test: 1. Inspect the pupils and to detect any abnormalities (localized disease, autonomic lesion, nuclear involvement in brainstem) 2. Evaluate the eye movement (muscular origin, lesion in occulomotor nerve, nuclei in brainstem, pathway of supranuclear control) 3. Evaluate the nystagmus (vestibular dysfunciton)

Inspection
Ptosis (absent/present) Squit(absent/ present) unilateral./ bilateral Exopthalmos (thyrotoxicosis, hydrocephalus, craniosyostosis) Enophthalmos (horners syndrome) Conjuctival hemorrhage(cranial trauma, subarachnoid haemorrhage) Telengiectases(louis bar syndrome) Color of the eyes(vascular disease)

Pupil size, shape equality, regularity of the pupil. Constricted pupil sympathetic dilator muscle(hypothalamus, brainstem sympathetic chain, pericarotid plexus,pontine tumor) Dilated pupil parasympathetic fibers pretectal nuclei, edinger westphal nucleus

Occular movement
Internal rectus Superior rectus Inferior oblique Inferior rectus Superior oblique External rectus

Conjugate eye movement


Frontal lobe contralateral conjugate gaze Brain stem ipsilateral gaze Nystagmus 1, detect nystagmus 2, rate, amplitude, direction 3,Peripheral, central, vestibular

Central nystagmus occurs as a result of either normal or abnormal processes not related to the vestibular organ. For example, lesions of the midbrain or cerebellum can result in up- and downbeat nystagmus. Peripheral nystagmus occurs as a result of either normal or diseased functional states of the vestibular system and may combine a rotational component with vertical or horizontal eye movements and may be spontaneous, positional, or evoked.

Gaze Induced nystagmus occurs or is exacerbated as a result of changing one's gaze toward or away from a particular side which has an affected vestibular apparatus. Positional nystagmus occurs when a person's head is in a specific position.An example of disease state in which this occurs is Benign paroxysmal positional vertigo(BPPV) Post rotational nystagmus occurs after an imbalance is created between a normal side and a diseased side by stimulation of the vestibular system by rapid shaking or rotation of the head. Spontaneous nystagmus is nystagmus that occurs randomly, regardless of the position of the patient's head.

5th nerve
Root pattern Brainstem pattern

Corneal reflex 5th to 7th Wasting of temporalis muscle Jaw jerk

8th nerve
Cochlear component: Whispering numbers to each ear.

webers test ? Conductive deafness Perceptive deafness

Rinnnes test? Conductive deafness bone conduction > nerve conduction Perceptive deafnessbone and air conduction impaired

9th and 10th


Vocal cord paresis voice high pitched Swallowing difficulty Nasal regurgitation of fluids Open the mouth asymmetry of palatal movements Gag reflex: Stimulate both side of the palate Afferent X Efferent IX

11th cranial nerve


Sternomastoid Trapezius

12th cranial nerve


Upper motor neuron lesion of 12th cranial nerve:
Weakness of opposite half of tongue and on protrusion Tongue deviates to the side opposite to that of lesion

Lower motor neuron lesion of 12th cranial nerve:


Ipsilateral half of the tongue and on protrusion tongue deviates towards the side of lesion due the unopposed action of genioglossus of the healthy side

Cerebrospinal fluid rhinorrhoea


Head injuries may tear the dura mater, leading to cerebrospinal fluid (CSF) leaking into the nasal cavity and dripping from the anterior

nasal aperture. This should be considered if clear fluid issues from


the nose after a head injury

Temporal lobe epilepsy Diseases such as epilepsy in the areas to which the olfactory impulses project (e.g. the temporal lobe) may cause olfactory hallucinations. The smells which are experienced are usually unpleasant and are often accompanied by pseudopurposeful movements associated with tasting such as licking the lips

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