Cranial Nerves

I to XII
Usually performed on alongside upper and lower limb neuro exam In OSCE it is performed isolated

I II III IV V VI

Olfactory Optic Oculomotor Trochlear Trigeminal Abducens

VII Facial VIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal

I II III IV V VI

Ooo Ooo Ooo To Touch And

VII Feel VIII Virgin IX Girls X V XI A XII H

On Occasion, Our Trusty Truck Acts Funny--Very Good Vehicle Any How

Cranial Nerve I: Olfactory Smell

Cranial Nerve I: Olfactory

Sense of smell Ask the patient if they have had any recent change in sense of smell
At the bed side can test each nostril with well known fragrance, e.g. Coffee or Peppermint Lack of smell = anosmia (colds, trauma, Parkinsons, frontal lobe tumour)

Cranial Nerve II: Optic Sight

Cranial Nerve II: Optic

AFRO
Acuity Fields Reactions Opthalmoscopy

Eye movements
III Oculomotor
Most of the eye muscles and movements

IV Trochlear
Superior oblique (look down nose)

VI Abducens
Lateral rectus (abducts eye)

Cranial Nerve III: Oculomotor

The III nerve also: Supplies eye lid (levator palpebrae superioris) Parasympathetic fibres to sphincter pupillae (constricts pupil)

Cranial Nerve IV: Trochlear

Figure IV from Table 13.2

Cranial Nerve VI: Abducens

Innervating the lateral rectus muscle (abducts the eye; thus the name abducens)

Cranial Nerve V: Trigeminal

Composed of three divisions Ophthalmic (V1) Maxillary (V2) Mandibular (V3) Conveys sensory impulses from areas of the face and supplies motor fibers (V3) for mastication

Cranial Nerve V: Trigeminal

Cranial Nerve V: Trigeminal

Motor
Muscles of mastication (Temporalis and Masseter and Pterygoid)
Palpate Masseter (clench jaw) Palpate Temporalis (above and lateral to eyes) Ask patient open and shut jaw, then open against resistance
Jaw will deviate to unaffected side due to unopposed action

Cranial Nerve V: Trigeminal

Reflexes
Jaw Jerk (motor and sensory)
Tap onto fingers rested on relaxed jaw

Corneal Reflex (sensory, VII motor)

Get patient to look away, touch with tip of cotton wool. Reflex involves closure of both eyes

Cranial Nerve VII: Facial

Cranial Nerve VII: Facial

Look at symmetry first (nasolabial folds good)
Raise eyebrows (UMNL vs LMNL) Squeeze eyes shut Puff out cheeks Show teeth

Facial nerve also

Innervates Stapedius (hyperacusis if not working) Transmits parasympathetic impulses to lacrimal and salivary glands (submandibular and sublingual glands) Sensory function is taste from taste buds of anterior two-thirds of the tongue

Cranial Nerve VIII: Vestibulocochlear

Two divisions cochlear (hearing) and vestibular (balance) Functions are solely sensory equilibrium and hearing

Cranial Nerve VIII: Vestibulocochlear

Figure VIII from Table 13.2

Rinnes and Webers

512Hz tuning fork
Rinnes test Tests air conduction vs bone conduction (mastoid process) Positive (normal) if air conduction is better than bone conduction Webers Place in middle of forehead Should be heard equally in either ear

Neurosensory deficit AC>BC and Webers quiet on affect side Conductive defect: BC>AC on affected side and Webers localises to affected side

Cranial Nerve IX and X Glossopharyngeal and Vagus

Taste and sensation on posterior 1/3 tongue and pharynx Swallow Gag reflex
Sensory: Glossopharyngeal Motor: Vagus

Cranial Nerve X: Vagus

The only cranial nerve that extends beyond the head and neck Parasympathetic supply to the heart, lungs, and visceral organs Paralysis leads to hoarseness (laryngeal branches)
Total destruction incompatible with life

Cranial Nerve X: Vagus

Cranial Nerve XI: Accessory

Innervates the:
Trapezius
(shrugs shoulders)

Sternocleidomastoid
(twists neck)

Cranial Nerve XI: Accessory

Figure XI from Table 13.2

Cranial Nerve XII: Hypoglossal

Innervates Tongue
If damaged, difficulties in speech and swallowing; inability to protrude tongue
Inspect for loss of muscle bulk and fasiculations (LMNL) Ask patient to stick tongue out (deviates to side of lesion)

Cranial Nerve II: Optic

AFRO
Acuity Fields Reactions Opthalmoscopy

Acuity
One eye at a time Snellen chart Near vision Ichihara plates (colour vision)

Acuity
One eye at a time at 6m Not testing refractive error (use pin hole if indicated - removes refractive error) If cant read top line move closer 3m->2m->1m (record as numerator) Fingers->Hand movements->Perception of light

Recording acuity
Record for both eyes
Top number is distance from chart (start 6m), bottom number is last completed line on chart, relates to the distance a normal person could read line

E.g.
Right: 6/12 Left: 6/12
(Both eyes can see at 6m what a normal person could be expected to see at 12m)

Right: 6/6

Left: PL

(Right eye normal, left only has perception of light)

Fields
Direct confrontation One eye at a time Can you see all of my face
All 4 fields Then Blind spot compare to yours, use red topped pen

Types of visual field defect

Monocular Blindness
Lesion of eye or optic nerve

Bitemporal Hemianopia
Lesion optic chiasm (pituitary tumour)

Left Superior Quadrantopia

Lesion right temporal lobe

Left Inferior Quadrantopia

Lesion right parietal lobe

Left Homonimous Hemianopia

Lesion optic tract to occipital cortex

Reactions
Direct
Same side constricts

Consensual
Opposite constricts

Swinging light reflex

Move light from side to side

Accommodation
Focus on distant point, then look at finger tip at 30cm

Pupillary responses
No Direct or Consensual present
lesion in III nerve

No Direct but Consensual intact

lesion in II nerve

RAPD (Relative Afferent Pupillary Defect)

e.g. in MS partial lesion in II results in Consensual response being stronger than Direct response resulting in paradoxical dialation

Opthalmoscopy
Looks directly at back of eye (retina)
Only place in boy where can directly visualise blood vessels Systemic conditions
Hypertension Diabetes

Other eye conditions

Optic neuritis Retinitis pigmentosa

Colour Vision
Inherited
X linked recessive
(Red green commonest ~5%)

Acquired
Optic neuritis (MS) Ethambutol (drug used in TB)

Pupils
Unequal
Anisocoria (20% people)

Large
III nerve lesion Drugs
Topical e.g. tropicamide Systemic e.g. Amphetamines, TCA overdose

Holmes Adie pupil

Pupils
Small
Argyll Robertson pupil
Syphilis (prostitute pupil), accommodates but does not react

Pontine haemorrhage Horners Syndrome Drugs

Opiates and Organophosphates Topical pilocarpine

Horners Syndrome
Interruption of sympathetic supply to eye
Miosis Ptosis Anhidrosis Sympathetic supply descends into thorax and then ascends via internal carotid artery. Classically caused by apical lung tumour (Pancoasts tumour).

III nerve palsy

Eye down and out, ptosis
Medical and Surgical
Surgical suggests compression (Mass - Tumour, aneurysm, coning) parasympathetic fibres compressed. Pupil dilated.
Painful III nerve palsy suggest posterior communicating artery aneurysm

Medical suggests infarction (DM, Vasculitis) parasympathetic fibres that run on outside of nerve can be spared, so pupil spared.

Ptosis
Drooping of eyelid
Dual innervation III and sympathetic
Large pupil suggests III (surgical) nerve palsy (eye down and out) Small pupil suggest interruption of sympathetic innervation of eye e.g. Horners syndrome Normal pupil suggests muscle weakness e.g Myasthenia gravis

Nystagmus
Involuntary eye movement (VOR)
Smooth pursuit, rapid saccaide Direction of nystagmus relates to the quick movement
2 beats at extremes of gaze is normal >2 suggests pathology, classically divided in central and peripheral causes Causes include Vestibular cause (BPPV, meneires) Cerebellar lesions, midbrain lesion, Drugs (alcohol, phenytoin)

Diplopia
Any lesion of III, IV or VI.
Also think conditions affecting muscles of eye
Myasthenia Gravis

Conditions interfering with orbital movement

Thyroid eye disease, orbital injury

INO
Important cause of diplopia
When looking horizontally III nerve has to communicate rapidly with VI nerve MLF (Medial Longitudinal Fasciculus) connects two nuclei. Multiple sclerosis likes MLF, interrupts communication between nuclei

 Lesion to Right MLF

Looking to right OK Looking to left
breakdown in communication See double Get nystagmus of left eye

Trigeminal neuralgia
Tic douloureux or trigeminal neuralgia
-Very painful, electric shock shooting pains - Often triggered by light touch
Usually responds to Carbemazepine (antiepileptic) In severe cases, nerve is cut; relieves agony but results in loss of sensation on that side of the face

VI nerve palsy
Can be due to central lesion but is a common False localising sign
Raised ICP forces VI nerve over rim of skull causing lesion of VI nerve regardless of site or cause of raised ICP.

Facial nerve
UMNL vs LMNL
Due to fibres crossing an upper motor neuron lesion will spare Frontalis due to bilateral innervation (fibres from opposite side innervating) Clinically
If cant raise eyebrows it is a LMNL i.e. Bells palsy, parotid tumour, sarcoid, surgery If eyebrow spared suggests UMNL i.e. Stroke, tumour

Bells Palsy
LMNL of facial nerve
Thought to be associated with herpes simplex virus Abrupt onset unilateral (LMNL) facial weakness, slight increased risk in diabetics and pregnancy Treat Prednisolone (steriod), look after eye (may need taping shut at night) Tends to resolve spontaneously, complications involve failure to resolve, corneal ulceration, aberant conduction after repair (crocodile tears)

Ramsay Hunt Syndrome

Varicella Zoster Virus (HHV3) (chickenpox/shingles) reactivates in VII nerve.
Causes LMNL of facial nerve plus vesicular rash of ear canal or pinna Treat Aciclovir and Prednislone

Vagal lesion
Laryngeal nerve (internal, external and recurrent)
Innervates voice box causes hoarse voice. Recurrent laryngeal loops into thorax and hoarse voce can be first presentation of lung cancer

Cut to heart fixed resting tachycardia Cut to Stomach decreased acid and decreased emptying (basis of old surgical operations for ulcers)

Bulbar and Pseudobulbar Palsy

Bulbar nerves emerge from Medulla in brainstem (IX, X, XI, XII)
Mostly involved in speech and swallowing
Bulbar Palsy is a LMNL Pseudobulbar palsy is UMNL

Bulbar Palsy
LMNL
Absent Gag Nasal regurgitation food Nasal speech Wasted fasciculating tongue

Pseudobulbar Palsy
UMNL
Brisk jaw jerk Brisk gag reflex Dysphagia Donald duck speech Shrunken tongue (no fasciculations) Emotional Lability

Pupils Third nerve palsy SAH Horners Opthalmoplegia Parkinsons MS INO Trigeminal neuralgia Stroke Bells palsy Bulbar and psudobulbar plasy Nystagmus

Pen tourch Tuning fork Tendon hammer Opthalmoscope Cotton wool