Cranial nerve examination

The cranial nerve exam is part of the neurological examination. It is used to identify problems with the cranial nerves by physical examination.

Components

Nerve	Evaluation	Associated conditions
I: Olfactory nerve	Smell is tested in each nostril separately by placing stimuli under one nostril and occluding the opposing nostril. The stimuli used should be non-irritating and identifiable. Some example stimuli include cinnamon, cloves, and toothpaste. Bilateral loss can occur with rhinitis, smoking, or aging. Unilateral loss indicates a possible nerve lesion or deviated septum. This test is usually skipped on a cranial nerve exam.	meningioma
II: Optic nerve	Visual acuity is tested in each eye separately. Ensure the patient's vision is corrected with eyeglasses or a pinhole. The patient is asked to read progressively smaller lines on the near card or Snellen chart. Visual fields are assessed by asking the patient to cover one eye while the examiner tests the opposite eye. The examiner wiggles the finger in each of the four quadrants and asks the patient to state when the finger is seen in the periphery. The examiner's visual fields should be normal, since it is used as the baseline. Fundoscopy Pupillary light reflex The patient stares into the distance as the examiner shines the penlight obliquely into each pupil. Pupillary constriction is tested for on the eye examined (direct response) and on the opposite eye (consensual response). The swinging flashlight test involves moving the light between the two pupils. Normally both direct and consensual responses are ellicited when the light shines on an eye, and some dilation will occur during the swing between.	Optic neuritis
III, IV, VI: Oculomotor nerve, Trochlear nerve, Abducens nerve	Extraocular movements: First, inspect for ptosis, eye position and nystagmus. The pupil size is measured, its shape and any asymmetry is tested. A commonly used abbreviation to describe normal pupils is PERRLA (pupils equal, round and reactive to light and accommodation). The examiner tests ocular movements by standing one meter in front of the patient and asking the patient to follow a target with eyes only, and not the head. The target is moved in an "H" shape and the patient is asked to report any diplopia. Then, the target is held at the lateral ends of the patient's visual field. Nystagmus is tested for. One or two beats is a normal finding. The accommodation reflex is tested by moving the target towards the patient's nose. As the eyes converge, the pupils should constrict. The optokinetic nystagmus test is optional and involves asking the patient to look at a moving strip of horizontal lines. Nystagmus is normally observed.
V: Trigeminal nerve	Light touch is tested in each of the three divisions of the trigeminal nerve and on each side of the face using a cotton wisp or tissue paper. The ophthalmic division is tested by touching the forehead, the maxillary division is tested by touching the cheeks, and the mandibular division is tested by touching the chin. Be careful not to test the mandibular division too laterally, as the mandible is innervated by the great auricular nerve (C2 and C3). A common mistake is to use a stroking motion, which will trigger pain and temperature nerves. Instead, a point stimulus should be applied. For pain and temperature repeat the same steps as light touch but use a sharp object and a cold tuning fork respectively. Corneal reflex is conducted along with the facial nerve section of the test. Note the sensory innervation of the cornea is provided by the trigeminal nerve while the motor innervation for blinking the eye is provided by the facial nerve.- Muscles of mastication (temporalis, masseter) should be inspected for atrophy. Palpate the temporalis and masseter as the patient clenches the jaw. The pterygoids can be tested by asking the patient to keep the mouth open against resistance, and move from side to side against resistance. A jaw jerk reflex can be tested by placing a finger over the patient's chin and then tapping the finger with a reflex hammer. Normally the jaw moves minimally.	trigeminal neuralgia
VII: Facial nerve	Inspect for facial asymmetry and involuntary movements. Motor 1) Raise both eyebrows 2) Frown 3) Close both eyes tightly so that you can not open them. Test muscular strength by trying to open them 4) Show both upper and lower teeth 5) Smile 6) Puff out both cheeks Sensory : test for taste	Bell's Palsy, Ramsay Hunt syndrome
VIII: Vestibulocochlear	Hearing: Whisper numbers in one ear as patient covers the other and ask the patient to repeat the numbers. Alternatively, have patient close their eyes and say "left" or "right" depending on the side from which they hear the sound. Vigorously rub fingers together in one ear at a time to produce rustling sound. Conduct the Rinne test and Weber test. Vestibular Function	acoustic neuroma
IX and X: Glossopharyngeal and Vagus	Gag response Visualizing uvula deviation away from affected side on articulating "AHH" with tongue depressor. Palatal articulation "KA" Guttural articulation "GO"	Lateral medullary syndrome (IX)
XI: Accessory nerve	Shrug shoulders Turn head from side to side
XII: Hypoglossal	Stick out tongue and move it to one side, then the other Inspect for tongue atrophy, fasciculations or asymmetry in movement or appearance

Popular Culture

Cranial nerve examinations are a common type of role-play in the ASMR community. The performer will pretend to perform the examination on the viewer as a way of triggering the ASMR sensation; these types of videos have amassed millions of total views on Youtube.

See also

• Cranial nerves
• Cranial nerve nucleus

External links

• NeurologyExam.com Free neurology exam videos by Cleveland Clinic trained neurologist.
• The Neurological Exam