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Head and Neck Clinical Skills > Cranial Nerve Examinations > Flashcards

Cranial Nerve Examinations Flashcards

1
Q

Introduction?

A
  1. Ensure adequate hand hygiene
  2. Check equipment
  3. Introduce self
  4. Confirm patient’s name and date of birth
  5. Briefly explain procedure and obtain consent to examine the patient
  6. Position patient, preferably on a chair
  7. Explain clearly, before each test, what you are going to do, and what you would like the patient to do
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2
Q

Equipment required for a cranial nerve examination?

A
  1. Item with distinct odour (e.g. orange/lemon peel, coffee, vinegar, onion)
  2. Hand washer
  3. Cotton ball
  4. Pen torch
  5. Fundoscope
  6. Tuning fork
  7. Neurological reflex hammer
  8. Snellen charts
  9. Ishihara plates
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3
Q

General inspection?

A
  1. Around the bed (glasses case) & general (glasses or hearing aid)
  2. Facial asymmetry e.g. Bell’s palsy (CNVII), Rash - herpes zoster (CN V)
  3. Position of head (e.g. CN IV)
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4
Q

Olfactory nerve?

A

Sensory (smell)

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5
Q

Olfactory nerve exam?

A
  1. Ask the patient: “Have you noticed any change in your sense of smell recently?”
  2. If no, no further testing is necessary.
  3. If yes, ask if currently patient has a cold or blocked nose, or had an injury to head
  4. If yes, change in sense of smell, but no cold, occlude one nostril at a time and ask the patient to smell and identify strong odours such as onion, soap, orange peel
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6
Q

Optic nerve?

A

Sensory (sight)

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7
Q

What you asses for when examining the optic nerve?

A
  1. Acuity
  2. Colour
  3. Fields
  4. Reflexes
  5. Accommodation
  6. Fundus of the eye
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8
Q

Inspection of eyes?

A
  1. Note the resting position of the eyes (primary gaze)
  2. Look for any abnormal position of the eyes
  3. Look for any eyelid (ptosis) or pupil abnormality
  4. Observe for nystagmus at rest
  5. Ask the patient:
    - “Do you ever get double vision?”
    - “Do you have any difficulty seeing the stairs when you walk downstairs?”
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9
Q

Test for visual acuity?

A
  • It is easily tested with Snellen charts.
  • If the patient normally wears glasses or contact lenses, then this test should be assessed both with and without their vision aids.
  1. Stand patient correctly at 6.1m from chart
  2. One eye clearly occluded
  3. If unable to read top line, ask patient to count fingers or recognize hand movements
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10
Q

Using a Snellen chart?

A

Normal visual acuity is denoted as:
20/20
4/4
6/6,
where the numerator signifies the patient’s distance from the chart in feet, and the denominator signifies
the smallest line of letters the patient can read

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11
Q

Testing for colour?

A

Colour vision is tested using Ishihara plates which identify patients who are colour blind

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12
Q

Test for visual field?

A
  1. Visual fields are tested by asking the patient to look directly at you whilst you wiggle one of your fingers
    in each of the four quadrants
    - Ask the patient to
    identify which finger is moving.
  2. Visual inattention can be tested by moving both fingers at the same time and checking if the patient identifies this
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13
Q

Testing the fundus?

A
  1. Visualise fundus of the right eye with an ophthalmoscope
  2. Visualise fundus of the left eye with an ophthalmoscope
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14
Q

Light reflexes?

A
  1. CN II optic (afferent pathway)
  2. CN III Oculomotor (efferent pathway)
    - Direct and consensual
    - Examine pupils for equality and shape
    - Check for direct and consensual reflexes with torch
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15
Q

Testing visual reflexes?

A

Visual reflexes comprise direct and consensual light
reflexes.
1. Place one hand vertically along the patients nose to block any light from entering the eye which is not
being tested
2. Shine a pen torch into one eye and
check that the pupils on both sides constrict
3. This should be tested on both sides

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16
Q

Marcus–Gunn swinging light test?

A
  • asseses the afferent limb of the pupillary light pathway
  • to look for a relative afferent pupil defect (RAPD).
  • a means of detecting differences between the two eyes in how they respond to a light shone in one eye at the time
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17
Q

If a relative afferent pupil defect is present how do you carry out a Marcus Gunn swing test?

A
  1. Shine light in the normal eye and both pupils constrict
    - The consensual response in the affected eye is intact
  2. Swing light to the affected eye and both pupils dilate
    - Afferent drive to cause constriction of the pupils from the affected eye is reduced compared to that of the unaffected eye
  3. Swing light back to the normal eye and both pupils constrict
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18
Q

How to test the efferent limb of the
pupil reflex (near reflex)?

A
  1. Ask the patient to focus on a distant object and then look immediately to your index finger held 730
    cm in front of their face.
  2. The normal response will be for the pupils to constrict in response to convergence and accommodation
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19
Q

Occulomotor nerve?

A
  1. Motor
    - 4 of 6 eye muscles
  2. Parasympathetic
    - constriction of pupil
    - movement of lens
20
Q

Trochlear nerve?

A

Motor (1 eye muscle)

21
Q

Abducens nerve?

A

Motor (1 eye muscle)

22
Q

Examining CNIII - Oculomotor Nerve,
(CNIV) -Trochlear Nerve and (CN VI)-Abducent Nerve?

A
  1. Involves movements of the eye
  2. Asking the patient to keep their head perfectly still directly in front of you, you should draw two large
    joining H’s in front of them using your finger andask them to follow your finger with their eyes
    Note: It is important the patient does not move their head
  3. Always ask if the patient experiences any double vision, and if so, when is it worse?
23
Q

Occulomotor nerve?

A
  1. Motor
    - 4 of 6 eye muscles
  2. Parasympathetic
    - constriction of pupil
    - movement of lens
24
Q

Trigeminal nerve?

A
  1. Sensory (face, nasal cavity, cheeks, lips, skin of mandible)
  2. Motor (muscles of mastication, anterior belly of digastric, mylohyoid)
    - There are 3 sensory branches of the trigeminal nerve: ophthalmic, maxillary and mandibular
25
Q

Examining the trigeminal nerve?

A
  • Initially test the sensory branches by lightly touching the face with a piece of cotton wool
  • followed by a blunt pin in three places on each side of the face:
    1. around the jawline (mandibular)
    2. on the cheek (maxillary)
    3. on the forehead (opthalmic)
26
Q

Corneal reflex test?

A
  • Do this by lightly touching the cornea with the cotton wool
  • This should cause the patient to shut
    their eyelids.
    Note: The corneal reflex should also be examined as the sensory supply to the cornea is from the trigeminal nerve
27
Q

Examining muscles of mastication?

A
  1. Inspect for wasting of temporalis
  2. To test the motor supply, ask the patient to clench their teeth together observing and feeling the bulk
    of the masseter and temporalis muscles.
  3. Ask the patient to then open their mouth against resistance.
  4. Finally perform the jaw jerk on the patient by placing your left index finger on their chin and striking it with a tendon hammer
    - This should cause slight protrusion of the jaw
28
Q

Examininf abducent nerve?

A

Abducent nerve (CN VI) is tested in the same manner as the oculomotor and trochlear nerves, again in eye movements

29
Q

Facial nerve?

A
  1. Sensory (taste)
  2. Motor (facial muscles, posterior belly of digastric)
  3. Parasympathetic (salivary glands, glands of nasal cavity)
30
Q

Examining the facial nerve?

A

asking the patient to
1. Crease up their forehead (raise their eyebrows),
2. Close their eyes and keep them closed against resistance,
3. Puff out their cheeks and reveal their teeth
- Facial nerve supplies motor branches to the muscles of facial expression.

31
Q

Vestibulocochlear?

A

Sensory (hearing and balance)
- The Vestibulocochlear nerve provides innervation to the hearing apparatus of the ear and can be used to differentiate conductive and sensori-neural hearing loss using the Rinne and Weber tests

32
Q

Rinne test?

A

place a sounding tuning
fork on the patient’s mastoid process and then next to their ear and ask which is louder
- A normal patient will find the second position louder

33
Q

Weber test?

A

place the tuning fork base down in the centre of the patient’s forehead and
ask if it is louder in either ear
- Normally it should be heard equally in both ears

34
Q

Sensorineural hearing loss?

A
35
Q

Conductive hearing loss?

A
36
Q

Mixed hearing loss?

A
37
Q

Glossopharyngeal nerve?

A
  1. Sensory (taste, back of mouth,
    tonsils, middle ear, palate)
  2. Motor (1 muscle of pharynx)
  3. Parasympathetic (salivary gland,
    glands of tongue)
38
Q

Examining glossopharyngeal nerve?

A
  1. Inspect palate and pharynx with a pen torch
  2. Ask patient to say “Ahh” (or “Arr”) - observe uvula
  3. Observe speaking, and coughing
  4. Gag reflex
39
Q

Vagus nerve?

A
  1. Sensory (taste, back of mouth,
    larynx, thoracic and abdominal organs)
  2. Motor (muscles of larynx, 1 muscle
    of tongue, pharynx)
  3. Parasympathetic (thoracic and
    abdominal organs)
40
Q

Examining vagus nerve?

A
  1. Asking the patient to speak gives a good indication to the efficacy of the muscles.
  2. The uvula should be observed before and during the patient saying “aah”.
    - Check that it lies centrally and does not deviate on movement.
41
Q

Accessory nerve?

A

Motor (sternocleidomastoid, trapezius)

42
Q

Examining the accessory nerve?

A
  1. To test it, ask the patient to shrug their shoulders and turn their head against resistance
  2. Sternocleidomastoid - head movement against resistance
  3. Trapezius – shrug shoulders against resistance
43
Q

Hypoglossal nerve?

A

Motor (tongue
and throat muscles)

44
Q

Examining of hypoglossal nerve?

A
  1. Observe the tongue for any signs of wasting or fasciculation’s.
  2. Ask the patient to stick their tongue out
  3. If the tongue deviates to either side, it suggests a weakening of the muscles on that side
45
Q

Ending an examination?

A

Thank the patient
Wash your hands
Properly record your findings.

Head and Neck Clinical Skills (5 decks)

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