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Clinical Examinations > Cranial Nerves > Flashcards

Cranial Nerves Flashcards

1
Q

What should you consider during the general observation, before starting the examination?

A
  1. Posture, gait and symmetry
  2. Any abnormal movements
  3. Whether the patient is wearing glasses or hearing aids
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2
Q

What is the test for the olfactory nerve?

A

A simple screening question to check if the patient has had any problems with their sense of smell

if there is any doubt, test using strong smelling food such as coffee or citrus fruit

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3
Q

When assessing the optic nerve, what four different aspects need testing?

A
  1. Pupillary reflexes to light and accommodation
  2. Visual acuity
  3. Visual fields
  4. Fundoscopy
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4
Q

What is the first stage in assessing pupillary light reflexes?

A

Test for the direct and consensual pupillary reflexes

direct pupillary light reflex:

  • shine a light into the left pupil
  • the left pupil should constrict to light

consensual light reflex:

  • shine a light into the right pupil
  • look for pupil constriction on the left side

Then check the opposite side

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5
Q

What is the second stage in the pupillary light reflex test?

A

Test for pupillary accommodation

  • hold your index finger approximately 1 metre away from the patient and gradually move it towards their nose
  • both pupils should constrict as the eyes converge and accommodate to continue focusing on the finger
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6
Q

What equipment is used to assess visual acuity?

A

Snellen Chart

this is designed to test visual acuity at a specific distance

the patient CAN wear glasses/contact lenses to read the chart, and each eye should be tested separately

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7
Q

How are visual fields usually assessed?

A

By checking that the patient can detect movement in each of the four quadrants of the visual field

testing is done by confrontation (testing with the patient sat opposite you)

each eye is tested separately, so the patient covers one eye and you cover the eye directly opposite to their covered eye

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8
Q

What is important to remember about positioning when conducting the visual field examination?

A

Position yourself and the patient at an arm-length apart, with your eyes level

this is important as you are testing the patient’s visual field in comparison with your own

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9
Q

How is the visual field examination actually conducted?

A

Ask the patient to say ‘yes’ when they see your fingers move

test all 4 quadrants of the visual field by gradually moving your fingers from the periphery of the visual field towards the centre

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10
Q

Why is fundoscopy used?

A

It allows for direct visualisation of the retina

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11
Q

How is the fundoscopy examination conducted?

A
  1. Place your hand on the patient’s forehead and look for the red reflex
  2. Use your right eye to visualise the back of the patient’s right eye
  3. Start by locating a vessel, follow it to the optic disc and repeat until you have followed all 4 vessels
  4. Finish by asking the patient to look directly into the light to visualise the macula
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12
Q

Why are the oculomotor (3), trochlear (4) and abducens (6) nerves tested together?

A

They work synergistically in normal eye movement

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13
Q

How is the examination of the oculomotor, trochlear and abducens nerves conducted?

A
  1. Start by looking or any asymmetry of eye position at rest, and checking for ptosis
  2. Move your finger along horizontal and vertical planes, then by making a letter H
  3. Ask the patient if they experience any double vision
  4. Note any nystagmus, which is likely to occur at extremes of gaze
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14
Q

What would a normal examination of the oculomotor, trochlear and abducens nerves look like?

A

The eyes will move smoothly and synchronously

where a cranial nerve abnormality exists, they eyes will NOT move synchronously and this will cause the patient to experience double vision

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15
Q

What is the test for the sensory division of the trigeminal nerve?

A

Light sensation:

  • test using cotton wool in each of the 3 divisions - ophthalmic, maxillary, mandibular
  • compare each side to the other

Sharp touch sensation:

  • the test is repeated using a neurotip
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16
Q

When is the corneal reflex tested?

A

It is not routinely tested unless a lesion is suspected as it is very uncomfortable for the patient

the afferent pathway for the reflex is the trigeminal nerve

the efferent pathway for the reflex is the facial nerve

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17
Q

How is the corneal reflex tested?

A

Touch the cornea (not sclera) with cotton wool

in a normal examination, both eyes should blink

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18
Q

What is involved in testing for the motor division of the trigeminal nerve?

A

It involves testing the muscles of mastication

  1. Temporalis
  2. Masseter
  3. Pterygoids
19
Q

How is the motor division of the trigeminal nerve tested?

A
  1. Ask the patient to clench their teeth while you palpate temporalis and masseter
  2. Test the pterygoid muscles by asking the patient to open their jaw and keep it open against resistance
  3. Ask the patient to move their jaw from side to side
20
Q

What should a normal examination of the motor division of the trigeminal nerve look like?

A
  1. You should be able to feel contraction of temporalis and masseter
  2. You should not be able to overcome the strength of the pterygoids
  3. Jaw movement should be equal on both sides
21
Q

How is the facial nerve tested for?

A

It involves testing the muscles of facial expression

  1. Frontalis
  2. Orbicularis oculi
  3. Orbicularis oris
  4. Buccinators
22
Q

What questions should you ask the patient when testing the facial nerve?

A

First observe for any facial asymmetry

  • “please could you raise your eyebrows as high as you can and keep them there - don’t let me push them down”
  • “squeeze your eyes tight - hold them there, don’t let me open them”
  • “show me your teeth and purse your lips”
  • “blow out your cheeks and keep them there”

In a normal examination, facial movement will be symmetrical

23
Q

What 3 tests are used to assess the vestibulocochlear nerve (8)?

A

It involves a simple screening test to identify hearing problems

  1. Clinical hearing test
  2. Rinne’s test
  3. Weber’s test
24
Q

What is involved in the clinical hearing test?

A
  1. Ask the patient if they have experienced any hearing difficulty
  2. Explain that you will whisper a number into each ear in turn and ask them to repeat it
25
Q

What should you do if hearing difficulty is detected during the clinical hearing test?

A

Further testing to distinguish between conductive and sensorineural deafness can be done using Rinne’s test and Weber’s test

26
Q

What is Rinne’s test used for?

A

It uses a tuning fork to ascertain whether bone conduction is louder than air conduction

it is used to measure conductive hearing impairment

27
Q

What are the 3 stages in Rinne’s test?

A
  • Ask the patient if they can hear the vibrating tuning fork held at the entrance to the external auditory canal
  • this is sound A for Air conduction
  • place the tuning fork on the bony prominence of the mastoid process
  • this is sound B for Bone conduction
  • ask which sound your patient perceives as being the loudest
28
Q

What is meant by a positive Rinne’s test?

A

Normal hearing

sound A (air conduction) is louder than sound B (bone conduction)

29
Q

What is meant by Rinne’s test being negative?

A

Conductive hearing impairment

bone conduction is louder than air conduction

30
Q

Why must Weber’s test be performed when Rinne’s test is positive?

A

Rinne’s test can be positive in patients with complete sensorineural deafness in one ear

air conduction and bone conduction are both reduced equally

31
Q

What is the purpose of Weber’s test?

A

It is designed in conjunction with Rinne’s test to further investigate unilateral hearing impairment

32
Q

How is Weber’s test conducted?

A
  • Place vibrating tuning fork in the centre of the patient’s forehead
  • ask whether they hear this equally on both sides, or whether they perceive the sound to be louder in one ear
  • in normal hearing, the sound is detected equally on both sides
33
Q

What could it mean if a hearing impairment is detected in Weber’s test?

A

If the sound localises to one ear, this can mean that there is either:

  1. Ipsilateral conductive hearing loss - which can be confirmed by the findings from a negative Rinne’s test
  2. Contralateral sensorineural hearing loss
34
Q

Why are the glossopharyngeal (9) and vagus (10) nerves assessed together?

A

They both supply sensation and the muscles controlling movement of the mouth and throat

35
Q

How are the glossopharyngeal and vagus nerves assessed?

A
  1. Ask patient to give a cough
  2. Then ask patient to open their mouth whilst you look at the soft palate
  3. Ask the patient to say “aaaah”

In a normal examination, the palate should rise equally on both sides

36
Q

When is the Gag reflex assessed?

What does it test for?

A

It is not routinely tested on a well patient

  1. Touch the posterior pharynx first to one side, and then the other, with a wooden stick
  2. This causes the palate to rise and the patient to “gag”

the afferent (sensory) pathway of this reflex is the glossopharyngeal nerve

the efferent (motor) pathway of this reflex is the vagus nerve

37
Q

What does the accessory nerve (11) supply?

A

Trapezius and sternocleidomastoid muscles

38
Q

How is the accessory nerve assessed?

A

Strength of trapezius:

  • ask patient to shrug their shoulders and keep them raised whilst you push down

Strength of sternocleidomastoid muscles:

  • ​ask patient to turn their head first to one side and then the other
  • ask them to keep this position against resistance

in normal examination, movement and power of the muscles should be equal on both sides

39
Q

What does the hypoglossal nerve supply?

A

The tongue

40
Q

How is the hypoglossal nerve tested for?

A
  1. Ask patient to stick out their tongue, looking for any wasting or fasciculation
  2. Ask patient to move their tongue to one side, and then the other
  3. Ask them to move their tongue into one cheek and keep it there against resistance, then check the other side
41
Q

What would a normal and abnormal examination of the hypoglossal nerve show?

A

Normal examination:

  • movement and power of the tongue should be equal on both sides

Abnormal examination:

  • tongue deviates towards the side of the lesion
  • the inactive fibres are overpowered by the functioning muscle fibres on the opposite side
42
Q

How should the cranial nerve examination be concluded?

A
  1. Thank the patient
  2. Consider the findings and how to present them in a logical and fluent order
  3. Consider the possible clinical significance of these findings
43
Q

What is important to remember at the start of the cranial nerves examination?

A
  1. Greet the patient and introduce yourself
  2. Explain your role
  3. Explain what you are going to do, why you need to do it, and gain consent to proceed with the examination

Clinical Examinations (12 decks)

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