Cranial nerves and ophthalmology Flashcards
1
Q
What are the common pathologies which can affect a cranial nerve?
A
Diabetes mellitus MS Tumours Sarcoid Vasculitis SLE Syphilis
2
Q
What should you look for on general inspection when performing a cranial nerve exam? (SWIFTLY)
A
Scars Wasting Involuntary movements Fasciculations, facial drop (asymmetry) Tremor Lids- ptosis, Horner's You- personal aids- glasses, hearing aids, walking stick
3
Q
What is the medical term for a loss of sense of smell?
A
Anosmia
4
Q
What can cause anosmia?
A
Ageing Traumatic brain injury Parkinson's Alzheimer's Tumour
5
Q
What should you assess for in the optic nerve?
A
Acuity Fields Reflexes Ophthalmoscopy Special tests (colour)
Apparently F’ing Remembering OSCE Sucks
6
Q
How should you assess the Pt’s acuity? What should you ensure?
A
Using a SNELLEN CHART
Make sure the patient wears their glasses if they normally wear glasses for reading
- position 6m away from chart
- cover one eye
- read from the lowest eye they can
- repeat with other eye
IN THE EXAM: ASK PT TO READ BOTTOM OF ID CARD
7
Q
What are the causes of a loss of acuity?
A
REFRACTIVE ERROR (ocular media)
- cataracts
- diabetes
RETINA
- age related macular degeneration
- diabetic retinopathy
OPTIC NEUROPATHY
- MS
- ischaemia
8
Q
What is conjunctivitis?
A
Inflammation of the conjunctiva
9
Q
What are the symptoms of conjunctivitis?
A
Conjunctival hyperaemia Chemosis (conjunctival swelling) Crust/discharge Foreign body sensation Photophobia
10
Q
What are the causes of conjunctivitis?
A
Bacterial
Viral
Allergic
11
Q
How can you typically differentiate a bacterial conjunctivitis from viral conjunctivitis?
A
BACTERIAL- unilateral, thick discharge, reduced vision, ?urethritis/vaginal discharge
VIRAL- bilateral, watery discharge, normal vision, signs of viral infection
12
Q
What is allergic conjunctivitis?
A
Type 1 hypersensitivity reaction
13
Q
What are the common triggers of allergic conjunctivitis?
A
Pollen, dust, chemical scents
14
Q
What are the clinical features of allergic conjunctivitis?
A
Conjunctivitis
Itching
Sneezing
Red, watery, oedematous eye
15
Q
What are cataracts?
A
Clouding of the lens of the eye
16
Q
What are the clinical features of cataracts?
A
Visual impairment
Glare/halos around light
Painless
Reduced red reflex
17
Q
What are the risk factors for cataracts?
A
Old age
Congenital
Diabetes
Steroids
18
Q
What is glaucoma?
A
Vision loss from optic nerve damage due to raised intraocular pressure
2nd leading cause of blindness
In an acute red painful eye, you need to rule out closed-angle glaucoma
19
Q
What is affected in open-angle glaucoma?
A
Dysfunction of trabecular meshwork
20
Q
What is affected in closed-angle glaucoma?
A
Compression of trabecular meshwork
21
Q
What are the differences between open-angle and closed-angle glaucoma?
A
OA- 90%, bilateral, progressive vision loss, initially asymptomatic, non specific symptoms
CA- 10%, unilateral, sudden onset, severe pain, N+V, cloudy cornea, headache, dilated pupil
22
Q
What are the investigations for glaucoma?
A
Fundoscopy
Gonioscope
Slit lamp
Tonometry
23
Q
What is the uvea made up of?
A
Choroid
Ciliary body
Iris
24
Q
What is uveitis?
A
Inflammation of the uvea
Can be anterior, posterior, complete, and intermediate
25
What are the causes of uveitis?
Systemic inflammation
| Infection
26
What is affected in anterior uveitis?
Iris
Ciliary body
Most common
27
What is affected in posterior uveitis?
Vitreous body
Choroid
Retina
28
What are the investigations for uveitis?
Fundoscopy
| slit lamp examination
29
What visual defect will present in a chiasmal lesion?
Bitemporal hemianopia
30
What visual defect will present in a pre-chiasmal lesion?
Ipsilateral monocular loss
31
What are the causes of a pre-chiasmal lesion?
Ischaemia- TIA (amaurosis fugax)
| Inflammation- MS
32
What are the causes of a chiasmal lesion?
Pituitary adenoma
| Chraniopharyngioma
33
A lesion in which part of the optic pathway can cause a contralateral homonymous hemianopia?
Optic tract lesion
34
A lesion in which part of the optic pathway can cause a contralateral homonymous superior quadrantanopia?
Lateral optic radiation lesion
35
A lesion in which part of the optic pathway can cause a contralateral homonymous inferior quadrantanopia?
Medial optic radiation lesion
36
A lesion in which part of the optic pathway can cause a macular sparing contralateral homonymous hemianopia?
Occipital visual cortex lesion
37
What is the cause of visual neglect?
Damage to the contralateral parietal lobe
38
What are some causes of Marcus Gunn pupil (RAPD)?
Optic neuritis
| Retrobulbar optic neuritis
39
What is anisocoria?
Unequal size of the pupils
40
What does Horner's syndrome consist of?
Ptosis
Miosis
Anhydrosis
41
What are some causes of Horner's syndrome?
```
Loss of sympathetic innervation due to either:
Carotid artery dissection
Pancoast tumour
SOL/stroke
MS
Cavernous sinus thrombosis
```
42
What is the sympathetic pathway that supplies the eye?
```
Hypothalamus
T1
Superior cervical ganglion
Carotid artery
Cavernous sinus
Target sites (dilator pupillae, lacrimal gland)
```
43
What are the investigations for Horner's syndrome?
CXR (Pancoast)
CT Head (stroke)
MRI/MRA (tumour/dissection)
Refer
44
What signs may you see on fundoscopy?
Diabetic retinopathy
Hypertensive retinopathy
Papilloedemea
45
How will a Pt with a COMPLETE CN3 palsy present?
- Ptosis (levator palpebrae dysfunction)
- Affected eye deviated to a “down and out position” (unopposed lateral rectus and superior oblique)
- Diplopia- worst when looking up and out
- Fixed, dilated pupil (mydriasis) - PSNS from ciliary ganglion affected
46
What are the causes of a unilateral ptosis?
3rd nerve palsy
- Down and out eye + fixed dilated pupil
Horner’s syndrome
- Ptosis + anhidrosis + miosis
Myaesthenia Gravis
- Bilateral facial weakness + proximal weakness with fatiguability + weak voice
Congenital
47
What is the difference between a medical and surgical CN3 palsy?
MEDICAL- pupil sparing, painless
- centre of CN3 is affected
- PSNS fibres are intact until the entire nerve affected
- diabetes, atherosclerosis + vasculitis
SURGICAL- fixed, dilated pupil
- PSNS fibres located on outside of CN3 trunk- first to be affected by compression
- eg by posterior communicating artery aneurysm, SOL, coning
48
Causes of ptosis
First Order Neurone lesion:
- Brainstem demyelination (MS)
- Brainstem tumour
- Brainstem infarct (lateral medullary infarct) /haemorrhage
Second Order Neurone lesion:
- Apical lung tumour – classically Pancoast tumour
- Apical TB
- Cervical rib
- Brachial plexus trauma
- Dissections + aneurysms of carotid and subclavian artery
Third Order Neurone lesion:
- Herpes Zoster
- Internal carotid artery dissection
49
How may a Pt with a CN4 palsy present?
HEAD TILT + UPWARDS GAZE (CANT FOCUS IN + DOWN)
CN4 palsy results in PT being unable to look down and in towards nose - diplopia especially on reading
Affected eye will be slightly raised compared to the unaffected eye
To counteract the diplopia Its raise level of the affected eye by tilting their head away
50
What are the commonest causes of a CN4 palsy?
Idiopathic
Head trauma
Diabetes
51
How may a Pt with a CN6 palsy present?
Failure to abduct ipsilateral eye
52
What are the causes of a CN6 palsy?
```
Due to the long course of the 6th nerve it is easily affected:
Stroke
Trauma
Viral illness
SOL
Inflammation
```
53
How does a Pt with internuclear ophthalmolegia present?
Eyes do not move together – dissociative conjugate movements
- Impaired adduction of the ipsilateral eye
- Nystagmus in the abducting contralateral eye
54
What are the causes of internuclear ophthalmoplegia?
If young and bilateral, MS
| If old and unilateral, stroke
55
What are the pathways for the corneal reflex?
V1 -> VII
56
What are the pathways for the jaw jerk reflex?
V3 -> V
57
Which part of the trigeminal nerves would be affected if there was a higher central lesion?
Contralateral nerves
58
What are the causes of a higher central trigeminal lesion?
Stroke
59
Which part of the trigeminal nerves would be affected if there was a brainstem lesion?
Ipsilateral nerves
60
What are the causes of a brainstem trigeminal lesion?
Stroke
| Raised ICP
61
Which part of the trigeminal nerves would be affected if there was a peripheral lesion?
Branch distribution
62
What are the causes of a peripheral trigeminal lesion?
Raised ICP
| Trauma
63
What are the branches of the facial nerve?
```
Two
Zebras
Bit
My (Massive)
Cock
```
```
Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical
```
64
What is Bell's palsy?
Facial paralysis of the ipsilateral side
65
What are the causes of Bell's palsy?
Idiopathic
Compression of the facial nerve
Inflammation (eg. viral)
-herpes simplex type 1, varicella zoster
66
What are the risk factors for Bell's palsy?
Diabetes
67
What are the investigations for Bell's palsy?
Serology
| -Lyme, herpes, zoster
68
What is the management for Bell's palsy?
Prevent corneal abrasions- wear an eye patch
| Steroids- prednisolone
69
What is Ramsay Hunt syndrome?
LMN facial palsy due to varicella zoster
70
What are the features of Ramsay Hunt syndrome?
Pain
Vesicles in ipsilateral ear, hard palate, anterior tongue
Deafness/vertigo/other CN features
71
If the forehead is spared in a CN7 pathology, where is the lesion?
UMN lesion
72
What is Weber's test assessing for?
Sensorineural and conductive hearing loss
73
What is Rinne's test assessing for?
Conductive hearing loss
74
What is a Rinne's positive sign?
Air is louder than bony conduction
75
What is the diagnosis:
Weber's: lateralises to the left
Rinne's L: negative
Rinne's R: positive
Left conductive hearing loss
76
What is the diagnosis:
Weber's: lateralises to the right
Rinne's L: negative
Rinne's R: positive
Mixed hearing loss
77
What is the diagnosis:
Weber's: lateralises to the left
Rinne's L: positive
Rinne's R: positive
Right sensorineural hearing loss
78
What is the diagnosis:
Weber's: no lateralisation
Rinne's L: positive
Rinne's R: positive
No abnormality
79
What are the causes of conductive hearing loss?
EAM:
- wax
- foreign body
- otitis externa
Drum:
-perforation
Middle ear:
-acute/serous otitis media
Oval window:
-otosclerosis
80
What are the causes of sensorineural hearing loss?
Inflammation:
- meningitis
- MMR
Tumour:
-acoustic neuroma (neurofibromatosis T2)
Ototoxic drugs:
- aminoglycoside ABx
- aspirin overdose
- loop diuretics
Trauma
Meniere's disease
81
What are the inheritance patterns for neurofibromatosis type 1 and 2?
Autosomal dominant
82
What is the gene and chromosome affected in NF1?
```
NF1
Chr 17 (neurofibromatosis: 17 letters)
```
83
What is the gene and chromosome affected in NF2?
NF2
| Chr 22
84
What is the presentation of NF1?
```
Cafe-au-lait spots
Freckling in skin folds
Neurofibromas
Lisch nodules
spinal scoliosis
Short stature
Mild intellectual disability
```
85
What is the presentation of NF2?
Sensorineural hearing loss
Bilateral acoustic neuromas
Symptomatic at the age of 20
Possible tinnitus/vertigo
86
What can you do/look at to assess CN IX and X?
```
Soft palate and uvula
Gag reflex
Cough
Swallow
Assess speech quality and hoarseness
```
87
What two muscles are supplied by CN XI?
Sternocleidomastoid
| Trapezius
88
What are you looking for when assessing CN XII?
Wasting
Fasciculations
Deviation of the tongue
Power of the tongue
89
What is a bulbar palsy?
Lesion affecting the medulla oblongata and its associated cranial nerves IX-XII
90
What are the clinical features of a bulbar palsy?
```
Absent gag reflex
Wasting/fasciculation of the tongue
Absent palatal movement
Absent/normal jaw jerk
Nasal speech
Normal emotions
Signs of underlying cause eg. limb fasciculations
```
(LMN signs)
91
What is a pseudobulbar palsy?
Lesion affecting the UMN supplying the medulla oblongata
92
What are the clinical features of a pseudobulbar palsy?
```
Increased/normal gag reflex
Spastic tongue
Absent palatal movement
Increased jaw jerk
Monotonous, slurred, high-pitched Donald Duck dysarthria
Labile emotions
Bilateral UMN limb signs
```
(UMN signs)
93
What are some causes of a bulbar palsy?
MND
| Guillain-Barre
94
What are some causes of a pseudobulbar palsy?
Stroke
MND
MS
95
A 24 year old woman presents to her GP with a red painful eye with blurry vision. She has noticed a lot of clear discharge coming from her eye. She has otherwise been well, apart from some recent diarrhoea. What is the most likely diagnosis?
```
A. Viral conjunctivitis
B. Bacterial conjunctivitis
C. Anterior uveitis
D. Posterior uveitis
E. Closed angle glaucoma
```
C. Anterior uveitis
Firstly, because this is not an acute presentation (she’s presented to her GP), we can rule out closed angle glaucoma.
Posterior uveitis and viral conjunctivitis are usually painless making them unlikely.
Although bacterial conjunctivitis is painful, it normally gives thick muculopurent discharge.
The clear discharge is most likely to be increased lacrimation, which is in keeping with anterior uveitis.
96
A 50 year old patient presents to A&E with diplopia. The doctor examines their cranial nerves and finds a palsy in the oculomotor nerve. Peripheral nerve exam demonstrated a length dependent sensory neuropathy. What did the doctor most likely see during the cranial nerve examination:
```
A. Internuclear ophthalmoplegia
B. Anhidrosis, miosis and ptosis
C. Down and out pupil
D. Mydriasis
E. Down and out pupil with mydriasis
```
C. Down and out pupil
The palsy is why the patient has diplopia. The length dependent sensory neuropathy is indicative of diabetes, and if the peripheral sensory nerves are affected then a cranial nerve may be affected.
DM can cause a medical palsy, so the oculomotor nerve is affected first before the sympathetic, therefore will see down and out pupil. Wont see mydriasis yet until parasympathetic is affected, ruling out D and E.
A is not associated with DM, and B is describing Horner’s.
97
A 28 year old lady presents to A&E thinking she is having a stroke, worried as she cannot move the right side of her face. On examination, the patient cannot smile, puff up her cheeks or wrinkle her forehead on the right side. Serology comes back positive for herpes simplex virus 1. What is the most likely diagnosis?
```
A. Stroke
B. Bell’s Palsy
C. MS
D. Ramsay Hunt syndrome
E. Horner’s
```
B. Bell’s Palsy
As the patient is young a stroke is very unlikely, given she cannot wrinkle her forehead. This also makes MS unlikely.
MS also unlikely as there is an infective cause, but not Ramsay Hunt since this would normally be varicella zoster, not HSV1.
98
A 20 year old lady sees her GP after having some hearing difficulties in the last week. On examination, Weber’s test lateralises to her left ear. Rinne’s test is negative in her left ear also, but positive in the right ear. She reported having a cold at the start of the month. Which of these is most likely?
```
A. Meningitis
B. Otitis media
C. Foreign body
D. Meniere's disease
E. Neurofibromatosis type 2
```
B. Otitis media
As Rinne's test is negative in the left ear we know it is a conductive problem in left ear, further supported by fact Weber’s lateralises to the left as well. This rules out meningitis and NF2 as they are a sensorineural problem, as is Meniere’s – Meniere’s is triad of sensorineural hearing loss, vertigo and tinnitus.
the fact they had a cold earlier points more towards B as this is an inner ear infection.
99
A 60 year old man presents to his GP with dysphagia. The GP notices he speaks with a nasally voice. Examination demonstrates a reduced gag reflex, as well as fasciculations and wasting of the tongue. Jaw jerk is normal. Which of these is the most likely cause of their dysphagia?
```
A. Stroke
B. Parkinson’s
C. Motor neuron disease
D. MS
E. Achalasia
```
C. Motor neuron disease
With this question the patient is old, making MS and achalasia unlikely – this is further supported by the LMN signs.
Stroke and Parkinson’s would give UMN signs, although both can cause dysphagia. The jaw jerk is normal suggesting that CNV is not affected, as is the case with a bulbar palsy.
100
A 66 year old woman presents with left sided upper and lower facial weakness as well as vertigo, which has worsened over the past few days. She is also suffering from a burning sensation over the left side of her face . This morning, she noticed a new rash in her left ear. On examination, clusters of vesicles on an erythematous base are noted in the patient’s left ear.
A. Bells Palsy
B. Ramsay Hunt syndrome
C. NF T2
D. Stroke
B. Ramsay Hunt syndrome
101
Name the 12 CN
- Olfactory I
- Optic II
- Oculomotor III
- Trochlear IV
- Trigeminal V
- Abducens VI
- Facial VII
- Vestibulocochlear VIII
- Glossopharyngeal IX
- Vagus X
- Accessory XI
- Hypoglossal XII
102
Role of CNI
SENSORY from nose
103
Role of CN II
SENSORY from eye
104
Role of CN III
MOTOR to eye:
- autonomic, parasympathetic to intrinsic muscles
- somatic: all extrinsic muscles except lateral rectus and superior oblique
105
Role of CN IV
MOTOR to superior oblique
| this pulls the eye infero-medially
106
Role of CN V
SENSORY to face
| MOTOR to jaw
107
Role of CN VI
MOTOR- to lateral rectus
| this abducts the eye
108
Role of CN VII
SENSORY- anterior 2/3rds of tongue
| MOTOR- to face
109
Role of CN VIII
SENSORY- to ear
110
Role of CN IX
SENSORY- to posterior 1/3rd of tongue (afferent to gag reflex)
MOTOR- to tongue and throat
111
Role of CN X
multiple functions
MOTOR- mouth and throat, efferent to gag reflex. autonomic (PSNS) to heart, lungs, and GI
SENSORY- throat, heart, lungs, and abdomen
112
Role of CN XI
MOTOR- to the sternocleidomastoid and trapezius muscles
113
Role of CN XII
MOTOR- to tongue
114
for each cranial nerve, state whether is is motor, sensory or mixed.
some say marry men but my brother says bad business marry money
```
Olfactory - Sensory - smell
Optic - Sensory - eye
Oculomotor - Motor - all eye
Trochlear - Motor - superior oblique
Trigeminal - Both - face + jaw
Abducens - Motor - lateral rectus
Facial - Both - ant 2/3 tongue, face
Vestibulochoclear - Sensory - ear
Glossopharyngeal - Both - post 1/3 tongue, throat
Vagus- Both- throat, heart, lungs, abdo
Accessory - Motor - trapezius, SCM
Hypoglossal - Motor - tongue
```
115
CN exam introduction
“I’d like to perform an examination of the nerves in your head and neck if that’s okay? In this examination I’ll be looking at the face, feeling different parts of the head and asking you to do some special movements if that’s okay?”
Ideally for this examination, I’ll need you to be undressed from the shoulders upwards, so would you be happy to take your shirt off?”
WIPER
116
WIPER
```
Wash hands
Introduce yourself + examination
Permission, Pain
Exposure
Reposition
```
117
In facial drop, what should you take special note of?
FOREHEAD SPARING
2 most common causes of facial drop are Bell's palsy and ischaemic stroke.
BELLS: forehead is NOT spared
STROKE: forehead SPARING- the upper face is supplied by both brain hemispheres so compensates
note: in stroke, there will also be associated facial numbness
118
How do you check olfactory nerve?
“Have you noticed any changes in your sense of smell?”
“I would ideally like to assess smell more formally using for example the Pennsylvania smell identification test”
119
What questions do you first ask before performing further examination of the optic nerve?
“Do you wear glasses or contact lenses?”
| “Have you noticed any changes in your vision recently?”
120
How do you test for visual inattention?
Tell patient: “look at my nose”
Put your arms out to the sides with fingers pointed upwards
Tell patient: “keep looking at my nose and point to the finger that moves”.
-Wiggle Left
-Wiggle Right
-Wiggle both at once
121
How do you test for visual fields?
“Look at my nose and cover your left eye with your left hand”
“With your right eye look into my left eye”
Close/cover your right eye
“Keep looking at my eye and tell me when you see my fingers out of the corner of your eye”.
Move your fingers towards the centre from all 4 corners of the visual field
122
Cause of monocular blindness
Optic nerve lesion- aka optic neuritis
- demyelinating disease- commonly MS
- autoimmune neuropathies, such as systemic lupus erythematosus
- compressive neuropathies, such as meningioma (a type of brain tumor)
123
State a common cause of bitemporal hemianopia
pituitary tumour- anything that compresses the optic chiasm
124
What causes nasal hemianopia?
a lesion involving the left perichiasmal area.
125
What causes homonymous hemianopia? give common pathologies
damage to the L/R visual cortex or optic tract
- stroke
- tumour
- abscess.
126
What are the 3 responses you are testing for in the reflex component of the optic nerve exam?
Direct response
When the light enters a pupil, it dilates
Consensual response
When the light enters one pupil, the contralateral pupil also dilates
```
Relative response (aka: swinging torch test)
If one pupil inappropriately dilates, suggests a sensory deficit from the other pupil
```
127
What would you ideally examine using opthalmoscopy?
the fundus
128
What are the 2 special tests used to further test the optic nerve?
Colour vision
“Ideally I’d test colour vision using Ishihara plates”
Blind Spot
“Ideally I’d test the patient’s blind spot using a red Q-tip”
129
Which muscles are affected in a CNIII palsy? What is the effect of this? State a common cause.
SR, IR, MR, IO
DOWN AND OUT appearance
commonly caused by diabetes
130
Which muscles are affected in a CNIV palsy? What is the effect of this? State a common cause.
Superior oblique
Head tilting- down and to the unaffected side to compensate for the vertical diplopia
can be caused by orbit trauma
131
State some unilateral causes of ptosis
CN III palsy (CNVII closes eyelid)
Horner’s syndrome
Congenital
132
State some bilateral causes of ptosis
Myasthenia Gravis
Myotonic Dystrophy
Congenital
133
Which muscles are affected in a CNVI palsy? What is the effect of this? State a common cause.
Lateral rectus
causes a convergent squint
raised ICP can be a cause
134
Describe how you would test for the oculomotor, trochlear and abducens nerve
H TEST
“Keep your head still and follow my finger with your eyes – tell me if at any point you see double or if moving your eyes is painful”
Finger ~50cm from face
Move slowly in a ‘H’ shape
Look for obvious Ophthalmoplegia and nystagmus
135
Causes of ophthalmoplegia
Myasthenia gravis
Cranial nerve palsy (e.g. due to raised ICP)
Grave’s disease
Wernicke’s encephalopathy (particularly failure of up-gaze)
Progressive supranuclear palsy (especially vertical gaze)
136
What is Internuclear Ophthalmoplegia
A disorder of conjugate lateral gaze (i.e. inability to move both eyes together in complete lateral abduction and adduction) caused by a lesion in the medial longitudinal fasciculus.
Causes a failure of adduction in the eye on the affected side
137
Describe the signs on H test of a Left internuclear opthalmoplegia
Lateral gaze to the left is normal
On attempting lateral gaze to the right:
- The right eye abducts normally
- However, the left eye cannot full adduct and remains looking straight ahead
- The right eye will consequently display nystagmus in an attempt to compensate
- The patient will experience lateral diplopia
Convergence is preserved however (i.e. the left can adduct normally if the goal is not lateral gaze)
138
Causes of internuclear opthalmoplegia
```
Multiple Sclerosis (almost always the cause in a young patient)
Stroke
Lyme disease (rare)
Tricyclic antidepressant overdose (rare)
```
139
3 branches of the trigeminal nerve
temporal
maxillary
mandibular
140
What are the 3 components of testing the trigeminal nerve?
Sensory- light touch to face
Motor- jaw clenching and opening against resistance
Reflexes- jaw jerk and corneal
141
Describe how you would test the sensory component of the trigeminal nerve
1. Ask patient to close their eyes
2. Test the cotton wool on their sternum
3. “Say yes when you feel the cotton wool touching your face”
4. Test all branches
5. Move from side to side and ask if it feels the same on both sides.
6. “Ideally I’d offer to test pain sensation with a neurotip
142
Describe how you would test the motor component of the trigeminal nerve
1. Palpate for masseter contraction over angle of the jaw
2. Palpate for temporalis contraction
3. push up against patient's chin, ask to open jaw against resistance
143
When opening the jaw against resistance, if there is a trigeminal nerve palsy the jaw will deviate where?
towards the side of resistance
144
What 3 things do you look for when inspecting facial tone?
Reduced wrinkling of the forehead
Drooping of the corner of the mouth
Flattening of the nasolabial folds
145
What 2 questions do you ask to check the sensory component of the facial nerve?
“Have you noticed any change in your taste recently?”
| “Do you feel you’re particularly sensitive to loud noises at the moment?”
146
How do you test the motor component of the facial nerve?
```
Raise eyebrows
Screw up eyes
Puff out cheeks
Smile
Purse lips
```
147
What is Bell's sign?
up-gaze on attempted eye closure
148
3 components of CNVIII exam
1. Crude test of hearing (whisper in ear, scratch on tragus of other ear)
2. Rinne's test
3. Weber's test
149
Which test tells you whether the auditory defect is conductive or sensorineural?
Rinne's test
150
Describe Rinne's test
1. Vibrate the 512Hz fork against the patient's mastoid bone
2. Ask PT to say when the sound is no longer heard.
3. Place fork 1–2 cm from the auditory canal- ask PT to indicate when sounds is no longer heard
151
Which auditory test helps identify the side of the auditory defect?
Weber's test
152
Describe Weber's test
Vibrate the tuning fork
Place tuning fork heel on the centre of the patient’s forehead
“Do you hear the sound more on the left or right, or just in the middle of your head?”
153
What is the meaning of a positive Rinne's test?
If the patient is not able to hear the tuning fork after it is moved from the mastoid to the pinna, BC>AC
Indicates inhibition of sound waves through the ear and into the cochlea
(i.e., there is a conductive hearing loss).
154
What are the components of the glossopharyngeal and vagus nerve exam?
- soft palate assessment
- say 'british constitution'
- cough assessment
- swallow assessment
- offer gag reflex
155
When do you assess swallow? What do you assess for?
only when other tests normal
Look for choking/spluttering (signs of possible bulbar defect)
Look for coughing or altered voice afterwards suggestive of insufficient swallow
156
afferent efferent gag reflex
Afferent: glossopharyngeal
Efferent: Vagus
157
What is a sign in the mouth of a vagus nerve lesion?
Vagus Nerve Lesion: Uvula deviates AWAY from the affected side
158
How do you test accessory nerve?
1. Inspect muscle bulk for wasting
2. Shrug shoulders against resistance
3. Turn head against resistance
159
Components of the Hypoglossal nerve examination
1. stick tongue out for inspection
2. tongue movement (side to side)
3. push tongue against resistance
160
What are you inspecting the tongue for signs of?
```
Wasting
Fasciculations
Flaccidity
Spasticity
Deviation
```
161
How do you test the tongue against resistance?
“Put your tongue in one cheek and push against my finger”
Press one finger against the tough and push medially
Repeat on the other side
162
feature of a hypoglossal nerve lesion
Hypoglossal Nerve Lesion: Tongue deviates TOWARDS the affected side
163
tongue appearance in bulbar palsy
Tongue appearance:
- Flaccid
- Wasting
- Fasciculating
Other features
- Inability to move the tongue
- Inability to move the palate
- Drooling (due to difficulty in swallowing)
- Dysphonia (inability to make a sound in order to speak, voice can be described as hoarse, rough, raspy, strained, weak, breathy, or gravely)
- Tremulous lips
164
Causes of bulbar palsies
```
Motor Neurone disease
Diphtheria
Polio
Myasthenia Gravis
Guillain Barre Syndrome
Syringiobulbia
```
165
What is pseudobulbar palsy?
An upper motor neurone lesion in the corticobulbar tract supplying the bulb
166
tongue appearance in psuedobulbar palsy
Tongue Appearance
- Spastic
- Contracted
Other features
- Drooling
- Dysphonia
- Emotional Lability
167
causes of psuedobulbar palsy
Motor Neurone Disease
Bilateral internal capsule stokes
Multiple Sclerosis
Pontine Glioma (tumour)
168
to complete the examination I would....(cranial nerve exam)
Take a full neurological history
Perform a complete neurological examination of the upper and lower limbs
Perform a mini mental state examination
Assess gait and balance
169
the following can cause pretty much ANY cranial nerve palsy....
```
Diabetes
Stroke
Multiple Sclerosis
Tumour
Sarcoid
SLE
Vasculitis
```
