Unit 5 - Neuro Cranial Nerves, Eyes, Ears Flashcards
Are cranial nerves upper or lower motor neurons and why?
Although they enter and exit the brain, they are lower motor neurons because they have direct innervation to end point (muscle, organ)
Please indicate the name and function of the cranial nerve.
Cranial Nerve I
Olfactory Nerve - Controls sense of smell
Purely sensory nerve
Please indicate the name and function of the cranial nerve.
Cranial Nerve II
Optic Nerve - Controls central and peripheral vision
Sensory nerve
Please indicate the name and function of the cranial nerve.
Cranial Nerve III
Oculomotor - Motor, most EOM movement, opening of eyelids.
Mixed nerves
Please indicate the name and function of the cranial nerve.
Cranial Nerve IV
Trochlear - Down and inward movement of the eye
Motor nerves
Please indicate the name and function of the cranial nerve.
Cranial Nerve V
Trigeminal - Muscles of mastication (motor)
Sensation of face and scalp, cornea, mucous membranes of mouth and nose (sensory)
Mixed nerves
Please indicate the name and function of the cranial nerve.
Cranial Nerve VI
Abducens - Lateral movement of eye
Motor nerves
Please indicate the name and function of the cranial nerve.
Cranial Nerve VII
Facial - facial muscles, close eye, labile speech, close mouth (motor)
Taste on anterior two thirds of the tongue (sensory)
Saliva and tear secretion (parasympathetic)
Mixed nerves
Please indicate the name and function of the cranial nerve.
Cranial Nerve VIII
Auditory/Vestibulocochlear - Hearing and equilibrium
Sensory nerve
Please indicate the name and function of the cranial nerve.
Cranial Nerve IX
Glossopharyngeal - phonation and swallowing (motor)
taste on posterior one third of tongue, gag reflex (sensory)
Parotid gland, carotid reflex (parasympathetic)
Mixed nerves
Please indicate the name and function of the cranial nerve.
Cranial Nerve X
Vagus - talking and swallowing (motor)
General sensation from carotid body, carotid sinus, pharynx, viscera (sensory)
Carotid reflex (parasympathetic)
Mixed nerves
Please indicate the name and function of the cranial nerve.
Cranial Nerve XI
Spinal Accessory - movement of trapezius and sternomastoid muscles
Motor Nerve
Please indicate the name and function of the cranial nerve.
Cranial Nerve XII
Hypoglossal - movement of tongue
Motor nerve
How would you assess a patients Cranial Nerve I (Olfactory)?
Assess patency of nostrils first
Use familiar scents, ask pt to close their eyes and occlude one nostril, complete bilaterally
Ask them to identify what they are smelling
Do not use a substance with a harsh odour or a scent that may not be distinguishable in all cultures
Why do we ask the patient to close their eyes when we are testing the olfactory nerve?
Because senses work together, if they see what they are smelling, their eyes will distinguish what the substance may be without actually smelling it.
How do we assess the Cranial nerve II (Optic) in patients?
Visual acuity (20 ft)
Colour blindness tests
Confrontation test
If pt A has a visual acuity of 20/20, pt B tests acuity of 20/40, and pt C tests acuity is 20/15. How would they rank from highest visual acuity to least?
Pt C - Highest at 20/15
Pt A - normal 20/20
Pt B - Lowest at 20/40
If someone uses glasses for everyday tasks, will you test visual acuity with or without glasses?
With, we are mostly wanting to see what their daily visual abilities are. If asked to do without we will complete both.
Optometrist will test without to ensure their corrected vision is appropriate and accurate.
In the confrontation test, what are the 4 areas we will be testing for the expected peripheral vision (including the degrees)?
Superior @ 50 degrees
Nasal @ 60 degrees
Inferior @ 70 degrees
Temporal @ 90 degrees
What cranial nerves do we test that are responsible for eye movement? (6 Cardinal positions of gaze)
Cranial nerves III (Oculomotor), IV (Trochlear), VI (Abducens)
How tests do we complete when testing the Cranial nerves III (Oculomotor), IV (Trochlear), VI (Abducens)?
Checking pupils for size, regularity, equality, direct and consensual light reactions and accommodation. (PERRLA)
Inspect eyelids for ptosis (drooping)
6 Cardinal positions of gaze - follow your finger/pen light without turning their head.
When may you experience nystagmus and it be a normal response?
During extreme lateral rectus movement, normally people would turn their head so it is a normal response during this exam.
What is nystagmus?
Rapid involuntary movements of the eyes. (shaking/twitching eyes)
What does PERRLA stand for?
Pupils, Equal, Round, Reactive to Light and Accomodate
What three areas are we assessing for the Trigeminal (CNV)?
Forehead (Ophthalmic)
Cheek (Maxillary)
Jaw (Mandibular)
How do we assess the Motor portion of Cranial nerve V (Trigeminal)?
Palpate temporal and masseter muscles as teeth are clenched, try to separate jaw with clenched teeth.
How do we assess the sensory portion of Cranial nerve V (Trigeminal)?
With eyes closed, take a cotton ball and brush across each area (Forehead, cheek, jaw). Ask them to say “now” when they feel it.
If you have abnormal results when testing the Tigeminal nerve, what is the next test that you may perform?
Corneal Reflex
What face movements do we ask patients to make to test the motor function of Facial Nerve VII?
Smile, frown, close eyes tightly (attempt to open), Lift eyebrows, show teeth, puff cheeks (Press in and not if air
Although not routinely tested, how do we test the sensory portion of the Facial nerve (CNVII)?
Use salt, sugar or lemon on anterior 2/3 of tongue.
When using the whisper test, how is it performed and which nerve is it testing?
Mask ‘good’ hear by rapidly pushing in the tragus, or just push and hold the tragus down. Cover your mouth to avoid lip reading, 30-60 cm away from patient and state a 2 syllable word (milkshake), pt should be able to repeat it immediately after.
We are testing CN VIII Vestibulocochlear/Acoustic
What two cranial nerves are normally tested together ? What are we looking for with these nerves (both motor and sensory) ?
Glossopharyngeal (CNIX) and Vagus (CNX)
Motor - Midline rise of the uvula and soft palate, tonsillar pillars more medially in response to “ahhh” or a yawn. Normally touch the posterior pharyngeal wall with tounge blade and watch response (gag)
Sensory - CN IX mediates taste on the posterior one third of the tongue but it is hard to get tastes.
Which Cranial Nerve is the longest is the human body?
The vagus nerve (CNX). It is the longest of the cranial nerves, extending from the brainstem to the abdomen by way of multiple organs including the heart, esophagus, and lungs.
How do we test the motor nerve abilities in the Spinal Accessory nerve (CNXI)?
Examine the sternomastoid and trapezius, Ask the patient to rotate head each way against resistance, and ask patient to shrug shoulders against resistance. Should be equal on both sides.
How do we test the hypoglossal (CNXII) nerve?
Ask patient to stick tongue out (inspect for wasting, tremors, and that it is midline)
Ask patient to say “light, tight, dynamite” (This is assessing the sounds of l, t, d and n)
We assess a patient for pain by using varied dull and sharp stimuli over various bothy parts, what sensory system is this assessment a part of?
Spinothalamic Tract
If a patient is unable to distinguish between the sharp and dull stimuli, what is the next assessment that we can do to assess the sensory system of the spinothalamic tract?
Temperature - Use two test tubes, one with hot and one with cold water and place on various parts of the body to see if they can distinguish between the two.
How do we assess the light touch portion of the the spinothalamic tract?
cotton wisps over various parts of the body.
What 3 areas are we assessing within the Posterior column tract?
Vibration, Kinaesthesia, Fine touch
What is the term that is used for the ability to identify an object that is placed in your hand?
Stereognosis
How does the graphaesthesia assessment work?
You draw with your finger in the palm of your patient, one hand can be a letter and the other hand can be a number. The patient should be able to identify what you are writing while their eyes are closed.
What is the term thats describes how much the eye is open?
Palpebral fissure
What makes up the outer layer of the eye? Briefly define each term.
Sclera - tough protective white covering, it is continuous anteriorly with the smooth, transparent cornea which covers the iris and pupil.
Cornera - part of the refracting media of the eye, bends incoming light rays so they are focused on the retina within
What components make up the middle layer of the eye? Could you explain what each part does or a defining characteristic?
Choroid - prevents light reflecting internally, highly vascular to deliver blood to retina
Iris - functions as a diaphragm, varying the opening at its centre (the pupil), it controls what is let in for light or not
Pupil - round and regular (its size depends on the para or sympathetic nervous system)
lens- transparent biconvex disc that serves as a refracting medium, keeping objects in view (contain ciliary body)
anterior/posterior chambers (Which contains the aqueous humour that supplies nutrients to the surrounding tissues. )
What is contained within the inner layer of the eye? What are the functions of each?
Retina - is the visual receptive layer of the eye in which light waves are changed into nerve impulses.
Optic disc - is the area in which fibres from the retina converge to form the optic nerve (located nasally)
Retinal vessels - the only place in the body where we can visually see blood vessels.
Macule - is located on the temporal side of the fundus, slightly darker pigmentation surrounding the area of fovea centralis.
Fovea centralis - the area of sharpest and keenest vision
Visual pathways/ fields
Please see page 300 & 334 in jarvis
*retina flips the image
What does ciliary body control within the eye?
Thickness of the lens, it will bulge or flatten depending on the distance of an object.
If someone expresses during their subjective data that they have a black dot that started to float around but disappeared, should we be concerned? What do we think they were experiencing?
More then likely it would be a floater, these can be normal but should be noted. Frequent or prolonged floaters can be sign of damage of the retina.
In older adults (40+), they can experience decrease size of their pupils, loss of elasticity in their lens and it is becoming hard and glasslike. Due to this they are unable to accommodate for near vision. What is the term for these changes?
Presbyopia
At 70 years of age, a yellowing and thickening of the lens would indicate the presence of what?
Senile Cataract
What is macular degeneration?
A breakdown of cells in the macula of the retina. A loss of central vision, the area of clearest vision and is the most common cause of blindness.
A patient as increased intraocular pressure which can lead to gradual loss of peripheral vision. What is this condition called?
Glaucoma
What is the leading cause of visual impairment in people younger than 65?
Diabetic retinopathy
What are some areas of subjective data that you should collect on a patient in an eye assessment?
Difficulty seeing, blurring or blind spots.
Pain
Hx of crossed eyes or double vision
Redness or swelling, Excessive tearing
Injury or eye surgery, glaucoma
Glasses or contact lenses
Self-care behaviours (occupational concerns), medications
What is the term used for double vision?
Diolopia - perception of two images of a single object.
True or False.
Photophobia is the ability tolerate light.
False - it is the inability to tolerate light
Myopia means _______ and Hyperopia means ________?
Myopia - Nearsightedness
Hyperopia - Farsightedness
What do we use to test visual acuity at a distance?
Snellen eye chart
When recording the results for visual acuity from the snellen chart, do we use the highest line read, or the lowest line read?
Lowest, as lower the number the better the vision. (20/15 is better then 20/20)
What is a corneal light reflex test and how is it completed?
Assessing the parallel alignment of the eye axes
Direct the patient to stare straight ahead as you hold the light about 30cm away, note the reflection of the light on the corneas, it should be the exact same spot on each eye.
What does the cover-uncover test reveal to us?
Detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel. A normal response is a fixed, steady gaze.
What is the difference between a phoria and a tropia?
Both can be seen with the cover/uncover test
Phoria is a mild weakness of they eyes when fusion is blocked.
Tropia is more severe, a constant misalignment of the eyes
What is the red reflex?
A red glowing filling of the patient’s pupil caused by a reflection of your ophthalmoscope light off the inner retina.
What parts make up the external ear (Auricle/pinna)?
External auditory meatus
Tragus, Antitragus
Helix, Antihelix
Lobule
What structures make up the middle ear?
Malleus (hammer), incus (anvil), stapes (stirrup) (Oval window)
Eustachian tube
What structures make up the inner ear (labyrinth)?
Bony labyrinth contains vestibule
Semicircular canals
cochlea
What bones or processes may be seen through the tympanic membrane?
Incus, Short process of malleus
True or false
The cone of light can be seen on the tympanic membrane around the 5:00 mark.
True. This is caused by the light from the otoscope.
The palperbral fissure is:
a) the border between the cornea and sclera
b) the open space between the eyelids
c) the angle where the eyelids meet
d) visible on the upper and lower lids at the inner canthus
b) the open space between the eyelids
The corneal reflex is mediated by cranial nerves:
a) II and III
b) II and VI
c) V and VII
d) VI and IV
c) V and VII
The retinal structures viewed through the ophthalmoscope are:
a) the optic disc, the retinal vessels, the general background, and the macula
b) the cornea, the lens, the choroid, and the ciliary body
c) the optic papilla, the sclera, the retina, and the iris
d) the pupil, the sclera, the ciliary body, and the macule
a) the optic disc, the retinal vessels, the general background, and the macula.
The examiner records “positive consensual light reflex”. This is:
a) the convergence of the axes of the eyeballs
b) the simultaneous constriction of the other pupil when one eye is exposed to bright light
c) a reflex direction of they eye toward an object attracting a person’s attention
d) the adaptation of the eye for near vision.
b) the simultaneous constriction of the other pupil when one eye is exposed to bright light
Several changes occur n the eye with the aging process. The thickening and yellowing of the lens is referred to as:
a) presbyopia
b) floaters
c) macular degeneration
d) senile cataract
d) senile cataract
Be alert to symptoms that may constitute an eye emergency. Identify the symptom(s) that should be referred immediately:
a) floaters
b) epiphora
c) sudden onset of vision change
d) photophobia
C) sudden onset of vision change.
Visual acuity is assessed with:
a) the Snellen eye chart
b) the ophthalmoscope
c) the Hirschberg test
d) the confrontation test
A) the Snellen eye chart
The cover test is used to assess for:
a) nystagmus
b) peripheral vision
c) muscle weakness
d) visual acuity
c) muscle weakness
When using the ophthalmoscope, you would:
a) remove your own glasses, and approach the patients left eye with your left eye
b) leave light on in the examining room, and remove glasses from the patient.
c) remove glasses and set the dioptre setting at 0
d) use the smaller white light, and instruct the patient to focus on the ophthalmoscope
a) remove your own glasses, and approach the patients left eye with your left eye
The six muscles that control eye movement are innervated by cranial nerves:
a) II, III, V
b) IV, VI, VII
c) III, IV, VI
d) II, III, VI
c) III, IV, VI
Conjunctivitis is always associated with:
a) absent red reflex
b) reddened conjunctiva
c) impairment of vision
d) fever
b) reddened conjunctiva
A patient has blurred peripheral vision. You suspect glaucoma, and test the visual fields. A person with normal vision would see your moving finger temporally at:
a) 50 degrees
b) 60 degrees
c) 90 degrees
d) 180 degrees
c) 90 degrees
A person is known to be blind in the left eye. What happens to the pupils when the right eye is illuminated by a penlight beam?
a) No response in either
b) both pupils constrict
c) right pupil constricts, left has no response
d) left pupil constricts, right has no response
b) both pupils constrict
Use of the ophthalmoscope: an interruption of the red reflex occurs when:
a) there is an opacity in the cornea or lens
b) the patient has pathology of the optic tract
c) the blood vessels are tortuous
d) the pupils are constricted
a) there is an opacity in the cornea or lens
One cause of visual impairment in aging adults is:
a) strabismus
b) glaucoma
c) amblyopia
d) retinoblastoma
b) glaucoma
Briefly describe the method of assessing the six cardinal fields of vision.
Instruct pt to hold the head steady and follow the examiner’s fingers. The examiner holds the finger 30 cm from the individual and moves it clockwise to the positions of 2, 3, 4, 8, 9, 10 o’clock and back to the centre each tome. A normal response is parallel tracking of the objects with both eyes.
Using the otoscope, the tympanic membrane is visualized. The colour of a normal membrane is:
a) deep pink
b) creamy white
c) pearly grey
d) dependent upon the ethnicity of the individual
c) pearly grey
Sensorineural hearing loss may be related to:
a) a gradual nerve degernation
b) foreign bodies
c) impacted cerumen
d) perforated tympanic membrane
a) a gradual nerve degeneration
Before examining the ear with the otoscope, __________, __________, and __________ should be palpated for tenderness.
a) helix, external auditory meatus, and lobule
b) mastoid process, tympanic membrane, and malleus
c) pinna, pars flaccida, and antitragus
d) pinna, tragus, and mastoid process
d) pinna, tragus, and mastoid process
During the otoscopic examination of a child younger than 3 years of age, the examiner,
a) pulls the pinna up and back
b) pulls the pinna down
c) holds the pinna gently but firmly in its normal position
d) tilts the head slightly toward the examiner
b) pulls the pinna down
While viewing the otoscope, the examiner instructs the person to hold the nose and swallow. During this manoeuvre, the eardrum should:
a) flutter
b) retract
c) bulge
d) remain immobile
a) flutter
To differentiate between air conduction and bone conduction hearing loss, the examiner would perform:
a) the Weber test
b) the Romberg test
c) the Rinne test
d) none of the above
d) none of the above
In examining the ear of an adult, the canal is straightened by pulling the auricle:
a) down and forward
b) down and back
c) up and back
d) up and forward
c) up and back
Darwin’s tubercle is:
a) an overgrowth of scar tissue
b) a blocked sebaceous gland
c) a sign of gout called tophi
d) a congenital, painless nodule at the helix
d) a congenital, painless nodule at the helix
When the ear is being examined with an otoscope, the patient’s head should be:
a) tilted toward the examiner
b) tilted away from the examiner
c) as vertical as possible
d) tilted down
b) titled away from the examiner
The hearing receptors are located in the:
a) vestibule
b) semicircular canals
c) middle ear
d) cochlea
d) cochlea
The sensation of vertigo is the result of:
a) otitis media
b) pathology in the semicircular canals
c) pathology in the cochlea
d) forth cranial nerve damage
b) Pathology in the semicircular canals
A common cause of a conductive hearing loss is:
a) impacted cerumen
b) acute rheumatic fever
c) a cerebrovascular accident (CVA)
d) otitis externa
a) impacted cerumen
Upon examination of the tympanic membrane, visualization of which of the following findings indicates acute purulent otitis media infection?
a) Absent light reflex, bluish drum, oval dark areas
b) Absent light reflex, reddened drum, bulging drum
c) Oval dark areas on drum
d) Absent light reflex, air-fluid level, or bubbles behind drum
e) Retracted drum, very prominent landmarks
b) Absent light reflex, reddened drum, bulging drum
In examining a young adult woman, you observe her tympanic membrane to be yellow in colour. You suspect she has:
a) serum in the middle ear
b) blood in the middle ear
c) infection of the drumhead
d) jaundice
a) serum in the middle ear
Risk reduction for acute otitis media includes:
a) use of pacifiers
b) increasing group daycare
c) avoiding breastfeeding
d) eliminating smoke in the house and car
d) eliminating smoke in the house and car.
What is another name for the auricle?
The pinna, it is the external ear that is built up of moveable cartilage and skin.
What is the opening in the external ear that funnels sound waves in?
External auditory canal (Meatus)
What is cerebrum?
a yellow waxy material that lubricates and protects the ear
What separates the external ear and the middle ear?
Tympanic membrane or eardrum
What are some of the characteristics of the tympanic membrane?
Translucent, pearly grey membrane, oval and slightly concave
What bone can be seen through the tympanic membrane?
Malleus
3 different parts make it up, the umbo, manubrium [handle] and the short process
What is the pars flaccida?
it is the small, slack, superior sections of the eardrum. ( roughly 1 o’clock)
Other then the small portion of the pars flaccida, what is the remainder of the eardrum called that is thicker and more taut?
Pars tensa
What is the annulus in the eardrum?
The outer fibrous rim surrounding the eardrum
What 3 bones are found in the middle ear?
Malleus, incus and stapes
The opening to the inner ear from the middle ear is called what?
The oval window
What connects the middle ear with the nasopharynx and allows the passage of air?
Eustachian tube
What are the 3 main functions of the middle ear?
- It conducts sound vibrations from the outer ear to the central hearing in the inner ear
- it protects the inner ear by reducing the amplitude of loud sounds
- its eustachian tube allowed equalization of air pressure on each side of the ear drum so that it does not rupture. (think airplanes!)
Where is the bony labyrinth located?
the inner ear
What holds the sensory organs for equilibrium and hearing?
Inner ear
What is contained in the bony labyrinth?
Vestibule, Semicircular canals and the cochlea.
What is the cochlea?
It contains the central hearing apparatus within the inner ear
What is the pathway of hearing through the ear? (Air)
- Tympanic membrane
- Stapes embedded in oval window
- Basilar membrane of cochlea contains organ of corti hair cells.
What are organ of corti?
Numerous fibres along the basilar membrane that are receptor hair cells. The sensory organ of hearing. As the hair bends, they mediate vibrations.
There are 2 main pathways of hearing. What are they and what is the main pathway of hearing?
Air Conduction and Bone conduction
Air is most common
What type of hearing loss is characterized by a mechanical dysfunction of the external or middle ear?
Conductive hearing loss
What type of hearing loss is characterized by a disease of the inner ear, cranial nerve, or auditory areas of the cerebral cortex?
Sensorineural hearing loss (perceptive loss)
What is the term called when one may experience conductive and sensorineural hearing loss?
Mixed loss
If someone is experiencing staggering gait, and a strong spinning whirling sensation, where would this be happening in their ear?
Inflammation of the labyrinth, (inner ear) as it then feeds the wrong information to the brain
True or false.
A child’s eustachian tube is relatively shorter, narrower and more horizontal than an adults?
False. Although it is shorter and more horizontal, it is also much more wider. This way it makes it easier for pathogens to migrate from the nasopharynx to the ear.
What is otosclerosis?
A conductive hearing loss in young adults between the ages of 20 and 40. it is a gradual hardening that causes the footplate of the stapes to become fixed in the oval window which impedes the transmission of sound. This will cause progressive deafness.
What is presbycusis?
Type of hearing loss that occurs with aging, a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
What is Otalgia?
Ear pain, may be from disease or referred pain from the teeth or oropharynx
What is some subjective data that you would collect from assessing the ears?
Px Hx of:
Earache, infections, discharge, hearing loss, environmental noise, tinnitus, vertigo, self-care behaviours
How should you hold the otoscope when inspecting the ear?
Upside down along your fingers and have the dora of that hand along the patients cheek braced to steady the otoscope.
What is the difference between the weber and rinne test?
Weber test - hearing better in one ear
Rinne - compares AirC and BoneC
