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clinical examinationof the cranial nerves
Dr. Craig G. Adams
Dept of Surgery at RMH
The University of Melbourne
04/11/23 2
review neuroanatomy
• position of cranial nerve nuclei in the brainstem
• central pathways of CN’s– brainstem; cerebral
peduncles; diencephalon; internal capsule; corona radiata; cerebral cortex
• intracranial & extracerebral course
• exit foramina• extracranial (peripheral)
course
consider:
04/11/23 16
introduction to patient • smile, make eye contact and shake
hands
• explain what you are about to do in simple terms
• patient should be seated comfortably in a chair or resting on pillows in bed
• while this is happening take a few seconds to look around the bed and make mental note of any relevant clues or hints … (eg mobility aids, drugs, IV drips, catheter bags, drainage bags, cards/flowers from relatives etc)
04/11/23 17
introduction
• methodically & systematically examine each cranial nerve
• from olfactory nerve ---> hypoglossal nerve
• consider fibre types in each cranial nerve:– somatic motor; visceral
motor; special motor; general sensory; special sensory; visceral sensory
04/11/23 18
olfactory nerve (CN I)
• olfactory nerve arises in nasal cavity from central processes of bipolar cells in mucosal epithelium
• enters cranial cavity as filaments through cribriform plate of ethmoid bone ---> olfactory bulb on the ventral portion of frontal lobe
04/11/23 19
olfactory nerve
04/11/23 21
olfactory nerve
• sense of smell is tested in both nostrils separately
• make sure nostrils are clear & not blocked
• use familiar smells (eg coffee, tobacco, peppermint, cloves)
patient in pub brawl - presented with epistaxis ? # nose
special sensory
04/11/23 22
olfactory nerve
don’t use pungent or irritating substances like smelling salts or ammonia as they stimulate the sensitive trigeminal nerve endings in the nasal mucosa!
# nasal bones
04/11/23 23
loss of smell
causes of anosmia
• colds, allergies, sinusitis, deviated nasal septum
• head injury (with or without # of bone) causing damage to olfactory filaments as they pass through cribriform plate
• tumours such as meningiomas, gliomas, others
• meningitis (acute or chronic)
04/11/23 24
anterior cranial fossa #’s
04/11/23 25
anterior cranial fossa tumours
04/11/23 26
nasal tumours
04/11/23 27
severe lacerations/fractures
04/11/23 28
warning ...
the next slide contains a most horrible image … deformities of the very worst kind … turn away now if you are squeamish !
04/11/23 29
04/11/23 30
optic nerve (II)
special sensory
• visual acuity (Snellen’s)• visual fields & blind spot
(red hat-pin)• visual attention• optic fundi
(ophthalmoscope)• colour vision (Ishihara)
QuickTime™ and aCinepak decompressor
are needed to see this picture.
04/11/23 31
optic nerve
• contains nerve fibres arising from the inner layer of the retina
• proceeding posteriorly to enter the cranial cavity via the optic foramen
• some fibres crossing to the opposite side via the optic chiasm
04/11/23 32
04/11/23 33
oculomotor nerve (III)
• leaves brain on medial side of cerebral peduncle between the posterior cerebral artery & the superior cerebellar artery
• passes anteriorly, lateral to internal carotid artery, through cavernous sinus
• leaves skull through superior orbital fissure
04/11/23 34
oculomotor nerve
• orbit– assess for any unusual
prominence of the eye (exophthalmos/proptosis)
• eyelids– the oculomotor nerve
supplies skeletal muscle component of levator palpebrae superioris
(? partial or complete ptosis)
04/11/23 35retro-orbital tumour - most commonly rhabdomyosarcoma
04/11/23 36
oculomotor nerve
pupils• parasympathetic fibres
course in the 3rd CN to synapse in the ciliary ganglion --> postganglionic fibres emerge as ciliary nerves and innervate sphincter pupillae
• therefore check pupillary size, shape & symmetry
QuickTime™ and a decompressor
are needed to see this picture.
04/11/23 37
oculomotor nervepupillary reflexes• direct/consensual response
– the normal pupil contracts briskly in the eye to which light is directed (direct response)
– and also in the opposite eye (consensual response)
• afferent limb is the optic nerve• efferent limb is the Edinger-
Westphal nucleus & 3rd CN
• accommodation response• normal pupils constrict as the
eyes converge (near response)
QuickTime™ and a decompressor
are needed to see this picture.
04/11/23 39
oculomotor nervemotor to 4 EOM’s
(except LR & SO)
• look at position of patient’s eyes at rest and during movement– ? squint/strabismus– ? nystagmus
• test movement in all directions– ? diplopia
04/11/23 40
analysis of eye movements
right eye deviated medially--> pull of SO directly down
right eye deviated laterally--> pull of SR directly up!
note: when eyes looking straight ahead (0 deg.) superior & inferior recti contribute mostly to vertical eyeball movement and the obliques to rotation (intortion & extortion) of the eye
04/11/23 41
oculomotor nerve lesions• ptosis (partial or complete)
• paralysis (varying degrees) of the extra-ocular muscles it supplies (MR, IR, SR, IO)
• pupil widely dilated (unopposed action of sympathetics on dilator pupillae)
• unreactive to light (disrupted parasympathetics)
patient is being asked to lookstraight ahead
04/11/23 43
trochlear nerve (IV)
• motor to superior oblique
• exits brainstem on dorsal surface
• curves around cerebral peduncles
• passes anteriorly through lateral wall of cavernous sinus
• enters orbit via superior orbital fissure
• assess for:– squint/strabismus; diplopia;
nystagmus
04/11/23 44
trochlear nerve lesions
• paralysis of superior oblique muscle --> weakness of downward gaze
• resulting in:– vertical diplopia– torsional diplopia– diplopia worse when the
patient is asked to look down & in (as in reading)
patient has been asked to lookdown and to his left
04/11/23 45
abducens nerve (VI)
• motor to lateral rectus• emerges from ventral
brainstem in groove b/n pyramid of medulla & caudal pons
• passes through cavernous sinus to exit cranial cavity via superior orbital fissure
• assess for:– squint/strabismus; diplopia;
nystagmus
04/11/23 46
abducens nerve lesions
paralysis of abduction (lateral deviation)– because of its long
intracranial course the sixth nerve is often involved secondarily to raised intracranial pressure (the nerve being stretched as it passes over the tip of the petrous temporal bone
04/11/23 47
left 6th CN lesion
at risk with deep lacerations/#’s lateral aspect of orbit
this is the result of a MBA (Harley) with no face plate on his helmet
04/11/23 48
left 6th CN nerve lesion
patient is looking straight ahead
04/11/23 49
left 6th CN nerve lesion
patient is now asked to look to his left ...
04/11/23 50
04/11/23 51
‘blow-out’ fracture of orbit
weakest link is inferiorly
04/11/23 52
‘blow-out’ fracture of orbit
patient is trying to look up
soft tissue trapped in maxillary antrum
04/11/23 53
Horner’s syndrome
“disruption to the sympathetic supply to the head and neck”
• associated classically with a ‘Pancoast’ tumour of apex lung
• also many other causes …. so be able to trace the course of the sympathetic fibres!
04/11/23 54
clinical features - Horner’s
on side of lesion:• partial drooping upper
eyelid• constricted pupil• ‘blood-shot’ eye• warm, red skin• dry face
04/11/23 55
trigeminal nerve (V)
• contains large sensory root & smaller motor root
• sensory (semilunar) ganglion near apex of petrous bone in middle cranial fossa– ophthalmic division enters
skull through superior orbital fissure
– maxillary division through foramen rotundum
– mandibular division (joined by motor portion) through foramen ovale
04/11/23 56
trigeminal nerve
? motor deficits• motor to muscles of
mastication
? sensory deficits• sensory distribution to entire
face
? alteration in reflexes• corneal reflex (afferent limb)
04/11/23 57
muscles of masticationask the patient to bite down hard - look and feel temporalis & masseter contracting!
04/11/23 58
sensory distribution
• test response to:– soft touch (cotton wool)
and– pain (‘orange’ stick or new safety pin)
– DO NOT use hypodermic needle!!
• map out any sensory deficit and compare with known territories of the 5th CN
04/11/23 59
trigeminal HZV neuralgia
maxillary division ophthalmic division
04/11/23 60
corneal reflex
“reflex bilateral tight closure of eyes if object touches cornea”
• afferent limb mediated by ophthalmic division of trigeminal nerve (5th CN)
• efferent limb mediated by facial nerve (7th CN)
04/11/23 61
corneal reflex
• test by gently touching centre of cornea with wisp of cotton wool
• look for reflex closing of BOTH eyes and ask patient if it felt uncomfortable!!
make sure you do not accidentally startle patient---> (startle or blink reflex)
try to ‘park’ the cotton wool on the cornea ...if you can ---> this is most abnormal !
04/11/23 62
facial nerve (VII)
• emerges from brainstem at the cerebellopontine angle
• leaves cranium through internal acoustic foramen
• exits skull through stylomastoid foramen
04/11/23 63
facial nervemotor - muscles facial
expression
– look for facial asymmetry (drooping of angle of mouth, loss of the nasolabial fold, loss of forehead wrinkles)
– test strength of frontalis, orbicularis oculi & orbicularis oris muscles
– ? sparing of upper part of face in UMN lesions
04/11/23 64
04/11/23 66
facial nerve (cont.)
• motor– stapedius, stylohyoid,
posterior belly of digastric– ? hyperacusis
(intensification of loud sounds)
• sensory to posterior aspect EAM (contentious)
• corneal reflex (efferent limb)---> strong bilateral closureof orbicularis oculi
04/11/23 67
facial nerve (cont.)
also consider nervus intermedius …
• taste (anterior 2/3rds)
• secreto-motor (parasympathetic)– lacrimal glands– submandibular glands– sublingual glands
“secreto-motor to every gland in the head except for the parotid gland”
04/11/23 68
vestibulocochlear nerve (VIII)
acoustic component
• ? tinnitus• simple bedside tests for
hearing • special tests
– Rinne’s– Weber’s
• formal audiometric testing
04/11/23 69
Rinne’s test
• activate a tuning fork (with a vibrating frequency of 256 Hz or 512 Hz)
• place it on the mastoid process
• ask patient if they hear the tone
04/11/23 70
Rinne’s test
• then hold the tuning fork directly in front of the external auditory meatus
• ask the patient: “does it sound louder in front or behind ?”
• determine if air conduction > bone conduction!
04/11/23 71
Weber’s test
• place tuning fork at the vertex of the skull
• ask patient to determine which side sounds louder
• if there is a problem with the middle ear complex, which side will be louder?
04/11/23 72
vestibulocochlear nerve
vestibular component
• concerned with posture & equilibrium
• caloric testing ‘COWS’• positional tests
– Hallpike test
• stepping test– Unterberger test
04/11/23 73
glossopharyngeal nerve (IX)
sensory fibres
• general sensory– oropharynx– post. 1/3rd tongue– soft palate– tonsils– middle ear
• special sensory– taste posterior 1/3rd
tongue
04/11/23 74
glossopharyngeal nerve
sensory fibres
• visceral sensation– blood pressure via
carotid sinus baro- (stretch) receptors
– pO2/pCO2 via carotid body chemoreceptors
04/11/23 75
glossopharyngeal nerve
motor fibres
• branchial motor to stylopharyngeus muscle
• visceral motor to parotid gland– parasympathetic secreto-
motor
04/11/23 76
glossopharyngeal nerve
reflexes• swallowing reflex
(afferent limb)
• pharyngeal ‘gag’ reflex (afferent limb)
• visceral reflexes– salivary (parotid)
– baroreceptor (carotid sinus)
– chemoreceptor (carotid body)
04/11/23 77
pharyngeal ‘gag’ reflex arc
• afferents– glossopharyngeal nerve
(receptors in oropharynx)
• CNS– brainstem (medulla)
• efferents– glossopharyngeal nerve– vagus nerve– accessory nerve (cranial
part)
04/11/23 78
pharyngeal ‘gag’ reflexthis reflex is subsumed in the swallowing reflex, being elicited by momentary & artificial
stimulation of the oropharynx (in contrast with food or drink which produce sustained, familiar stimulation)
• gently touch posterior oropharynx with sterile swab
• look for abnormal deviation away from side of lesion
the two key features are:
• inhibition of respiration
• raising of soft palate
04/11/23 79
vagus nerve (X)
sensory branches• meningeal branch
– dura
• auricular branch– to EAC
• pharyngeal branch– to soft palate
• superior laryngeal nerve– internal & external brs
• recurrent laryngeal nerve
04/11/23 80
vagus nerve
sensory branches (cont.)
• visceral branches– aortic arch baroreceptors – heart– lungs– abdominal organs
04/11/23 81
cranial accessory nerve (XI)
motor• functionally the motor part of the
vagus nerve– to muscles of pharynx & larynx
• same named branches as for the vagus
• test by:– assessing speech (laryngeal
muscles) & swallowing (efferent limb pharyngeal mm)
– looking at position of uvula at rest and with elevation on saying “Ahh”
04/11/23 82
spinal accessory nerve
motor
• trapezius muscle
• sternocleidomastoid muscle (SCM)
04/11/23 83
hypoglossal nerve (XII)
motor
• look for fasciculations & wasting (with tongue at rest)
• look for deviation on protrusion
• test strength on both sides, assess for paresis/paralysis
forward pull of genioglossus deviatestongue towards the side of a unilateralhypoglossal lesion
04/11/23 84
04/11/23 85
this patient has a unilateral CN XII lesion and is attempting to poke his tongue straight out … which side is the lesion ?
04/11/23 86
this patient is also attempting to poke her tongue straight out … the camera has‘freeze framed’ fasciculations on the effected right side
04/11/23 87
ventral surface of tongue
veinlingual frenulum
papilla
submandibularduct
‘tongue deviates to side of lesion’ … verify by visualizing (in 3D) the attachments & action of both genioglossus muscles
04/11/23 88
references
• Introductory Neuroscience• Professor J.G. McLeod• Professor J.W. Lance
• Essential Neurosurgery• Professor Andrew H. Kaye• Professor Stephen Davis
• clinical anatomy/surgery lecture notes• Dr Craig G. Adams
http://www.surgeryrmh.unimelb.edu.au