Osce Cranial Nerves PDF

SAN BEDA COLLEGE OF MEDICINE
NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER
EXAMINATION OF THE CRANIAL NERVES: NERUROLOGICAL EXAM & THEORETICALS
Outline
I. Examination the cranial nerve: steps and how to report your findings
II. Pathway of the cranial nerve
III. Theoreticals
Legend
Blue – Demyers;
Red – asked/said during preceptorials
Table of Contents
Cranial nerve I ...................................................................................................................................................................................... 2
Cranial nerve II .................................................................................................................................................................................... 3
Cranial nerve III .................................................................................................................................................................................. 10
Cranial nerve IV ................................................................................................................................................................................. 19
Cranial nerve V ................................................................................................................................................................................... 20
Cranial nerve VI ................................................................................................................................................................................. 26
Cranial nerve VII ................................................................................................................................................................................. 28
Cranial nerve VIII ............................................................................................................................................................................... 32
Cranial nerve IX .................................................................................................................................................................................. 35
Cranial nerve X .................................................................................................................................................................................. 35
Cranial nerve XI .................................................................................................................................................................................. 39
Cranial nerve XII ................................................................................................................................................................................ 40
SBCM 2019 SECTION A Page 1 of 42

NEUROLOGY:
CRANIAL NERVE I: OLFACTORY NERVE

I. Steps 
LEFT RIGHT
1. Ask patient first if he has a cold or any olfactory problem at the
moment.
2. Check the patency of both nostrils by placing a tissue against a
nostril and asking the patient to blow through his nose.
3. Ask the patient to close his eyes.
4. While one nostril is occluded, ask the patient to sniff and identify
the various odorants.
5. For the second trial, compress the opposite nostril and this time do
not present the stimulus.
6. The 3rd time, present the stimulus to the untested nostril.
How to report
 The patient has patent nostrils with intact cranial nerve 1
II. Pathway
Bipolar cells in neuroepithelium (receptors)
2o olfactory nerve fibers---Cribriform plate---Dura Arachnoid
Olfactory bulb
Olfactory tract
Anterior perforated substance and uncus
Bypass the thalamus
Activates cortex, brainstem and hypothalamic nuclei
III. Theoretical 
GENERAL SKULL TYPE/SITE OF ABNORMAL

CLASSIFICATION FUNCTION ORIGIN/NERVE
DISTRIBUTION OPENING LESION FINDING
Sensory (special
visceral afferent or
SVA)
 Use at least 3 substances

 Use aromatic, non-irritating substances (e.g. COFFEE)in testing the olfactory nerve
 Readily available aromatic substances are oil of lemon, orange peel or apple skin and soap
 Do not use alcohol or perfume
o Noxious stimuli will stimulate the trigeminal nerve in the nasal mucosa.
o AMMONIA irritates all receptors of a mucous membrane.
 Injury to the anterior cranial fossa may damage the nerve and can lead to anosmia (injury to the cribriform plate of ethmoid) and
CSF rhinorrhea.
 Unilateral Anosmia: Hippocampus problem
 Bilateral Anosmia: Nasal Congestion or common colds
If ever there is a polyp, how would you know if the nostrils are working? Get a piece of tissue paper or a paper then let the
patient exhale through the nose, the air coming out would move the tissue. If the patient has runny nose, the tissue would
be wet after exhaling.

NEUROLOGY:
CRANIAL NERVE II: OPTIC NERVE
I. Steps
A. PUPILLARY LIGHT REFLEX RIGHT LEFT
DIRECT
1. Shine light in from the side of each eye to gauge pupil’s light reaction.
2. Observe for constriction.
CONSENSUAL
1. Watch the patient’s left eye while shining on the right.
SWINGING FLASHLIGHT TEST

1. Alternately swing the light from one eye to the other and hold it on the
new eye for 3- to 5-second intervals.
2. Watch for equal reactions of both pupils.
3. If the Pt has an afferent defect in one optic nerve (e.g., due to optic
neuritis), the pupils will dilate as the light swings from the normal to
the affected eye (Marcus-Gunn pupil or relative afferent pupillary
defect) rather than maintaining the same degree of constriction
.
How to report
 PERRLA as shorthand for “pupils equal, round and react to light and in accommodation”.
 CN II – afferent and CN III – efferent (a2e3)
 Direct and Consensual reflex are intact.
 Damaged CN II of eye A
o When light shines on eye A: no response in either eye: “negative direct and consensual responses”
 Damaged CN III of eye A
o When light shines on eye A: no response in A, but positive consensual response of B: “negative direct but
positive consensual response”
Example: Pupils 3 mm, equal, centered, react to light and in accommodation and dilate promptly in dim light.
B. TEST FOR CENTRAL VISION RIGHT LEFT
VISUAL ACUITY
Snellen’s/Jaeger’s Test:
1. Allow the patient to use his/her glasses if available. (Although glasses
improve acuity by correcting for a refractive error, they do not improve
acuity impaired by opacities of the refracting media of the eye or retinal or
optic nerve lesions)
2. Let the Pt hold a Snellen’s chart at a 20 meter distance. (Jaeger’s chart at a 20/____ 20/____
14 inch ‘reading’ distance or arm’s length of the patient)
3. Have the patient cover one eye at a time.
4. Ask the Pt to read progressively smaller letters until they can go no
further.
5. Record the smallest line the patient read successfully. Repeat with the
other eye.
20/____ 20/____
If vision is not 20/20, do Pinhole Test
____/____ ____/____
If still not able to see letters, let the Pt move closer to the chart (10m away, 5m

NEUROLOGY:
away).
VISUAL ACUITY OF PARTIALLY BLIND
1. If still not able to see letters, check for Counting Fingers
2. Appreciation of Hand Movements (waving effect)
3. Perception of Direction of Light (peripheral flashlighting)
4. Perception of Light (direct flashlighting)

If even bright light can’t be seen, the vision in the involved eye is NLP (no
light perception)
How to report
 Visual acuity is __/__ for the right and __/__ for the left.
 A 20/30 vision means normal people could see from “30 meters away” what the Pt sees 20 meters away.
 If the Pt is 10m or 5m away from the chart: A 10/30 vision means normal people could see from 30m away what the Pt
could see from 10m away.
C. TEST FOR PERIPHERAL VISUAL FIELDS RIGHT LEFT
CONFRONTATION TEST
1. Station yourself directly in front of Pt. Start with your left eye directly in 45: _____ 45: _____
line with the Pt’s right eye, at a distance of about 50 cm—eye to eye but
not breath to breath. The Pt covers the left eye with the left hand.
2. Hold up your left index finger just outside your own peripheral field, in the 135: ____ 135: ____
inferior temporal quadrant. Hold the finger about equidistant between
your eye and the Pt’s.
3. Move finger very slowly toward the central field. Request the Pt to say 225: ____ 225: ____
“now” as soon as the finger is seen. Try to match the perimeter of the Pt’s
visual field against your own. Test all quadrants of each eye separately,
each time starting at the limit of the field. 315: ____ 315: ____
4. After surveying the visual field by the wiggling finger, you can refine the
test by asking the Pt to count the number of fingers presented in each of
the four quadrants of the visual field of each eye. Then randomly hold up
one, two, or five digits (three or four is too complicated) in each quadrant
for the Pt to count.
5. Instruct the patient not to look at your nose. The Pt’s eyes will converge,
and your fields will not match.
How to report
 On visual confrontation, ‘there are no visual field cuts’ or ‘there is bitemporal hemianopia’ or ‘there is left/right
homonomous hemianopia’

NEUROLOGY:
C. OPHTHALMOSCOPY TEST RIGHT LEFT
How to Test:
1. Remove your and the patient’s glasses

2. Darken the room
3. Ask the patient to fix his/her eyes on a specific point straight ahead
4. Instruct the patient to blink as needed and breathe normally
5. Hold the opthalmoscope in your right hand and move your right eye as you examine the patient’s eye
6. Turn the rheostat on the ophthalmoscope down a little to avoid too strong a beam of light.
7. Start with the ophthalmoscope 10 to 15 cm from your partner’s eye and, with a strong positive lens, focus on the
media in succession from cornea to lens to vitreous, using successively weaker lenses.
8. Inspect the cornea with and without the scope for opacities and for a circular ring near the limbus.
9. Next focus on a retinal vessel by using whatever lens setting, from 0 to a strong plus or minus that is required to
overcome refractive errors. After locating a retinal vessel, follow it along until you find the optic disc (optic papilla).
10. Next, identify the pigment ring around the disc, note the disc color, and the presence or absence of a physiologic cup.
If present, the physiologic cup is white as compared with the rest of the disc.
11. Identify the arteries, the thin, brighter appearing vessels, and the thicker, duller appearing veins.
12. Look for venous pulsations where the veins bend over the edge of the physiologic cup.
13. Follow each artery out as far as possible. Locate the macula, a darker, avascular area two disc diameters lateral to the
disc.
CORNEA
 Inspect the cornea with and without the scope for opacities and for a
circular ring near the limbus, which, if grayish-white, is an arcus senilis,
or, if greenish brown, a Kayser-Fleischer ring pathognomonic of Wilson
hepatolenticular degeneration.
RETINAL VESSEL
Color (Bleeding, Exudate)
 Arterioles: with bright light reflex, light red color, smaller than veins
 Veins: absent or inconspicuous light reflex, dark red color, larger and
pulsating
Pulsation
 Venous pressure slightly exceeds the intraocular pressure. Visible
pulsation occurs in nearly 90% of normal Pts when both eyes are
examined.
 Venous pulsations disappear at intracranial pressures above 190 mm
H2O.
 Because of the absence of visible pulsations in some normal persons,
the presence of pulsation is more important than its absence.
Condition (Pigmentation, Occlusion)
 Retinal lesions: lesions on retinal background may be
red/black/gray/white, flame-shaped/round, diffuse/spotting
OPTIC DISC
 Color (Pink/Pale): if pale → optic atrophy
 Margins (Clear): if blurred margin or indistinct border (cannot see disc
well) → Optic disc swelling (pappilledema due to increased ICP)
 State of Cup → Deep pale cup – Glaucoma

NEUROLOGY:
Normal optic disc
Swollen disc but Pt can see as usual  papilledema

Swollen disc but Pt CANNOT see well  papillitis
Normal disc but Pt CANNOT see well or blind  acute retrobulbar neuritis
MACULA (located one disc size temporally/lateral; is avascular; larger than the
disc; and with indistinct margins)
 Fovea Light Reflex (Note the pearl of light reflecting from the fovea
centralis, the center of the macula. This light reflection fades in older
persons.)
 Bleeding, Exudate: (A fluid rich in protein and cellular elements that
oozes out of blood vessels due to inflammation and is deposited in
nearby tissues)
 Edema, Drusen: (tiny yellow or white accumulations of extracellular
material)
How to report
 The cup-to-disc ratio compares the diameter of the "cup" portion of the optic disc with the total diameter of the optic
disc. A good analogy to better understand the cup-to-disc ratio is the ratio of a donut hole to a donut. The hole represents
the cup and the surrounding area the disc. If the cup fills 1/10 of the disc, the ratio will be 0.1. If it fills 7/10 of the disc,
the ratio is 0.7. The normal cup-to-disc ratio is 0.2:0.5. A large cup-to-disc ratio may imply glaucoma or other
pathology.[2] However, cupping by itself is not indicative of glaucoma.
 (-) Papilledema (means blurred or elevated optic papilla resulting from the edema fluid in the nerve fibers as they across
the disc to perforate the lamina cribosa and enter the optic nerve.
 A-V ratio 3:2
 First to be seen when doing ophthalmoscopy: media (liquid portion). If media is hazy, there is papilledema that may be
indicative of an increased intracranial pressure.

NEUROLOGY:
II. Pathway
Pathway for pupillary light reflex

NEUROLOGY:
Afferent Limb (CN2), Efferent Limb (CN3)
Rods and cones  Optic chiasm  Mesencephalon  Edinger-Westphal nucleus  consensual pupillary constriction equals the
direct constriction
III. Theoretical

Sensory Vision Retina of the Optic Canal Cerebrum Direct trauma Loss of
SSA (Bipolar cells eye (Diencephalon/ to eyeball pupillary
of retina) Retinal ganglion Optic canal constriction
cells) fracture and visual field
pressure on defects
optic pathway
laceration
intracerebral
clot
 Two cranial nerves, II and V, convey afferents from the eye to the brain
1. The optic nerve, cranial nerve (CrN) II, conveys the afferent axons for two functions, the special sense of vision and
pupilloconstriction.
2. The trigeminal nerve, CrN V, conveys the afferents for general sensation: Ocular pain; Tearing reflex; Corneal reflex;
Proprioception from the extraocular muscles
 The cone receptors of the macula mediate the two functions of the central field of vision:
i. Visual acuity
ii. Color vision
 In the periphery of the retina, concentrically surrounding the macula, rod receptors mediate the two functions of the
peripheral field of vision:
i. Night vision
ii. Motion detection
 Clinical relevance of pupillary light reflex

 Age: The pupils of the fetus are large and fail to react to light until the 30 to 32 weeks of gestational age. Then at term birth
the pupils are small. The pupils enlarge through adolescence (the so-called “wide-eyed” innocent look). The size and
reactivity then gradually diminish until senility when the pupils again become small and poorly reactive.
 Pupillodilation: Mydriasis
 Pupilloconstriction: Cormiosis
 Marcus gunn pupil: This is a CN 2 lesion, where the light is shone on one eye first then the other (swinging-flashlight test).
The affected eye demonstrates slight dilation of the pupil.

NEUROLOGY:
 Horner Syndrome: ptosis, miosis, anhydrosis, vasodilation

(upper motoneuron Pathway: hypothalamus → brainstem tegmentum → spinal cord → synapses on the GVE lower
motoneurons of the intermediolateral cell column of the spinal cord gray matter: T1 to L2 and L3→paravertebral ganglion
→ superior cervical → carotid sympathetic → smooth muscles of the external carotid artery (→ sympathetic axons → sweat
glands of the face) & internal carotid artery ( → sympathetic axons → ocular smooth muscles and the sweat glands of the
forehead)
Lesion: Superior cervical ganglion
 Clinical relevance of test for central vision

Pinhole Test corrects “Error of Refraction”, but the following are not correctable:
 Opthalmologic problems: Cataract, corneal lesion, Retinal Hemorrhage/infarct, Macular degeneration
 Optic neuropathy: inflammatory, ischemic compression
 Bilateral occipital lesions: cortical blindness
Nice to know only: Screening central vision with an Amsler Grid
1. With each eye separately, the patient fixates on a dot in the center of a grid work held about 30 cms away.
2. Ask the patient whether he/she can see four corners and whether any of the squares in the grid are missing or distorted.

NEUROLOGY:
Lesion sites and their corresponding visual field defects
CRANIAL NERVE III: OCULOMOTOR NERVE
I. Steps
GENERAL LEFT RIGHT

Note the following:
Pupil’s shape
Pupil’s relative size ___ ___
Ptosis ___ ___
Diplopia ___ ___
Nystagmus
DIRECT AND CONSENSUAL PUPILLARY LIGHT REFLEX

DIRECT
1. Shine light in from the side of each eye to gauge pupil’s light ___ ___
reaction.
CONSENSUAL
1.Watch the patient’s left eye while shining light on the right. ___ ___
2.Observe for constriction.
How to report
 (The pupils are symmetrical and measure _ mm, equally & briskly reactive to light/ there is photophobia, etc.)

NEUROLOGY:
EXTRAOCULAR MOVEMENTS
CARDINAL POINTS IN AN ‘H’ PATTERN
1. Look for failure of movement and nystagmus.

 Make sure to check it during upward and lateral gaze.
2. Instruct the patient to look directly into your index finger level on
his eyes.
3. Ask the patient to follow your finger without moving his head.
4. Do the ‘H’ pattern.
Lateral Rectus ___ ___

Medial Rectus ___ ___
Superior Rectus ___ ___
Inferior Rectus ___ ___
Superior Oblique ___ ___
Inferior Oblique ___ ___
How to report
 Patient was able to follow the finger without moving his head indicating intact cranial nerve 3,4, and 6.
TEST FOR CONVERGENCE

1. Instruct the patient to look at your index finger.
2. From distance of about 20 cm, move your index finger at the tip
of patient’s nose, and move it away. ___ ___
3. Observe for convergence and divergence.
How to report

TEST FOR ACCOMODATION

1. Ask the patient to look into your eyes.
2. While holding the pen, instruct the patient to look to the pen and
at your eyes alternately. ___ ___
3. Observe for constriction
How to report
 Patient was able to look alternately with pupil constriction indicative of intact cranial nerve 3.
During the accommodation reflex for near vision, 3 distinct events occur. The visual axes converge onto the fixation point, the pupils
construct, and the lens thicken.
 Convergence: medial recti (skeletal)
 Pupilloconstriction: iris (smooth muscle;parasympathetic)
 Lens thickening: ciliary muscle (smooth muscle;parasympathetic)
II. Pathway

NEUROLOGY:
III. Theoretical
 Primary position of the eye: look straight ahead, essential parallel

 Visual Axis – a line drawn from the fovea centralis of one eye to the center of its visual field, line of sight, no refraction,
fixated in an infinity distance
 Convergence – adduction of the eye
 Diplopia – physiologic diplopia, had to consciously attend to the point of non-fixation to get diplopia
 False Image – Because the right eye fails to abduct to align with the left as it adducts the retinal image of the right eye falls
on the nasal half of the retina, by learning, the mind projects the visual image to the right temporal side
 Swing Light Test: CN2 - AFFERENT, CN3- EFFERENT
ACTIONS OF THE EXTRAOCULAR MUSCLES

 Elevation/supraduction – upward
 Depression/infraduction - downward  
 Intorsion/incyclotorsion – rotation of the upper pole of the vertical meridian of the eye towards the nose  
 Extorsion/excyclotorison – rotation of the upper pole of the vertical meridian of the away from the nose  
 SUPRANUCLEAR CONTROL OF EYE MOVEMENTS:
HORIZONTAL GAZE
Cortical areas involved in the generation of saccades:
1. Frontal eye fields (FEF) – main horizontal gaze control center

2. The supplementary eye field
3. Posterior eye field (in the parietal lobe)
 FEF controls horizontal saccades to the opposite side.

NEUROLOGY:
(Area colored green is the frontal eye field, or Brodmann Area 8.)
 To understand how yoking of the eye muscles occur, study the following pathway:
Left frontal eye field
III
Medial Longitudinal
PPRF Fasciculus
VI
LR MR
Right Left
Which Frontal Eye Field Is Active?

(Left or Right)
Answer:
Left!
VERTICAL GAZE
 In contrast to horizontal gaze, vertical eye movements are generally under BILATERAL control of the cerebral cortex and the
upper brainstem.
 The groups of nerve cells and fibers that govern upward and downward gaze are situated in the pretectal areas of the
midbrain and involve 3 integrated structures:
1. The rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF)
2. Interstitial nucleus of Cajal (INC)
3. Nucleus and fibers of the posterior commissure

NEUROLOGY:
 Projections for upgaze cross through the commissure before descending to innervate the third nerve nucleus while those
for downgaze may travel directly to the third nerve, thus accounting for the frequency of selective gaze palsies (for
example, upgaze may be paralyzed but downgaze may be preserved).
 Clinical relevance
 There are three main anatomical causes of an oculomotor nerve lesion:
1. Increasing intracranial pressure – this compresses the nerve against the temporal bone.
2. Aneurysm of the posterior cerebral artery.
3. Cavernous sinus infection or trauma.
 Note: there are other pathological causes of oculomotor nerve palsy such as
1. diabetes,
2. multiple sclerosis,
3. myasthenia gravis
4. giant cell arteritis.
 The oculomotor nerve is the major nerve supplying the ocular and extraocular muscles.
 The clinical signs of CN III injury are all associated with the eye:
1. Ptosis (drooping upper eyelid) – due to paralysis of the levator palpabrae superioris.
2. Eyeball resting in the ‘down and out‘ location – due to the paralysis of the superior, inferior and medial rectus, and the
inferior oblique. The patient is unable to elevate, depress or adduct the eye.
3. Dilated pupil – due to the unopposed action of the dilator pupillae muscle.
Oculomotor nerve palsy. Note the ‘down and out’ position of the eye.
 Neurological pathways governing ocular motility (i.e., how our eyes move) are independent of vision (i.e., what the eyes see)
although they are virtually inseparable.
 The neural mechanisms that govern eye movements reside mainly in the midbrain and pons (where the nuclei of these cranial
nerves are) but are greatly influenced by centers in the medulla, cerebellum, basal ganglia, and the frontal, parietal and occipital
lobes of the brain.

NEUROLOGY:
 Conjugate movement of the the eyes – symmetrical and synchronous movement of the eyes
 Disconjugate or disjunctive – simultaneous movement of the eyes in the opposite direction
 The 6 recognized eye movement/ control systems (mostly, operational definitions):

1. Saccades – rapid movements of the eyes that serve to fixate on a target
2. Smooth pursuit – following movements of the eyes when they are fixated on a moving target
3. Vergence – disconjugate eye movements which serve to maintain binocular single vision and depth perception
4. Fixation – maintains the eyes on a target by constant tonic contraction of the extraocular muscles (gaze holding)
5. Optokinetic nystagmus – If a series of visual targets enters the visual field, as when one is watching trees from a moving
car, or the stripes of a rotating drum, repeated quick saccades refocus the eyes centrally; the resulting repeated cycles
of pursuit and refixation are termed optokinetic nystagmus.
6. Vestibulo-ocular reflex – by means of this reflex, a movement of the eyes is produced that is equal and opposite to
movement of the head.
DISORDERS OF OCULAR MOTILITY
Peripheral Disorders Central Disorders

Left frontal eye field Left frontal eye field
A. Extraocular
muscles
B. Cranial nerve
nuclei
C. Cranial nerve III III
fascicles
PPRF PPRF
VI VI
LR MR LR MR
PERIPHERAL DISORDER
A. OCULOMOTOR NERVE PALSY

NEUROLOGY:
CENTRAL DISORDERS
A. SUPRANUCLEAR – any lesion which can affect the frontal eye fields and the pathway down to the PPRF
B. INTERNUCLEAR – between the PPRF and cranial nerve nuclei
HORIZONTAL GAZE PALSIES:

1. INTERNUCLEAR OPHTHALMOPLEGIA (INO) OR MEDIAL LONGITUDINAL FASCICULUS SYNDROME
 Contralateral (with respect to the PPRF) medial rectus does not receive a signal to contract.
 As a result, gaze to one side results in abduction of the eye ipsilateral to PPRF, with no adduction of contralateral eye.
 There may be nystagmus of the abducting eye.
 INO is labeled by the side with adduction failure.
 Common in multiple sclerosis and brainstem strokes.
III
PPRF PPRF
VI VI
LR MR
R L
In medial longitudinal fasciculus syndrome, upon asking the patient to look to the RIGHT, the right eye abducts, while the LEFT eye
remains frozen (adduction failure of the LEFT eye)
Upon asking the patient to look to the LEFT, both eyes can look to the LEFT.
2. “THE ONE-AND-A-HALF SYNDROME”

 There is a conjugate gaze palsy to one side (“one”) and
 Impaired adduction on looking to the other side (“and a half”)
 Most often caused by multiple sclerosis, infarcts, hemorrhages, trauma, basilar artery aneurysms, brainstem
arteriovenous malformations and tumors.
“One-and-a-half syndrome”
III
PPRF PPRF
VI VI
LR MR
Upon asking the patient to look to the right, RIGHT eye abducts (with nystagmus), while LEFT eye remains midline.
Upon asking the patient to look to the left, both eyes are still.
Suppose one horizontal movement, say abduction, is ½; and adduction, ½. In this scenario, the only remaining movement is
abduction of one eye, and the other 1 ½ movements are affected, hence the name “one and a half syndrome.”

NEUROLOGY:
VERTICAL GAZE PALSIES:
1. PARINAUD SYNDROME
 Usually results from a mass lesion involving the region of the posterior third ventricle and upper dorsal midbrain
 Also known as Sylvian aqueduct syndrome, dorsal midbrain syndrome, or the syndrome of the posterior commissure.
 The pupils may have a poor, rarely absent, light response, and much better near response.
 The pupils also tend to be large.
 Consists of:
 Paralysis of upward gaze
 Failure of convergence
 Retraction nystagmus
 “Setting sun” sign
(Site of lesion causing Parinaud syndrome)
EXAMINATION OF OCULAR MOTILITY
Type of eye movement Method of examination
1. Spontaneous movements during ordinary Inspection while taking the history. Look for
behaviour and ordinary environmental stimuli malalignment, range and persistence of eye
movements, and for hyperkinesias such as
nystagmus.
2. Volitional fixation and volitional movements Examiner observes steadiness and range of eye
movements after commanding the patient to fixate
on a distant object straight ahead and then to move
the eyes to the right, left, up and down.
3. Visual reflex ocular movements
a. Smooth pursuit The patient’s eyes pursue the examiner’s finger as it

moves through the full range of ocular movements.
b. Vergences The examiner directs the patient to look at near and

distant objects and to follow the examiner’s moving
finger in toward the patient’s nose

NEUROLOGY:
c. Reflex fixation The patient fixates straight ahead and the examiner
turns the patient’s head slowly to the right, left, up
and down.
d. Alignment lock As the patient fixates straight ahead, the examiner

alternately covers and uncovers first one, then the
other eye, and looks for deviation in alignment after
monocular occlusion of vision (cover-uncover test).
e. Optokinetic nystagmus Patient fixates on rotating drum or a moving striped

strip.
4. Non-visual reflex ocular movements
a. Caloric nystagmus – study this and how to Irrigation of ears with hot or cold water.
interpret
b. Positional nystagmus Placing the patient’s head in various postures.
c. Contraversive eye-turning test (Doll’s eye test, Quick turning of the patient’s head by the examiner’s
oculo-cephalic test) – study this, and interpretation hands; used in comatose patients
of the test
Pupillary defects
a. Anisocoria: Left or Right?

 inequality in the size of the pupils of the two eyes, usually a difference of more than 1mm in diameter
 named after pupil that is bigger
*If the pupils are equal and normally reacting, it’s the normal variant
b. Senile Miosis
 Normal age-related change
c. HORNER’s Syndrome
 miosis, partial ptosis, enopthalmos (a condition in which the eye is normally sunken into the socket) and loss of
hemifacial sweating
 Central- Stroke (Wallenberg), demyelination
 Peripheral- Pancoast’s tumor (apical bronchial CA), Trauma, Carotid dissection
d. Cortical blindness
 Occipital or post-Geniculate ganglion
 If a patient is blind yet pupils are briskly reactive
e. Marcus Gunn pupil
 Lesion anterior to optic chiasm side of lesion: Pupil that dilates

NEUROLOGY:
CRANIAL NERVE IV: TROCHLEAR NERVE

I. Steps 
EXTRAOCULAR MOVEMENTS
1. During the history, the Ex judges the range of volitional eye
movements.
2. Start the formal examination with the Pt sitting. Gently press on
top of the Pt’s head with one hand and fix the head in position by
a “proprioceptive link” between yourself and the Pt, permitting
only the eyes to move. Mentally retarded or demented Pts have
difficulty separating eye and head movements.
3. Ask the Pt to fixate on your finger, which you hold up in the
midline, about 50 cm away
___ ___
4. Request the Pt to follow your finger with their head still, moving
___ ___
their eyes only.
___ ___
5. Move your index finger in an H shape in front of the patient so
___ ___
that the patients eyes are seen to move fully to right, left,
___ ___
superior, inferior and oblique.
___ ___
 look for extra ocular palsy and nystagmus
 ask the patient to tell you if they have any double vision
 Avoid extremes of gaze as this can cause a physiological
nystagmus
How to report
 “ Cranial neve 4 is intact”
II. Pathway
 The trochlear nerve provides motor innervation to only one of the extraocular muscles of the eye, the superior oblique
muscle (a common mnemonic is SO4).
 The nerve cell bodies of GSE neurons reside in the trochlear nucleus, which lies adjacent to the midline in the tegmentum of
the caudal midbrain.
 Fibers arising from this nucleus initially descend for a short distance in the brainstem and then course dorsally in the
periaqueductal gray matter. The fibers decussate posteriorly and emerge from the brainstem at the junction of the pons
and midbrain, just below the inferior colliculus.
III. Theoretical
Cranial Nerve: Innervation Clinical Effects of interruption of

nerve
CN 4 – Trochlear Nerve (Mixed) Striated muscle: superior oblique Diplopia, most severe on looking
down and in; eye extorted; head
tilted to side opposite paralyzed eye
Action of the Superior Oblique Muscle
 The superior oblique originates from the lesser wing of the sphenoid bone, just above the annulus of Zinn. Its tendon runs
through a trochlea (pulley) attached to the rim of the bony orbit
 When the tendon runs to the eye, it inserts posteriorly to allow the superior oblique to have an effective pull when
contracting. In so attaching, the tendon runs somewhat medial to the vertical axis, like the superior and inferior recti.
 Contraction of the superior oblique, when the eye starts in the primary position, causes:
a) A primary action to DEPRESS the eye
b) A secondary action to ABDUCT the eye
c) A tertiary action to INTORT the eye

NEUROLOGY:
CN IV Palsy
CRANIAL NERVE V: TRIGEMINAL NERVE
I. Steps 
MOTOR FUNCTION TEST

A. Teeth Clenching
HOW TO ASK:
1. Ask the patient to clench teeth together strongly and unclench several
times. “Kagat po kayo nang madiin.”
2. Inspect and palpate the temples and cheeks of the patient for atrophy of
the Temporalis and Masseter.
3. Simultaneously palpate the muscles of the two sides as they mound up and
relax under the examiner’s fingertips.
WEAK NORMAL REMARKS

TEMPORALIS MUSCLE
MASSETER MUSCLE
B. Mouth Opening
HOW TO ASK:
1. Ask the patient to open mouth widely. Look for deviation to the weak side.
2. Ask the patient to push his mouth open against your hand. “Buksan nyo po ang bibig ninyo.
3. Resist his jaw opening with your hand under his chin. Susubukan ko pong isara, pero labanan
nyo po ang pwersa ko.”
NOTE: If the jaw deviates to the right side, you’re testing the left pterygoid muscle
(Masseter and Pterygoid)
WEAK NORMAL REMARKS
C. Jaw Diversion (Lateral Pterygoid)

HOW TO ASK:
1. Ask the patient to forcefully open jaw and move the jaw from side to side.
2. Tell the patient, “Move your jaw to the right against my hand.” “Buksan nyo po ang bibig ninyo. Igalaw po
3. Do the same on the opposite side. ninyo papunta sa kanan. Susubukan ko
pong itulak pakaliwa, pero labanan nyo po
NOTE: Weakness of one lateral pterygoid muscle can cause the jaw to deviate to the ang pwersa ko.”

NEUROLOGY:
IPSILATERAL SIDE.
WEAK NORMAL REMARKS
RIGHT SIDE
LEFT SIDE
How to report
 All muscles for mastication (Masseter, Temporalis and Pterygoids) are intact on both sides.
SENSORY FUNCTION TEST

A. Touch Sensation Test
Procedure: HOW TO ASK:
1. With eyes open, let the patient feel the touch using wisp cotton.
2. Start at the normal side of the patient so that the patient will know the 1. Meron po akong ipararamdam sa inyo,
normal sensation to be expected. (Brush on normal side) naramdaman
3. Then ask the patient to close his eyes and say “YES” in response to each nyo po ba? (Should be YES)
touch by a wisp of cotton. 2. Ngayon naman po, ipikit ninyo ang
4. Lightly brush each area of the three sensory divisions of the CN V using mata ninyo at sabihin po ninyo ang
wisp of cotton. “Oo”, kung may naramdaman po kayo.
5. Touch the areas alternately and randomly. 3. (If YES, quantify) “Kung yung kanan po
6. Change the time between touches to keep the patient from getting into ay piso (P1.00), ano po yung kaliwa?
rhythm of answering without actually feeling the sensation. Or “Kung yung kanan po ay 100, ano
7. Ask the patient if he/she felt the sensation. po yung kaliwa?”
8. Ask the patient to compare and quantify the sensation using percentage or
currency. (same/ increased/ decreased/ __%/ P1.00/ P0.50) To confirm: Ipaturo sa pasyente kung
saan nila naramdam para alam mong
NOTE: Corners of the jaw near the mastoid process is NOT supplied by CN V but by may na feel talaga sila
C2
LEFT RIGHT REMARKS
V1 Opthalmic (vertex-forehead-nose
tip)
V2 Maxillary (medial aspect of cheek)
V3 Mandibular (chin)
B. Pain Sensation Test
HOW TO ASK:
1. With eyes open, let the patient feel the sharp end and the blunt end of 1. Meron po akong ipararamdam sa inyo,
the tongue depressor. Introduce to the patient what is SHARP and what is ito po ang matalas at ito po ang
BLUNT. mapurol/malambot, (touch on normal
2. Start at the normal side of the patient so that the patient will know the side) Naramdaman nyo po ba? (Should
normal sensation and the difference between SHARP and BLUNT be YES)
sensations to be expected. 2. Ngayon naman po, ipikit ninyo ang
3. Then ask the patient to close his/her eyes. mata ninyo at sabihin po ninyo kung
4. Alternately touch the areas of the face (Opthalmic/ Maxillary/ MATALAS o MAPUROL ang
Mandibular) using the SHARP and BLUNT ends, randomly. naramdaman ninyo.
5. In touching the areas of the face, ask the patient if it is SHARP or BLUNT.
To confirm: Ipaturo sa pasyente kung
may na feel talaga sila
LEFT RIGHT REMARKS
tip)
C. Temperature Discrimination
Procedure: HOW TO ASK:
1. With eyes open, let the patient feel the HOT and COLD, using fingers for
HOT sensation and using the metal shaft of the tuning fork for COLD. 1. Meron po akong ipararamdam sa inyo,
Introduce to the patient what is HOT and what is COLD. ito po ang MAINIT at ito po ang
2. Start at the normal side of the patient so that the patient will know the MALAMIG, (touch on normal side)
normal sensation and the difference between HOT and COLD sensations Naramdaman nyo po ba? (Should be
to be expected. YES)

NEUROLOGY:
3. Then ask the patient to close his/her eyes. 2. Ngayon naman po, ipikit ninyo ang
4. Alternately touch the areas of the face (Opthalmic/ Maxillary/ mata ninyo at sabihin po ninyo kung
Mandibular) using your fingers as HOT and tuning fork as COLD, randomly. MAINIT o MALAMIG ang naramdaman
5. In touching the areas of the face, ask the patient if it is HOT or COLD. ninyo..”
To confirm: Ipaturo sa pasyente kung

may na feel talaga sila
LEFT RIGHT REMARKS

tip)
D. Corneal Reflex
HOW TO ASK:
1. Pull out a wisp of cotton. Ask the patient to
look on the lateral side, oppositely to the “Tumingin po kayo sa kaliwa (if you’re
eye being tested. For example, if you are testing the right eye). Idadampi ko lang po
testing the right eye, ask the patient to look nang mabilis ang bulak sa mata ninyo.”
on the left corner of the eye.
2. Target the limbus (corneoscleral junction) of
the eye, approaching from the lateral side of
the eye being tested so that the patient
won’t see the cotton tip.
NOTE: NORMAL REFLEXBLINKING of the eyes.

AVOID touching the eyelashes when approaching the eyes, this may cause
blinking.
AFFERENT: CN V EFFERENT: CN VII
LEFT RIGHT REMARKS
CORNEAL REFLEX (+/-)
How to report
 Touch Sensation
 Patient can/cannot able to detect light touch in all areas.
 There is _____% deficit to light touch on R/L part of the face on V1/V2/V3 branches of the trigeminal nerve
 Pain Sensation
 Patient can/cannot able to detect pain in all areas.
 Temperature Discrimination
 Patient can/cannot able to discriminate hot and cold temperature in all areas.
 Corneal Reflex
 Positive/Negative corneal reflex.
 Corneal Reflex of R/L eye is not responsive to touch.
II. Pathway
1. Cn 5 at the level of the pons

2. Motor root (mandibular division; V3) passes inferiorly to the sensory root (V1, V2) and exits at
the foramen ovale supplying muscles of mastication
3. Sensory root (V1 Opthalmic; V2 Maxillary) exits at the superior orbital fissure

NEUROLOGY:
III. Theoretical

Mixed  Face Derivatives of  Superior  Somatic Terminal  Loss of pain
 GSA (Gasserian sensation frontonasal orbital fissure (general) branch injury and touch
ganglion)  Taste process and 1st  Foramen sensory: in roof of sensation in
 SVE (motor (anterior 2/3 of pharyngeal arch rotundum trigeminal maxillary face
nucleus of tongue)  Foramen ganglion sinus,  Deviation of
trigeminal) ovale  Somatic pathology mandible on
(branchial) same side of
motor: upper lesion when
pons mouth is
opened
 No
contraction of
masseter and
temporalis
muscle
 Sensory: Face
 Motor: Muscles for Mastication
 Temporal
 Lateral and Medial Pterygoids
 Masseter
 trigeminal nerve is a mixed nerve. It has a larger component consisting of sensory fibers for the face and a smaller component
consisting of motor fibers for muscels of mastication
 CN V conveys no efferents to glands or smooth muscle and no special afferents
 Trigeminal Nerve three large branches:
V1- Opthalmic
V2- Maxillary
V3 - Mandibular
 V1 and V2- Sensory
 V3- Sensory and Motor
 Tip of the nose – V1
 Angle of the mandible- Not included sa
CN V kasi C2 na un.
 Trigeminal Sensory Nuclei:

o Spinal trigeminal nucleus
→ Located in the medulla
→ For deep/crude touch, pain and temperature from the ipsilateral face
→ CNs VII, IX and X also convey pain information from their areas to the spinal trigeminal nucleus
o Principal sensory nucleus
→ subserves
o discriminative sensation
o light touch of the face
o conscious propioception of the jaw
→ all of which via first order neurons
o Mesencephalic nucleus
→ propioception of the face (feeling of position of the muscles)
→ The only structure in the CNS to contain the cell bodies of a primary afferent, which are usually contained within
ganglia
→ Peripheral processes of neurons in this nucleus receive impulses from peripheral receptors in the muscle spindles in
the muscles of mastication, and from other receptors that correspond to pressure

NEUROLOGY:
 Trigeminal Motor Nucleus

→ Contains motor neurons that innervate muscles of the first branchial arch, namely the muscles of mastication,
o tensor tympani
o tensor veli palatine
o mylohyoid
o anterior belly of the digastrics muscle
also innervates the masseter, temporalis, and medial and lateral pterygoid
Lower motorneuron lesions (LMN)
 Unilateral destruction of the axons of the CN V causes complete paralysis of all IPSILATERAL chewing muscles
 Denervated muscles undergoes:
o atrophy and paralysis
 The 2 most obvious sign of Lower motorneuron lesions (LMN)
 Masseter - the most readily palpated muscle for atrophy

NEUROLOGY:
Upper motorneuron lesions (UMN)

 Usually Contralateral
Axial muscles Appendicular muscles
- acts symmetrically - ordinarily contract unilaterally

- receives the same amount of crossed and - distal muscles
uncrossed UMN axons
-proximal musles
* trunk
* muscles for chewing
* swallowing
BILATERAL UMN INNERVATION CONTRALATERAL UMN INNERVATION
Corneal (Blink) reflex:

o touch the cornea (not just the conjunctiva) lightly with a fine wisp of cotton.
Direct corneal: stimulate one side, blink on same side
Consensual corneal: stimulate one side, both eyes blink, equally forceful
CN V- Afferent arm (sensory)

CN VII- Efferent arm (motor)
 Right Side is Stimulated tapos ung Left Side ang nag blinked
Saan ang problem? CN V or CN VII?

- CN VII Efferent (motor) problem
 Stimulation is applied , neither eyes blinked
Saan ang problem? CN V or CN VII?

- CN V Afferent (sensory) problem
Corneomandibular reflex (von solder phenomenon)
 Stimulation of one cornea causes contraction of the ipsilateral pterygoid muscle and a twitch of the jaw to the opposite
side.
o So kunwari stimulate mo ung right eye, ung magco contract ay ung RIGHT ipsilateral pterygoid muscle tapos ung
jaw mag ti twitch sa LEFT
 It may indicate a UMN lesion more sensitively in amyotrophic lateral sclerosis than other UMN signs.
 It may also appear in parkinsonism.
Glabellar blink reflex
 Consist of bilateral contraction of the orbicularis oculi muscle in response to percussion of the glabella with the fingertip or
a percussion hammer or to electrical stimulation of the supraorbital branch of the trigeminal nerve.
Trigeminal neuralgia
- The most common ailment affecting CN V (usually V1 and V2)
- Very painful when you chew or eat
Nucleus of tractus solitarius – for swallowing

NEUROLOGY:
CRANIAL NERVE VI: ABDUCENS NERVE
I. Steps 
PHYSICAL/GENERAL RIGHT LEFT
Shape of pupils
Size of pupils
Ptosis
Diplopia (disorder of vision in which two images of a single

object is seen)
Nystagmus (rapid involuntary oscillations of the eyeballs)
EXTRAOCULAR MOVEMENT TEST USING “H” PATTERN RIGHT LEFT
1. Observe for failure of movement and nystagmus.

(Check it during upward and lateral gaze)
2. Instruct the patient to look directly into your index
finger leveled on the pt’s eyes
3. Ask the pt to follow your finger without moving
his/her head
4. Do the “H” pattern (See cranial nerve III)
Lateral Rectus
Medial Rectus
Superior Rectus
Inferior Rectus
Superior Oblique
Inferior Oblique
Note
● All eye muscles are innervated/controlled by CN 3

except:
● Lateral rectus (CN 6)
● Superior Oblique (CN 4)
How to report
Cranial nerve 6 intact

NEUROLOGY:
II. Pathway
Abducens Nerve = Somatic Efferent Nerve
Main Nucleus
 The abducens nucleus is located in the pons, on the floor of the fourth ventricle, at the level of the facial colliculus.
 Motor axons leaving the abducens nucleus run ventrally and caudally through the pons.
 The abducens nerve leaves the brainstem at the junction of the pons and the medulla, medial to the facial nerve. In
order to reach the eye, it runs upward (superiorly) and then bends forward (anteriorly).
Remember!
Nuclei: Abducens Nerve
Origin: Junction of Pons and Medulla
Opening: Superior Orbital Fissure
Supplies: Motor and Lateral Rectus Muscle
III. Theoretical

Fracture Diplopia on
Extraocular
Superior Orbital involving Lateral Gaze;
Moves Eye Muscle (Lateral Pons (Upper)
Fissure cavernous eye falls to
Rectus)
sinus or orbit move laterally

NEUROLOGY:
 Paralysis of the Lateral Rectus Muscle - Medial Strabismus and Horizontal Diplopia
 A lesion in the abducens nerve result in paralysis of the lateral rectus muscle that normally ABDUCTS the eye. The
eye will then deviate medially as a result of the unopposed action of the medial rectus. The individual can turn the
ipsilateral eye from its medial position to the center (looking straight ahead), but not beyond it - Medial
strabismus (Convergent, internal strabismus, esotropia)
 Eyes become misaligned, the individual experiences - Horizontal diplopia (Double Vision)
CRANIAL NERVE VII: FACIAL NERVE

Branches: Temporal, Zygomatic, Buccal, Mandibular, Cervical
I. Steps 
Inspect the face, both at rest and during conversation with the patient. Note any asymmetry (Asymmetry of Frontalis muscle,
Asymmetry of wrinkles for orbucularis oculi, asymmetry of nasolabial fold for Buccinator and asymmetry for Platysma), and observe
any tics or other abnormal movements.
NOTE: Asymmetry is the clue to unilateral weakness and is best perceived during conversation when the patient is unaware of being
observed.
Tests of the Facial Muscles Innervated by Cranial Nerve VII Remarks:

Examiner’s Command Inspect for: Muscle Tested Right Left
”Wrinkle up your forehead” or Inspect for asymmetry Frontalis Muscle
“Look up at the ceiling”
”Close your eyes tight and don’t let Inspect for asymmetry of Orbicularis oculi
me open them” wrinkles; try to pull the
eyelids apart
”Pull back the corners of your Inspect for asymmetry of Buccinator
mouth, as in smiling” nasolabial fold
“Puff your cheeks”
”Wrinkle up the skin on your neck” Inspect for asymmetry Platysma
or “Pull down hard on the corners
of your mouth”
How to report
 Normal/abnormal nasolabial fold, eyelid sagging, mouth drooping
 Intact cranial nerve 7 (if no significant findings)

NEUROLOGY:
Tests of the Unilaterality of Facial Movements Remarks:

Examiner’s Command Results Right Left
Retract one corner of your mouth at a time. Every normal person can do it; the
movement is unilateral.
Wink one eye at a time; watch in your Most can do it, but some cannot wink one
mirror for simultaneous contraction of the eyen without the other; when one eye
opposite orbicularis oculi muscle. winks, the opposite orbicularis oculi
contracts to some degree.
Elevate one eyebrow at a time. Few can do it unilaterally, but everyone can
elevate them together; the movement is
essentially bilateral.
How to report
 Able/not able to do unilateral facial movements on (both) right and left side of the face
Test of the Sensory Branch of CrN VII
Do test for Taste - Cranial Nerve VII is responsible for taste sensation in the anterior 2/3 of the
tongue
*** this test is usually done in line with examination of CrN IX
Prepare:
 Sugar and Salt

 card with "Salty" and "Sweet" written on it
 cotton applicator or cotton or tongue blade
 water
Directions:
 Use cotton application/cotton to obtain sample of sugar and salt

 Have the Pt stick out his tongue
 Place cotton app with salt/sugar in the lateral aspect of Pt's tongue for a few seconds
 Have the patient identify the taste
 Use water to wash the substance from your pt's tongue
How to report
 Appreciation of taste of substance on Left and Right anterior 2/3 of the tongue
 Impairement: Ageusia(absence) or hypogeusia (decreased) or hypergeusia (abnormally heightened)
II. Pathway

NEUROLOGY:
III. Theoretical
General characteristics of CrN VII
 All first-order sensory neurons are found in the geniculate ganglion within the temporal bone.
 exits the brainstem in the cerebellopontine (CP) angle.
 enters the internal auditory meatus and the facial canal.
 exits the facial canal and skull via the stylomastoid foramen.
 mediates facial movements, taste, salivation, and lacrimation.
***Remember the clinically important functions of CrN VII other than innervation of facial muscles, this will be one of the anticipated
questions during our OSCE according to our Preceptor 
Functions of the facial muscles (Frontalis muscle, Orbicularis oculi, Buccinator and Platysma)
a. Expression of emotions, such as when frowning and smiling.

b. Compression of lips for whistling, blowing, and spitting; labial sounds of speech; swallowing and other feeding actions.
c. Controlling and protecting the facial apertures: the palpebral fissures, oral fissure, nares, lips, and external auditory canals.
d. Dampening excessive movement of the ossicles by stapedius muscle contraction during loud sounds. After stapedius paralysis,
ordinary sounds may seem uncomfortably loud, a symptom called hyperacussis.
Types of Facial Paralysis: Central Lesion vs Peripheral Lesion of CrN VII
Facial weakness or paralysis may result either from:
(1) Peripheral lesion of CN VII, the facial nerve, anywhere from its origin in the pons to its periphery in the face
(2) Central lesion involving the upper motor neuron system between the cortex and the pons.
These can be distinguished by their different effects on the upper part of the face. The lower part of the face normally is controlled
by upper motor neurons located on only one side of the cortex—the opposite side.
Left hemispheric damage to these pathways, as in a stroke, paralyzes the right lower face. The upper face, however, is controlled by
pathways from both sides of the cortex. Even though the upper motor neurons on the left are destroyed, others on the right remain,
and the right upper face continues to function fairly well.

NEUROLOGY:
A peripheral lesion of CN VII, exemplified here by a Bell’s palsy, is compared with a central lesion, exemplified by a left hemispheric
cerebrovascular accident:

NEUROLOGY:
CRANIAL NERVE VIII: VESTIBULOCOCHLEAR NERVE
I. Steps
1. Explain to the patient what examination you will perform.
2. Ask the patient about hearing deficits or has tinnitus. (abnormal sound perceived in the ear, hearing buzzing, clicking, ringing or
roaring sounds that only the patient can hear. Subjective tinnitus-arises not from real sounds but from auditory system disorder
eg. Presbyacusis, cochlear dse., or caused by drugs such as salicylates, loop diuretics, “mycin antibiotics, quinine , cysplastin.
Objective tinnitus is caused by real sound, audible to the Ex. Eg. Bruit from AV malformation, fistula.)
3. Do Otoscopy to ensure that the external auditory canals are open and that the eardrums are normal. (check for damaged
eardrums, wax, foreign bodies in EAC, etc.-mechanical impediment to sound conduction. )
How do you pull the ear for otoscopy? Pull the ear superiorly, posteriorly, laterally
Adult: up and out
Pedia: down and out
4. Rub your fingers together beside the patient’s ear and then the other.
5. Present a vibrating tuning fork prongs perpendicularly to each of the patient’s ears alternately and ask the patient to compare
loudness.
(forks with 512-2000 cps match frequencies most imp’t for speech perception.)
To semi quantitate the test, move the fork from one ear to the other and ask the Pt to compare the loudness of the sound in the
two ears. Also compare the distance from the ear at which you hear the sound with the distance at which the Pt hears it.
6. Report findings of patient’s gross hearing.
7. Air-Bone conduction test of Rinne compares the efficiency of the conduction of sound vibrations by bone and by air. (sensory
neural)
perform Rinne’s test with watch – usually sound is heard thru air conduction twice longer than bone conduction.
a. Hold a faintly vibrating tuning fork on the patient’s mastoid process until patient says that the sound can no longer be
heard.
b. Hold the same vibrating tuning fork to the patient’s ear.
c. Ask the patient to compare the sound with a tuning fork applied to the bone compared to that heard with the ear.
d. Report the findings on the Rinne test.
Analysis: Px hear better with tuning fork applied to his mastoid = conduction hearing loss.
*Conduction (mechanical) hearing loss- due to impediment of the conduction of sound vibration through the EAC or ossicles of the
middle ear.
If Px showed reduced hearing for air and for bone conduction = neurosensory loss.
*neurosensory hearing loss- reduction of hearing by a lesion of the organ of corti or of the auditory nerve- CN VIII.
If you press your fingertip in your ear completely occluding the ext. ear canal while holding a tuning fork against your mastoid, the
sound gets louder. This shows that even a mechanical obstruction of auditory canal decreases sound by air conduction, it causes
increase in bone conduction.
Bone mechanically transmits vibrations to the inner ear. It tests the integrity of the nerve. Neurosensory hearing loss impairs the
hearing of high frequencies by air conduction and decreases hearing via bone conduction. Nerve lesions block hearing by air and
bone, mechanical lesions block air conduction.
8.Sound lateralization test of Weber
a. Place a vibrating tuning fork on the middle of the Pt’s forehead or on the vertex of the skull.
b. Ask the patient if sound is equally heard in both ears.
c. Report the findings of Weber’s test
***Normal person hears the vertex vibration equally in both ears. If a mechanical impediment blocks sound conduction in
one ear, the vertex sound localizes to the same ear. (R- heard louder, R ear impeded). If the Pt has auditory nerve lesion on
one side, the vertex vibration sounds loudest on the opposite side. Only a consistent lateralization to one side after several
trials is considered significant.
NEUROLOGY:
9. Schwabach’s Test
a. Strike the tuning fork and place it on the mastoid area of the patient
b. Tell the patient to notify you if the sound is gone
c. If the patient says the sound is not already heard, put the tuning fork on your mastoid area to clarify
***Normally, wala ka na dapat marinig pag nilagay mo yung tuning fork sa mastoid mo. Pag nilagay mo sayo at may narinig
ka pa after the patient verbalized na wala na sya marinig, then there’s a problem.
9. Technique for caloric irrigation
a. Forewarn and position the Pt: Because of discomfort, the Ex should warn the Pt about the test, but mentioning the
expected symptoms voids the objectivity and validity of the test. Therefore, say this: “I will be rinsing your ear. It’s
somewhat uncomfortable, but I want you to pay attention to what you feel.” Because vertigo may cause the Pt to fall, place
the Pt in a sitting or reclining position.  
b. Do otoscopy: Exclude a mechanical impediment such as wax, otitis, or a perforated eardrum that might allow water into
the middle ear, causing pain and infection. Remove excessive wax that may preclude adequate heat conduction.  
c. Place spectacles on the Pt that have strong positive lenses (+10 to 30 diopters, Frenzel lenses). (You can buy them cheaply
in chain stores.) The lenses serve two purposes. They magnify the Pt’s eyes, making any nystagmus easier to see, and they
impair fixation by blurring vision. Fixation inhibits vestibular-induced nystagmus. Thus, the glasses increase the likelihood of
eliciting nystagmus, and make it easier to study if it occurs
d. Instruct the Pt to gaze ahead: Place an emesis basin or a towel next to the Pt’s ear to prevent wetting the Pt (and also for
emergency service should the Pt vomit).  
e. Irrigate the ear with warm or cold water: Barber (1974) advocated instilling only 2 mL of ice water through a 14- to 16-
gauge needle. Tilt the Pt’s head to the opposite side and hold the water in the canal for a timed 20 seconds. After 20
seconds, place the horizontal canal vertical and watch for nystagmus. For a second method, fill a 50-mL syringe with water
at a temperature of 7°C above or below the normal 37°C of body temperature (30°C or 44°C). Gently instill the 50 mL of
water through a short rubber tube into the external auditory canal over a timed period of 40 seconds. Test both ears
because a consistent difference is required for significance. Wait about 5 minutes between each test.  
f. Observe the Pt’s responses: At the end of irrigation, ask the Pt to direct the gaze more or less ahead and hold the arms
straight out. Inspect the Pt for the following:
 Nystagmus: Record the duration and direction.

 Postural deviation and past-pointing: To test for past-pointing, have the Ex and Pt sit facing each other. Each
extends the arms out from the shoulder so that the index fingers of Pt and Ex touch. The Ex instructs the Pt to
close the eyes and extend the arm straight up and Ex’s finger in the original position. Look for the Pt’s finger to
miss by con- stantly deviating to one side.
g. Ask about symptoms: Ask whether the caloric irrigation reproduced the Pt’s usual sensation of movement, and ask about
the direction of any vertigo.
 Patients with vertigo and postural deviations sometimes report confusing directionality, depending on whether
they are attending to their vertigo or their body tilt.
 Normal individuals also respond somewhat variably to caloric irrigation.
 Some Pts show little or no response from either ear. Determine whether irrigation of the two ears produces any
consistent difference.
 a strong normal response from the right ear with little or no response from the left indicates a lesion of the
vestibular end organ, nerve, or immediate central connections on the left.

NEUROLOGY:
SCREENING HEARING YES NO
Hear the sound of the phone/cellphone ringing
Hear the normal conversation voice
Hear whispering
OTOSCOPY LEFT RIGHT
External Auditory Canal [ ] Open [ ] Open
[ ] Close [ ] Close
Eardrums [ ] Open [ ] Open
[ ] Close [ ] Close
Normal Color: Pinkish gray [ ] Normal [ ] Normal
WHISPER TEST LEFT RIGHT
Whisper
RINNE’S TEST (AIR-BONE CONDUCTION) LEFT RIGHT
Air Conduction
Bone Conduction
WEBER’S TEST RIGHT MIDDLE LEFT
Lateralization [ ] [ ] [ ]
II. Pathway
Central connections of the cochlear nerve.
A. Upon penetrating the brainstem, the cochlear axons synapse at the cochlear nuclei.
B. These nuclei drape around the inferior/caudal cerebellar peduncle.
C. In the auditory pathway, the cochlear nuclei contain the secondary neurons.
D. In ascending through the brainstem, the auditory pathway disperses about equally ipsilaterally and bilaterally. Therefore, if
a Pt has a profound unilateral hearing loss, the lesion most likely would affect an auditory nerve.
E. The name of the auditory pathway that ascends through the brainstem is the lateral lemniscus through which axons run to
the inferior colliculus.
F. From the inferior colliculus, the pathway runs to the medial geniculate body.
G. Neurons of the medial geniculate body relay to the superior surface of the temporal lobe (transverse temporal gyri of
Heschl).
The cochlea senses and codes the vibrations, and nerve impulses are sent to the brain through the cochlear nerve.
From the external ear through the middle ear -conductive phase
Disorder: causes conductive hearing loss
From cochlea and the cochlear nerve - sensorineural phase
Disorder: causes sensorineural hearing loss

NEUROLOGY:
III. Theoretical
-Cranial Nerve 8 is purely sensory in classification
-Consists of Cochlear (auditory) and vestibular divisions. Cochlear division mediates hearing only and detects sound vibrations bet 20
and 20, 000 cps.
Cochlea contains receptor (organ of Corti) and the cochlear (Spiral) ganglion that originates from Cochlear division of CNVIII.
1. Receptor for hearing: The cochlea contains the receptor (the organ of Corti) and the cochlear (spiral) ganglion that originates the
cochlear division of VIII (see Fig. 9-6).
2. The cochlear ganglion contains the outside primary neurons for hearing.
3. Peripheral course of the cochlear nerve: The cochlear and vestibular divisions of VIII run through the internal auditory canal,
accompanied by CrN VII
4. CrNs VII and VIII attach to the brainstem at the pontomedullary sulcus.
IV. Report of findings
If intact: Cranial nerve 8 intact
Rinne test: AC>BC (Normal); BC>AC (Conductive hearing loss); AC>BC but not twice as long (Sensorineural)
Weber test: Sound equal in both ears (Normal); Sound lateralize to good ear (Sensorineural);
Sound lateralize to bad ear (Conductive)
CRANIAL NERVE IX & X: GLOSSOPHARYNGEAL & VAGUS NERVE
GENERAL SKULL TYPE/SITE ABNORMAL

DISTRIBUTION OPENING OF LESION FINDING
CN IX: Glossopharyngeal
Mixed
 SVA/GVA
(petrosal
Brainstem  Loss of taste
ganglion)  Taste: Somatic lesion or  Loss of
 SVE (nucleus Derivatives of 3rd Jugular
posterior 1/3 (brachial) motor: deep sensation of
pharyngeal arch Foramen
ambiguous)  Swallowing medulla laceration of soft palate
 GVE (inferior neck (same side)
salivatory
nucleus)
CN X: Vagus
 Somatic
(brachial)
motor:
medulla
 Somatic
Mixed
(general)  Soft palate
 SVA/GVA
sensory: sagging
(ganglion Brainstem
superior  Deviation of
nodosum) lesion or
 Heart rate Derivatives of 4th Jugular ganglion the uvula to
deep
 SVE (nucleus  Digestion pharyngeal arch Foramen  Visceral motor: normal side
laceration of
ambiguous) Presynaptic =  Hoarseness
neck
 GVE (dorsal medulla (due to vocal
motor nucleus)  Postsynaptic = fold paralysis)
visceral
neurons
 V and S:
inferior
ganglion

NEUROLOGY:
I. Steps
SPEECH
Test for articulation by the soft tissues, the soft palate, tongue, and lips, with the KLM test. Kuh, Kuh, Kuh tests the function of the
soft palate/velopharyngeal valve; La, La, La, tests the tongue/lingual; Mi, Mi, Mi tests the lips/labials.
KLM TEST NO REMARKS

YES
Kuh Kuh Kuh
La La La
Mi Mi Mi
Taste test NO REMARKS

YES
The examiner can use a cotton tip applicator dipped in a solution
that is sweet, salty, sour, or bitter to assess ability to taste of
posterior third of tongue (CrN 9)
Other tests for velopharyngeal valve function (sibilants &

NO REMARKS
fricatives) YES
SSS or Hisssss
V, V, V; Z, Z, Z; F, F, F
ABILITY TO SWALLOW/DYSPHAGIA
Ask the patient to swallow. To test for mild to moderate dysphagia, give the patient a glass containing 150 ml water. The patient
should swallow it a rate exceeding 10ml/s. any patient with dysphagia may aspirate food or fluids into the lung, causing aspiration
pneumonitis.
ABILITY TO SWALLOW
Instruct the patient to swallow
EXAMINATION OF THE PALATE AND LARYNX
Ask the patient to say Ahh, inspect the tonsillar pillars for asymmetry as they arch upward and medially to form the palate.
Look at the arch, the arch above, not the uvula.
Ask the Pt to repeat: “We see three gray geese” to test palatal function. Traditionally, it was asking the Pt to say, Ahh… But
the vowel E requires tighter palatal closure, though the Pt can say Ah more easily with the mouth open to permit palatal
inspection.
PALATE AND LARYNX RIGHT LEFT
 Ask the Pt to say ‘Ahh’

 Inspect the tonsillar pillars for asymmetry as they
arch upward and medially to form the palate.
 Look at the arch, the arch above, not the uvula.  Palatal Palsy  Palatal Palsy
 Watch the levator veli palatini muscle.  Normal  Normal
 Ask the Pt to repeat “We see three gray geese.”

NEUROLOGY:
GAG REFLEX YES NO
 The gag reflex is an additional test for palatal elevation.

 Touch one tonsillar pillar and then the other with a tongue blade.
 The afferent arc of the gag reflex is primarily CrN IX. The efferent arc is CrN X.
If the palate fails to elevate when the Pt says ‘Ah’ but does elevate during the gag reflex, the Pt
would have a lesion of the UMN.
II. Pathway
The glossopharyngeal nerve is a motor and a sensory nerve.
The glossopharyngeal nerve has three nuclei:

(1) the main motor nucleus
(2) the parasympathetic nucleus, and
(3) the sensory nucleus.
Course of the Glossopharyngeal Nerve
glossopharyngeal nerve (anterolateral surface of the upper medulla)  groove b/w olive and inferior cerebellar peduncle
laterally in the posterior cranial fossa  jugular foramen (where superior and inferior glossopharyngeal sensory ganglia
are situated)  descends through upper neck with the internal jugular vein and internal carotid artery  posterior border
of the stylopharyngeus muscle  passes forward between superior and middle constrictor muscles of the pharynx (sensory
branches to pharynx and the posterior third of the tongue
The vagus nerve is a motor and a sensory nerve.
Vagus Nerve Nuclei
The vagus nerve has three nuclei:
(1) the main motor nucleus
(2) the parasympathetic nucleus
(3) the sensory nucleus.
Course of the Vagus Nerve

NEUROLOGY:
III. Theoretical
LMN innervation of the pharynx and larynx by cranial nerves 9 and 10
The skeletal muscles supplied by CrNs IX and X originally came from branchial arches. The branchial efferent nucleus for IX and X, the
nucleus ambiguus, is in the medulla. CrN IX supplies only one muscle exclusively (stylopharyngeus). Because this muscle aids in
swallowing, its isolated function cannot be tested clinically. The remaining branchial efferent fibers of CrNs IX and X supply the
pharyngeal constrictors. Because they act as a unit in swallowing, the isolated function of the individual constrictors cannot be
tested at the bedside.
Cranial nerve IX innervate palate, tongue, and pharynx. Motor axons innervate the stylopharyngeus and middle pharyngeal
constrictor muscles. Sensory axons mediate taste from the tongue, the gag reflex, and the vasomotor, cardioinhibitory, and
respiratory reflexes of the carotid body and sinus
Normal Swallowing
Swallowing requires afferent information via CrNs V, IX, and X, and motor actions are mediated by CrNs V, VII, IX, X, and XII.
Connections in the region of the nucleus of the tractus solitarius in the medulla, in proximity to the respiratory center, act as a
swallowing center. It coordinates the actions of swallowing and breathing to avoid aspiration.
Clinical physiology of the soft palate
The levator veli palatini muscle, innervated via the pharyngeal plexus by CrN X, swings the soft palate upward and backward to
contact the posterior wall of the pharynx. This action seals off the naso pharynx from the oro pharynx. Unless the soft palate
elevates, there will be “nasal swallowing” and “nasal speech”.
The palate elevates when you:
 Swallow
 Whistle/ trumpet
 Make certain speech sounds
Upper motor neuron innervation of cranial nerves 9 and 10
The palate, pharynx, and vocal cords act with bilateral synchrony. By knowing this fact,you can predict that the number of crossed
and uncrossed UMN fibers from each cerebral hemisphere would be about equal. Because of the usual bilateral UMN innervation,
unilateral UMN lesions that cause hemiplegia only rarely cause unilateral weakness of the palate (Willoughby and Anderson, 1984),
but Pts with acute hemiplegia frequently show mild dysarthria (about 60%).
Articulation of Speech
Vowels require palatal elevation. The palate does not completely seal off the nasopharynx during most speech sounds. Instead, it
reduces the nasopharyngeal aperture, thereby detouring most of the air through the mouth, the path of least resistance. Only a few
sounds require complete palatal closure:
 Plosives: K or hard G , as in good .

 Vowels: sustained EEEEE… or Ah…
Plosive sounds require momentary impounding of air and sudden release (Puh, puh, puh and kuh, kuh, kuh).
Sibilants are hissing or whistling sounds (SSS… or a prolonged Hisssss…)
Fricatives are high-frequency frictional or rustling sounds (V , V , V… ; Z , Z , Z… ; and F , F , F…) To produce sibilants and fricatives,
you must force a strong stream of air through a small aperture formed by lips, tongue, and teeth.
Removal of the adenoid tissue increases the distance the palate has to close to shut off the nasopharynx. A weak palate is now even
less capable of preventing nasal escape of air.

NEUROLOGY:
If the patient does not have any abnormal findings then you can say that “The cranial nerves 9 & 10 are intact”. Kapag naman may
abnormal findings halimbawa hindi sya nag-respond sa gag reflex pwede mong sabihin na “The patient has cranial nerves 9 and 10
deficit” since efferent arc ng gag reflex ang CN X at afferent naman ang CN IX. Tapos sa palate at larynx naman, kung saan magde-
deviate, nandun yung deficit so pwedeng pag sa left “The patient has a left CN X deficit”
V. Other
Electrical stimulation of the vagus nerve, called vagus nerve stimulation (VNS), is sometimes used to treat people with epilepsy or
depression.
The vagus nerve is involved in one of the most common causes of fainting, called vasovagal syncope.
It is known to be one of the longest of all the cranial nerves.
CRANIAL NERVE XI: SPINAL ACCESSORY NERVE

 SCM and
Upper
Superficial
Motor (General Jugular Medulla/Spinal Neck Trapezius
Moves Head Layer of the
Somatic Efferent) Foramen Cord Laceration paralysis
Neck
 Drooping of
shoulder
I. Steps
Test for Sternocleidomastoid (SCM) - The sternocleidomastoid is a long muscle in the side of the neck that extends up from the
thorax to the base of the skull behind the ear. When the sternocleidomastoid on one side contracts, the face is turned to the
opposite side. When both muscles contract, the head is bent toward the chest.
LEFT RIGHT
Weakness Weakness
1. Inspect the SCM muscles for size and symmetry
Assymetry Assymetry
2. Palpate the muscles at rest and as they exert their actions.
Atrophy Atrophy
1. Facing the patient, place your right hand on the left check of the patient
and your left hand on his right shoulder to brace him.
2. Command the patient, “Turn your head to the left. Do not let me push it
back”
3. Examiner tries to force his head to the midline.
4. Repeat on the other side
* With the patient’s head turned to the left, you test the right SCM. (SCM
turns the head to the opposite side)
* The Patient’s head turns to the side of the lesion because of assumed
weakness of the SCM ipsilateral to the lesion
1. Ask the patient to tilt (as if touching the tip of shoulder with the ear)
* SCM tilts the head to the same side

1. Place 1 hand on the patient’s forehead and push backward. Place the
other hand on the vertebrae prominence and press forward.
2. Tell the patient to push his head forward as hard as possible
* SCM thrusts the head forward
Test for Trapezius Muscle - responsible for moving, rotating, and stabilizing the scapula (shoulder blade) and extending the head at
the neck. It is a wide, flat, superficial muscle that covers most of the upper back and the posterior of the neck. Like most other
muscles, there are two trapezius muscles – a left and a right trapezius – that are symmetrical and meet at the vertebral column.

NEUROLOGY:
Remarks
 Weakness
1. Inspect the Trapezius muscles for size and symmetry.
 Assymetry
2. Palpate the muscles at rest and as they exert their actions.
 Atrophy
1. Place your hand on both patient’s shoulders and press down
* Watch for Scapular Winging (Trapezius or SCM)
II. Pathway
NUCLEI C1-C5 anterior horns

COMES FROM Medulla
GOES THROUGH Jugular Foramen
SUPPLIES Sternocleidomastoid and Trapezius
III. Theoretical
2 Parts:
1. Spinal- supplies Sternocleidomastoid, Trapezius

2. Accessory- accessory to the Vagus Nerve
Actions of the SCM:
 Thrusts head FORWARD

 Turns head to the OPPOSITE SIDE
 Tilts head to the SAME SIDE
ORIGIN INSERTION
STERNOCLEIDOMASTOID Sternum, Clavicle Mastoid Process
Occiput, Spinous process of all cervial
TRAPEZIUS Clavicle, Scapula
and thoracic vertebrae
*CN 11 innervates ONLY the rostral part of the Trapezius muscle (used to lift the shoulders)
Report that cranial nerve is intact without any evidence of Dysfunction upon assessment
Report patient was able to resist the strength that was applied if normal
Report any abnormalities: scapular winging, any weakness or atrophy on the side tested and muscle asymmetry.
CRANIAL NERVE XII: HYPOGLOSSAL NERVE

 Protruded
tongue
Neck
Motor  deviates
Hypoglossal laceration
GSE (hypoglossal Moves tongue Tongue muscle Medulla towards the
canal Basal skull
nucleus) affected side
Fracture
 Moderate
dysarthria
I. Steps
RANGE OF MOVEMENT MOVEMENT REMARKS

Adduction
1. Ask the patient to move the tongue alternately to the
Abduction
right and to the left and to try to touch the tip of the
Upward
tongue to the tip of the nose and to the chin.
Downward
2. On protrusion, the tongue tip should extend well
Left Side
beyond the teeth.
Right Side

NEUROLOGY:
TONGUE MOTILITY AND DEVIATION TEST LEFT RIGHT

1. Inspect the tongue for the most reliable sign of CN XII
lesion, hemiatrophy.
2. While wearing a rubber glove, palpate each of the
tongue between your thumb and index finger.
Tongue Deviation:
1. Tell the patient “stick out your tongue as far as
possible and hold it there”
2. Check for the alignment of the median raphe of the
tongue with the crevice between the incisor teeth.
 Tongue deviates to the paralyzed side
1. Have the patient press tongue against a cheek while
you press your finger against the cheek
 With the tongue inside the mouth, the patient can
deviate the tip of the tongue to the non-paralyzed side
but not to the paralyzed side, in contrast to its
deviation to the paralyzed side when outside the
mouth.
 The genioglossus, an intrinsic muscle, acts on the
protruded tongue, whereas the intrinsic muscles,
cause lateral movement of the tip of the non-
protruded tongue.
II. Pathway
1. Arises from the hypoglossal nucleus of the medulla
2. Exits the medulla in the preolivary sulcus
3. Exits the skull via the hypoglossal canal
III. Theoretical
What are the three main articulators?
1. Air cavities- containers of air molecules of specific volumes and masses

- supraglottal cavity and subglottal cavity
2. Pistons- used to initiate a change in the volumes of air cavities
3. Valves- regulate airflow between cavities. Airflow occurs when an air valve is open and there is a pressure difference
between the connecting cavities
FUNCTION:
Supplies intrinsic muscle of the tongue
Muscle Origin Action

Depresses and protrudes
Genioglossus Mental spine of mandible
tongue
Body and greater horn of Depresses and retracts
Hyoglossus
hyoid bone tongue
Styloid process and stylohyoid
Styloglossus Retracts tongue and draw
ligament
Describe the laterality and function of the genioglossus muscle.
Apex- originates from the apex of the mandible, (hard, unyielding and immobile)
Base: Fans out to insert into the base of the tongue (soft, fleshy, and mobile)
Symmetrical genioglossus contraction must pull the base of the tongue forward.
Therefore if tongue protrudes in the midline, genioglossus contracts equally.

NEUROLOGY:
CLINICAL CORRELATION
1. HEMIPARALYSIS of the tongue

2. Protrusion cause the tongue to point toward the weak side because of the unopposed action of the opposite genioglossus
muscle
3. Ask the patient to protrude tongue
4. Watch for deviation
a) Deviates toward the same side in a peripheral lesion
b) Deviates toward the opposite side in a central lesion
Left genioglossus Muscle that turns tongue to the right

Right Lateral Pterygoid Muscle that turns the mandible to the left
Left SCM Muscle that turns the head to the right
Extrinsic muscle (genioglossus) acts on the protruded tongue
Intrinsic Muscle – cause lateral movement of the tip of the non-protruded tongue
LOWER MOTOR NEURON LESION OF CRN 12
Interruption of CRN 12 causes muscle fiber of the ipsilateral tongue to undergo atrophy .
Sign: Ipsilateral atrophy
Ipsilateral deviation
Tongue is midline on protrusion

No atrophy by inspection
CN 12 is intact
V. Other
 If the hypoglossal nerve is affected on one side, the tongue often deviates toward the side of the lesion on protrusion due
to imbalance of genioglossus contraction
 When the hypoglossal nerve or its nucleus is damages, atrophy and fasciculation of the tongue are noted on the evaluation
 The larynx may deviate towards the active side in swallowing due to unilateral paralysis of the hyoid depressors.
 Lesions of the hypoglossal nerve may occur anywhere along its course and may result from tumor, demyelinating diseases,
syringomyelia and vascular accidents.
AUTHORS:
Abdon, Sarah Jane Baquiran, Liza Esguerra, Maqui

Alfaro, Aireeze Birol, Karen Favila, Stephanie
Aliento, EJ Cabana, Karen Gelito, Leonise
Ambatali, Sarah Cacho, Patriz Go, Nicole
Angeles, Ruel Canlas, Rozz Guialab, Hanan
Arana, Marjorie Carvajal, Mary Imperial, Jeremiah
Badua, Patricia Chua, Kristel Jaravata, Catherine
Bagamano, Kristine Cinco, Tanya
Ballesteros, Junjee Daroya, Katherine

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SAN BEDA COLLEGE OF MEDICINE

EXAMINATION OF THE CRANIAL NERVES: NERUROLOGICAL EXAM & THEORETICALS

SBCM 2019 SECTION A Page 1 of 42

CRANIAL NERVE I: OLFACTORY NERVE

Bipolar cells in neuroepithelium (receptors)

2o olfactory nerve fibers---Cribriform plate---Dura Arachnoid

Anterior perforated substance and uncus

Bypass the thalamus

Activates cortex, brainstem and hypothalamic nuclei

GENERAL SKULL TYPE/SITE OF ABNORMAL

 Use at least 3 substances

SBCM 2019 SECTION A Page 2 of 42

CRANIAL NERVE II: OPTIC NERVE

A. PUPILLARY LIGHT REFLEX RIGHT LEFT

SWINGING FLASHLIGHT TEST

B. TEST FOR CENTRAL VISION RIGHT LEFT

SBCM 2019 SECTION A Page 3 of 42

2. Appreciation of Hand Movements (waving effect)

3. Perception of Direction of Light (peripheral flashlighting)

4. Perception of Light (direct flashlighting)

C. TEST FOR PERIPHERAL VISUAL FIELDS RIGHT LEFT

SBCM 2019 SECTION A Page 4 of 42

C. OPHTHALMOSCOPY TEST RIGHT LEFT

1. Remove your and the patient’s glasses

SBCM 2019 SECTION A Page 5 of 42

Normal optic disc

Swollen disc but Pt can see as usual  papilledema

SBCM 2019 SECTION A Page 6 of 42

Pathway for pupillary light reflex

SBCM 2019 SECTION A Page 7 of 42

Afferent Limb (CN2), Efferent Limb (CN3)

GENERAL SKULL TYPE/SITE OF ABNORMAL

 Clinical relevance of pupillary light reflex

SBCM 2019 SECTION A Page 8 of 42

 Horner Syndrome: ptosis, miosis, anhydrosis, vasodilation

 Clinical relevance of test for central vision

SBCM 2019 SECTION A Page 9 of 42

Lesion sites and their corresponding visual field defects

CRANIAL NERVE III: OCULOMOTOR NERVE

GENERAL LEFT RIGHT

DIRECT AND CONSENSUAL PUPILLARY LIGHT REFLEX

SBCM 2019 SECTION A Page 10 of 42

1. Look for failure of movement and nystagmus.

Lateral Rectus ___ ___

TEST FOR CONVERGENCE

TEST FOR ACCOMODATION

SBCM 2019 SECTION A Page 11 of 42

 Primary position of the eye: look straight ahead, essential parallel

ACTIONS OF THE EXTRAOCULAR MUSCLES

 SUPRANUCLEAR CONTROL OF EYE MOVEMENTS:

Cortical areas involved in the generation of saccades:

1. Frontal eye fields (FEF) – main horizontal gaze control center

 FEF controls horizontal saccades to the opposite side.

SBCM 2019 SECTION A Page 12 of 42

Left frontal eye field

Which Frontal Eye Field Is Active?

SBCM 2019 SECTION A Page 13 of 42

SBCM 2019 SECTION A Page 14 of 42

 Disconjugate or disjunctive – simultaneous movement of the eyes in the opposite direction

 The 6 recognized eye movement/ control systems (mostly, operational definitions):

DISORDERS OF OCULAR MOTILITY

Peripheral Disorders Central Disorders

SBCM 2019 SECTION A Page 15 of 42

Lateral Rectus _ _