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Cranial Nerve Exam

Introduction

Greetings
Hand wash
Verify the patient's identity using at least two or three details
Explanation
Consent

CN 1: Olfactory

Ask any change to sense of smell or difficulty smelling

CN 2: Optic

Visual acuity
Pupils and responses
Symmetry

~1:20 people have asymmetrical pupils normally

Response to light
Ipsilateral (direct)
Contralateral (consensual)
Shines light from side of the eye

Not in front, to avoid testing accommodation

Accommodation reflex

Place object ~20cm from eyes, ask patient to look at wall then object

Visual fields: Assess for 10, 2, 8 and 4 o' clock positions in both eyes

Screening test for hemianopia / quadrantanopia

CN 3, 4, 6: Oculomotor, trochlear, abducens

Do an H shape with your finger and ask the patient to follow
(optional) place hand gently on patient's chin to stop head from moving
Ask the patient to comment on diplopia, and you can comment on abnormal movements of the pupil(s) if there are any

CN 5: Trigeminal

Assess sensory with monofilament / cotton / pinprick (whichever available) for:
V1
V2
V3
Ask if it feels normal and same on both sides (don't just ask if they can feel it)
Assess for motor with muscles of mastication: Put your hand on temporomandibular joint (TMJ) or temporal fossa and ask them to clench their teeth

CN 7: Facial

Comment on symmetry
Movement
Eyebrows up
Eyes tight shut
Puff out cheeks
Bare teeth / smile
Ask about loss or change in sensation on face

CN 8: Acoustic

Vestibular component: Dix-Hallpike manoeuvre

Positive test: nystagmus after latent period, waxing then waning. No latent period or persistent nystagmus suggests central lesion

Cochlear component
Cover one ear and whisper a number and ask them to repeat it
Rinne test

Normally, air conduction > bone conduction. Rinné negative in conduction deafness

Weber's test

Sound localizes to normal ear in nerve deafness, to affected ear in conduction deafness

CN 9 and 10: Glossopharyngeal & Vagus

Observe uvula

Should lift symmetrically. Unilateral weakness deviates away from lesion

Explain gag reflex properly
Assess for gag reflex

Important for swallow and risk of aspiration

CN 11: Accessory

Shoulder shrug and neck turning. Then observe for symmetry / range of movement / muscle bulk
Do above again while resisting

Test SCM strength by resisting head turn

CN 12: Hypoglossal

Tongue movements

Tongue will deviate towards the lesion

(Optional but good) assess tongue strength by asking the patient to press their tongue against the inside of their cheek while you apply pressure from the outside with your hand.
Wash hands

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