Cranial nerve 1 to 6 with clinical application and examination

1. CRANIAL NERVE
EXAMINATION 1 - 6
by- NAMITA KAUSHIK
MPT(NEUROLOGY)
Certified in SCI PT Management
(ISCOS)

3. FUNCTIONAL DIVISION
SENSORY
1
2
8
MOTOR
3
4
6
11
12
MIXED
5
7
9
10

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Unilateral or bilateral
Altered taste
Past head injury;
Smoking
Recent upper-respiratory infection
Systemic illness
Nutrition
Exposure to toxins, medications or illicit drugs.

6. Before evaluating smell- nasal passages are open.
Smell is tested using nonirritating stimuli.
Avoid irritating substances-stimulate trigeminal nerve
Examine each nostril separately while occluding
other with eyes closed
Perception more important than accurate
identification

7. Term Definition
Anosmia No sense of smell
Hyposmia decrease in the sense of smell
Hyperosmia overly acute sense of smell
Dysosmia Impairment or defect in the sense of smell
Parosmia Perversion or distortion of smell
Phantosmia Perception of an odor that is not real
Presbyosmia Decrease in the sense of smell due to aging
Cacosmia Inappropriately disagreeable odors
Coprosmia fecal scent
Olfactory agnosia Inability to identify or interpret detected odors

8. OLFACTORY NERVE
Use familial , non irritant substance(e.g. coffee ground) and
test each nostril alone with eyes closed.

9. Smoking
Pregnancy
Chronic rhinitis
Dental trauma
Deviated nasal septum
Intranasal tumors (e.g., epidermoid
carcinoma)
Neuro-olfactory tumor
(esthesioneuroblastoma)
Nasal polyps
Antihistamines
Propylthiouracil
Olfactory dysgenesis
Cadmium toxicity
Chemical burns of the olfactory
epithelium
Vitamin deficiency (B6, B12, A)
Postviral
Zinc or copper deficiency General
anesthesia Kallmann's syndrome
Olfactory groove
meningioma
Craniocerebral trauma,
including surgery
Frontal lobe tumor,
especially glioma
Normal aging
Multiple sclerosis
Sellar/parasellar tumor
Congenital anosmia
Meningitis
Korsakoff's syndrome
Alzheimer's disease
Parkinson's disease
Familial dysautonornia
Temporal lobectomies
Refsums disease
CAUSES

11. OPTIC NERVE
Visual Acuity
Colour Vision
Light reflex
Accomodation Reflex
Visual Field

12. Visual
acuity
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Minimum visibility-smallest area that can be
perceived
Minimum separability-ability to recognize the
separateness of two close points or lines
Snellen chart for distance and near card for near
Acuity- line where more than half of characters are
accurately read
Distance from test chart, 20 or 6-numerator, and
distance at which smallest type read by patient
should be seen by a person with normal acuity-
denominator.

13. Near vision
Jaeger chart
Newspaper want-ad text is approximately J- 0,
regular newsprint J-6, and newspaper headlines
J-17.
Counts fingers (CF), hand motion (HM), light
perception (LP), or no light perception (NLP).
Count fingers at 5 ft-20/800.

14. Snellen’s chart Jaeger’s chart
VISUAL ACUITY

15. Color Vision; Day and Night Vision
Color plates or pseudoisochromatic plates
(Ishihara, Hardy-Ritter-Rand )
In neurologic disease, red perception usually lost
first
Compare brightness or intensity of examining
light in one eye versus other

16. Ishihara chart
COLOUR VISION

19. Visual field
Normal VF- 90 degrees to 100 degrees
temporally, about 60 degrees nasally, 50
degrees to 60 degrees superiorly, and 60
degrees to 75 degrees inferiorly
Examination most accurate in an individual
who is alert and cooperative and maintain
fixation.
Confrontation test

20. Confrontation
test

21. Optic neuritis
Ischemic optic neuropathy
Optic nerve compression
Papillophlebitis
Optic nerve infiltration (carcinomatous, lymphomatous)
Sarcoidosis
Diabetic papillopathy
Tobacco-alcohol amblyopia
Nutritional deficiency, especially vitamin B12
Drugs
Toxins
Hereditary optic neuropathy (Leber, Kjer)
Glaucoma

22. Chiasmal Lesions
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Pituitary tumors
Craniopharyngiomas
Meningiomas
Gliomas
Carotid aneurysms
Demyelination
Ischemia
Radionecrosis

23. OCCULOMOTOR, TROCHLEAR &
ABDUCENS NERVES

26. TRIGEMINAL NERVE
SENSORY
MIXED

27. Sensory : With cotton swab (light touch)
and pin (pain).
Check for: Both Sides
Inner & outer face
Each division
Important: Ask patient to close eyes

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Motor: Muscles of mastication
Temporalis muscle : clench teeth + palpate
muscle
Masseters : clench teeth + palpate muscle,
holding its ant. & post. Borers.
Pterygoids: Fixed head ; open mouth + open
mouth against resistance to test tone
Clinical significance:
In Unilateral pterygoid paralysis : The jaw is
deviated to the diseased side
In Bilateral pterygoid paralysis : inability to
open mouth

29. CLENCHING OF JAW AND MUSCLE
PALPATION AREA

30. Pterygoid paralysis (unilateral)

31. Reflexes:
REFLEX AFFERENT EFFERENT
CORNEAL REFLEX CN - V (ophthalmic) CN - VII
JAW JERK CN - V (iii, SENSORY) CN – V (iii, MOTOR)

32. JAW JERK

33. CORNEAL REFLEX

34. Trigeminal Neuralgia:-
also known as Fothergill’s disease
Tic douloureux (painful jerking)
it is defined as , sudden ,usually ,unilateral ,severe
,brief ,stabbing , lancinating , recurring pain in the
distribution of one or more branches of trigeminal
nerve.
Mean age: 50 y onwards
Female predominance (male : female = 1:2 ~2:3)

35. ETIOLOGY
It is usualy idiopathic.
The probable etiologic factors are:-
Intra cranial tumors:-Traumatic compression of the
trigeminal nerve by neoplastic (cerebellopontine angle
tumor) or vascular anomalies eg arteriovenous
malformations
Infections :- granulomatous and non granulomatous
infections involving 5th cranial nerve.

36. General characteristics
Incidence:- seen in about 4 in 100000 persons
Age of occurrence:- 5th to 6th decade Sex predilection:
-female predisposition
Side involved more frequently:-right side
Division of trigeminal nerve involve; most commonly
mandibular > maxillary >ophthalmic

37. Provocated by obvious stimuli like
Touching face at particular site Chewing
Speaking Brushing Shaving Washing the face
The characteristic of the disorder being that the
attacks do not occur during sleep.

38. Clinical characteristics:-
sudden
unilateral
intermittent paroxysmal sharp shooting
lancinating shock like pain elicted by slight touching

39. superficial trigger points which radiates across the
distribution of one or more branches of the trigeminal
nerve
pain rarely crosses the midline
pain is of short duration and last for few seconds to
minutes
in extreme cases patient has a motionless face called
the frozen or mask like face
presence of intraoral or extraoral trigger points

40. Wallenberg syndrome:-a stroke which causes loss of pain/temperature
sensation from one side of the face and the other side
of the body.
ETIOLOGY:-
In the medulla, the Ascending Spinothalamic Tract
(which
carries pain/temperature information from
the opposite side of the body) is adjacent to the
Descending
Spinal Tract of the fifth nerve (which carries pain
/temperature information from the same side of the

41. THANK YOU