FACT SHEET – CRANIAL NERVE ASSESSMENT

Compiled By: RA Gapuz Review Center Mentors

DESCRIPTION

The cranial nerve exam is a type of neurological examination. It is used to identify problems with the cranial
nerves by physical examination. It has nine components. Each test is designed to assess the status of one or more
of the twelve cranial nerves (I-XII). These components correspond to testing the sense of smell (I), visual fields and
acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face
(V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal
movement and reflex (IX, X), tongue movements (XII).

PROCEDURE

Associated
Nerve(s) Function(s) Evaluation(s)
conditions

Smell is tested in each nostril separately by placing

stimuli under one nostril and occluding the opposing
nostril. The stimuli used should be non-irritating and
identifiable. Some example stimuli
I: Olfactory nerve Sense of smell include cinnamon, cloves, and toothpaste. Bilateral loss meningioma
can occur with rhinitis, smoking, or aging. Unilateral
loss indicates a possible nerve lesion or deviated
septum. This test is usually skipped on a cranial nerve
exam.

Visual fields are assessed by asking the patient to

cover one eye while the examiner tests the opposite
eye. The examiner wiggles the finger in each of the four
quadrants and asks the patient to state when the finger
is seen in the periphery. The examiner's visual fields
should be normal, since it is used as the baseline.
Visual fields
II: Optic nerve Optic neuritis
and acuity
Visual acuity is tested in each eye separately. Ensure
the patient's vision is corrected with eyeglasses or a
pinhole. The patient is asked to read progressively
smaller lines on the near card or Snellen chart.

Fundoscopy

Ocular movements are tested by standing one meter in

front of the patient and asking the patient to follow a
target with eyes only, and not the head. The target is
moved in an "H" shape and the patient is asked to
report any diplopia. Then, the target is held at the
lateral ends of the patient's visual field. Nystagmus is
tested for. One or two beats is a normal finding.
The accommodation reflex is tested by moving the
III, IV, Ocular and target towards the patient's nose. As the eyes
VI: Oculomotor extraocular converge, the pupils should constrict. The optokinetic
nerve, Trochlear movements, nystagmus test is optional and involves asking the
nerve, Abducens pupillary patient to look at a strip of vertical lines moving
nerve response horizontally across visual field. Nystagmus is normally
observed.
Extraocular movements is tested
by inspecting for ptosis, eye position and nystagmus.
The pupil size is measured, its shape and any
asymmetry is tested. A commonly used abbreviation to
describe normal pupils is PERRLA (pupils equal, round
and reactive to light and accommodation).
 Pupillary light reflex is tested by having the patient stare
into the distance as the examiner shines
the penlight obliquely into each pupil. Pupillary
constriction is tested for on the eye examined (direct
response) and on the opposite eye (consensual
response). The swinging flashlight test involves moving
the light between the two pupils. Normally both direct
and consensual responses are ellicited when the light
shines on an eye, and some dilation will occur during
the swing between.

Light touch is tested in each of the three divisions of the

trigeminal nerve and on each side of the face using a
cotton wisp or tissue paper. The ophthalmic division is
tested by touching the forehead, the maxillary division
is tested by touching the cheeks, and the mandibular
division is tested by touching the chin. Be careful not to
test the mandibular division too laterally, as the
mandible is innervated by the great auricular nerve (C2
and C3). A common mistake is to use a stroking
motion, which will trigger pain and temperature nerves.
Instead, a point stimulus should be applied. For pain
and temperature repeat the same steps as light touch
but use a sharp object and a cold tuning fork
respectively.
Facial trigeminal
V: Trigeminal nerve Corneal reflex is conducted along with the facial
sensation neuralgia
nerve section of the test. Note the sensory innervation
of the cornea is provided by the trigeminal nerve while
the motor innervation for blinking the eye is provided by
the facial nerve.-
Muscles of mastication (temporalis, masseter) should
be inspected for atrophy. Palpate the temporalis and
masseter as the patient clenches the jaw. The
pterygoids can be tested by asking the patient to keep
the mouth open against resistance, and move from side
to side against resistance. A jaw jerk reflex can be
tested by placing a finger over the patient's chin and
then tapping the finger with a reflex hammer. Normally
the jaw moves minimally.

Inspect for facial asymmetry and involuntary

movements.

• Motor
1) Raise both eyebrows
2) Frown Bell's
Palsy, Ramsay
VII: Facial nerve Facial muscles 3) Close both eyes tightly so that you can not open
Hunt
them. Test muscular strength by trying to open them
syndrome
4) Show both upper and lower teeth
5) Smile
6) Puff out both cheeks

• Sensory : test for taste

• Hearing is tested by whispering numbers in one ear
as patient covers the other and ask the patient to
repeat the numbers. Alternatively, have patient
close their eyes and say "left" or "right" depending
VIII: Vestibulocochle on the side from which they hear the sound. acoustic
Hearing
ar Vigorously rub fingers together in one ear at a time neuroma
to produce rustling sound. Conduct the Rinne
test and Weber test.
• Vestibular Function
 • Gag response
IX and Taste, • Visualizing uvula deviation away from affected side Lateral
X: Glossopharyngeal pharyngeal on articulating "AHH" with tongue depressor. medullary
and Vagus movement • Palatal articulation "KA" syndrome (IX)
• Guttural articulation "GO"
Shoulder girdle • Shrug shoulders
XI: Accessory nerve
muscles • Turn head from side to side
• Stick out tongue and move it to one side, then the
Tongue other[3]
XII: Hypoglossal
movements • Inspect for tongue atrophy, fasciculations or
asymmetry in movement or appearance