Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women's/Massachusetts General Hospital, Boston, Massachusetts, USA
The cranial nerve examination follows the mental status evaluation in a neurological exam. However, the examination begins with observations made upon greeting the patient. For example, weakness of the facial muscles (which are innervated by cranial nerve VII) can be readily apparent during the first encounter with the patient. Cranial nerve VII (the facial nerve) also has sensory branches, which innervate the taste buds on the anterior two-thirds of the tongue and the medial aspect of the external auditory canal. Therefore, finding ipsilateral taste dysfunction in a patient with facial weakness confirms the involvement of cranial nerve VII. In addition, knowledge of the neuroanatomy helps the clinician to localize the level of the lesion: unilateral weakness of the lower facial muscles suggests a supranuclear lesion on the opposite side, while lesions involving the nuclear or infranuclear portion of the facial nerve manifest with an ipsilateral paralysis of all the facial muscles on the involved side. Cranial nerve VIII (the acoustic nerve) has two divisions: the hearing (cochlear) division and the vestibular division, which innervates the semicircular canals and plays an important role in maintaining balance. During a routine neurological examination, special testing of the vestibular nerve is usually not performed.
Cranial nerve IX (the glossopharyngeal nerve) and cranial nerve X (thevagus nerve) arise from the medulla and have laryngeal and pharyngeal function; their function is tested by assessing speech and motility of the soft palate.Because cranial nerves IX and Xform the sensory and motor limbs of the gag reflex, eliciting for gag reflex can also test their function. Cranial nerve XI (the spinal accessory nerve) innervates the sternocleidomastoid muscle and the upper portion of the trapezius muscle. These muscles control side-to-side turning the head and shrugging of the shoulders. The cranial nerve exam concludes by testing cranial nerve XII (the hypoglossal nerve), which provides motor control of the muscles of the tongue.
During the neurological assessment, the clinician should always be trying to tie together the findings of the exam to get insight into the underlying disease. The important diagnostic clues might include signs of multiple cranial nerve involvement and unilateral vs. bilateral cranial nerve dysfunction. It will help the clinician formulate differential diagnoses to know whether the patient's symptoms occurred suddenly (as expected with a stroke), over about a day (as in Bell's palsy), or gradually over weeks to months (as with an expanding mass lesion).
Evaluation of cranial nerves I-VI is covered in another video of this collection. This video demonstrates the systematic examination of cranial nerves VII-XII (Table 1).
|II||Optic||Visual acuity, afferent pupillary response|
|III||Oculomotor||Horizontal eye movements (adduction), efferent pupillary response|
|IV||Trochlear||Downward vertical eye movement, internal rotation of eye|
|V||Trigeminal||Facial sensation, jaw movement|
|VI||Abducens||Horizontal eye movement (abduction)|
|VII||Facial||Facial movement and strength, taste, dampening of loud sounds, sensation; anterior wall of external ear canal|
|VIII||Acoustic||Hearing, vestibular functioning|
|IX||Glossopharyngeal||Movement of pharynx, sensation of pharynx, posterior tongue (including taste of posterior tongue), and most of ear canal|
|X||Vagal||Movement and sensation of palate, pharynx, gag reflex, guttural sounds|
|XI||Spinal accessory||Strength of sternocleidomastoid and trapezius muscles|
|XII||Hypoglossal||Tongue protrusion and lateral movements|
Table 1. The 12 cranial nerves and their basic functions
1. Cranial Nerve VII: Facial
- Begin by observing the patient. If there is facial asymmetry, determine which side is affected, which may not be immediately obvious. Remember that most people have a slight bony facial asymmetry. Smoothing of the nasolabial folds or widening of a palpebral fissure on one or both sides could be subtle signs of facial weakness.
- The following maneuverstest the motor function of the facial nerve. Peripheral facial palsy (Bell's palsy) manifests with unilateral weakness of both the upper and lower facial muscles, unlike central facial palsy (such as seen in stroke) where the upper facial muscles are not affected by weakness because of the bilateral cortical innervation of the forehead.
- Ask the patient to raise the eyebrows. Look for an inability to wrinkle the forehead on the involved side.
- Tell the patient to smile or show teeth, which will accentuate the weakness on the involved side, as the patient may not be able to fully raise the ipsilateral upper lip, resulting in a crooked appearance.
- Ask the patient to close the eyes tightly against resistance applied by the examiner. You can also assess if the patient buries the eyelashes equally on both sides.
- Ask the patient to blow up the cheeks and try to push the air out against pursed lips.
- Bell's palsy may result in an ipsilateral loss of taste on the anterior 2/3 of the tongue. Therefore, special testing of the taste sensation can be performed.
- Tell the patient to stick out the tongue.
- Hold the tip of the tongue with a gauze pad.
- Swab the side of the tongue with the solution of sugar water.
- Ask the patient to identify the taste.
- Ask the patient to rinse out the mouth with water, and repeat the testing on the other side. Ask the patient to compare the sense of taste on each side of the tongue.
2. Cranial Nerve VIII: Acoustic
- Make sure the room is quiet before starting the test.
- Hearing assessment:
- Begin by observing whether or not the patient can hear you during the interview. Note whether the patient is wearing hearing aids.
- A quick hearing assessment can be done by holding your fingers a few inches away from the patient's ear and rubbing them together softly.
- Ask the patient if the finger rub is audible. Repeat on the other side, and assess if hearing is the same on both sides.
- The tuning fork tests (the Weber and Rinne tests) are performed if hearing loss is found, as these tests can help to distinguish between conductive hearing loss (such as from otitis media or perforation of the eardrum) and sensorineural hearing loss (as can occur with aging, acoustic neuroma, or from exposure to loud noises).
- The Weber test is performed to assess for lateralization.
- Hit the tuning fork's tines with the heel of your hand, and place the stem of the fork at the vertex of the patient's head. Be careful not to interrupt the vibration in the tines. The sound produced by a tuning fork is conducted through both the air and vibration of the bones. It is normally heard equally on both sides.
- Ask the patient where the sound is heard. Patients with normal hearing will hear the sound in the center of the head or equally in both ears.
- Sensorineural hearing loss should be suspected if the sound lateralizes (is louder on) to the "good" side; conductive hearing loss should be suspected if the sound lateralizes to the "bad" side.
- The Rinne test complements the Weber test in further differentiating between a conductive hearing loss and a sensorineural hearing loss
- Hit tuning fork tines with heel of hand, and place stem of the fork on the mastoid bone.
- Ask the patient to say "now" when the tone is no longer heard.
- Quickly move the tines adjacent to the outer ear canal, and ask the patient if the sound still can be heard. In the case of conductive hearing loss, the patient will hear the sound louder when the tuning fork is on bone compared to when it is in the air.
- The Weber test is performed to assess for lateralization.
3. Cranial Nerves IX and X: Glossopharyngeal and Vagus
- Listen to the patient's voice and determine if nasal quality of speech, which is characteristic to palatal weakness, is present.
- Have the patient say "AAH" and look for elevation of the soft palate. Check for symmetry of the two sides and deviation of the uvula.
- On a routine neurologic exam, it is generally not necessary to test the gag reflex. However, gag reflex should be elicited if there is concern for palatal weakness or reduced palatal sensation.
- Have the patient open the mouth wide. Then touch the patient's posterior pharynx with a cotton swab.
- Observe for the elevation of the soft palate, and note if any asymmetry is present. Note that about 20% of normal individuals do not have a gag reflex, and many older patients have diminished or absent gag reflexes. The most important thing to assess for is presence of any asymmetry.
4. Cranial Nerve XI: Spinal Accessory
- Observe trapezius muscle from behind the patient for signs of atrophy or fasciculations (twitching). Ask the patient to shrug their shoulders upward and then repeat the movement as the examiner provides resistance by pushing the patient's shoulders down. Look for weakness or asymmetry.
- To test the strength of the sternocleidomastoids muscle, instruct the patient to turn the head to the left as you try to resist the movement by pushing the patient's chin in the opposite direction with the palm of your hand. Repeat with the patient turning head to the right.
5. Cranial Nerve XII: Hypoglossal
- Inspect the tongue inside the mouth;look for fasciculations, which may be seen with amyotrophic lateral sclerosis and other motor neuron diseases.
- Ask the patient to stick the tongue out straight, andlook for possible deviation to one side. If any weakness is present, then the patient's tongue would deviate to the side of the weakness.
- Place your hand against the patient's cheek, and tell the patient to push the tongue against their same cheek. Repeat on the other side, each time looking for weakness or asymmetry.
Systematic cranial nerve testing can sometimes give a clinician early and detailed information about specific pathologic processes affecting the brain. Anatomically, the twelve cranial nerves arise from distinctive locations in the brain and innervate various head and neck structures, as well as several organs in the thorax and abdominal cavity.
The cranial nerve exam part one focused of nerves one through six. In this installment we will briefly review the functions of nerves seven through twelve, followed by demonstration of specific tests that can provide valuable diagnostic information associated with the damage of these specific nerves.
We will start with a short discussion of the anatomy and physiology of cranial nerves VII to XII.
The cranial nerve VII is predominantly composed of motor fibers that supply muscles of facial expression. The facial nerve also carries taste information from the anterior two-thirds of the tongue and provides parasympathetic supply to the lacrimal, sublingual and submandibular glands. Cranial nerve VIII, the vestibulocochlear nerve, consists of cochlear and vestibular divisions, which relay sound and equilibrium information, respectively, from the inner ear to medulla.
Cranial nerve IX, the glossopharyngeal nerve arises from medulla and innervates the posterior one-third of the tongue and soft palate. It also stimulates the parotid gland to secrete saliva, and supplies the stylopharyngeus muscle, which helps in swallowing. Therefore, damage to this nerve may lead to the absence of the normal gag reflex. On the other hand, cranial nerve X, the vagus nerve, which also rises from the medulla, is a widely distributed, complex nerve that innervates various structures in head, neck, thorax and abdomen. However, all the functions of this nerve are not tested during a routine physical exam.
Cranial nerve XI, the spinal accessory nerve, innervates the sternocleidomastoid muscles and the upper portion of the trapezius. These muscles control turning the head to the side and shrugging of the shoulders. The cranial nerve exam concludes by testing cranial nerve XII, the hypoglossal nerve, which provides motor control of the muscles of the tongue involved in speech control and swallowing.
Now let's review the systematic approach to examine this set of cranial nerves. Begin with the assessment of the facial nerve. Observe the patient's face for signs of weakness, such as smoothing of nasolabial folds or widening of a palpebral fissure. Then have the patient raise their eyebrows and look for an inability to wrinkle their forehead on the involved side that can be seen in peripheral facial palsy, or the Bell's palsy, which occurs due to facial nerve damage and manifests with unilateral weakness of both-the upper and lower facial muscles. This differs from the central facial palsy - seen in stroke patients with supranuclear lesion - which only affects the lower portion of one side.
Next, ask the patient to smile. Note an asymmetry in the contour of the smile, which can result from inability to fully raise the lip on the affected side in patients with either peripheral or central facial nerve palsy. Following that, instruct the patient to close their eyes tightly and assess if they "bury" their lashes equally on both sides. Then ask them to close their eyes again, and keep it closed while you try to open them. And, finally, have the patient blow up their cheeks while you try to push the air out of their pursed lips.
The next step is to assess the taste sensation, for which you will need cotton-tipped applicator, sugar water solution, and water for rinsing the mouth. Tell the patient to stick out their tongue, so that you can swab the sides with the sugar solution. Ask the patient to identify the taste. After getting the patient's response have them rinse their mouth and repeat the testing on the other side of tongue. Then, ask the patient to compare the sense of taste on each side of the tongue.
The next group of tests evaluates the cochlear division of the cranial nerve VIII, the acoustic nerve. The assessment of hearing function starts with observing whether or not the patient can hear you during the interview. Note if they are wearing hearing aids. First perform a quick hearing assessment by holding your fingers a few inches away from the patient's ear and softly rubbing them together. Ask the patient if they can hear the finger rub, then repeat on the other side, and inquire if the perceived sound is same for both sides.
Next, if the patient shows signs of hearing impairment, move onto the Weber and Rinne tests, also known as the tuning fork tests. These are performed to distinguish between conductive hearing loss and sensorineural hearing loss. Conductive hearing loss results from the external or middle ear disorders, such as otitis media or perforation of the eardrum. And sensorineural hearing loss occurs due to the damage of the cochlear nerve or the auditory pathways in the brain, which may result from aging, acoustic neuroma, or constant exposure to loud noises.
First let's review the Weber test. Hit tuning fork tines with the heel of your hand and place the stem at the vertex of the patient's head. Now ask the patient where they hear the sound. The sound produced by a tuning fork is conducted through both-air and vibration in the bones. Patients with normal hearing will hear the sound in the center of their head and equally in both ears. If the patient is experiencing hearing loss on one side, and if the nature of loss is sensorineural, then the sound lateralizes, or is perceived louder on the "good" side. Whereas, if the nature of loss is conductive, then the sound lateralizes to the "bad" side, since the well-functioning inner ear on this side might pick up the sound transmitted by the skull bones, causing it to be perceived as louder than the unaffected side.
If the Weber test is abnormal, move onto performing the Rinne test. For this, hit the tuning fork tines and place stem on the mastoid bone. Instruct the patient to say "now" when they no longer hear the tone and quickly move the tines adjacent to the outer ear canal. Ask the patient if they can still hear the sound. In the case of conductive hearing loss, the patient will hear the sound for a longer time when the tuning fork is on the bone, compared to when it is in the air near the external ear canal.
Next, evaluate the cranial nerves IX, the glosspharyngeal nerve and cranial nerve X, the vagus nerve, together. Begin by asking the patient to say one full sentence to determine if their speech has nasal quality, which is characteristic to palatal weakness.
After that, ask the patient to open their mouth and say, "AAH". While the patient is doing so, observe the elevation of their soft palate and note if any asymmetry is present. In the cranial nerve X paralysis, the soft palate fails to rise and the uvula deviates towards the opposite side.
Following that, move to cranial nerve XI or the spinal accessory nerve evaluation. Start by asking the patient to shrug their shoulders upward. Then instruct them to repeat the movement, while you provide resistance by pushing the shoulders down to check for weakness or asymmetry. Next, instruct the patient to turn their head to one side, and ask them to resist your attempt to push their chin in the opposite direction. Repeat the test with the patient turning their head to the opposite side. This is done to assess the strength of the sternocleidomastoids muscle.
Conclude the examination by testing cranial nerve XII, the hypoglossal nerve. For this, ask the patient to open their mouth and first observe their tongue at rest. Look for fasciculations, as may be seen with amyotrophic lateral sclerosis and other motor neuron diseases. Then instruct the patient to stick their tongue out straight; it should be in midline. Unilateral weakness may cause it to deviate towards the weak side.
For the final test assessing the strength of tongue muscles, ask the patient to push their tongue against their cheek, and instruct them to resist while to try to push it back in. Repeat on the other side, each time looking for weakness or asymmetry. This concludes the examination of all the cranial nerves.
You've just watched a JoVE video on examination of the cranial nerves from VII to XII. You should now have an understanding of the orderly approach that a clinician should follow while going through a comprehensive cranial nerve exam. The practice of tying together the findings of this exam with the patient history can help a physician gain an insight into the underlying neurological disease. As always, thanks for watching!
Applications and Summary
An examiner should develop an orderly approach to going through each nerve in numerical order, and document what test is performed and any findings. Abnormalities found in the cranial nerve exam may impact the remainder of the examination, requiring the examiner to look for other signs of diseases, such as multiple sclerosis (MS), myasthenia gravis, or amyotrophic lateral sclerosis (ALS) on the motor examination. For example, motor dysfunction of the lower cranial nerves, often called bulbar weakness, can be an early sign of muscle weakness, as seen in diseases such as ALS or myasthenia gravis. These findings on the cranial nerve examination will help the clinician focus the rest of the neurologic exam to help reach a possible diagnosis. Knowledge of the anatomy of the cranial nerves, head, and neck is important in both localization and diagnosis.