Cranial nerves and its

examination
Components of nervous system
Names of cranial nerves
 Classification
• Sensory cranial nerves: contain only afferent (sensory) fibers
– I Olfactory nerve
– II Optic nerve
– VIII Vestibulocochlear nerve
• Motor cranial nerves: contain only efferent (motor) fibers
– III Oculomotor nerve
– IV Trochlear nerve
– VI Abducent nerve
– XI Accessory nerve
– XII Hypoglossal nerve
• Mixed nerves: contain both sensory and motor fibers---
– V Trigeminal nerve,
– VII Facial nerve,
– IX Glossopharyngeal nerve
– X Vagus nerve
• Special Sense Nerves
–I,II,VIII
• Somatic Motor Nerves
–Eye—III,IV,VI
–Tongue—XII
•Face and jaws
–VII, V
•“Rest of body” nerves
–IX,X,XI

Human Anatomy, Frolich, Head/Neck IV: Cranial Nerves

 Nomenclature
• Somatic - Relating to the skeleton or skeletal
(voluntary) muscle.

• Visceral – Relating to (involuntary) muscle and its

(autonomic) innervation. An organ of the digestive,
cardiac, respiratory, urogenital, and endocrine
systems.
• Special – Relating to special sense
organs (smell, vision,equilibrium and
hearing)

• Afferent – incoming, sensory

• Efferent – Outgoing, motor

 Functional components
• General somatic afferent fibers (GSA): transmit
exteroceptive and proprioceptive impulses from
head and face to somatic sensory nuclei (V)

• General somatic efferent fibers (GSE): innervate

skeletal muscles of eye and tongue (III, IV, VI, XII)
• General visceral afferent fibers (GVA):
transmit interoceptive impulses from the
viscera to the visceral sensory nuclei (VII,
IX, X)
• General visceral efferent fibers (GVE):
transmit motor impulses from the general
visceral motor nuclei and relayed in
parasympathetic ganglions. The
postganglionic fibers supply cardiac
muscles ， smooth muscles and glands
(III,VII,IX, X)
 Special components
• Special visceral afferent fibers (SVA): transmit sensory
impulses from special sense organs of smell and taste to the
brain (VII, IX, X,I)
• Special somatic afferent fibers (SSA): transmit sensory
impulses from special sense organs of vision, equilibrium
and hearing to the brain (VIII)
• Special visceral efferent fibers (SVE):
transmit motor impulses from the brain to
skeletal muscles derived from brachial
arches of embryo. These include the
muscles of mastication, facial expression
and swallowing (V, VII, IX, X, XI)
 General concept
• Motor nuclei – send fibers directly to
muscles
• Nuclei for cardiac, visceral and glands –
send fibers to autonomic ganglion for
relay.
• Sensory nuclei – cell bodies of second
neuron, first neurons are outside CNS in
the gaglion.
• The central process of the cells in the
nuclei go to three sensory destination
1. Motor nuclei for reflex
2. Cerebellum
3. Opposite thalamus for relay in sensory
cortex.
 I. Olfactory nerve
• -is a special visceral
afferent (SVA) nerve
that mediates the
sense of smell
(olfaction).
• the only cranial nerve
that projects directly
to the forebrain
• Enter the bulb to synapse on mitral
cells.
• The central processe pass in the
olfactory tract to anterior perforated
substance and uncus

• The olfactory system consists of the

olfactory epithelium, bulbs and tracts
along with olfactory areas of the
brain collectively known as the
rhinencephalon
• Clinical correlation- CN I damage
-results in anosmia, loss of olfactory
sensation
 II.Optic nerve
• special somatic afferent
nerve
• Arises from the retina of the
eye
• Optic nerves pass through
the optic canals and
converge at the optic chiasm
• Lateral geniculate body –
relay and sorting station.
• They continue to the
thalamus where they
synapse
• From there, the optic
radiation fibers run to the
visual cortex
• Functions solely by
carrying afferent impulses
for vision
• Clinical correlations-CN II
• -When it is transected, ipsilateral blindness and
loss of direct pupillary light reflex result;
regeneration of the optic nerve does not occur.
• -When it is subjected to increased intracranial
pressure (e.g., tumor), papilledema, a "choked"
optic disk results.
• When it is constricted, optic atrophy (i.e., axonal
degeneration) results.
 III. Occulomotor
• contains general somatic efferent and
general visceral efferent fibers.
• Is a pure motor nerve that moves the eye,
constricts the pupil, Accommodates and
converges.
 III.Occulomotor
• NUCLIE

• Nucleus of oculomotor
Motor to superior, inferior and medial recti; inferior
obliquus; levator palpebrae superioris

• Accessory nucleus of oculomotor (Edinger- Westphal)

Parasympathetic to sphincter pupillea and ciliary muscle

• Leaves the skull through - Superior orbital fissure

 Ciinical correlations-CN III
• 1. Oculomotor paralysis is seen frequently with
transtentorial herniation (subdural, epidural
hematoma).
• -results in diplopia (double vision) when the
patient looks in the direction of the paretic
muscle.
• Results on ptosis, loss of accomodation and
dilatation of pupil.
 IV.Trochlear
• Is a pure GSE nerve that innervates the
superior oblique muscle,which
depresses, intorts, and abducts the eye.
• Nuclei - trochlear nucleus of the
midbrain.
• Passes through the lateral wall of the
cavernous sinus,
• Leaves the skull - superior orbital fissure.
 Clinical correlations
CN IV paralysis
• results in the following
conditions:
• 1. Extorsion of the
eye and weakness of
downward gaze
• 2. Vertical diplopia,
which increases when
looking down
 V. Trigeminal nerve
Components of fibers
• SVE fibers: originate from motor nucleus of
trigeminal nerve, and supply masticatory
muscles
• GSA fibers: transmit facial sensation to
sensory nuclei of trigeminal nerve, the GSA
fibers have their cell bodies in trigeminal
ganglion, which lies on the apex of petrous
part of temporal bone
 Nuclei
• One motor and three sensory
• Motor
Masticatory muscle, mylohyoid, tensor palati
• Sensory
1. Mesencephalic – Propioception for muscle of
mastication, face, tongue, orbit
2. Main sensory – Touch from trigeminal area
3. Spinal nucleus – Pain and temprature from
trigeminal area
Branches
• Ophthalmic nerve (V1,
sensory) leave the skull
through the superior orbital
fissure, to enter orbital cavity
• Branches
– Frontal nerve:
• Supratrochlear nerve
• Supraorbital nerve
– Lacrimal nerve
– Nasociliary nerve
Distribution:
• Sensation from
cerebral dura mater
• Visual organ
• Mucosa of nose
• Skin above the eye
and back of nose
Maxillary nerve
(V2, sensory)
• Leave skull through
foramen rotundum
• Branches
– Infraorbital nerve
– Zygomatic nerve
– Superior alveolar
nerve
– Pterygopalatine
nerve
Distribution:
• Sensation from cerebral
dura mater
• Maxillary teeth
• Mucosa of nose and
mouth
• Skin between eye and
mouth
Mandibular nerve (V3,
mixed)
• Leave the skull through the
foramen ovale to enter the
infratemporal fossa
• Branches
• Main trunk – nervous spinosus
and nerve to medial pterygoid
• Anterior trunk – buccal nerve,
nerve to massticatory muscles.
• Posterior trunk –
auricuotemporal, lingual, inferior
alveolar.
Distribution:
• Sensation from cerebral dura mater
• Teeth and gum of lower jaw
• Mucosa of floor of mouth
• Anterior 2/3 of tongue
• Skin of auricular and temporal
regions and below the mouth
• Motor to masticatory muscles,
mylohyoid, and anterior belly of
digastric
• Parotid gland – sensory through
auriculotemporal nerve
 Clinical correlations-lesions of
CN V
• 1. Loss of general sensation from the face
and mucous membranes of the oral and
nasal cavities
• 2. Loss of the corneal reflex
• 4. Deviation of the jaw to the weak side,
due to the unopposed action of the
opposite lateral pterygoid muscle
 VI Abducent
• Fibers leave the inferior pons and enter the orbit
via the superior orbital fissure
• Arises from the abducent nucleus of the caudal
pons
• Primarily a motor nerve innervating the lateral
rectus muscle (abducts the eye; thus the name
abducent)
 Clinical correlations-CN VI
paralysis

• Is the most common isolated muscle palsy.

• Results in the following conditions:
• 1. Convergent strabismus (esotropia), with the
inability to abduct the eye due to the unopposed
action of the medial rectus muscle
• 2. Horizontal diplopia, with maximum separation
of the double when looking toward the paretic
lateral rectus muscle
 Facial nerve (V)
Components of fibers
• SVE fibers originate from nucleus of facial nerve, and supply
facial muscles
• GVE fibers derived from superior salivatory nucleus and relayed
in pterygopalatine ganglion and submandibular ganglion. The
postganglionic fibers supply lacrimal, submandibular and
sublingual glands
• SVA fiber from taste buds of anterior two-thirds of tongue which
cell bodies are in the geniculate ganglion of the facial nerve and
end by synapsing with cells of nucleus of solitary tract
• GSA fibers from skin of external ear
Course: leaves skull through
internal acoustic meatus,
facial canal and
stylomastoid foramen, it
then enters parotid gland
where it divides into five
branches which supply facial
muscles
Branches within the facial canal
• Chorda tympani : joins lingual branch of mandibular
nerve
– To taste buds on anterior two-thirds of tongue
– Relayed in submandibular ganglion, the
postganglionic fibers supply submandibular and
sublingual glands
• Greater petrosal nerve: GVE fibers pass to
pterygopalatine ganglion and there relayed through the
zygomatic and lacrimal nerves to lacrimal gland
• Stapedial nerve : to stapedius
Branches outside of facial canal
• Temporal
• Zygomatic
• Buccal
• Marginal mandibular
• Cervical
 Clinical correlations-lesions of
CN VII
1. Flaccid paralysis of the muscles of facial
expression (upper and lowl face)
2. Loss of the corneal (blink) reflex (efferent
limb), which may leads corneal ulceration
(keratitis paralytica)
3. Loss of taste (ageusia) from the anterior
two-thirds of the tongue
4. Hyperacusis (increased acuity to sounds),
due to stapedius paralysis
5. Bell palsy - vis caused by trauma to the nerve
within the facial canal. It is a lower motor neuron
(LMN) lesion with paralysis of all muscles of
facial expression.
6. Central facial palsy- (supranuclear palsy)
(UMN).
-results in contralateral facial weakness below
the orbit.
-frontalis and orbicularis occuli escape due to
bilateral representation in cerebral cortex
7. Crocodile tears syndrome (lacrimation
during eating) is caused by a facial
nerve lesion proximal to the geniculate
ganglion.
• Regenerating 'preganglionic salivatory
fibers are misdirected to the
pterygopalatine ganglion, which projects
to the lacrimal gland.
 Cranial Nerve VIII:
Vestibulocochlear
• Two divisions – cochlear (hearing) and
vestibular (balance)
• Functions are solely sensory – equilibrium and
hearing
• Fibers arise from the hearing and equilibrium
apparatus of the inner ear, pass through the
internal acoustic meatus, and enter the
brainstem at the pons-medulla border
Cranial Nerve VIII: Vestibulocochlear

Figure VIII from Table 13.2

 Clinical correlation
lesions of the vestibular nerve
• -result in disequilibrium, vertigo, and
nystagmus.
lesions of the cochlear nerve
• -result in hearing loss (sensorineural
deafness)
• -cause tinnitus (irritative lesions).
 Glossopharyngeal nerve (IX)
Components of fibers
• SVE fibers: originate from nucleus ambiguus, and
supply stylopharygeus
• GVE fibers: arise from inferior salivatory nucleus
and ralyed in otic ganglion, the postganglionic fibers
supply parotid gland (secretomotor)
• SVA fibers: arise from the cells of inferior ganglion,
the central processes of these cells terminate in
nucleus of solitary tract, the peripheral processes
supply the taste buds on posterior third of tongue
• GVA fibers: visceral sensation from mucosa
of posterior third of tongue, pharynx,
auditory tube and tympanic cavity, carotid
sinus, and end by synapsing with cells of
nucleus of solitary tract
• GSA fibers: sensation from skin of posterior
surface of auricle
Course: leaves the skull via jugular foramen
Branches
• Lingual branches : to taste buds and mucosa of
posterior third of tongue
• Pharyngeal branches : take part in forming the
pharyngeal plexus
• Tympanic nerve : GVE fibers via tympanic and lesser
petrosal nerves to otic ganglion, with postganglionic
fibers via auriculotemporal (Ⅴ3) to parotid gland
• Carotid sinus branch : innervations to carotid sinus
• Others: tonsillar and stylophayngeal branches
 Clinical correlations-lesions of
CN IX
1. Loss of the gag (pharyngeal) reflex
2. Loss of the carotid sinus reflex
3. Loss of taste from the posterior third of
the tongue
4. Glossopharyngeal neuralgia
 Vagus nerve (X)
components of fibers
• GVE fibers: originate from dorsal nucleus of vagus
nerve, synapse in parasympathetic ganglion, short
postganglionic fibers innervate cardiac muscles,
smooth muscles and glands of viscera
• SVE fibers: originate from ambiguus, to muscles of
pharynx and larynx
• GVA fibers: carry impulse from viscera in neck,
thoracic and abdominal cavity to nucleus of solitary
tract
• GSA fiber: sensation from auricle, external acoustic
meatus and cerebral dura mater
Branches in neck
• Superior laryngeal nerve:
– Internal branch, which pierces thyrohyoid
membrane to innervates mucous membrane of
larynx above fissure of glottis
– External branch, which innervates cricothyroid
• Cervical cardiac branches : descending to
terminate in cardiac plexus
• Others: auricular, pharyngeal and meningeal
branches
Branches in thorax
• Recurrent laryngeal nerves
– Right one hooks around right
subclavian artery, left one hooks
aortic arch
– Both ascend in tracheo-esophageal
groove
– Innervations: laryngeal mucosa
below fissure of glottis , all laryngeal
muscles except cricothyroid
• Bronchial and esophageal branches
Branches in
abdomen
• Anterior and posterior
gastric branches
– supply pyloric part
• Hepatic branches:
supply liver and
gallbladder
• Celiac branches:
sympathetic fibers to
liver, pancreas, spleen,
kidneys, intestine
 Clinical correlations-lesions of
CN X

1. Ipsilateral paralysis of the soft palate,

pharynx, and larynx leading to dysphonia
(hoarseness), dyspnea, dysarthria, and
dysphagia
2. Loss of the gag (palatal) reflex
3. Anesthesia of the pharynx and larynx,
leading to unilateral loss of the cough
reflex
 XI Accessory
• Mediates head and shoulder movement and
innervates laryngeal muscles.
• 1. Cranial division
• -arises from the nucleus ambiguus of the medulla.
• --exits the medulla and joins the vagal nerve
• --exits the skull via the jugular foramen with CN IX
and CN X.
• -innervates the intrinsic muscles of the larynx via
the inferior (recurrent) laryngeal nerve, with the
exception of the cricothyroid muscle.
• 2. Spinal division
• -arises from the ventral horn of cervical segments
CI-C6.
• -Spinal roots exit the spinal cord laterally between
the ventral and dorsal spinal roots, ascend through
the foramen magnum, and exit skull via the jugular
foramen.
• -innervates the sternocleidomastoid (with C2) and
trapezius rn cles (with C3 and C4
 Clinical correlations - lesions of
CN XI
1. Paralysis of the sternocleidomastoid muscle
-results in difficulty in turning the head to the side
opposite the lesion.
2. Paralysis of the trapezius muscle
-results in a shoulder droop.
-results in the inability to shrug the ipsilateral
shoulder.
3. Paralysis of the larynx occurs if the cranial root
is involved
• Hypoglossal Nerve (CN XII)
• A. General characteristics-CN XII
• -mediates tongue movement.
• -arises from the hypoglossal nucleus of
the medulla.
• -exits the skull via the hypoglossal canal.
• -innervates intrinsic and extrinsic muscles
of the tongue except palatoglossus .
 B. Clinical correlations-CN XII

• -When it is transected, hemiparalysis of

the tongue results.
• -When it is protruded, the tongue points
toward the weak side due to the
unopposed action of the opposite
genioglossus muscle
 Terminal nerve or Cranial nerve
zero
• It was first found in humans in
1913, although its presence in humans
remains controversial.
• However, a study has indicated that the
terminal nerve is a common finding in the
adult human brain.
• It projects from the nasal cavity, enters the
brain as a microscopic plexus of
unmyelinated peripheral nerve fascicles.
• The nerve is often overlooked in autopsies because it
is unusually thin for a cranial nerve, and is often torn
out upon exposing the brain. Careful dissection is
necessary to visualize the nerve
• It is very close to and often confused for a branch of
the olfactory nerve, This fact suggests that the nerve is
either vestigial or may be related to the sensing
of pheromones.
• The nerve zero projects to the medial and lateral septal
nuclei, and the preoptic areas all of which are involved
in regulating sexual behavior in mammals.
Neurologic examination
CRANIAL NERVES
 Cranial Nerves Exam

CRANIAL NERVE I (OLFACTORY NERVE)

Olfaction depends on the integrity of the olfactory neurons in the

roof of the nasal cavity and their connections through the
olfactory bulb, tract to the olfactory cortex

To test olfaction:
1. An odorant, such as concentrated vanilla, perfume or coffee,
is presented to each nostril in turn.
2. The patient is asked to sniff (with eyes closed) and identify
each smell.
Olfaction is frequently not tested because of unreliable patient
responses and lack of objective signs.
Cranial Nerve I
 Cranial Nerves Exam

CRANIAL NERVE 2 (OPTIC NERVE)

 Evaluation gives important information about the nerves,

optic chiasm, tracts, thalamus, optic radiations, and visual
cortex.
CN 2 is also the afferent limb of the pupillary light reflex.
The optic nerve is tested in the office by visual acuity
measurement, color vision testing, pupil evaluation, visual field
testing, and optic nerve evaluation via ophthalmoscopy
II - Optic
Examine the Optic Fundi
Test Visual Acuity

1. Allow the patient to use their glasses if available. You are

interested in the patient's best corrected vision.
2. Position the patient 20 feet in front of the Snellen eye
chart
3. Have the patient cover one eye at a time with a card.
4. Ask the patient 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.
 There are hand held cards that look like Snellen Charts but are positioned
14 inches from the patient. These are used simply for convenience. Testing
and interpretation are as described for the Snellen.

Hand held visual acuity card

Screen Visual Fields
1. Stand two feet in front of the patient and have them look
into your eyes.
2. Hold your hands about one foot away from the patient's
ears, and wiggle a finger on one hand.
3. Ask the patient to indicate which side they see the finger
move.
4. Repeat two or three times to test both temporal fields.
5. If an abnormality is suspected, test the four quadrants of
each eye while asking the patient to cover the opposite
eye with a card.
Test Pupillary Reactions to Light

1. Dim the room lights as necessary.

2. Ask the patient to look into the distance.
3. Shine a bright light obliquely into each pupil in turn.
4. Look for both the direct (same eye) and consensual
(other eye) reactions.
5. Record pupil size in mm and any asymmetry or
irregularity.
If abnormal, proceed with the test for
accommodation.
Test Pupillary Reactions to
Accommodation

Hold your finger about 10cm from the patient's nose.

Ask them to alternate looking into the distance and at

your finger.
Observe the pupillary response in each eye.
CRANIAL NERVE 3 (OCULOMOTOR NERVE)
CRANIAL NERVE 4 (TROCHLEAR NERVE)
CRANIAL NERVE 6 (ABDUCENS NERVE)

The pneumonic:
“S O 4 – L R 6 – All The Rest 3”
may help remind you which CN does what
Observe for Ptosis
Test Extraocular Movements
1.Stand or sit 3 to 6 feet in front of the patient.
2.Ask the patient to follow your finger with their eyes
without moving their head.
3.Check gaze in the six cardinal directions using a
cross or "H" pattern.
4.Pause during upward and lateral gaze to check for
nystagmus.
5.Check convergence by moving your finger toward
the bridge of the patient's nose.
Test Pupillary Reactions to Light
Testing CN III, IV, and VI:
To test the extraocular muscles, have the
patient follow a target through the six
principal positions of gaze ("H" pattern).
Right CN3 Lesion: Note patient's right eye is deviated
laterally and there is ptosis of the lid.
Right CN3 Lesion: The right pupil (upper left picture) is
more dilated than the left pupil.
It’s also worth noting that disorders of the extra ocular muscles
themselves (and not the CN which innervate them) can also lead to
impaired eye movement.

An example is a patient who has suffered a traumatic left orbital injury. The
inferior rectus muscle has become entrapped within the resulting fracture,
preventing the left eye from being able to look downward.
CRANIAL NERVE 5 (TRIGEMINAL)

Assessment of CN 5 Sensory Function:

• Use a sharp implement
• Ask the patient to close their eyes so that they
receive no visual cues.
• Touch the sharp tip of the stick to the right and
left side of the forehead, assessing the
Ophthalmic branch.
• Touch the tip to the right and left side of the
cheek area, assessing the Maxillary branch.
• Touch the tip to the right and left side of the
jaw area, assessing the Mandibular branch.
• The patient should be able to clearly identify
when the sharp end touches their face.
CRANIAL NERVE 5 (TRIGEMINAL)
The Ophthalmic branch of CN 5 also receives sensory input
from the surface of the eye.

To assess this component:

1. Pull out a wisp of cotton.
2. While the patient is looking
straight ahead, gently brush
the wisp against the lateral
aspect of the sclera (outer
white area of the eye ball).
3. This should cause the patient to
blink.
Blinking also requires that CN 7
function normally, as it
controls eye lid closure.
CRANIAL NERVE 5 (TRIGEMINAL)
The motor limb of CN 5 innervates the Temporalis and
Masseter muscles, both important for closing the jaw.
Assessment of CN 5 Motor Function:
• Place your hand on both Temporalis muscles, located on
the lateral aspects of the forehead.

• Ask the patient to tightly close their jaw, causing the

muscles beneath your fingers to become taught.

• Then place your hands on both Masseter muscles.

• Ask the patient to tightly close their jaw, which should again
cause the muscles beneath your fingers to become taught.
Then ask them to move their jaw from side to side, function
of lateral and medial pterygoid
CRANIAL NERVE 5 (TRIGEMINAL)
CRANIAL NERVE 7 (FACIAL)
This nerve innervates muscles of facial expression.
Assessment is performed as follows:
• First look at the patient’s face. It should appear
symmetric.
– There should be the same amount of
wrinkles apparent on either side of the
forehead
– The nasolabial folds should be equal
– The corners of the mouth should be at the
same height
• If there is any question as to whether an
apparent asymmetry if new or old, ask the
patient for a picture for comparison.
Testing the facial nerve.
The patient wrinkles her forehead
while the two sides are compared.
Patient tightly shuts eyelids while
examiner attempts to pry open.
The two sides are compared.
Patient smiles and shows her teeth
while the examiner compares the
nasolabial folds on either side.
CRANIAL NERVE 7 (FACIAL)

Interpretation:
CN 7 has a precise pattern of innervation, which
has important clinical implications.
The right and left upper motor neurons (UMNs)
each innervate both the right and left lower
motor neurons (LMNs) that allow the forehead to
move up and down.
However, the LMNs that control the muscles of the
lower face are only innervated by the UMN from
the opposite side of the face.
 Central Facial Paralysis (Central Seven)
• caused by a lesion of the corticonuclear (corticobulbar) tract above the
level of the facial nucleus (upper motor neuron lesion)
• causes paralysis/paresis of the muscles of the contralateral lower face
• upper part of facial nucleus contains motor neurons that innervate
muscles of upper face  it is innervated by ipsilateral and contralateral
corticonuclear fibers  unilateral lesion of corticonuclear tract does not
affect muscles of upper face on either side
• lower part of facial nucleus contains motor neurons that innervate
muscles of lower face  it is innervated only by contralateral
corticonuclear fibers  unilateral lesion of corticonuclear tract (above
the level of facial nucleus) affects muscles of lower face on opposite side
of lesion
Textbook Fig. 25-14
CRANIAL NERVE 7 (FACIAL)

Interpretation:
Thus, in the setting of CN 7 dysfunction, the pattern of
weakness or paralysis observed will differ depending on
whether the UMN or LMN is affected.
UMN dysfunction: This might occur with a central nervous
system event, such as a stroke. In the setting of R UMN
CN 7 dysfunction, the patient would be able to wrinkle
their forehead on both sides of their face, as the left CN
7 UMN cross innervates the R CN 7 LMN that controls
this movement. However, the patient would be unable to
effectively close their left eye or raise the left corner of
their mouth.
Right central CN7 dysfunction:
Note preserved ability to wrinkle forehead.
Left corner of mouth, however, is slightly lower than right.
Left nasolabial fold is slightly less pronounced compared with right.
Right central CN7 dysfunction:
Note preserved ability to wrinkle forehead.
Left corner of mouth, however, is slightly lower than right.
Left nasolabial fold is slightly less pronounced compared with right.
CRANIAL NERVE 7 (FACIAL)

Interpretation:
LMN dysfunction: This occurs most commonly in the setting
of Bell’s Palsy, an idiopathic, acute CN 7 peripheral
nerve palsy. In the setting of R CN 7 peripheral (LMN)
dysfunction, the patient would not be able to wrinkle
their forehead, close their eye or raise the corner of
their mouth on the right side. Left sided function would
be normal.
Left peripheral CN7 dysfunction:
Note loss of forehead wrinkle, ability to close eye, ability to raise corner of
mouth, and decreased nasolabial fold prominence on left.
Left peripheral CN7 dysfunction:
Note loss of forehead wrinkle, ability to close eye, ability to raise corner of
mouth, and decreased nasolabial fold prominence on left.
Left peripheral CN7 dysfunction:
Note loss of forehead wrinkle, ability to close eye, ability to raise corner of
mouth, and decreased nasolabial fold prominence on left.
CRANIAL NERVE 7 (FACIAL)

• CN 7 is also responsible for carrying taste

sensations from the anterior 2/3 of the tongue.
• To test the sensory fibers of the facial nerve,
apply sugar, salt, or lemon juice on a cotton
swab to the lateral aspect of each side of the
tongue and have the patient identify the taste.
Taste is often tested only when specific
pathology of the facial nerve is suspected.
CRANIAL NERVE 8 (ACOUSTIC)

CN 8 carries sound impulses from the cochlea to the brain.

Prior to reaching the cochlea, the sound must first
traverse the external canal and middle ear.

Assessment is performed as follows:

• Stand behind the patient and ask them to close their
eyes.
• Whisper a few words from just behind one ear. The
patient should be able to repeat these back accurately.
Then perform the same test for the other ear.
• Alternatively, place your fingers approximately 5 cm
from one ear and rub them together. The patient
should be able to hear the sound generated. Repeat
for the other ear.
CRANIAL NERVE 8 (ACOUSTIC)

• These tests are rather crude. Precise

quantification, generally necessary whenever
there is a subjective decline in acuity
• Hearing is broken into 2 phases: conductive and
sensorineural.
• The conductive phase refers to the passage of
sound from the outside to the level of CN 8. This
includes the transmission of sound through the
external canal and middle ear.
• Sensorineural refers to the transmission of
sound via CN 8 to the brain.
• Identification of conductive (a much more
common problem in the general
population) defects is determined as
follows:
CRANIAL NERVE 8 (ACOUSTIC)
Weber Test

1. Grasp the 512 Hz tuning fork by the stem and strike it against the
bony edge of your palm, generating a continuous tone.
2. Hold the stem against the patient’s skull, along an imaginary
line that is equidistant from either ear.
3. The bones of the skull will carry the sound equally to both the
right and left CN 8. Both CN 8s, in turn, will transmit the
impulse to the brain.
4. The patient should report whether the sound was heard equally
in both ears or better on one side then the other (referred to as
lateralizing to a side).
CRANIAL NERVE 8 (ACOUSTIC)

Weber Test
CRANIAL NERVE 8 (ACOUSTIC) Webber test
Interpretation:
• In the setting of a conductive hearing loss (e.g. wax in the
external canal), the Webber test will lateralize (i.e. sound will be
heard better) in the ear that has the subjective decline in
hearing. This is because when there is a problem with
conduction, competing sounds from the outside cannot reach
CN 8 via the external canal. Thus, sound generated by the
vibrating tuning fork and traveling to CN 8 by means of bony
conduction is better heard as it has no outside “competition.”
• In the setting of a sensorineural hearing loss (e.g. a tumor of
CN 8), the Webber test will lateralize to the ear which does not
have the subjective decline in hearing. This is because CN 8 is
the final pathway through which sound is carried to the brain.
Thus, even though the bones of the skull will successfully transmit
the sound to CN 8, it cannot then be carried to the brain due to
the underlying nerve dysfunction.
CRANIAL NERVE 8 (ACOUSTIC)
Rinne Test:

1. Grasp the 512 Hz tuning fork by the stem and strike it

against the bony edge of your palm, generating a
continuous tone.
2. Place the stem of the tuning fork on the mastoid bone,
The vibrations travel via the bones of the skull to CN 8,
allowing the patient to hear the sound.
3. Ask the patient to inform you when they can no longer
appreciate the sound. When this occurs, move the
tuning fork such that the tines are placed right next to
(but not touching) the opening of the ear. At this point,
the patient should be able to again hear the sound. This
is because air is a better conducting medium then
bone.
CRANIAL NERVE 8 (ACOUSTIC)

Rinne Test:
CRANIAL NERVE 8 (ACOUSTIC)

Rinne Test:
CRANIAL NERVE 8 (ACOUSTIC) Rinne Test

Interpretation:
• In the setting of conductive hearing loss, bone
conduction (BC) will be better then air conduction
(AC) when assessed by the Rinne Test. If there is a
blockage in the passageway (e.g. wax) that carries sound
from the outside to CN 8, then sound will be better heard
when it travels via the bones of the skull.
• In the setting of a sensorineural hearing loss, air
conduction will still be better than bone conduction (i.e. the
normal pattern will be retained). This is because the
problem is at the level of CN 8. Thus, regardless of the
means (bone or air) by which the impulse gets to CN 8,
there will still be a marked hearing decrement in the
affected ear
CRANIAL NERVE 8 (ACOUSTIC)

Summary:
• First determine by history and crude acuity testing
which ear has the hearing problem.
• Perform the Webber test. If there is a conductive
hearing deficit, the Webber will lateralize to the
affected ear. If there is a sensorineural deficit, the
Webber will lateralize to the normal ear.
• Perform the Rinne test. If there is a conductive hearing
deficit, BC will be greater then or equal to AC in the
affected ear. If there is a sensorineural hearing deficit,
AC will be greater then BC in the affected ear.
CRANIAL NERVE 9 (GLOSSOPHARYNGEAL)
CRANIAL NERVE 10 (VAGUS)

These nerves are responsible for raising the soft palate of

the mouth and the gag reflex, a protective mechanism
which prevents food or liquid from traveling into the
lungs. As both CNs contribute to these functions, they
are tested together.
Testing Elevation of the soft palate:
• Ask the patient to open their mouth and say, “ahhhh,”
causing the soft palate to rise upward.
• Look at the uvula.
• The Uvula should rise up straight and in the midline.
CRANIAL NERVE 9 (GLOSSOPHARYNGEAL)
CRANIAL NERVE 10 (VAGUS)

Normal Oropharynx
CRANIAL NERVE 9 (GLOSSOPHARYNGEAL)
CRANIAL NERVE 10 (VAGUS)

Interpretation:
If CN 9 on the left is not functioning, the uvula will be pulled to the right.
CRANIAL NERVE 9 (GLOSSOPHARYNGEAL)
CRANIAL NERVE 10 (VAGUS)

Left peritonsillar abscess: infection within left tonsil has

pushed uvula towards the right.
CRANIAL NERVE 9 (GLOSSOPHARYNGEAL)
CRANIAL NERVE 10 (VAGUS)

Testing the Gag Reflex:

• Ask the patient to widely open their mouth. If
you are unable to see the posterior pharynx
(i.e. the back of their throat), gently push down
with a tongue depressor.
• In some patients, the tongue depressor alone
will elicit a gag. In most others, additional
stimulation is required. Take a cotton tipped
applicator and gently brush it against the
posterior pharynx or uvula. This should
generate a gag in most patients.
CRANIAL NERVE 9 (GLOSSOPHARYNGEAL)
CRANIAL NERVE 10 (VAGUS)

CN 9 is also responsible for taste originating on the

posterior 1/3 of the tongue.

CN 10 also provides parasympathetic innervation to the

heart, though this cannot be easily tested on physical
examination.
CRANIAL NERVE 11 (SPINAL ACCESSORY)

CN 11 innervates the muscles which permit shrugging of

the shoulders (Trapezius) and turning the head
laterally (Sternocleidomastoid).

Assessment is performed as follows:

• Place your hands on top of either shoulder and ask the
patient to shrug while you provide resistance.
Dysfunction will cause weakness/absence of
movement on the affected side.
• Place your open left hand against the patient’s right
cheek and ask them to turn into your hand while you
provide resistance. Then repeat on the other side. The
right Sternocleidomastoid muscle causes the head to
turn to the left, and vice versa.
CRANIAL NERVE 11 (SPINAL ACCESSORY)
CRANIAL NERVE 11 (SPINAL ACCESSORY)
CRANIAL NERVE 12 (HYPOGLOSSAL)

CN 12 is responsible for tongue movement.

Each CN 12 innervates one-half of the tongue.

Assessment is performed as follows:

• Ask the patient to stick their tongue straight out of their
mouth.
• If there is any suggestion of deviation to one
side/weakness, direct them to push the tip of their
tongue into either cheek while you provide counter
pressure from the outside.
CRANIAL NERVE 12 (HYPOGLOSSAL)
CRANIAL NERVE 12 (HYPOGLOSSAL)

Interpretation:
• If the right CN 12 is dysfunctional, the tongue will deviate
to the right. This is because the normally functioning left
half will dominate as it no longer has opposition from the
right. Similarly, the tongue would have limited or absent
ability to resist against pressure applied from outside the
left cheek.
CRANIAL NERVE 12 (HYPOGLOSSAL)

Left CN 12 Dysfunction: Stroke has resulted in L CN 12 Palsy.

Tongue therefore deviates to the left.
Testing the hypoglossal nerve.
Patient is instructed to stick out the tongue
and then move it laterally against resistance.
 Summary
Cranial Nerve Number Innervation(s) Primary Test(s)
Function(s)
Olfactory I Sensory Smell Identify odors
Optic II Sensory Vision Visual acuity,
fields, color,
nerve head
Oculomotor III Motor Upper lid elevation, Physiologic "H"
extraocular eye and near point
movement, pupil response
constriction,
accommodation
Trochlear IV Motor Superior oblique Physiologic "H"
muscle
Trigeminal V Motor Muscles of Corneal reflex
mastication
Trigeminal V Sensory Scalp, conjunctiva, Clench
teeth jaw/palpate,
light touch
comparison
Abducens VI Motor Lateral rectus muscle Abduction,
physiologic "H"
Facial VII Motor Muscles of facial expression Smile, puff
cheeks, wrinkle
forehead, pry
open closed lids

Facial VII Sensory Taste-anterior two thirds of

tongue
Vestibulocochlear VIII Sensory Hearing and balance Rinne test for
hearing, Weber
test for balance

Glossopharyngeal IX Motor Tongue and pharynx Gag reflex

Glossopharyngeal IX Sensory Taste-posterior one third of

tongue
Vagus X Motor Pharynx, tongue, larynx, Gag reflex
thoracic and abdominal
viscera
Vagus X Sensory Larynx, trachea, esophagus
Accessory XI Motor Sternomastoid and trapezius Shrug, head turn
muscles against
resistance
Facial VII Motor Muscles of facial expression Smile, puff
cheeks, wrinkle
forehead, pry
open closed lids

Facial VII Sensory Taste-anterior two thirds of

tongue
Vestibulocochlear VIII Sensory Hearing and balance Rinne test for
hearing, Weber
test for balance

Glossopharyngeal IX Motor Tongue and pharynx Gag reflex

Glossopharyngeal IX Sensory Taste-posterior one third of

tongue
Vagus X Motor Pharynx, tongue, larynx, Gag reflex
thoracic and abdominal
viscera
Vagus X Sensory Larynx, trachea, esophagus
Accessory XI Motor Sternomastoid and trapezius Shrug, head turn
muscles against
resistance
THE END