Olfactory nerve examination
• Ask patient to close one nostril and to expirate to see f there is
• Closing one nostril, ask patient to know the smell on the other.
• Repeat for the other nostril.
Optic nerve examination
• 5 things to examine in optic nerve
• Visual acuity
• Visual field
• Color vision
• Pupillary reflex (2 is afferent, 3 is efferent)
• Accomodation reflex (2 is afferent, 3 is efferent)
• Ophthalmoscopic examination
• Snellen's chart.
• Evaluation of patient with poor vision.
• Sensory Inattention
• Central visual field
• Examination of blind spot
• Peripheral visual field examination
CNs III, IV, VI
Prime position H test Pupillary reaction
Ptosis Nystagmus Direct reaction reflex
Proptosis Eye limitation Indirect reaction reflex
Anisocoria (pupillary inequality) Diplopia Accomodation reflex
• Unilateral due to CN III palsy or Horner's syndrome
• mydriasis is pupillary enlargement, meiosis is constriction.
Oculomotor III, trochlear IV and abducent VI
• H test
• In abducent paralysis, eye on medial side on rest and can not go
• In trochlear nerve injury, eye on rest laterally and above which can
not on movement go medially and below, and worsen when head
laterally flexed to normal area.
Trigeminal nerve examination
1. Test for sensory functions
• Examine the 3 divisions of V nerve bilaterally.
2. Test for motor function
• Muscle wasting (temporalis, masseter)
• Clench teethes to palpate masseter
• Open jaw and see deviation
• Open mouth against resistance
3. Test for reflexes
1. Corneal reflexes (5 is afferent, 7 is efferent)
2. Jaw jerk
5+12 = 17
• Damage to V cranial nerve cause jaw to deviate to the affected side
(As the 12th cranial nerve)
• Normally, slide closure or no reaction at all.
• In pseudobulbar palsy (UMNL), this reflex is exaggerated.
• This will lead to clenching of teeth.
Fascial nerve VII Examination
• Weather it is bilateral, unilateral or upper MNL or LMNL and ipsilateral or
• 5 things
• Test sensation in anterior 2 /3 of mouth
• raise your eyebrows
• Close your eyes
• Nasolabial fold
• Blowing air wheezing صفير
• Corneal reflex (5 is afferent, 7 is efferent)
How to know if this is UMNL or LMNL in
patient with fascial nerve VII exam?
• Bells phenomena present and Frontal wrinkles – absent in patient
with LMNL on the ipsilateral side.
• Both mouth deviation to normal side and nasolabial fold absent are
found in UMNL and LMNL.
• Bilateral lower motor neuron lesion will have absent of both forehead
wrinkles with absent nasolabial fold on both side that mimic normal
• LESION A ?!!!
• weakness of
lower left half of
• Contralateral !
• LESION B ?!!
weakness of left
half of the face
UMNL Vs. LMNL of fascial nerve
Most common cause ....
• Most common cause of upper motor neuron lesions is multiple
• Most common cause of lower motor neuron lesions is poliomyelitis.
Glossopharyngeal IX and vagus X nerves
• Speach (dysarthria and dysphonia)
• Air escape from nose
• In unilaterla X nerve damage, uvula will deviated to normal side (like
VII nerve) the rule of 10 and 7 = 17.
Spinal accessory nerve XI
• Inspect SCM for wasting or hypertrophy and palpate them to assess
• Stand behind patient and inspect trapezius
• Ask patient to shrunk shoulders and apply downward power to assess
• Assess SCM power by examining it against resistance
Hypoglossal nerve XII
• The tongue is deviated to the affected side.
• Usually lower motor neuron lesion
• Lesion in contralateral side