EXAMINATION OF CNS - Cranial nerves

examination of cranial nerves is important part of CNS examination, this PowerPoint is very helpful for MBBS students

1. Clinical Examination of the Cranial Nerves I - XII By, Dr.Prajwal

2. Clinical Examination of Nervous System This should proceed along the following lines: General Physical Examination; Examination of Higher Mental functions; Speech and Language functions; Cranial nerves; Motor functions and reflexes; Cerebellar functions; Sensory functions; Peripheral nerves. The test must be first explained to the patient(Subjective).

3. Cranial nerves There are 12 pairs of cranial nerves. The olfactory (I) nerve The optic (II) nerve The oculomotor (III) nerve The trochlear (IV) nerve The trigeminal (V) nerve The abducens (VI) nerve The facial (VII) nerve The vestibularcochlear (VIII) nerve The glossopharyngeal (IX) nerve The vagus (X) nerve The accessory (XI) nerve The hypoglossal (XII) nerve Some of them are purely sensory (afferent), others are motor (efferent), while still others are mixed. Cranial nerve nuclei ƒ Midbrain—nuclei of CN III, IV ƒ Pons—nuclei of CN V, VI, VII, VIII ƒ Medulla—nuclei of CN IX, X, XII ƒ Spinal cord—nucleus of CN XI

4. The olfactory (I) nerve The olfactory nerve conveys the sense of smell.

5. Procedure Ask the subject to close his eyes, Occlude one of his nostrils. Then have him smell and distinguish the odors of each of the test substances, one by one, In each nostril, separately Precautions Eyes Closed Familiar Smell, Non irritant Examine each nostril, separately Nostrils Patent, No inflation Ask for olfactory hallucination

6. The University of Pennsylvania Smell Identification Test (UPSIT).

7. Loss of Sense of Smell (Anosmia) 1. This most commonly occurs due to nasal diseases like catarrh, sinusitis, hay fever 2. Head injuries may result in shearing strain and tear of olfactory filaments. This is the most common neurological cause of anosmia 3. Tumours of the anterior cranial fossa from frontal lobe 4. Chronic basal meningitis (tuberculous, syphilitic or neoplasm) 5. Kallman’s syndrome (anosmia, obesity, hypogonadism, midline defects) 6. Tabes dorsalis, atrophic rhinitis 7. Internal hydrocephalus 8. Ageing 9. Alzheimer’s disease 10. Parkinson’s disease 11. Huntington’s chorea 12. Down syndrome. A subfrontal tumour such as a meningioma may cause unilateral anosmia,

8. Increased Olfactory Acuity ( Hyperosmia ) 1. It is occasionally a feature of premonitory phase of migraine 2. Addison’s disease 3. Hyperemesis gravidarum 4. Mucoviscidosis 5. Strychnine poisoning. Perversion of Smell ( Parosmia ) 1. It is seen during partial recovery, from traumatic anosmia 2. Severe nasal infection 3. Ingestion of drugs (phenytoin) 4. Psychological.

9. Foul Smell ( Cacosmia ) This is said to be present when the patient perceives unpleasant odours in the absence of a stimuli. It is seen in severe upper respiratory tract infections. Olfactory Hallucinations They are usually of unpleasant nature and characteristic of epilepsy arising in the uncinate gyrus of temporal lobe . They may also occur in psychosis.

10. The optic (II) nerve 1.Visual Acuity a. Distant Vision (Snellen’s chart) b. Near Vision (Jaeger’s chart) 2.Color Vision (Ishihara charts) 3.Field of Vision (Finger Confrontation) 4. Pupillary responses 5. Inspection of optic nerve head and fundus by ophthalmoscopy.

11. 1.Visual Acuity Visual acuity (VA) is the ability to see the details and contours of objects clearly. the minimum distance between two points or lines when they can be recognized as two. It is the function of cones It is tested for both distant as well as near vision. a. Distant Vision (Snellen’s chart) b. Near Vision (Jaeger’s chart)

12. TEST FOR DISTANT VISION Snellen’s chart. The distant vision is clinically tested with this chart. arranged in eight lines . The top letter , the largest, is visible to the naked eye at a distance of 60 meters , and the subsequent letters at distances of 36, 24, 18, 12, 9, 6 and 5 meters respectively. In the Landolt ring chart , the gap in the ring is positioned at random in the 8 lines. The width of the gap subtends an angle of 1 minute at the nodal point. In the E Test chart , the letter E is printed in 8 lines, the “legs” of the letters pointing in different directions. A person (or a child ) who cannot read , has to indicate the direction in which the legs of each letter are pointing.

13. Snellen’s chart

14. Testing the Distant Visual Acuity The subject is seated at a distance of 6 meters (20 feet) from a well-lighted chart and is asked to read the letters down the chart as far as she can read. Each eye is tested separately . 4. The VA is recorded according to the formula VA = d/D where d is the distance at which the letters are read, and D is the distance at which the letter should be read by a person with normal vision. 5. A normal person should be able to read at least the 7th line , i.e. have a VA of 6/6 (20/20 in terms of feet, commonly pronounced “twenty-twenty” vision.) 6. If the VA is less than 6/60, the subject is moved towards the chart until she can read the top letter. 7.The VA is 2/60 if she can read it at 2 meters. The VA less than 1/60 is recorded as “ counting fingers ”(CF), “ hand movements ” (HM); “ perception of light ” (PL), or as “ no perception of light ” (no PL).

15. TEST FOR NEAR VISION The subject is asked to read Jaeger’s chart held at the ordinary reading distance of 15 inches. This chart is made up of reading material of various sizes with the smallest size at the bottom. The subject reads the material down the chart and VA is recorded as the smallest type that can be read comfortably. The result used to be expressed as J1, J2, J3, J4 etc. J1-- (the smallest size) indicates normal vision. These days a modification of the original Jaeger system is used and VA is expressed in terms of printers’ point system —N36, N18, N8, N6, and N5 instead of J1, J2 etc ; N5 being the smallest type instead of J1. A Landolt ring chart for near vision is also available. Charts with pictures are used for children.

16. Jaeger’s chart

17. Causes of Decreased Visual Acuity 1. Papillitis 2. Retrobulbar neuritis 3. Refractive errors a. Myopia b. Presbyopia c. Astigmatism 4. Primary ocular disorders a. Iridocyclitis b. Corneal opacities c. Cataracts d. Vitreous opacities e. Retinal detachment f. Glaucoma.

18. Hypermetropia (long-sightedness) Rays of light from a distant object are focused behind the retina. Thus the near objects are not seen clearly The condition is corrected with convex lenses.

19. Myopia (Short-sightedness) Parallel rays of light coming from a distant object are brought to a focus in front of the retina Thus distant objects cannot be seen clearly. This error is corrected with concave lenses.

20. 2.Color Vision The human eye is sensitive to all wavelengths of light from 400 nm to 700 nm which constitute the visible part of the electromagnetic spectrum. Colors are perceived by cones that are concentrated in fovea The color vision is clinically tested using Ishihara charts II. Edridge -Green Lantern III. Holmgren’s wools (Yarn matching test).

21. It is particularly important in the following groups of people: 1. Drivers of air, sea, and road transport vehicles, railway engine drivers, bus and truck drivers, pilots, etc. 2. Workers of textile industry where dyeing of cloth requires a high degree of color perception. 3. Paint and printing industries . Interior decorators and visual artists DEFECTS OF COLOR VISION Abnormal color vision is present as an inherited defect(XR). The prefix deuter- refers to green color, trit - refers to blue, and prot - refers to red color . The suffix -anomaly refers to color weakness while suffix - anopia refers to color blindness. Monochromats have only one cone system present, dichromats have two cone systems, and trichromats have all three cone systems but one may be weak.

22. 3.Field of Vision The full extent of vision observed while visualizing an object is known as the visual field. The field of vision is limited by the area of the retina and by the margins of the orbit, nose and cheek. Normal visual field using 5 mm white object is approximately 100 temporally, 60 nasally, 60 superiorly and 75 inferiorly. Confrontation method:

23. The oculomotor (III) , trochlear (IV) and abducens (VI) nerves These three nerves and their central connection are usually considered together, since they function as a physiological unit in the control of ocular movements The 6th nerve supplies the lateral rectus, LR6 the 4th nerve innervates the superior oblique, SO4 the 3rd nerve supplies all the other external ocular muscles. O3 It also sends fibers to the levator palpebrae superioris and through the ciliary ganglion, it supplies parasympathetic fibers to the sphincter pupillae and the muscle of accommodation , the ciliary muscle

24. 1. Size of Palpebral Fissures Look for narrowing of the palpebral fissures ( Ptosis ). Ptosis may be congenital or acquired, unilateral or bilateral, partial or complete. Causes for Unilateral Ptosis Third nerve lesion b. Lesion of cervical sympathetic pathway ( Horner’s syndrome ) c. Trauma d. Lesions of the upper eyelid Causes for Bilateral Ptosis a. Myopathies b. Myasthenia gravis c. Bilateral Horner’s syndrome d. Snake bite e. Botulism.

25. 2. Size of Pupils Normal size of pupil varies from 3 to 5 mm. Pupils < 3 mm size in average condition of illumination are called miotic and pupils > 5 mm are called mydriatic. Pin point pupil is said to be present when the pupillary size is less than or equal to 1 mm. Causes for Miosis a. Old age b. Horner’s syndrome c. Drugs or toxins • Neostigmine • Morphine • Organophosphorous poisoning d. Pontine haemorrhage . Causes for Mydriasis a. Infancy b. Lesion of third cranial nerve (midbrain lesion) c. Drugs like atropine and pethidine d. Blindness due to optic nerve damage (optic atrophy).

26. Ocular movements

27. Ocular movements ■ Hold your finger vertically at least 50 cm away from the patient, and ask him to follow it with his eyes, without moving his head. ■ Move your finger steadily to one side, then up and down, then to the other and repeat, describing the letter H in the air.

28. Pupillary Reflexes Light Reflex Direct light reflex . Each eye is tested separately in a shady place. The subject is asked to look at a distance. A bright light from a torch, brought from the side of the eye, is shined into the eye—the result is a prompt constriction of the pupil . Indirect or consensual light reflex . A hand is placed between the two eyes, and light is shined into one eye, observing the effect on the pupil of the unstimulated side . There is a constriction of the pupil in the other eye Thus, the pupils of both eyes constrict when light is thrown into any eye.

29. Retinal receptors → Optic nerve → Optic chiasma → Optic tract → Pretectum of midbrain → Edinger-Westphal nuclei of both sides → Oculomotor nerve → Ciliary ganglion → Ciliary nerves → Sphincter muscle of iris → Constriction of pupil

30. Demonstrate the reaction of the pupil to accommodation for near vision. The subject is asked to look at the far wall of the room. The observer then suddenly brings his finger, holding it vertically, about 15 cm in front of the subject’s nose, and the subject is asked to look at it. The response is convergence of the eyes and pupillary constriction Retina → Optic nerve → Optic tract → Lateral geniculate body → Geniculocalcarine tract (Optic radiation) → Visual cortex (area 17) → Frontal eye-field area (area 8 ab δ) → Edinger-Westphal nucleus of opposite side → Oculomotor nerve → Ciliary ganglion → Ciliary nerves → Constrictor pupillae muscle.

31. A pupil in which the accommodation reflex is present but the light reflex, both direct and consensual, is absent, is called the Argyll-Robertson pupil. Usually seen in neurosyphilis Nystagmus It is a disturbance of ocular movement characterised by involuntary, conjugate, often rhythmical oscillation of the eyes. Strabismus or Squint It is an abnormality of ocular movement, in which the visual axis do not meet at the point of fixation There are two types of strabismus: 1. Paralytic strabismus 2. Concomitant strabismus.

32. The trigeminal (V) nerve Sensory Ask the patient to close his eyes and say ‘yes’ each time he feels you lightly touch them using a cotton wool tip. Do this in the areas of V1, V2 and V3. Compare both sides. If you identify an area of reduced sensation, map it out.

33. Motor Inspect for wasting of the muscles of mastication (most apparent in temporalis). Ask the patient to clench his teeth; feel the masseters, estimating their bulk. Place your hand under the jaw to provide resistance; ask the patient to open his jaw. Note any deviation. The motor fibers of the 5th nerve, (its nucleus lies at the mid-pontine level) innervate the muscles of mastication— masseter , temporalis , and medial and L ateral pterygoids —and the tensor tympani of middle ear.

34. Demonstrate the corneal reflex. Light wisp of absorbent cotton is twisted to a fine hair. The subject is asked to look at the far wall and, approaching from the side, the lateral edge of the cornea is lightly touched with the cotton. The response is bilateral blinking; and the two sides should be compared. The afferent path of this reflex is ophthalmic division of the 5th nerve , the efferent path is 7th nerve , while the center is in the nuclei of these nerves in the pons. The conjunctival reflex, also a superficial reflex, is elicited in the same manner as corneal reflex. Touching the conjunctiva with a wisp of cotton causes bilateral blinking. (The conjunctiva of the lower lid is supplied by maxillary division of the 5th nerve).

35. The jaw jerk (maxillary reflex) is tested by placing a finger on the chin below the lower lip, with the mouth open , and striking it with a percussion hammer. The response is closure of the mouth . Normally this jerk is hardly detectable, but it is exaggerated in upper motor neuron lesions. Jaw jerk is exaggerated in pseudobulbar palsy Both the afferent and efferent paths are along 5th nerve and the center is in the pons.

36. Herpes-zoster ophthalmicus : Herpes-zoster commonly affects the ophthalmic division of the fifth cranial nerve. Trigeminal Neuralgia

37. The facial ( VIi ) nerve

38. Inspection 1. Observe the face for any asymmetry which may be related to paresis of facial muscles 2. Observe the symmetry of blinking and eye closure and the presence of any tics or spasms of the facial musculature 3. Observe spontaneous movements of the face, particularly the upper and lower facial musculatures during actions such as smiling.

39. Examination of Motor Function The motor function of the facial nerve is tested by asking the patient 1. To raise the eyebrows 2. Wrinkle the forehead by asking the patient to look upwards at the examiner’s hand, held above 3. Close the eyes as tightly as possible 4. To show the teeth ; the angle of the mouth is drawn to the healthy side 5. To blow out the cheeks against the closed mouth; air can be made to escape from the mouth more easily on the weak or paralysed side by tapping the inflated cheek with the finger 6. To purse the mouth 7. To whistle .

40. Bilateral LMN Palsy Bilateral UMN palsy Bell’s phenomenon—present Bell’s phenomenon—absent Emotional fibers—affected Emotional fibers—spared Corneal reflex—absent Corneal reflex—present

41. primary sensations of taste . They are sour, salty, sweet, bitter , and “ umami .” The sweet taste is better experienced near the tip of the tongue, salt on the sides and top, bitter in the posterior part, and sour sensation in between these areas. Abnormalities of taste. ageusia (absence of taste), hypogeusia (decreased sensitivity) dysgeusia (disturbed taste). Different diseases and some drugs can cause these conditions.

42. Examination of Sensory Functions Taste Examine the anterior two-third portion of each half of the tongue separately. Ask the subject to rinse his mouth; then dry it with gauze. a few drops of sugar solution, apply it to the tip of the tongue, and ask him to indicate, the taste experienced by him, without withdrawing the tongue. Have him rinse his mouth; dry the tongue with gauze, and repeat the procedure with the salt solution. Repeat this procedure with all the four substances, one by one, on the sides, Gently hold the protruded tongue with a swab, and wipe off the saliva. Ask the patient to identify the substance by pointing to the appropriate word written on a card.

43. Examination of the Secretory Functions Lacrimation Schirmer’s Test Nasolacrimal Reflex Afferent Trigeminal nerve Efferent Greater superficial petrosal nerve (a branch of facial nerve). Salivation Examination of the Reflexes Corneal Reflex Afferent Trigeminal nerve (descending or bulbospinal tract) Efferent Facial nerve. Stapedial Reflex Afferent Vestibulocochlear nerve Efferent Facial nerve.

44. Bell’s Palsy: It is due to an acute onset of non- suppurative inflammation of the facial nerve within the facial canal above the stylomastoid foramen, producing a unilateral lower motor neuron type of facial palsy. • Aaetiology of Bell’s palsy is not known. At times, Bell’s palsy can be bilateral. Syndrome of crocodile tears: It is characterised by unilateral lacrimation on eating Ramsay-Hunt syndrome: This is due to affection of the geniculate ganglion by Herpes zoster. Patients present with vesicular lesions over the external auditory meatus and pharynx, lower motor neuron type of facial nerve palsy, loss of taste, salivation and lacrimation and hyperacusis if stapedius is weak.

45. The vestibulocochlear (VIII) nerve

46. Tests of Hearing 1. Whisper test. 2. Watch test. 3. Tuning-fork tests. These are the most commonly used tests in clinical practice. 4. Recording of brain stem auditory evoked potentials (BAEP). 5. Audiometry 512 Hz tuning fork is most commonly used as it falls in the mid speech frequency and has minimum overtones and undertones. Tuning forks of lower frequency produce more bone vibration. Tuning forks of higher frequency have shorter decay time

47. Air (Ossicular) Conduction (AC) Normally, most of the energy of incident sound waves is transmitted via the outer ear, tympanic membrane, and middle ear ossicles to the cochlea where it stimulates the sensory hair cells of the organ of Corti . Bone Conduction (BC) Since cochlea is enclosed in a bony cavity (bony cochlea), vibrations of the skull bones themselves can be transmitted to the organ of Corti .

48. Rinne’s test This test compares the subject’s AC hearing with his BC hearing, in each ear separately. ■ Hit the prongs of the fork against a padded surface to make it vibrate. ■ Place the base of the vibrating tuning fork on the Mastoid process ■ Ask him to raise his hand when the sound stops ■ When the sound stops, bring the prongs in front of the ear—the sound will become audible once again.

49. Weber’s test This test compares the bone conduction of the subject in his two ears. ■ Hit the prongs of the fork against a padded surface to make it vibrate. ■ Place the base of the vibrating tuning fork in the middle of the patient’s forehead. ■ Ask: ‘Where do you hear the sound?’ ■ Record which side Weber’s test lateralizes to if not central

50. Schwabach’s Test This test compares the subject’s bone conduction with the examiner’s bone conduction. It is assumed that the examiner’s hearing is normal. ■ Hit the prongs of the fork against a padded surface to make it vibrate. ■ Place the base of the vibrating tuning fork on the Mastoid process ■ Ask him to raise his hand when the sound stops ■ When the sound stops, place the fork on your own mastoid process. Modified Schwabach’s Test or Absolute bone conduction test (ABC) Similar to Schwabach’s Test but the testing ear is occluded

51. Vestibular Part Giddiness or Vertigo Nystagmus Romberg’s test Balancing – Vision Cerebellum Vestibule

52. Test of Vestibular Function Barany caloric test. Barany chair test

53. The glossopharyngeal (IX) nerve The 9th nerve is motor to the middle constrictor of pharynx and stylopharyngeus , sensory for the posterior third of the tongue (both general and taste sensations), and mucous membrane of the pharynx. Parasympathetic fibers from inferior salivatory nucleus , after relaying in the otic ganglion, innervate parotid gland . This nerve is rarely involved alone, but generally with the 10th and 11th nerves

54. Tests for 9th nerve The sensation of taste over the posterior third of the tongue is tested. 2. Each side of the pharynx is touched lightly with a wooden spatula. The response is constriction of the pharynx. The afferent path is 9th nerve; the center is in medulla; and the efferent path is 10th nerve . Thus, this pharyngeal (or gag) reflex tests vagus as well. A soft touch is applied on the soft palate ; the response is elevation of the soft palate. The reflex arc is the same as in the gag reflex described above. Exaggerated gag reflex is seen in pseudobulbar palsy (upper motor neuron type of palsy).

55. The vagus (IX) nerve The vagus nerve is motor for soft palate, pharynx, and intrinsic muscles of the larynx. Somatic sensory fibers from unipolar cells in jugular ganglion supply external auditory meatus and part of the ear. The visceral sensory fibers of unipolar cells in ganglion nodosum innervate pharynx, larynx, trachea, and thoracic and abdominal viscera. The parasympathetic fibers arise from nucleus ambiguous and supply the heart (inhibitory), bronchial muscle and glands, glands and the smooth muscle of most of the gastrointesinal tract, and suprarenal gland.

56. Tests for vagus nerve 1. The pharyngeal and palate reflexes are tested as described for 9th nerve. 2. Using a tongue depressor, the subject is asked to open his mouth wide and say “ah”. The response is constriction of posterior pharyngeal wall ( Vernet’s rideau phenomenon), and movement of the uvula backwards in the midline. But in vagal paralysis , the uvula is deflected to the normal side . 3. The subject is asked for history of regurgitation of food through the nose, which is due to total paralysis of vagus ; a nasal voice may also be noted. 4. Laryngoscopy is done to note the position and movement of the true vocal cords. 5. Blood pressure regulation

57. The accessory (XI) nerve This purely motor nerve innervates some muscles in the pharynx and larynx (internal or medullary branch, arising from nucleus ambiguus ), as well as sternomastoid and the trapezius (external or spinal branch arising from the anterior horn cells of upper 5 or 6 spinal cord segments ).

58. The hypoglossal (XII) nerve Asks the subject to push out his/her tongue as far as possible, Then inspects its position, evidence of wasting and fasciculation. Asks the subject to move his/her tongue from side to side over the lips and against the walls of the cheeks. Places his/her finger over the subject’s cheek and asks him/her to push against it. Repeats on the opposite side The fibers innervate the muscles of the tongue and depressors of the hyoid bone.

59. Examination of Cranial Nerves I-VI Name: Age: Sex: Address: Occupation: The olfactory (I) nerve Substance Right Nostril Left Nostril Coffee Powder Normally Perceived Normally Perceived Cloves Normally Perceived Normally Perceived Garlic Normally Perceived Normally Perceived

60. The optic (II) nerve Tests Right Eye Left Eye 1.Visual Acuity With Specs Without Specs With Specs Without Specs a. Distant Vision (Snellen’s chart) b. Near Vision (Jaeger’s chart) N - ? N - ? N - ? N - ? 2.Color Vision (Ishihara charts) Normally Perceived Normally Perceived 3.Field of Vision (Finger Confrontation) Similar to that of examiner Similar to that of examiner Tests Right Eye Left Eye 1.Visual Acuity With Specs Without Specs With Specs Without Specs a. Distant Vision (Snellen’s chart) b. Near Vision (Jaeger’s chart) N - ? N - ? N - ? N - ? 2.Color Vision (Ishihara charts) Normally Perceived Normally Perceived 3.Field of Vision (Finger Confrontation) Similar to that of examiner Similar to that of examiner

61. The oculomotor (III) , trochlear (IV) and abducens (VI) nerves Observation Right Eye Left Eye Ptosis No No Nystagmus No No Movement of Eye Abduction Normal Normal Adduction Normal Normal Elevation Normal Normal Depression Normal Normal Intorsion Normal Normal Extortion Normal Normal

62. Observation Right Eye Left Eye Size of Pupil 3 mm 3 mm Pupillary Reflexes a. Light Reflex Direct light reflex Constriction of pupil Constriction of pupil Consensual light reflex Constriction of pupil of left Eye Constriction of pupil of Right Eye b. Accommodation reflex Adduction of eye + Constriction of pupil Adduction of eye + Constriction of pupil The oculomotor (III) , trochlear (IV) and abducens (VI) nerves

63. N - Normally Perceived Report : Cranial Nerves I to VI of the subject is clinically Normal The trigeminal (V) nerve Observation Right Left A. Sensory Functions Ophthalmic (V1) Maxillary (V2) Mandibular (V3) Ophthalmic (V1) Maxillary (V2) Mandibular (V3) Touch N N N N N N Temperature N N N N N N Pain N N N N N N Pressure N N N N N N Vibration N N N N N N B. Motor Functions On clenching teeth—the temporalis and masseter muscles become equally prominent on the both sides, On mouth opening — no deviation of jaw C. Reflexes Corneal bilateral Blinking of eyelid bilateral Blinking of eyelid Conjunctival bilateral Blinking of eyelid bilateral Blinking of eyelid Jaw Jerk Normal-closure of the mouth

64. The Facial (VII) nerve Muscle Right Left Occipitofrontalis On raising the eyebrows Horizontal wrinkling of the forehead Horizontal wrinkling of the forehead Orbicularis Oculi Tight closure of eye against Resistance Tight closure of eye against Resistance Orbicularis Oris On Showing teeth No deviation of angle of mouth No deviation of angle of mouth Buccinator blow out his cheeks No escape of air on tapping cheek No escape of air on tapping cheek Platysma On clenching teeth Prominence of muscle seen Prominence of muscle seen Motor Functions Testing for Muscles of Facial Expression

65. Solution Right Left Sweet Normally Perceived Normally Perceived Salt Normally Perceived Normally Perceived Sour Normally Perceived Normally Perceived Bitter Normally Perceived Normally Perceived Sensory Functions Testing ‘Taste Sensation’ from anterior two-thirds of the tongue. The Facial (VII) nerves

66. The vestibulocochlear (VIII) nerve Vestibular Part No Tinnitus, Giddiness, Vertigo or Nystagmus Romberg’s test Negative Test Right Left Watch Test Sound Perceived at ___cm from ear Sound Perceived at ___cm from ear Rinne’s test Air conduction is greater than Bone conduction (AC>BC) Air conduction is greater than Bone conduction (AC>BC) Weber’s test Intensity of sound heard equally on both sides (No lateralization of sound) ABC test Modified Scheabch’s test Bone conduction is equal to that of examiner Bone conduction is equal to that of examiner Cochlear Part

67. Solution Right Left Sweet Normally Perceived Normally Perceived Salt Normally Perceived Normally Perceived Sour Normally Perceived Normally Perceived Bitter Normally Perceived Normally Perceived Sensory Functions Testing ‘Taste Sensation’ from posterior one-thirds of the tongue. The glossopharyngeal (IX) nerve Motor Functions Pharyngeal Reflex: Constriction of posterior pharyngeal wall seen on touching pharyngeal wall Palatal Reflex: E levation of the soft palate seen on touching soft palate

68. The vagus (IX) nerve Arches of palate: Position of the Arch and uvula – Normal On saying ‘ah’ – elevation of the soft palate on both sides and the uvula is central Pharyngeal Reflex: Constriction of posterior pharyngeal wall seen on touching pharyngeal wall Palatal Reflex: E levation of the soft palate Present seen on touching soft palate

69. The accessory (XI) nerve Test for spinal part of the accessory nerve Trapezius – Prominence of muscle is seen on both sides on shrugging of shoulder against resistance Normal Power on both sides Sternocleidomastoid – Prominence of muscle is seen when the chin is turned to opposite side against resistance Prominence of muscle is seen on both sides when the chin is depressed against resistance Normal Power on both sides

70. On protrusion of the tongue – it remains in the midline, there is no deviation of the tongue Subject can push against the examiner’s finger kept over the cheek with his tongue. No wasting, tremor or fasciculation seen. The hypoglossal (XII) nerve Report : Cranial Nerves VII to XII of the subject is clinically Normal