Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women's/Massachusetts General Hospital, Boston, Massachusetts, USA
During each section of the neurological testing, the examiner uses the powers of observation to assess the patient. In some cases, cranial nerve dysfunction is readily apparent: a patient might mention a characteristic chief complaint (such as loss of smell or diplopia), or a visually evident physical sign of cranial nerve involvement, such as in facial nerve palsy. However, in many cases a patient's history doesn't directly suggest cranial nerve pathologies, as some of them (such as sixth nerve palsy) may have subtle manifestations and can only be uncovered by a careful neurological exam. Importantly, a variety of pathological conditions that are associated with alterations in mental status (such as some neurodegenerative disorders or brain lesions) can also cause cranial nerve dysfunction; therefore, any abnormal findings during a mental status exam should prompt a careful and complete neurological exam.
The cranial nerve examination is applied neuroanatomy. The cranial nerves are symmetrical; therefore, while performing the examination, the examiner should compare each side to the other. A physician should approach the examination in a systematic fashion and go through the cranial nerves in their numerical order.
I | Olfactory | Smell |
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 sternocleidomastoids and trapezius muscles |
XII | Hypoglossal | Tongue protrusion and lateral movements |
Table 1. The 12 Cranial Nerves and Their Basic Functions
Cranial nerve I (the olfactory nerve) is a purely sensory nerve that conveys the sense of smell, and is not routinely tested during most examinations. Cranial nerve II (the optic nerve) is the only cranial nerve that can be directly visualized as it exits from the central nervous system. Its axons convey visual information and compose the afferent limb of the pupillary reflex. Testing of the pupillary responses also assesses the function of cranial nerve III (the oculomotor nerve), parasympathetic fibers of which form the efferent limb of the pupillary reflex. Cranial nerve exam includes assessment of the extraocular movements, which are controlled by cranial nerves III, IV and VI. Cranial nerve III innervates the superior, medial, and inferior rectus muscles, as well as the inferior oblique muscle, which together function to move eyes medially and in the vertical plane. Cranial nerve IV (the trochlear nerve_ innervates the superior oblique muscles, which moves the eye downward and outward. Cranial nerve VI (the abducens nerve) innervates the lateral rectus muscles, which abducts the eyes. The function of the medial and lateral rectus muscles is straightforward: Lateral rectus is involved in abduction, meaning lateral movement along the horizontal plane. Medial rectus adducts moving the eye medially movement along the horizontal plane. The remaining muscles each causes movement in more than one direction and some combination of elevation/depression, abduction/adduction, intorsion/extorsion.
Muscle | Innervation | Primary action | Secondary action | Tertiary action |
Medial rectus | CN III | Adduction | -- | -- |
Superior rectus | CN III | Elevation | Intortion | Adduction |
Inferior rectus | CN III | Depression | Extortion | Adduction |
Inferior oblique | CN III | Extorsion | Elevation | Abduction |
Superior oblique | CN IV | Intorsion | Depression | Abduction |
Lateral rectus | CN VI | Abduction | -- | -- |
Table 2. The function of the six extraocular muscles.
This first part of the cranial nerve exam concludes by testing cranial nerve V (the trigeminal nerve). This nerve has both motor and sensory components. It controls facial sensation, masticatory movements and forms the afferent limb of the corneal reflex. There are 3 major sensory branches of the trigeminal nerve - the ophthalmic, maxillary, and mandibular (also labeled V1, V2, and V3, respectively).
1. Cranial Nerve I (Olfactory Nerve)
The olfactory nerve exam is performed on patients acknowledging a decreased sense of smell, especially after an acceleration/deceleration head injury, as the olfactory nerves are prone to such shearing injuries.
2. Cranial Nerve II (Optic Nerve).
The assessment of the optic nerve assessment includes fundoscopy, visual acuity testing, visual field examination, and testing for pupillary responses.
3. Cranial Nerves II and III.
Pupillary light reflex controls the diameter of the pupil in response to the light intensity. Both cranial nerves II and III are being tested when the pupillary response is checked, as the optic nerve carries the afferent fibers of the reflex, and the efferent limb is supplied by cranial nerve III (the oculomotor nerve).
4. Cranial Nerves III, IV, and VI.
5. Cranial Nerve V (Trigeminal Nerve).
This video demonstrates a systematic approach to examining the first six cranial nerves. The central and peripheral nervous systems are an integrated system. Therefore, if the clues to a neurological problem are uncovered while taking medical history or during the mental status exam, it should make the clinician more vigilant during the rest of the examination of the nervous system to look for other abnormalities. A clinician should develop a pattern of going through each nerve in numerical order and only document those nerves that were actually examined in the final report. Patients are often being followed for diseases (such as multiple sclerosis) where findings may be changing over time. The documentation from one examination to another are important to follow and the findings should be carefully charted. It is not adequate to just look at the patient and then state "cranial nerves II-XII are intact," as is so often recorded during a typical physical examination.
Skip to...
ABOUT JoVE
Copyright © 2024 MyJoVE Corporation. All rights reserved