CRANIAL

NERVE
EXAMINATION
CARL BRYAN NUCUM, CKTP, MPH, PTRP
Course Objectives:
At the end of the lesson, the learner should be able to:
• Discuss the twelve cranial nerve and their functions
• Identify the test used and its responses for each
cranial nerves
• Identify the strategies to assess cranial nerves in
young children and newborn
• Perform the skill in cranial nerve assessment and
examination.
 Cranial nerves
• Cranial nerves are associated with the brain, but are
considered peripheral nerves as they provide sensory,
motor, and autonomic innervation to the head and
select parts of the body.
• There are 12 pairs of cranial nerves, most of which
emerge from the brainstem. Two emerge from the
forebrain (CN I and CN II) and one emerges from the
spinal cord (CN XI)
• Sensory function: CN 1,2,8
• Motor function: CN 3,4,6,11, 12
• Mixed: CN 10,9,7,5
• Forms part of parasympathetic: CN 10, 9, 7 ,3
Cranial nerves
 CRANIAL NERVE I: OLFACTORY NERVE
➢Function: Sense of Smell
➢Test: Patient is asked to smell different
common or familiar, non – irritating
odors placed in a small bottle and are
placed under each nostrils and are
tested separately for identification like
coffee, vanilla, alcohol and perfume
- Each nostril should first be evaluated for potency
by compressing one nostril and having the patient
breathe through the opposite and identify the
substance placed under the open nostril. The
patient should also close his eyes
 CRANIAL NERVE II: OPTIC NERVE
➢Function: Vision; Sense of Sight; includes test for
visual acuity and color blindness
❖Visual acuity - is the ability of the eye to perceive fine
detail when reading

➢Test for Visual acuity:

▪ Using Snellen’s chart - most commonly used and
accurate measure of visual acuity. It has lines of letters
arranged in decreasing size.
- Patient is asked to identify letters or numbers – 6
meter (20 feet) away from the chart
 CRANIAL NERVE II: OPTIC NERVE
➢Test for Visual acuity:
✓Snellen’s chart
 CRANIAL NERVE II: OPTIC NERVE
➢Test for Visual acuity:
▪ Using a Jaeger’s chart/card – used for near vision at a
normal reading distance, where the chart is placed
30cm or 14 inches from the patient
 CRANIAL NERVE II: OPTIC NERVE
➢Visual field (a.k.a. peripheral vision or peripheral
limitation of vision) - is the side vision of the eye that
allows an individual to view the objects around them,
without the need to turn their head or move their eyes,
- A normal visual field for a person covers 170 degrees
around, while peripheral vision covers 100 degrees of
this field.
- Normal value of visual
field on one eye: about
50-60° superiorly; 90-
100° temporal, 70-75°
inferiorly, and 60° nasal
 CRANIAL NERVE II: OPTIC NERVE
➢Test: Confrontation visual field testing
- Procedures: Ask the patient to cover one eye (example
right) while the examiner covers his opposite eye (left)
and look straight at your eyes. The distance between
the patient and examiner is approx. 1 meter
 CRANIAL NERVE II: OPTIC NERVE
➢Peripheral vision confrontational test
▪ Procedures:
- Examiner moves the right arm to one
side (example at right side of vision)
and wiggle the fingers to see whether
the patient can recognize the
movement, or may ask patient count
fingers (using 1, 2 or 5)
- Test all four quadrants in a similar
fashion, one quadrant at a time
 CRANIAL NERVE II: OPTIC NERVE
➢Test for color vision – for color blindness
❑ Ishihara’s chart/plate - most well known color
blindness test
- To pass each test you must identify the correct
number, or correctly trace the wiggly lines.
 CN III: OCULOMOTOR NERVE
➢Function:
- Raises the upper eyelid; turns the eyeball upward,
downward and medially
- Constricts the pupil, direct light reflex, accommodation
reflex and consensual light reflex
 CN III: OCULOMOTOR NERVE
➢Test:

❖Ocular muscle tracking – patient is asked to follow

tracking or movement of the therapist index finger and
able to move the eyeball upward, downward and
medially in an “H” pattern about 18 inches
 CN III: OCULOMOTOR NERVE
➢Test:
❖Ocular muscle tracking
- Commonly, move the index finger/penlight 25 cm (10
inches) from patients’ nose, then the penlight/index
finger is moved approximately 30 cm (12 inches) to the
patients’ right; then moved up by 20 cm (8 inches).
Then moved down 40 cm (16 inches) and then moved
back to the midline. Then repeat the procedure going
to the left
 CN III: OCULOMOTOR NERVE
➢Pupillary light reflex – it is the pupils reaction to light
▪ Normally when a light is shone in one eye, an
examiner will observe constriction of both pupils first,
followed by slight dilatation

❑The reaction of the eye being

tested is called “Direct Light
reflex”
❑The reaction of the opposite
eye to the light is called
“Consensual Light reflex”
 CN III: OCULOMOTOR NERVE
Pupil sizes
- normal pupil size in adults varies from 2 to 4 mm in
diameter in bright light to 4 to 8 mm in the dark

➢Miosis – small constricted pupil

➢Mydriasis – dilated large pupil
➢Anisocoria – unequal pupil

➢Tests for Pupillary Light Response

- Light Response Pupil Test
- Swinging Flashlight Pupil Test
- Near Response Pupil Test
 CN III: OCULOMOTOR NERVE
➢Light Response Pupil Test
- assesses the reflex that controls the size of the pupil in
response to light

Procedure: (performed in a room with dim light)

- The examiner ask the patient to look at an object in the
distance, with both eyes open
- Using a penlight, a light is shone to the side of an open
one eye for 5 seconds, observing the reaction
(constriction) of both pupils as to size and shape
- Do on the opposite eye and again observing the
reactions of both pupils
 CN III: OCULOMOTOR NERVE
➢Swinging Flashlight Pupil Test
- looks for differences between the visual afferent
pathways of the two eyes

Procedure: (performed in a room with dim light)

- The examiner ask the patient to look at an object in the
distance, with both eyes open
- The examiner will "swing" the light rhythmically from
one eye to the other, noting the response of each pupil
- The light should be shined for 2–4 seconds at each
eye and then rapidly moved to the other eye
- The pupils should constrict or stay the same size when
the light is shone on them
 CN III: OCULOMOTOR NERVE
➢Near Response Pupil Test
- it measures the pupil's response to a near target
- not commonly performed—it's usually only done in
cases where certain diseases are being ruled out

Procedure: (performed in a room with normal lighting)

- The examiner ask the patient to look at a distant
object. then move a small object or card in front of the
eyes
- As patient is asked to fixate the eyes on the near
object, the examiner watches the pupils closely to
make sure both constricts quickly as fixation changes
from far to near.
 CN III: OCULOMOTOR NERVE
➢ Pupillary light reflex
 CN III: OCULOMOTOR NERVE
❖ Accommodation (Accommodation-Convergence)
reflex
- is an adjustment of the eye for near vision, which
involves three phenomena:
- Increased convexity of the lens
- Pupillary constriction
- Convergence of the eyes – moves medially
 CN III: OCULOMOTOR NERVE
❖ Accommodation reflex
➢Procedure:
- the patient is asked to look at distant objects and then
at a test object – either a pencil or the examiners
finger and move it at about 10 cm from the bridge of
the nose.
- Response: Normally, the eyes will dilate when the
patient looks at far objects and constricts when focus
on near objects. The eyes will also adduct (going cross
eyed) when looks at the close object.
- If the pupils do not react, there is possible problem to
the oculomotor nerve or injury to the head
 CN IV: TROCHLEAR NERVE
➢Function: It supplies the superior oblique muscle that is
responsible for eye intorsion (internal rotation),
depression and abduction

➢Test: Ocular muscle tracking - patient is asked to follow

tracking or movement of the therapist index finger and
able to move the eyeball downward and laterally
 CN V: TRIGEMINAL NERVE
➢Sensory Function:
➢Sensation of the face and
the cornea, scalp, eyelids,
and nose; mucous
membrane of the nose,
mouth and anterior part of
the tongue; maxillary sinus
and palate, paranasal
sinuses and nasal cavity;
teeth of the upper and
lower jaw; and the
temporomandibular joint
 CN V: TRIGEMINAL NERVE
➢Motor function: Motor supply to the muscles of
mastication and chewing ability

➢Reflex: Corneal reflex or corneal wink or conjunctival

reflex; jaw jerk reflex and sneeze reflex

➢Tests:
❖ Sensory Test:
- Assess for the sensation of the
face (refer to the procedures for
sensory assessment –
superficial somatic sensation)
 CN V: TRIGEMINAL NERVE
➢Tests:
❖ Motor Test: Assess the strength of the muscles of
mastication
- Ask the patient to open and close the mouth, clenched
the teeth or either let the patient chew
 CN V: TRIGEMINAL NERVE
➢Tests:
❖ Sneeze reflex - A sneeze is a sudden, forceful,
uncontrolled burst of air through the nose and mouth.
- To stimulate, Roll the corner of a tissue into a point,
and place it in one nostril and gently move the tissue
back and forth, until feeling a tickling sensation; may
sniff a perfume or spices
 CN V: TRIGEMINAL NERVE
➢Tests:
❖ Jaw reflex
- Procedure: the examiners thumb
Is placed on the chin of the
patient with the mouth relaxed
and slightly open
- This test can also be done by placing a tongue
depressor firmly against the lower teeth with patient
relaxes the jaw muscles and mouth slightly opens
- The examiner then taps the thumbnail or the tongue
depressor with a neurologic hammer
- Response: Reflex initiates closure of the mouth
 CN V: TRIGEMINAL NERVE
➢Tests:
❖ Corneal Reflex: this reflex is used to test if there is
damage or dysfunction to the pons
- Procedure: the patient is asked to look on one side to
avoid involuntary blinking. The examiner touches the
cornea (not the eyelashes or conjunctiva) with a small,
fine point of cotton
- Response: the normal
response is bilateral blink
because the reflex arc
connects both the facial
nerve nuclei
 CN VI: ABDUCEN NERVE
➢Function: It supplies the lateral rectus muscle that
turns the eyeballs laterally

➢Test: Ocular muscle tracking - patient is asked to follow

tracking or movement of the therapist index finger and
able to move the eyeball laterally
 CN VII: FACIAL NERVE
➢Function:
- Sensory function: Taste of the anterior two thirds of the
tongue from floor of the mouth and palate
- Motor innervation of the muscle of the face and scalp,
stapedius, posterior belly of digastric and stylohyoid
muscle
- Secremotor parasympathetic innervation of the
submandibular and sublingual salivary glands, lacrimal
glands and glands of the nose and palate
- Assists in corneal reflex
 CN VII: FACIAL NERVE
➢Test:
❑Sensory Test: Introduce different foods of different
tastes (sweet, sour, salty and bitter) at the anterior two
thirds of the tongue

❑Corneal reflex (see trigeminal nerve)

 CN VII: FACIAL NERVE
➢Test:
❑Motor Test: Ask the patient to perform different facial
expressions such as wrinkling the forehead, close the
eyes, close the mouth; puff out both cheek and smile,
etc... The therapist may also apply resistance to
assess facial muscle strength
- Signs of facial weakness include flattening of the
nasolabial groove, slower blinking, and loss of facial
wrinkles
 CN VII: FACIAL NERVE
➢Test:
❑Motor Test:
- Check the amount of voluntary muscle
contraction/motion in each of the five peripheral
branches by having the patient perform the following:
- (1) temporal—raise the eyebrow s, wrinkle the brow
- (2) zygomatic —close the eyes gently, and with
maximal effort try to keep the eyes closed while the
examiner attempt s to open them
- (3) buccal—smile, show teeth, puff out the cheeks
- (4) mandibular— pout, purse the lips
- (5) cervical— sneer
 CN VIII: VESTIBULOCOCHLEAR NERVE
➢Functions:
❑ Vestibular part – primarily responsible for maintaining
balance and eye movement
- sensation on the utricle and saccule – maintenance of
head position relative to the force of gravity and are
responsible for static equilibrium
- Semicircular canal is responsible for position and
movement of the head and for balance and dynamic
equilibrium (acceleration and deceleration)

❑Cochlear part – responsible for sense of Hearing

(Organ of Corti)
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part)
➢Spin’s test
❖Procedure:
- Ask the patient to stand and open the eyes throughout
the test
- Examiner spin around the patient for 10x
- Watch the response of the eyes (abnormal reaction
nystagmus).
- The normal response for spinning movement is a
feeling of vertigo (a sense that the patient is dizzy or
the room is moving).
- Do not permit the patient to fall or walk until dizziness
is completely gone.
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Doll’s Eye test (Oculocephalic Reflex).
- assess brainstem function in a comatose patient
- as the head is turned, the eyes move toward the
opposite side
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Doll’s Eye test (Oculocephalic Reflex).
❖Procedure:
- Rotate the head to one direction. The eyes should
deviate in the opposite direction. This deviation should
be smooth and conjugate.
- Keep the head in that position. The eyes should slowly
return to midline.
- Rotate the head to the opposite direction; i.e. if facing
to the right, turn the head to face the left. This is the
maximal stimulus for this test. Again, the eyes should
move smoothly in the opposite direction.
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Doll’s Eye test (Oculocephalic Reflex).
❖Procedure:
- Tilt the head up and down, as if nodding. The eyes
should still move in the opposite direction. On tilting
the head down, the eyelids might also open (this is
called the doll's head phenomenon)

- Response: A normal response is the conjugate

deviation of gaze, and an abnormal response is a
persistent fixed gaze, with no eye movement
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Caloric Oculovestibular reflex
- used to test brainstem function in profoundly comatose
patients
- Eyes deviate towards the tested ear in response to
cold and eyes move to the opposite side of the tested
ear in response to warm
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Caloric Oculovestibular reflex
- Procedures:
- Raise the head of the bed to 30 degrees, to bring the
horizontal semicircular canal in to a vertical position so
that the response is maximal.
- Infuse ice water into the ear canal (recommended at a
rate of about 10ml/min using a syringe tipped with a
plastic catheter (such as IV cannula)
- Wait for about 5 mins. before testing the opposite ear
❖Normal response: The eyes should deviate towards
the tested ear in response to cold; if warm water is
used, the eyes deviate to the opposite side
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Caloric Oculovestibular reflex
- Procedures:
- In order to complete the test, one should also perform
the irrigation of both ears.
❖Normal response: Cold water in both ears should
cause a downward deviation of the eyes, and warm
water should cause an upward deviation

❖Abnormal Response: fast nystagmus (cold will move

eyes to the opposite and warm moves the eyes to the
irrigated side
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Caloric or Temperature test (based from Magee)
❖Procedure:
- The examiner alternately applies hot and cold test
tubes behind the patient ears on each side of the
head; each side is done in turn
- Response: a positive test is associated with
inducement of vertigo, which indicated inner ear
problem
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for vestibular part
➢Mittelmeyer test or “Turning test”
❖Procedure:
- Ask patient to march on the spot with arms
outstretched & eyes closed:
- Normal response: patient remains in the same position
- If with Vestibular lesion – patient will turn toward the
side of the lesion
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for cochlear part
➢Finger Flickering
- on either side of the patient ears with eyes close, the
examiner flickers finger about 1 inch near the ears and
be able to identify sounds in any directions

➢Finger rubbing
- With eyes closed, the patient should be instructed to
acknowledge hearing the gentle rubbing of the
examiner's fingers approximately 3-4 inches away
from his right and left ear
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for cochlear part
➢Weber test
- Procedure 1: the examiner places the
base of the tuning fork on the midline
of the vertex of the patients head;
- then patient is asked if the sound is
heard equally on both ears or is heard
better in one ear (lateralization of
sound)
- Response: Normally the patient should hear the sound
equally on both ears. If the sound is lateralized, the
patient is asked to identify through which ear the
sound is heard better
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for cochlear part
➢Weber test
- Procedure 2: To test the reliability of the patient, the
examiner repeats the procedure while occluding one
ear with a finger and asks the patient through which
ear the sound is heard better
- Response: the sound is heard better in the occluded
ear
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for cochlear part
➢Rinne’s test – allows unilateral
comparison between air and
bone conduction
- Procedure: Place a vibrating
tuning fork at the mastoid
process and ask the patient to
say when it has stopped
- then move the still vibrating
tuning fork to the external
meatus at least 1 cm away
- You can also ask the patient
which position is loudest
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for cochlear part
➢Rinne’s test
▪ Normal (positive) response: If the sound heard at the
meatus is greater in air conduction than bone
conduction
▪ Negative response:
- if bone conduction greater than air conduction - seen
in sensorineural deafness
- If sound is not heard at the meatus: seen in conduction
deafness
 CN VIII: VESTIBULOCOCHLEAR NERVE
❑Test for cochlear part

❖Sensorineural or perceptual hearing loss

- Caused by inner ear disease or damage to the
cochlear nerve; indicates the patient has difficulty
interpreting sounds heard

❖Conductive hearing loss

- caused by diseases of the middle ear, such as
otosclerosis or otitis media; and obstruction of the
outer auditory canal, as seen in cerumen impaction,
- patient experiences reduction of all sounds rather than
difficulty in interpreting sounds
CN IX: GLOSSOPHARYNGEALNERVE
➢Function:
- Sensation on the posterior one third of the tongue and
pharynx
- Supplies motor function of the stylopharyngeus muscle
– that assists in swallowing
- Provides secremotor parasympathetic function for
parotid salivary gland; carotid sinus (baroreceptor) and
carotid body (chemoreceptor)

➢Test:
❑ Sensory Test: Introduce different foods of different
tastes (sweet, sour, salty and bitter) at the posterior
one third of the tongue
CN IX: GLOSSOPHARYNGEALNERVE
➢Test:
❑ Assess soft palate & uvula:
- Symmetry – note any obvious deviation of
the uvula
- Ask patient to say “ahhhh” – observe
uvula moving upwards
❑Ask patient to cough– damage to nerves
IX & X can result in a bovine cough
❑ Swallow – ask patient to take a sip of
water – note any coughing / delayed
swallow
❑ Gag Reflex: (see vagus nerve).
 CN X: VAGUS NERVE
➢Function: Supplies both sensory and motor innervation
to the heart and great thoracic vessels; larynx, trachea,
bronchi, lungs; alimentary tract from pharynx to splenic
flexure of the colon; liver, kidneys and pancreas
➢Test: assess for Gag Reflex
▪ Procedure: The patient is instructed
to say “ahh” & a tongue depressor
is inserted at the posterior pharynx
and depressed towards the uvula or
at the hypopharynx to test for
sensation of the pharynx
▪ Response: Positive response is when patient attempts
to vomit, Also check for the palatal movement
 CN XI: ACCESSORY NERVE
➢Function:
❖Cranial Root – supplies motor function of the muscle of
soft palate (except the tensor veli palatine); pharynx
(except stylopharyngeus) larynx (except cricothyroid)
and branches supplied by vagus nerve

❖Spinal Root – supplies the motor function of the

sternocleidomastoid and trapezius muscle
 CN XI: ACCESSORY NERVE
➢Test:
❑To test the Trapezius: Ask the patient to
shrug both shoulder and then apply a
downward resistance. Compare the
strength of the muscles on both sides

❑To test the Sternocleidomastoid: flex

the head forward then side flex to one
side (test side) followed by rotating the
head to the opposite side against
resistance; or to put the chin on each
shoulder in turn against resistance
 CN XII: HYPOGLOSSAL NERVE
➢Function: Motor innervations to the
muscles of the tongue (except
palatoglossus) controlling its shape
and movement)

➢Test: Ask the patient open the mouth and protrude the
tongue. Let the patient move the tongue in any
direction (ex. From side to side)
- Place your finger on the patient’s cheek & ask to push
their tongue against it
 STRATEGIES TO ASSESS CRANIAL
NERVES IN YOUNG CHILDREN
Cranial
Activity Strategies
Nerve
Testable in older children only; introduce different
I Olfaction
odors
Use Snellen chart after age 3 years.
II Visual acuity Test visual fields as for an adult. A parent may need
to hold the child’s head.
Have the child track a light or an object (a toy is
III, IV, Extraocular
preferable). A parent may need to hold the child’s
VI movements
head.
Motor movt. of
Have the child clench the teeth and chew or swallow
jaw
some food.
V
Sensation of
Play a game with a soft cotton ball to test sensation.
Face
 STRATEGIES TO ASSESS CRANIAL
NERVES IN YOUNG CHILDREN
Cranial
Activity Strategies
Nerve
Have the child “make faces” or imitate you as you
Facial
VII make faces (including moving your eyebrows), and
Expressions
observe symmetry and facial movements.
Perform auditory testing after age 4 years.
VIII Acoustic Whisper a word or command behind the child’s
back and have the child repeat it.
Have the child stick the “whole tongue out” or “say
Swallow and
IX,X ‘ah’.” Observe movement of the uvula and soft
gag
palate or Test the gag reflex.
Have the child push your hand away with his head.
Head bending
Have the child shrug his shoulders while you push
XI and Shoulder
down with your hands to “see how strong you are.”
shrugging
Tongue
XII Ask the child to “stick out your tongue all the way.”
movement
 Newborn cranial nerves
- Examination of the baby’s cranial nerve function is
often accomplished by observing spontaneous activity
- Testing a baby’s behavior response to light, CN II and
sound (CN VIII) also adds to the cranial nerve exam.
- Pupillary light reflex, corneal reflex, gag reflex and
funduscopic exam are done in the same manner as
the adult exam.
- Eye movements CN III, IV and VI can be assessed by
using the vestibulo-ocular reflex (doll’s eyes maneuver
(CNVIII)).
- When the head is turned, there is conjugate eye
movement in the opposite direction.
 Newborn cranial nerves
- During crying, facial movement, CN VII is observed for
fullness or asymmetry.
- The quality and strength of the cry is a way of looking
at CN IX and CN X function.
- Sucking and swallowing assesses, CN V, VII, IX, X
and XII because all of these cranial nerves are
involved in this complex act.
 REFERENCES
- O’Sullivan, S. And Schmitz, T. Physical Rehabilitation
Assessment and Treatment. (6th edition) Philadelphia:
F. A. Davis Co.
- Fruth, Stacie J. Fundamentals of the Physical Therapy
Examination (2ND edition) Jones & Bartlett Learning,
LLC, an Ascend Learning Company 2018
- Magee, David (2014): Orthopedic Physical
Assessment, 6th edition, Saunders, an imprint of
Elsevier Inc.
- Bickley, L; Bate’s Guide to Physical Examination and
History taking 10th edition, Lippincott Williams &
Wilkins, a Wolters Kluwer
 REFERENCES
- Copyright © 2020 Elsevier B.V. or its licensors or
contributors. ScienceDirect ® is a registered trademark
of Elsevier B.V.
- Lindsay, K: Neurology and Neurosurgery Illustrated;
Elsevier 5th edition
- https://www.verywellhealth.com/pupil-testing-
3421844#:~:text=4%EF%BB%BF%20Your%20doctor
%20will,and%20shape%20of%20your%20pupils