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Wessex LMC Masterclass Cranial Nerve Examination Dr Sam Davies, GP Locum Aims Clinical examination demo Individual nerve functions Clinical scenarios/cases Questions Mnemonics Oooh Oooh Ooooh To Touch And Feel Very Good Velvet. Such Heaven! Some Say Marry Money But My Brother Says Big Brains Matter More! Cranial Nerves I: Olfactory II: Optic (acuity, visual fields, pupils, ophthalmoscopy) III: Oculomotor (superior and inferior) IV: Trochlear (superior oblique) – “SO4” V: Trigeminal (3 branches) VI: Abducens (lateral rectus) – “LR6” Cranial Nerves VII: Facial VIII: Vestibulocochlear IX: Glossopharyngeal X: Vagus XI: Spinal Accessory XII: Hypoglossal The Examination Demo! I: Olfactory Sensory: smell Test each nostril individually Pathology: trauma meningitis frontal lobe disease/tumour II: Optic Acuity: Snellen Chart Visual fields: detailed examination Pupil responses Ophthalmoscopy to assess optic disc Visual field defects http://interestingmedical.com/visual-field-defects/ Causes of a non-reactive pupil? Non-reactive pupil Acute angle-closure glaucoma Encephalitis Drug reaction Ocular trauma Opiates Uveitis http://www.mcleishoptometrists.com/information/further-information/eye-problems/pupilproblems/ Wernicke’s disease III: Oculomotor Motor: all movements apart from superior oblique and lateral rectus CN III lesion results in ptosis The eye moves “down and out” Dilated pupil due to unopposed sympathetic nerve input http://www.slideshare.net/hytham_nafady/oculomotor-nerve-35361054 IV: Trochlear Motor: supplies the superior oblique muscle “SO4” Responsible for depression and adduction of the eye (down and in) Patient may report diplopia/double vision on looking down and in compensatory head tilt V: Trigeminal Sensory: corneal reflex face (3 divisions: ophthalmic, maxillary, mandibular) Motor: muscles of mastication (masseter, frontalis, pterygoids) Corneal Reflex https://www.youtube.com/watch?v=x4UrvhaetdE Sensory function of CN V http://medical-dictionary.thefreedictionary.com/trigeminal+nerve Motor function of CN V Chewing! Palsy deviation to the side of the lesion, open jaw Sensory loss: trigeminal neuralgia, herpes zoster, nasopharyngeal carcinoma Motor loss: bulbar palsy, acoustic neuroma https://quizlet.com/97749796/neuro-ii-flash-cards/ VI: Abducens Motor: controls lateral rectus (pulls eye out) “LR6” Palsy results in an inability to look laterally Also may have convergent strabismus Most common isolated ocular nerve palsy Abducens nerve palsy Vasculopathic (DM, HTN, atherosclerosis), trauma, idiopathic (25%) Less commonly: raised ICP, MS, sarcoidosis, vasculitis, SOL, stroke, giant cell arteritis, Wernicke’s http://www.rcemlearning.co.uk/modules/cranial-nerves-one-to-six/abducens-nerve-vi/introduction/ VII: Facial Motor: muscles of facial expression Sensory: taste to anterior 2/3 of tongue Test voluntary facial movements: Wrinkling brow Showing teeth Frowning Closing eyes tightly Pursing lips Puffing out cheeks Facial Nerve Palsy LMN lesion: one side of face affected • • • • • • • Bell’s palsy Polio Otitis media Skull fracture Cerebellopontine angle tumour Parotid tumours Herpes Zoster Ramsay Hunt syndrome UMN lesion: lower 2/3 of face affected only • Stroke • Tumour VIII: Vestibulocochlear Auditory Vestibular function: Balance (Rhomberg’s Test) Nystagmus Pathology: noise, labyrinthine problem, Meniere’s disease, acoustic neuroma, brainstem CVA, drugs IX and X: Glossopharyngeal and Vagus Sensory: taste to posterior 1/3 of tongue Motor: controls swallow, gag reflex and voice Pathology: trauma, brainstem lesions, neck tumours XI: Spinal Accessory Motor: supplies trapezius and sternocleidomastoid muscles Test: shrug shoulders against resistance turn head to R/L against resistance Pathology is rare: Polio, trauma, bulbar palsy, local lymphadenopathy What does this slide show? https://surgicaleducation.wordpress.com/2010/07/18/iatrogenic-nerve-palsy/ Finally… XII: Hypoglossal! Motor function to tongue Ask patient to stick tongue out If palsy present will deviate toward side of lesion Pathology: trauma, brainstem lesions, neck tumours Case 1 • Jim, 34 years old, presents to duty team • Usually fit and well • Recent viral URTI • Woke this morning looking like this • Reports facial numbness and altered taste • What is the diagnosis? • How might you treat this? http://medicalpicturesinfo.com Bell’s Palsy https://www.researchgate.net/figure/259808463_fig2_Drawing-representing-a-man-with-Bell'spalsy-showing-right-facial-hemiparalysis Bell’s Palsy LMN/facial palsy - unilateral Peak age 10 - 40 years, M = F, 1 in 60 during lifetime Eyebrow droops, brown wrinkles smoothed out Impossible to frown or raise eyebrows Sudden-onset, sometimes post-auricular pain +/- facial numbness +/- hyperacusis +/- watery eye Tx: 80% sponataneously improve. High-dose prednisolone and aciclovir (if < 72 hours) IMPORTANT! Bell’s Palsy = LMN lesion Ability to wrinkle brow is lost In UMN palsy, ability to wrinkle brow is preserved Full neurological examination including cranial nerves is therefore essential Case 2 • • • • • • • • Sarah, 51 years old Known HTN, on ramipril 5mg OD Otherwise fit and well 2/52 intermittent burning pain to L mandibular region Well between episodes Exacerbated by talking or laughing What is your differential? What might you do next? Trigeminal Neuralgia http://www.cohenkayedental.com/pages/whatWeDo/orofacial/trigeminalNeuralgia.htm Trigeminal Neuralgia Paroxysms of burning/stabbing/”electric shock” 96% unilateral Mandibular/maxillary > ophthalmic F > M, more common > 50 years old Cause unclear, more common in MS or those with HTN Tx: carbamazepine Refer if < 50 years old or unable to control symptoms Is This Physician Really So Cool… Inspection Tone Power Reflexes Sensation Co-ordination Summary Takes some practice! Important in helping formulate a differential Low threshold for referral/2nd opinion Systematic approach Questions…