Neuro

Olfactory

Optic

Occulomotor

Trochlear

Trigeminal

Abducens

Facial

Acoustic/Vestibulocochlear

Glossopharyngeal

Vagus

Spinal Accessory

Hypoglossal

Sensory only

Smell

Pocket Smell Test or other substances with familiar and distinctive aroma (e.g. coffee, mint, etc.); many versions available

• Lesions can cause loss of smell (anosmia) or taste
• Some pt. not aware of their own anosmia

Sensory only

Vision

• Test with standard vision tests
• Look at lecture note for different deficits

• a monocular visual defect due to loss of input from the ipsilateral eye
• Damage to the Right optic nerve:
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• Loss of peripheral vision in both eyes
• This is a compromise of the decussating fibers from both nasal hemiretinas
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• (Ex: aneurysm of the interanl carotid artery)
• Occurs with damage to the lateral aspect of the optic chiasm
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• Results in loss of the contralateral visual fields in both eyes
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Fibers of the optic radiation are considerably more spread out than those of the optic tract. As a result, damage normally only occurs to a portion of the geniculocalcarine tracts:

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Motor only

• Eye and eyelid movement
• Somatic: Supplies four of the six extraocular muscles of the eye and the levator palpebrae superioris muscle of the upper eyelid
• Autonomic: parasympathetic (pupillary constrictor)

Eyelid drop

• Compressive lesions are peripheral and usually dilate the pupil
• Ischemic lesions usually affect central portion of the nerve and don't usually dilate the pupil
• If completely paralyzed, eyes will deviate to the lateral side do result is diplopia

• First: inspect the eyes =
• look for ptosis
• note appearance of the eyes
• check for ocular alignment (the light source reflection should fall at the same location on each eyeball).
• Test extraocular range of motion: have patient follow a target through the six principal positions of gaze ("H" pattern). The patient is positioned in sitting and is asked to follow an object with their eyes as it is moved vertically, horizontally, and diagonally. The therapist should make sure the patient does not rotate their head during testing and should inspect the patient's eyes for asymmetry: misalignment of the eyes or complaints of diplopia.
• Specifically for CN 3: note adduction (medial rectus), depression while abducting (inferior oblique), and elevation (superior rectus and inferior oblique).
• Test pupillary constriction with the light reflex.
• Positive test indicated by:
• Tracking deficit
• asymmetry
• ptosis

Motor only

Eye Movement (Superior Oblique Muscle)

Trochlear nerve

• Test: have patient turn eye downward and outward (paralysis will prevent eye from moving down & out)
• The patient is positioned in sitting and asked to follow an object such as a writing utensil with their eyes as it is moved in an inferior direction.
• The therapist should make sure the patient does not move his head downward.
• A positive test results by an inability to depress and/or complaints of diplopia.

Sensory and Motor

• Motor - muscles of mastication (chewing)
• Sensory - face

• Opthalmic
• Maxillary
• Mandibular

• motor: eyeball, tear gland
• sensory: eye lining, brow, forehead

• motor: muscles of temple
• sensory: side of forehead, cheek, mouth membranes, lower eyelid

• motor: chewing muscles, salivary glands, anterior 2/3 of tongue
• sensory: teeth and gums of jaw, external ear, temple: tongue-not taste

• Anesthesia to half of the face
• Inflammation of cornea
• Chewing muscles paralyzed

• The therapist uses a piece of cotton and a safety pin to alternately touch the patient's face. The patient is asked to classify each contact with the face as sharp or dull. A positive test for the sensory component bay be identified by impaired or absent sensation or the inability to differentiate between sharp or dull.
• Corneal Reflex: Immediate closure of both eyelids should occur as examiner touches temporal aspect of cornea with cotton wisp.

• The motor component is tested by asking the patient to perform madibular protrusion, retrusion, and lateral deviation.
• A positive test may be indicated by an impaired ability to move the mandible through the specific motions.

• The mandible (lower jaw) is tapped at a downward angle just below the lips at the chin while the mouth is held slightly open. In response, the masseter muscles will jerk the mandible upwards. Normally this reflex is absent or very slight.
• In individuals with upper motor neuron lesions the jaw jerk reflex can be quite pronounced.
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Motor only

• Controls eye movements:
• Contraction of the lateral rectus muscle
• Controls eye abduction (lateral eye movement)

• The patient is positioned in sitting. The therapist asks the patient to abduct their eyes without rotating the head.
• A positive test may be indicated by an inability to abduct the eyes.

• Left-sided pontine lesion can damage the abducens nerve and prevent lateral movement of left eye
• Lesions can cause patients to be cross-eyed
• Often injured in skull fractures

Both sensory and motor

• Branchial motor: muscles for facial expression and has 5 branches
• Visceral motor: parasympathetic to all glands of head except the parotid
• General sensory: for ear and tympanic membrane
• Special sensory: taste, anterior 2/3 tongue

• Sudden paralysis of one or more nerves in the face
• Signs: twitching, weakness, drooping eyelid or corner of mouth, drooling from one side of the mouth, eyebrow sagging, inability to close the eye, disappearance of the fold between the nose and upper lip, decreased tearing, and/or loss of taste sensation on the front of the tongue may occur in more severe cases
• 8-10% recurrence

• Cause: herpes simplex virus (HSV) or other virus causes inflammation and swelling of either side facial nerve
• As the nerve swells due to infection, it becomes compressed and the protective sheath breaks down, interfering with the nerve's ability to communicate with the muscles.
• Result: characteristic weakness or paralysis of the facial muscles

• A) Demonstrates inability to raise the left eyebrow or generate wrinkles on the left side of forehead;
• B) Demonstrates difficulty closing the left eye and inability to raise the left corner of mouth;
• C) Demonstrates drooping at the left corner of mouth, loss of the left nasolabial fold, and inability to completely close the left eye. These findings are the result of idiopathic peripheral cranial nerve 7 palsy (Bell's palsy).

• The patient wrinkles her forehead while the two sides are compared.
• Patient tightly shuts eyelids while examiner attempts to pry open. The two sides are compared.
• Patient smiles and shows her teeth while the examiner compares the nasolabial folds on either side.
• Patient is asked to purse lips or whistle.

• The patient is asked to distinguish between sweet and salty substances placed on the anterior portion of the tongue.
• A positive test for the sensory component may be identified by an inability to accurately identify sweet and salty substances.

Sensory only

Hearing and balance

Auditory nerve and causes bilateral hearing loss

The patient is positioned in sitting in a quiet location. The therapist, positioned behind the patient and to one side, slowly brings a ticking watch toward the patient's ear. The therapist records the distance from the ear when the patient is able to identify the ticking sound. The therapist repeats the procedure on the contralateral ear and compares the measurements. A positive test is indicated by an inability to hear the ticking sound at 18-24 inches or a significant bilateral difference.

Rinne's test - a vibrating tuning fork is placed on the mastoid process (the bony mass just behind the ear), and is then quickly placed around 4cm from the ear hole. The sound should normally be louder next to the ear hole than it is when in contact with the mastoid process, as the bones of the middle ear that amplify sound are bypassed when the sound travels in through the mastoid process. Each ear should be tested independently.

Weber's test - a vibrating tuning fork is placed against the middle of the forehead. The sound should be equally audible in both ears.

Both sensory and motor

• Branchial motor: Stylopharyngeus muscle
• Visceral motor: Parotid gland
• General sensory: Sensation posterior 1/3 tongue and internal surface of tympanic membrane
• Visceral sensory: Carotid body
• Special Sensory: Taste posterior 1/3 tongue

The patient is positioned in sitting. The therapist touches the pharynx with a tongue depressor. A positive test may be indicated by lack of gagging.

• The sensory component is tested by assessing the patient's ability to distinguish objects by taste after they are placed on the posterior portion of the tongue. A positive test for the sensory component may be identified by an inability to accurately identify tasted substances, especially sour and bitter substances, placed on the posterior third of the tongue.
• Also: inability to feel the tongue depressor touch the back of the throat.

Both sensory and motor

Clinical presentation: hoarseness, difficulty swallowing; occasionally caused by compression from goiter (thyroid) pressing on part of Vagus nerve

• Somatic motor: muscles of the pharynx/larynx
• Autonomic motor: parasympathetic to neck, thorax, abdomen
• General sensory: sensory from pharynx/larynx/viscera

• The therapist touches the pharynx with a tongue depressor. A positive test may be indicated by a lack of gagging or an inability to feel the tongue depressor touch the back of the throat. If the gag reflex is absent the therapist should carefully assess the movement of the soft palate and uvula.
• Say “aaah,”---uvula will deviate to strong side away from lesion side or will not elevate if bilateral full paralysis

Motor

Some laryngeal muscles and some muscles of the back and neck

Torticollis

• The patient is positioned in sitting with the arms at the side. The therapist asks the patient to shrug their shoulders and maintain the position while the therapist applies resistance through the shoulders in the direction of shoulder depression. A positive test may be indicated by an inability to maintain the position against resistance.
• Turn head back to center against resistance
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Motor Only

• The therapist asks the patient to protrude the tongue. A positive test may be indicated by an inability to fully protrude the tongue or the tongue deviating to weak side during protrusion.
• Test speech: have patient repeat a phrase with lots of r’s in it or say “la la la”
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• Patient is instructed to stick out the tongue and then move it laterally against resistance.