7. Purpose of the test
To
determine any impairment of smell is
unilateral or bilateral
Whether impairment is due to any local nasal
disease or neural lesion
8. Method of testing
Small
bottles containing
essences of very familiar
odour are required
• Coffee
• Lemon
• Chocolate
• Asafetida etc
9. PROCEDURE
Compress 1 nostril & sniff the taste odour twice
Ask whether he can smell or identify odour
Repeat test on other nostril & ask if smell
is similar in both nostril
Allow odour to disperse & repeat test with other
2 test odour, ask he can distinguish smell
10. Interpretation of result
Who can recognize & name odours quickly (females)
Who can recognize but difficult in naming (males)
Who can smell & know difference but neither recognize
nor naming
•
The above 3 should be accepted as normal
Who feel each odour is similar but is distorted &
unpleasant (parosmia)
Those who cant smell anything or is much reduced
compared to the other (anosmia)
Those whose responses are vague & variable
11. Common causes of anosmia
Acute/chronic
inflammatory nasal disease
Heavy smoking
Head injury
Intra cranial tumour compressing the
olfactory bulb
Atrophy of olfactory bulb
Chronic meningeal inflammation
Parkinson’s disease
13. Function
Carries
the visual impulses from the retina to
the optic chiasma & in the optic tract to the
lateral geniculate body
The impulse acts as an afferent pathway for
the pupillary light reflex
14. Purpose of the test
To
measure aquity of vision & determine if
any disease is due to local occular disease or
neural impairment
To chart the visual field
15. Method of testing
Visual
acuity
• The standard snellen’s
chart can be used for vision
& the Jaegar type card can
be used for near vision
[the commonest causes of
visual error lies in the eye only]
16. Visual field
Purpose:
• To chart periphery of visual field
• To detect position, size & shape of the blind spot
17. Confrontation test
Pt & examiner sit face to face
Pt covers left eye & examiner right
PT moves the test object from outside the
visual field towards midline
Instruct Pt to indicate appearance of
the object
18. Common causes
Total
unilateral loss of vision: optic nerve
lesion
Homonymous hemianopia: lesion between
optic tract to occipital cortex
Bitemporal hemianopia: lesion of optic
chiasma
21. Purpose of the test
Inspect
pupils to rule out a local disease,
peripheral lesion or a nuclear involvement
Examine eye movement & determine if
defects is muscular origin or neural
involvement
To detect nystagmus
22. Method of testing
Observation
• Presence & absence of ptosis & squint
• Whether unilateral or bilateral
• Constant or variable
• Size, shape, equality & regularity of the pupils
23. Reaction to light
Reduce
illumination of room & vision
should focus on a far object
A bright beam of light is shone from the side
of one eye
Repeat on the other side
[the pupil should constrict briskly]
Shield one eye & perform test on the other
& see for consensual reaction
24. Reaction to convergence &
accommodation for near vision
Fix
vision on a distant object & instruct to
look in a near object
Place finger tip in front of the bridge of the
nose (22 cm)
Then return to the far object
Observe pupillary reaction in both
25. Examination of occular movement
Observe
lagging of one
or both eye
• Observe nystagmus
26. Analysis of diplopia
Shield
one eye with a transparent red shield
Object is moved from left to right, up & down
Ask if -
• He sees 1 or 2 object
• Object lies one above the other or side by side
27. Rules governing analysis of diplopia
Separation
of image is greatest in the
direction in which the weak muscle has its
purest action
False image is displaced farthest in the
direction in which the weak muscle should
move the eye
28. Analyzing nystagmus
Watch
the patients eye while talking
Ask to look at a definite point & move the
point from left to right & up to down
Hold each end position for 5 sec & assess
nystagmus (direction, rate amplitude)
29. Common causes of paralysis
Pontine lesions
Neoplasms
Vascular accidents
Demyelinating disease
Meningeal inflammation
Tumour of base of skull
Increased intra cranial pressure
Head injury
[Total paralysis of III, IV & VI nerve indicates a lesion in
cavernous sinus (carotid aneurism)]
31. Function
Carries
all forms of sensation from the face,
anterior scalp,eye & the anterior 3rd of the
tongue
Also supplies the muscles of mastication
32. Purpose of the test
To
determine any sensory impairment
To determine unilateral or bilateral motor
weakness & determine UMN from LMN
33. Method of examination
Superficial
sensory asst from mainly 6 areas
(mainly light touch & pain)
• Forehead & upper part of the side of nose
(ophthalmic)
• Malar & upper lip region (maxillary)
• Chin & anterior part of tongue (mandibular)
34. Interpretation
Total
loss of sensation: lesion of ganglion or
sensory root
Total sensory loss over 1 division: partial
lesion of ganglion or root
Touch only lost: pontine lesion affecting
sensory nucleus
Pain & temp lost: dissociate anesthesia
(seringobulbia)
35. Corneal reflex
Using
a cotton piece the
cornea is teased
Normal response is a
bilateral blink
(facial nerve forms the
efferent loop of the reflex arc)
36. Interpretation
No
closure: ophthalmic division of the facial
nerve
No response in either lid when abn. is tested
& bilateral blink when normal is tested: V
nerve lesion
No response of the affected side whichever
side is tested: VII nerve lesion
37. Motor assessment
Muscles of mastication
Have Pt bite against resistance
Have Pt protrude mandible
against resistance
Have Pt go into lateral
excursive movts against
resistance
Jaw jerk
38. Common causes
Tumours
of base of skull
Chronic meningeal lesion
Trigeminal sensory neuropathy
Acoustic neuroma
Syringomyelia
Multiple sclerosis
40. Function
Supplies
the muscles of facial expression
including platysma & stapedius muscle
Secretomotor fibers to the lacrimal gland &
the salivary gland
Carries sensation of taste from anterior 2/3
of tongue & general sensation from external
acoustic meatus
41. Purpose of the test
To
detect any unilateral or bilateral
weakness of facial muscles (UMN or LMN)
Detect impairment of taste
42. Method of testing
Observation
• Symmetry and asymmetry of
•
face
Nasolabial fold & wrinkle on
forehead
Ask
the Pt to close the
eyes, raise the eyebrows,
blow out the cheek,
whistle etc
43. Examination of taste
The
four primary taste (sweet, salt, sour,
bitter) can be carried out by using sugar,
salt, vinegar & quinine
The side of the tongue is moistened by the
test substance
Ask the Pt to indicate taste by pointing
44. Secretomotor function
The
flow of tears of two side can be
compared by giving ammonia to inhale
which will result in tearing of eye
The flow of saliva can be tasted by keeping a
spicy substance in the tongue & the tip is
raised to observe the sub maxillary salivary
flow
45. Reflexes
Corneal
reflex
Nasopalpebral reflex: tap on the
nasopalpebral ridge will produce
closure of both eyes. In bells palsy
there is failure to close on the
affected side
48. Function
Carries
the impulses of sound from the hair
cell of organ of corti to cochlear nucleus in
pons
Control balance through vestibular nerve
49. Purpose of the test
To
determine any deafness is bilateral or
unilateral
Whether deafness is due disease of middle
ear or cochlear nerve
To determine the disturbance of vestibular
functions
50. Test of hearing
Observe
if the patient turns
one ear towards you
Evaluate hearing using a
ticking watch, rub fingers
together, whisper.
51. Rinne’s test
Strike
a tuning fork gently, hold it near one
external meatus & ask the Pt if he can hear it
Place it on the mastoid, ask if he can still
hear it & instruct him to say “NOW” when
sound ceases, & keep it on the external
meatus again (normally the note is still
audible)
52. Interpretation
In
middle ear deafness – the note is not heard
In nerve deafness – air & bone conduction
are reduced but air remains better
53. Weber’s test
The
fork is place on the vertex
Ask the Pt if he can hear the sound all over
the head, in both ears or in one ear
In nerve deafness the sound appear to be
heard on the normal ear
On chronic middle ear disease it is conducted
to the abnormal ear
54. Common causes of deafness
Disease
of external & middle ear &
Eustachian tube
Prolonged exposure to loud noise
Old age
Meningitis
Demyelinating disease
Deafness due to drugs
55. Test of vestibular function
Observe
equilibrium as patient
walks or stands
Observe abnormal eye movts
Ask for -
• Dizziness
• Falling
• Nausea and vomiting
57. Function
General Sensory: posterior 1/3
of tongue, tonsil, skin of
external ear, tympanic
membrane & pharynx
Visceral Sensory:
subconscious sensation
from carotid body & sinus
Visceral Motor:
parasympathetic stimulation of
parotid gland, & controls blood
vessels in carotid body
Special Sensory: carries
taste from posterior 1/3
of tongue
Branchial Motor:
Supplies styolopharyngeus
muscle
59. Function
General Sensory: posterior meninges,
concha, skin at back of ear, external
tympanic membrane, pharynx &
larynx
Visceral Motor: parasympathetic
stimulation to smooth muscle &
glands of pharynx, larynx; thoracic
& abdominal viscera & cardiac
muscle
Visceral Sensory: from larynx,
trachea, esophagus, & thoracic &
abdominal viscera, stretch
receptors & chemoreceptors
Motor: superior, middle, inferior
constrictors; levator palati,
salpingopharyngeus,
palatopharyngeus, palatoglossus
60. Purpose of the test
To
test the elevation of palate & contraction
of pharynx
To examine the movts of vocal cords
[note: the IX & X nerve are tested together]
61. Method of testing
Notice
the pitch & quality of voice, cough &
difficulty in swallowing saliva
Ask the Pt to open his mouth wide after a few
movts ask to say “AH” while breathing out &
“UGH” while in
The palate should move symmetrically upwards
& backwards, the uvula in mid line & two sides
of pharynx contract symmetrically
62. Common causes of lesion
Poliomyelitis
Syringobulbia
Posterior
fossa tumor
Advanced parkinsonism
Myasthenia gravis
Enlarged cervical glands
Surgical operation of the neck
67. Common causes of paralysis
MND
Poliomyelitis
Polyneuropathy
Trauma
in the neck or base of skull
Tumour at jugular foramen
Syringomyelia
69. Function
Control
movts of the tongue, hyoid bone &
larynx during & after deglutition
Supplies 3 of 4 extrinsic
muscles of tongue &
all intrinsic muscles of
tongue
70. Purpose of the test
To
inspect the surface of the tongue
To detect wasting, weakness & involuntary
movts
To examine voluntary muscle control
71. Method of testing
Ask
the Pt to protrude the
tongue & observe for
• Reduction in size of affected side
• Excessive ridging & wrinkling
• Restricted protrusion
• Deviation towards one side
73. 13th Cranial nerve
Known
as cranial nerve zero or Terminal
Nerve
It projects from nasal cavity, enters
brain just a little bit ahead of other
cranial nerves as a microscopic plexus of
unmyelinated peripheral nerve fascicles
74. FunCtion
The
nerve is vestigial or related to
sensing of pheromones
Regulates sexual behavior in mammals
