Case 4

Cranial nerves examination

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Olfactory nerve

• Why ?
• Head trauma ; suspicion of a lesion anterior level of the base of the skull
• If the patient has smell or taste disorder

• How ?
• Ask the patient to identify some odors by smelling them one nostril at a time

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Optic nerve

• Why ?
• Head trauma ; suspicion of a lesion anterior level of the base of the skull
• If the patient has vision disorder

• How ?
• Visual acuity tests :
• Monoyer, Snellen scale for far vision
• Parinaud scale for near vision
• Color vision test :
• Ishihara scale
• Hardy Rand Rittler for illiterate
• Visual field test
• Pupillary reflex
• Fundus

--> Normal visual exam.

Cf : Case 1

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Oculomotor, trochlear, abducens nerve

• Why ?
• Head trauma
• If the patient has vision disorder

• How ?
• Check for the symetry of eye movement (Is there any asymetry ?)

--> Ask the patient to follow a pen / target with is eyes without moving the head--> Nystagmus ? Paralysis ?

• Ptosis ? (dropping eyelids)
• Ocular globe or eyelids fluttering ?
• Pupillary reflex

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Trigeminal nerve

• Why ?
• Head trauma
• To test facial sensibility and motor innervation

• How ?
• Sensitive function :
• Test all 3 sensitive territory with a needle : ophtalmic, maxillary and mandibular
• Search for the corneal reflex by using sterile cotton : https://youtu.be/0swL3FJPg1k?feature=shared&t=8
• Motor function :
• Ask the patient to grit his teeth, then palpating the masseter and the temporal muscles
• Ask the patient to open his mouth against resistance : the jaw deviate to the affected side if there is pterygoid muscle deficiency

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Facial nerve

• Why ?
• Head trauma
• To search for facial paralysis

• How ?
• Facial movement :
• an asymetry of facial movement is usually more evident during a conversation or asking the patient to smile
• paralysed side :
• nasolabial fold erased
• eyelid cleft expanded
• The taste :
• Using a cotton soaked in (sugar) solution to test the front 2/3 of the tongue on the two side
• Hyperacusis :
• Use a tuning fork next to the ear

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Vestibulocochlear nerve

• How ?
• Hearing Test :
• Weber and Rhinne Test (cf case 2)
• Vestibular Test :
• search for nystagmus
• Acute vestibular syndrome : Halmagyi maneuver : https://youtu.be/a-_TlXUtNA4?feature=shared

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Glossopharyngeal and vagus nerve

• How ?

• Ask the patient to say "Ah..." and take a look at the veile of the palace if it rises in the same way on the two side
• We can also use a tongue depressor to test the gag reflex
• Dysphonia ? Hoarse voice ?
• Any abnormality when swallowing ?

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Accessory nerve

• How ? Motor nerve : test the innervation

• Sternocleidomastoid muscle : Ask the patient to turn his head against resistance and palpate the muscle
• Trapezius muscle : Ask the patient to raise his shoulder against resistance

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Hypoglossal nerve

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• How ?
• Ask the patient to stick out his tongue and search for an asymetry, a deviation...
• Test the muscular strenght by pushing the check with the tongue on the two side against resistance

Glasgow scale

In the case : 10/15

"The first examinations show that the patient has lost the use of his left eye. His verbal responses are sometimes incoherent, but remain intelligible, the Glasgow score is 10. The patient's motor functions remain intact."

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Frontal lobe function

• Primary motor cortex : role in every voluntary movement --> muscle weakness ?
• Medial frontal area : make decision, motivation

--> unable to plan activities

• Orbito-frontal cortex : social behavior --> impulsive and agressive
• Left posterio-inferior frontal cortex : language, speaking
• Dorsolateral frontal cortex : recent memory

Frontal cortex epilepsy

--> Partial crisis (not all the nervous system concerned)--> Usually, the seizure happens at night--> quite quick (few seconds to few minutes)--> facial fibrillation, muscle twitches...--> genetic issue : 80% of the patient has a seizure before 20yo--> Can appear after a head trauma--> Anti-epileptic drugs as Lamotrigine

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