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We know that there are 12 pairs of cranial nerves and 31 pairs of spinal
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nerves. Cranial nerves carry information to and from the brain. 8
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Mixed nerve – These nerves have both sensory & motor fibres
cribriform plate to the olfactory bulb, then it forms the olfactory tract. POPULAR ARTICLES
Olfactory tract passes posteriorly and divides into the medial and lateral
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Optic nerve
Retina is formed by rods and cones, these synapse with the bipolar cells,
these in turn synapse with the ganglionic cells. The fibers of the ganglionic
cell forms the optic nerve. The optic nerve leaves the orbit through optic
foramen, it unites with the other optic nerve at optic chiasma. Only the fibers
of the nasal ½ of the retina passes to the other side while the fibers from the
temporal half passes straight. Then it forms the optic tract. Optic tract comes
to the lateral geniculate body. A few fibers leaves the tract before reaching
the lateral geniculate body and pass to the superior colliculus – these fibers
are those which are concerned with light reflex. From the lateral geniculate
body the fibers get fanned out. This is called optic radiation. In optic
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radiation fibers which carry information from the lower ½ of visual field
passes through the parietal lobe and fibers which passes information
through the upper ½ of visual field passes through the temporal lobe. It is
important that the ocular system reverses the image. The nasal side of the
fundus picks up the temporal image and temporal side of the fundus picks
up the nasal image. Damage to nasal side of retina will produce a temporal
visual defect and vicevera.
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Visual inattention is often tested by confrontation test. Here two eyes are
kept open and two identical objects (examiners index finger) are presented
simultaneously in corresponding positions of both visual fields. If visual
inattention is present, the patient appreciates the finger only on one side.
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Visual acuity – Visual acuity tests the central vision. Visual acuity is the
resolving power of eye for the central vision. Both the eye is assessed
separately. Both near and distant vision is tested.
If there is severe visual impairment v.a can be assessed by asking the patient
whether he can appreciate light. If not it is written as no P.L. Ask whether the
patient can see hand movement. If not it is written as ‘no H.M.’. Ask if the
patient can count fingers if not it is written as ‘no C.F.’.
If the patient can read, near vision and distant vision is tested. Near vision is
tested by using an Jaeger type card. It is held 35cm from the patients eye. To
exclude the difficulty due to refractory errors a pin hole card can be used. The
patient is asked to look through a 1mm size pin hole punched in a card. The
pinhole allows the light to fall only on the central part of the retina. If the
visual acuity which is originally impaired improves on pin hole test, the visual
impairment is due to refractive errors and not due to neurological causes.
Distant vision is tested using the snellen’s chart. Visual acuity is expressed as
‘d/D’. d is the distance of which the patient sits is 6m. ‘D’ no of the line that
patient can read.
Optic fundus examination can be done using an ophthalmoscope
Color vision is tested. Ask whether the patient can appreciate colors. Color
vision is also tested by using Ishiara’s chart.
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vertical and horizontal eye movements made from the mid position of gaze
are called the cardinal movements . Then examine the other directions of
gaze .
Total paralysis of the 3rd,4th& 6th cranial nerves is known as the internal
opthalmoplegia . Paralysis of the extra occular muscles is called the external
opthalmoplegia . Paralysis of the intrinsic muscles of the eye ( ciliary muscles
and constrictor pupillae) is called the intrinsic opthalmoplegia.
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Diplopia
Diplopia is said to be present when the patient complains of seeing two
images when he looks at an object . This is due to the paralysis of one or a
group of extra ocular muscles . When the eyes are fixed on an object the
image falls on the macular area in normal eyes and outside macular area in
the parietic eye .Thus two images of an object are perceived The image
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which is seen by the parietic eye is called the false image and by the normal
eye is the true image. The patient s asked to look at all directions of gaze and
determine in which position maximum separation of true and false images
occur. Maximum separation occurs in which direction of gaze , the muscle
responsible for gaze in that direction is the parietic one .The abnormal eye
can be determined by covering one eye and noting the effect on diplopoia . If
this results in disappearance of false image then the paretic muscle belongs
to that eye.
Squint
Refers to the abnormal deviation of eye. The abnormal deviation of eyes can
be divergent , convergent , upwards or downwards . When squinting is
noticeable ,if both eyes are open it is called manifest squint . If squinting is
noticed on covering one eye , it is called latent squint .
nystagmus
Nystagmus is defined as the involuntary to and fro movement of the eye in
the horizontal vertical ,rotatary or mixed direction .Occular posture or tone of
extra ocular muscles is normally maintained by the impulses which reach the
eye from the retina , labyrinth, cerebellum and midbrain .
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Grade
I – Nystagmus is present only when the eyes are deviated to one side .
II – Nystagmus produced in mid position and also when the eyes are
deviated to one side.
III – Nystagmus present in all direction of gaze .
Nystagmus can be pendular – eyes found to drift in one direction giving rise
to a slow phase as a corrective phenomenon they are quickly brought back
into the neutral position – Quick phase
.Nystagmus can be of eqnal amplitude to both sides
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3,4 5 , 6. 8., 11, and 12th cranial nerves.These bundles have connections also
with brainstem and motor nuclei of the upper cervical nerves ).
Pathway
A stimuli such as bright light shone in one eye will send an afferent impulse
along the optic nerve and the efferent impulse pass to the eye through the
occulomotor nerve .
Accomodation reflex
This reflex occurs when the patient immediately focuses his vision on a near
object.
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Test – The patient is asked to fix his eyes on the examiners index finger kept
at a meter away and rapidly brought near the patient’s nose.
The 3 “ C” of accommodation
1) Convergence of eye .
2) Contraction of ciliary muscle .
3) Constriction of pupil.
Ciliospinal reflex
When the skin over the neck is pinched , pupil on the same side dilate
reflexively . This results from the stimulation of the sympathetic nerves
which supply the dialator pupillae muscles . Ciliospinal reflex is abolished in
lesions of cervical sympathetic nerves , affection of upper cervical and
thoracic segments and medulla oblongata .
Trigeminal nerve
Trigeminal nerve is the largest of all cranial nerves. It is a mixed nerve. It has
got 4 nuclei.
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Main sensory nucleus is situated in pons and it extends to the spinal nucleus.
The spinal nucleus extends through the whole length of medulla oblongata
into spinal cord. Mesencephalic nucleus is in the midbrain and extends to
pons and motor nuclei is situated in the pons itself. All these nuclear fibers
join to form the trigeminal nerve. Trigeminal nerve comes out from the
middle of the pons. As it passes down it divides into 3 branches.
1) Opthalmic
2) Maxillary
3) Mandibular
Corneal reflex
Test the corneal sensation by touching with a wisp of wet cotton wool . A
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Motor examination
Ask the patient to clench the jaws and teeth together , feel the temporalis
and masseter .Observe for wasting and thinning of temporalis muscle and
masseter . look for hollowing out of temporalis fossa .
Ask the patient to open the mouth against resistance . Action of both
pterygoid muscles keeps the open jaw in the midline. If pterygoid muscles of
one side is paralysed , the jaw is deviated to the paralysed side ( Pterygoid
musckes of one side pushes the jaw to the opposite side normally )
Jaw jerk
Ask the patient to relax jaw .Place finger on the chin and tap with a hammer .
Slight jerk occurs normally .Increased jerk occurs in bilateral upper motor
lesions. Absence of jaw jerk is not significant since in may also occur in
normal persons .
Facial nerve
Facial nerve is a mixed nerve . It has three nuclei –motor nuclei, sensory
nuclei and parasympathetic nuclei
Sensory nuclei receives fibers from anterior 2/3rd of tongue , floor of the
mouth and soft palate . Main motor nuclei is situated deep in pons. Fibers
coming from above the nuclei from cerebral hemisphere supplies the lower
part of the face on contralateral side . Fibers from below the nuclei supplies
the whole half of the same side .In supra nuclear lesion there will be
contralateral involmemt of lower face .In infranuclear lesion there will be
involvement of upper and lower face on same side .
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On attempting to close the eyes the eyeballs pass upwards reflexively –Bell’s
sign.In facial palsy, this reflex is exaggerated & the whole cornea goes under
the eyelid . This is called Bell’s phenomenon .
In UMN lesions the lower part of the face on contralateral side is affected .
There is no Bell’s phenomenon , closing of eyes is possible , there is no
obliteration of wrinkles on forehead .
In LMN all features are seen because half of the face is involved . In bilateral
LMN lesion the whole face is involved.
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Vestibulocochlear nerve
Vestibulocochlear or 8th cranial nerves consists of two divisions.
Vestibular nerve arises from the utricle, saccule and semicircular canal while
cochlear nerve arises from the cornea. Both these nerves enter the brain
stem separately at pontomedullary junction
From brain stem cochlear nerve passes to the cochlear nuclei. From there
fibers pass to medial geniculate body , inf-colliculus and finally end in
auditory cortex in temporal lobe.
Vestibular nerve passes to vestibular nuclei and from there fibers pass to
cerebellum, spinal cord and medical longitudinal fasciculus.
Any lesion in the nerve manifests as tinnitus vertigo and deafness.
Tinnitus
Tinnitus is the sensation of noise in absence of any external stimuli. Tinnitus
takes several forms such as tunning, roaring, whistling, buzzing etc. It is felt
mostly during sleep when the environment is silent. It may interfere with
normal hearing.
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Tuning fork
Tunning fork test helps us to differentiate conduction deafness from nerve
deafness.
1) Weber’s test
Place the base of the tuning fork on the vertex of the patient and ask the
patient in which ear the sound is heard more loudly. Normally the sound is
equally heard in both the ears.
In conductive deafness, the deafness is louder in the affected ear since
distraction from outside is reduced in that ear.
Nerve deafness – sound is louder in the normal ear.
2) Rinne’s test
Hold the base of tuning fork against mastoid bone. Ask the patient whether
he hears the sound. When sound disappears hold the tuning fork near the
external meatus. Patient hears the sound again .Normally the air conduction
is better than bone conduction.
In conduction deafness bone conduction is better than air conduction.
In nerve deafness both are impaired.
Glossopharngeal nerve
Glassopharyngeal nerve is a mixed nerve with both sensory and motor fibers.
It has got 3 nuclei – main motor nucleus, sensory nucleus and
parasympathetic nucleus.
The main motor nucleus is situated in medulla oblongata. The sensory nuclei
is a part of tractus solitarius . Sensory nucleus it receives fibres from post
1/3rd of tounge post.part of soft palate, tonsils and pharynx.
Test
Afferent for gag reflex is 9th cranial nerve
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Inspect the soft palate and pharynx while the patient keeps his mouth wide
open. Gently touch both sides of pharyngeal wall one after another with a
swab stick. In normal subjects this should evoke a gag reflex i.e contraction
of pharynx with elevation of the roof of the tongue and a feeling to vomit.
Also verify that he feels the touch sensation equally in both sides. Sometimes
even in normal individuals gag reflex may be absent.
3) Test the taste sensation in post 1/3rd of tongue. Technically this is difficult.
Other alternate method is to apply a weak electric current to the back of the
tongue. Normally this evokes a sour taste.
Vagus nerve
Vagus nerve is a mixed nerve .It arises from medulla oblongata. It sends
motor fibers to pharynx and larynx . It receives sensory fibers from tongue ,
larynx, pharynx , oesophagus , stomach and intestine .
Motor function
Observe the arches of the palate on both sides with the patient holding the
mouth wide open . Normaly both sides should be symmetrical .In unilateral
palatal paralysis the arch will be at a lower level . Ask the patient to say ‘ah ‘
and observe the movements of the palate .Normally both the arches will lift
to the same extent and the base of the uvula will be moving in the midline .
In unilateral palatal paralysis only the normal side will rise up while the
paralysed side remains immobile. The midline raphe of the palate and base
of the uvula will be pulled towards the normal side .
Unilateral palatal weakness causes minimal symptoms but bilateral palatal
weakness causes nasal regurgitation and nasal quality for speech .
Ask the patient to swallow a mouthful of water in sitting position , the fluid
regurgitates through the nose . In patients who have some paralysis of vagus
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Pharyngeal weakness
In unilateral paralysis pharyngeal wall droops on the affected side . In
bilateral paralysis there is marked dysphagia and bubbling speech because of
pooling of saliva in the pharynx .Patients may develop cough or choking
when he attempts to swallow fluids .
Larynx
Paralysis leads to hoarseness, stridor , breathlessness and bovine cough.
Accessory nerve
The 11thCranial nerve is purely a motor nerve. It has a cranial component and
a spinal component . The cranial component arises from medulla oblongata .
Spinal component arises from upper five cervical spinal segments .The spinal
components emerge and forms a trunk which then passes upwards and
meets the cranial trunk , then it leaves through jugular foramen and travels
down the neck as spinal accessory nerve. Fibers of the cranial root are
distributed along with the pharyngeal and recurrent laryngeal branches of
the vagus. Fibers of the spinal root supplies the sternomastoid and trapezius
muscles.
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Hypoglossal nerve
Motor nerve arising from lower part of medulla oblongata and ends in the
oral cavity . It supplies the intrinsic muscles of the tongue . These muscles
help in protruding the tongue and also takes part in bending , twisting
movements of the tongue.
Test
1)Deviation of tongue
Ask the patient to open his mouth and put out his tongue .Normally tongue
protrudes in the midline. If there is paralysis of one side , the tongue deviates
to the affected side because of contraction of muscles of the opposite side (
Hypoglossus, styloglossus , Genioglossus)
2) Ask the patient to move his tongue from side to side and note the rate and
range of movements .Ask him to push out the cheek with the tip of the
tongue from within , against resistance offered by your finger from outside
.Note the strength .
3) Ask the patient to curl his tongue up and down
4)Small twitching moments that occur spontaneously is called fasciculation .
Reduction of the bulk of tongue on one or both sides suggests atrophy .
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