Cranial Nerves. Cranial Nerve 1: Olfactory Nerve. Cranial Nerve 1: Olfactory Nerve. Cranial Nerve 2: Optic Nerve. Cranial Nerve 2: Optic Nerve
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1 Cranial Nerves Examination of Cranial Nerves and Palsies Drs Nathan Kerr and Shenton Chew 1 Olfactory On 2 Optic Old 3 Oculomotor Olympus 4 Trochlear Towering 5 Trigeminal Top 6 Abducens A 7 Facial Finn 8 Auditory And 9 Glossopharyngeal German 10 Vagus Viewed 11 Accessory A 12 Hypoglossal Hop Cranial Nerve 1: Olfactory Nerve Not routinely tested Cranial Nerve 1: Olfactory Nerve Cranial Nerve 2: Optic Nerve Cranial Nerve 2: Optic Nerve 1
2 Cranial Nerve 2: Optic Nerve Visual Acuity 1 Visual acuity 2 Visual fields 3 Colour vision 4 Pupils 5 Fundoscopy Snellen Chart Visual Acuity Visual Acuity Distance at which the chart is viewed Distance at which a normally sighted person can view the letter* *The distance at which the letter subtends five minutes of arc If patient cannot read largest line Visual Fields 1 Move chart closer 2 Counting fingers Normal Hand movements Perception of light 4 2
3 Visual Fields Colour Vision Colour Vision Pupils Pupils Fundoscopy 3
4 8/28/2008 Direct Ophthalmoscope Direct Ophthalmoscope Lens dial Aperture dial Current lens Extra lenses Viewfinder On/off switch & brightness Filters Fundoscopy Cranial Nerves 3,4,6: Oculomotor, Trochlear, Abducens Cranial Nerves 3, 4, 6: Oculomotor, Trochlear, Abducens Look Look Eyelid droop Alignment of eyes Corneal light reflexes 4
5 8/28/2008 Cranial Nerves 3, 4, 6: Oculomotor, Trochlear, Abducens Move Move H-pattern Double vision LR6SO4 6th-Lateral Rectus 4th-Superior Oblique 3rd-Everything else Cranial Nerve 5: Trigeminal Nerve Cranial Nerve 5: Trigeminal Nerve Cranial Nerve 5: Trigeminal Nerve Cranial Nerve 5: Trigeminal Nerve 5
6 Cranial Nerve 5: Trigeminal Nerve Cranial Nerve 7: Facial Nerve Cranial Nerve 7: Facial Nerve Cranial Nerve 7: Facial Nerve Look Facial droop Move Facial expression R L abnormal normal Cranial Nerve 8: Auditory Nerve Cranial Nerve 8: Auditory Nerve 6
7 8/28/2008 Cranial Nerve 8: Auditory Nerve Cranial Nerves 9, 10: Glossopharyngeal, Vagus Cranial Nerves 9,10: Glossopharyngeal, Vagus Uvula deviation Gag reflex R normal Cranial Nerves 9,10: Glossopharyngeal, Vagus L abnormal Cranial Nerve 11: Accessory Spinal Cranial Nerve 11: Accessory Spinal 7
8 Cranial Nerve 11: Accessory Spinal Cranial Nerve 12: Hypoglossal Nerve Cranial Nerve 12: Hypoglossal Cranial Nerve 12: Hypoglossal Tongue deviation R L normal abnormal Cranial Nerve Palsies Cranial Nerve Palsies Sight Threatening Life Threatening 8
9 Symptoms Double vision Ptosis Painful or painless* *Does not distinguish between microvascular and compression Signs Ptosis Eye down and out Limitation of eye movements in all directions except toward the ear Dilated pupil, minimally reactive to light Causes Pupil involving: compressive lesion Pupil sparing: microvascular disease 9
10 8/28/
11 Management 1. Immediate FBC, ESR, CRP if > 55 y 2. Immediate neuroimaging if pupil involving Fourth nerve palsy Fourth nerve palsy History Vertical double vision Fourth nerve palsy Fourth nerve palsy Exam Head tilt (toward normal side) Affected eye higher (often subtle) Causes Trauma Microvascular GCA Tumour, hydrocephalus, aneurysm 11
12 Fourth nerve palsy Management MRI Brain (Age<45, other CN nerves involved) FBC, ESR, CRP (Age>55) Refer Ophthalmology Sixth nerve palsy Sixth nerve palsy Sixth nerve palsy History Horizontal double vision Exam Eye turned in Poor outwards movement?bilateral?swollen discs Sixth nerve palsy Sixth nerve palsy Causes Microvascular (DM, Atherosclerosis) Trauma, GCA Raised intracranial pressure?mass Management MRI Brain (Age<45, bilateral, swollen discs) FBC, ESR, CRP (Age>55) Refer Ophthalmology 12
13 Symptoms Weakness of one side of face Inability to close eye Excessive drooling Examination Weakness of one side of the face Loss of nasolabial fold Drooping of corner of mouth Ectropion Lagophthalmos Causes Tumours Trauma Stroke Infection Iatrogenic Idiopathic (Bell s palsy) 13
14 Management Refer as appropriate Tape eye at night Lacrilube nocte Monitor for exposure keratopathy Prognosis 86% of patients with Bell s palsy recover completely within 2 months Giant Cell (Temporal) Arteritis Giant Cell (Temporal) Arteritis Polymyalgia Rheumatica (PMR) Giant Cell Arteritis (GCA) Giant Cell Arteritis Giant Cell Arteritis History Age > 50 Headache Scalp tenderness Jaw claudication Fever, fatigue, weight loss Proximal myalgia Exam Temporal arteries (tender, not pulsatile) Cranial Nerve 2 (vision, colour, pupil, fundus) Cranial Nerve 3, or 4, or 6 Vision Loss (15-20%) Double vision* 14
15 Arteritic Ischaemic Optic Neuropathy (Giant Cell Arteritis) Management 1. Immediate FBC, ESR, CRP 2. Immediate systemic steroids (determine dose with Ophthalmology Registrar) 3. Transfer Ophthalmology 4. Temporal artery biopsy Thank you 3cm 15
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