Benjamin Papadakis MD

Checklist Cranial Nerve Examination Detailed

8 min read

Highly Detailed Cranial Nerve Examination — Reusable Checklist

Purpose: A practical, reusable checklist distilled from the recording to help you run a thorough cranial nerve examination efficiently and consistently.

Patient & Session Details

  • Patient name / ID: __________________________
  • DOB / Age: __________________________
  • Date & Time: __________________________
  • Examiner: __________________________
  • Presenting symptoms / reason for exam: ____________________________________________
  • Relevant past eye/ENT/neuro history: ____________________________________________

Equipment & Setup

  • Quiet, well‑lit room with chair facing examiner at eye level
  • Scratch‑and‑sniff smell cards (avoid environmental cueing)
  • Occluder or patient’s hand/tissue to cover one eye
  • Reading material (newspaper/near vision card) or Snellen chart
  • Ishihara plates (for colour vision)
  • Red pin (for central/peripheral fields to red and blind‑spot comparison)
  • Penlight/torch (for pupillary light responses)
  • Cotton wool wisp (optional: corneal reflex)
  • Tuning fork (for screening Weber/Rinne)
  • Ophthalmoscope (fundoscopy done at end)
  • Gloves, tissues, hand hygiene

Ergonomic flow (from the recording): Be opportunistic; think in functional chunks (e.g., eyes → mouth → face → ears/balance → neck) rather than marching strictly I–XII. Do fundoscopy last because it can be uncomfortable and cause photosensitivity.

High-Level Screening vs. Detailed Exam

  • If symptoms unlikely to involve cranial nerves (e.g., typical migraine/fainting) → do a brief screen.
  • If symptoms suggest cranial nerve/brainstem involvement (e.g., visual failure, facial numbness) → do this full detailed checklist.

EYES: CN II, III, IV, VI (do together where convenient)

A. CN I — Olfactory (when indicated)

  • Explain: “I’ll test your sense of smell. Please don’t guess from other cues.”
  • One nostril occluded, present scratch‑and‑sniff card to the other nostril
    • Side 1: Identifies correctly? ☐Yes ☐No Notes: ______________________
    • Side 2: Identifies correctly? ☐Yes ☐No Notes: ______________________
  • Notes:
    • Olfactory testing is rarely done; use scratch‑and‑sniff to avoid cueing (avoid coffee/oranges in room, etc.).

B. CN II — Optic

Visual Acuity (one eye at a time; push for best performance)

  • Right eye (with/without habitual correction): __________________________
  • Left eye (with/without habitual correction): __________________________

Colour Vision (when relevant)

  • Ishihara Right eye result: __________ Left eye result: __________
  • Notes:
    • Colour impairment may occur in optic neuritis; some people have lifelong red–green deficiency—only significant if new.

Visual Fields

  • Rapid screen (binocular):
    • Patient fixates examiner’s face; which fingers move? Detected symmetrically? ☐Yes ☐No
  • Detailed (monocular to red pin):
    • Compare patient’s blind spot to examiner’s; check central & peripheral detection to red.
    • Right eye: __________________ Left eye: __________________
  • Notes:
    • Common patterns: Homonymous hemianopia (optic tract/radiations, intracranial) vs bitemporal hemianopia (chiasm/pituitary). These are not technically “cranial nerve lesions”, but this is the logical time to screen.

Pupils

  • Size & symmetry in ambient light: __________________
  • Direct & consensual light responses: ☐Normal ☐Abnormal → Describe: __________________
  • Near response (accommodation): Convergence with miosis? ☐Yes ☐No Notes: __________
  • Notes:
    • Many people have benign pupil variants (e.g., Adie’s); new, substantial anisocoria can indicate CN III palsy.

Fundoscopy (do at end of full exam)

  • Right eye: Optic disc/retina/vessels: __________________________________
  • Left eye: Optic disc/retina/vessels: __________________________________
  • Notes: Fundoscopy can be unpleasant and cause photosensitivity (especially in migraine); therefore perform last.

C. CN III, IV, VI — Oculomotor/Trochlear/Abducens (Eye Movements)

  • Method: Keep head still; follow target horizontally (far left/right) then vertically (up/down) and through an H‑pattern.
  • Horizontal gaze far left: nystagmus? ☐Yes ☐No Right eye adduction? ☐Intact ☐Impaired
  • Horizontal gaze far right: nystagmus? ☐Yes ☐No Left eye adduction? ☐Intact ☐Impaired
  • Vertical gaze up/down full range: ☐Normal ☐Restricted → Notes: __________
  • H‑pattern (off midline for suspected CN IV): ☐Completed ☐Abnormal → Notes: __________
  • Pursuit (smooth following): ☐Normal ☐Abnormal → Notes: __________
  • Key clinical patterns from the recording:
    • CN III or VI palsy: patient usually reports diplopia and “things look funny.”
    • CN IV palsy: diplopia on looking down; often head tilted away from lesion; may not show obvious strabismus.
    • Internuclear ophthalmoplegia (INO): failure of one/both eyes to adduct on gaze toward nose; nystagmus in abducting eye. Think brainstem lesion (often MS; can be tumour, stroke, or occasionally myasthenia).
    • Localization tip: Horizontal movements localize lower in brainstem than vertical movements.

FACE: CN V & VII

D. CN V — Trigeminal

Sensation (light touch ± blunt/sharp)

  • V1 (ophthalmic): ☐Normal ☐Reduced/Absent Notes: __________
  • V2 (maxillary): ☐Normal ☐Reduced/Absent Notes: __________
  • V3 (mandibular): ☐Normal ☐Reduced/Absent Notes: __________
  • Blunt vs sharp discrimination (if needed): ☐Consistent ☐Inconsistent → Notes: __________
  • Notes:
    • Angle of jaw spared in true trigeminal lesions; if the angle is involved, consider non‑trigeminal or non‑organic patterns.

Corneal Reflex (optional; uncomfortable)

  • Remove contact lenses; touch cornea (mostly V1; small inferotemporal zone V2) with cotton wisp → blink present? ☐R ☐L ☐Both ☐Neither
  • Notes: Rarely needed in routine clinic; if you are this worried, you’re likely proceeding to brain imaging anyhow.

Motor (muscles of mastication)

  • Masseter/temporalis palpation during clench: ☐Symmetric ☐Weak → Notes: __________
  • Jaw opening against resistance: ☐Strong ☐Weak → Notes: __________
  • Lateral jaw deviation (pterygoids) against resistance both ways: ☐Strong ☐Weak → Notes: __________
  • Notes:
    • Weak jaw closure is generally myasthenia gravis, not an isolated CN V palsy.

E. CN VII — Facial

General principle from the recording: In isolated Bell’s palsy, upper & lower face should be equally involved; ensure there is no concurrent hearing loss, balance issue, or eye movement abnormality (otherwise more than a facial palsy).

Upper Face

  • Frown: ☐Symmetric ☐Weak R ☐Weak L
  • Tight eye closure (bury eyelashes): ☐Symmetric ☐Weak R ☐Weak L
    • Try to gently overcome eye closure: ☐Resists well ☐Opens easily
    • Notes: If apparent “weakness,” the eyeball should roll up with genuine effort; if not, patient may not be trying.

Lower Face

  • Smile/snarl—show teeth: ☐Symmetric ☐Weak R ☐Weak L
  • Turn lip out: ☐Symmetric ☐Weak R ☐Weak L
  • Flare nostrils (some can): ☐Yes ☐No → Notes: __________

Other facial movement disorders

  • Hemifacial spasm (twitching “flip‑flip‑flip,” often peri‑ocular): ☐Absent ☐Present → Notes: __________
    • Notes: Typically benign; can be treated with botulinum toxin.

EARS & BALANCE: CN VIII

Hearing (screen)

  • Whispered numbers (use numbers to avoid misunderstanding)
    • Right ear: Identified? ☐Yes ☐No → Number: ________
    • Left ear: Identified? ☐Yes ☐No → Number: ________
  • Weber (midline skull): ☐Midline ☐Lateralizes R ☐Lateralizes L → Notes: __________
  • Air vs. bone conduction (Rinne): Air > Bone? ☐R ☐L If not, suspect conductive deficit.
  • Notes:
    • If Weber lateralizes without conductive loss, suspect sensorineural problem. Neurologically important cause: acoustic neuroma (low threshold to scan). Many hearing problems go ENT first.

Balance / Vestibular (from the recording)

  • Head‑impulse (VOR) test: Patient fixates your nose; deliver small, quick, unpredictable head thrusts to each side.
    • Catch‑up saccade / impaired VOR? ☐Right ☐Left ☐Neither → Notes: __________
  • Notes:
    • Acute vestibular neuritis: profound vertigo, vomiting, nystagmus, but no ataxia (patients feel awful but it’s typically not serious).

MOUTH & THROAT: CN IX, X, XII (inspect tongue while you’re in the mouth)

F. CN IX — Glossopharyngeal

  • (Usually omitted) Sensory testing of the palate with a long instrument is not recommended in routine practice per recording.

G. CN X — Vagus

  • Inspect palate/uvula at rest and on phonation: ☐Uvula central ☐Deviated → Notes: __________
  • Notes: The vagus does “a lot,” but in clinic we typically only inspect the palate/uvula.

H. CN XII — Hypoglossal

Inspect for fasciculations (correct method)

  • Ask patient to open wide and say a prolonged “ahh” while you watch the tongue at rest in the mouth.
    • Fasciculations in‑mouth? ☐Yes ☐No → Notes: __________
  • Notes:
    • All protruded tongues appear to fasciculate—ignore that; look in‑mouth for true fascics. Fasciculations are an important sign in motor neurone disease.

Motor

  • Protrude tongue: midline? ☐Yes ☐No → Deviation toward: __________
  • Tongue‑in‑cheek strength (each side against your hand): ☐Strong R ☐Weak R ☐Strong L ☐Weak L → Notes: __________

NECK: CN XI — Accessory

  • Trapezius (shoulder shrug against resistance): ☐Symmetric ☐Weak R ☐Weak L → Notes: __________
  • Sternocleidomastoid (turn head against resistance each way): ☐Strong R ☐Weak R ☐Strong L ☐Weak L → Notes: __________
  • Notes from the recording:
    • True CN XI weakness from skull‑base lesions is rare.
    • Spasmodic torticollis (dystonia; basal ganglia) is common in clinic—overactivity rather than underactivity; muscles may look like “strong iron straps.”

FUNDOCOPY (END OF EXAM)

  • Re‑confirm patient consent and warn about brief photosensitivity
  • Right eye findings: __________________________________________
  • Left eye findings: ___________________________________________

Quick Reference — Red Flags & Practical Tips (from the recording)

  • New anisocoria → consider CN III palsy.
  • Field defects: bitemporal (chiasm/pituitary) or homonymous (tract/radiations) → intracranial workup.
  • Abnormal VOR / catch‑up on head‑impulse → supports vestibular pathway problem.
  • Corneal reflex is unpleasant; remove contacts first; if you’re this worried, you’re likely heading to neuroimaging.
  • Acoustic neuroma considered with sensorineural loss; low threshold for scanning.
  • Many pupils are “funny” (e.g., Adie’s); focus on change from prior records.
  • Ergonomics matter: combine steps logically (e.g., while in the mouth, check palate (X) and tongue (XII) together).
  • Practice drives proficiency—especially visual fields to red pin and fundoscopy.

Documentation Summary (copy into notes)

  • Overall impression: __________________________________________________________
  • Cranial nerves with abnormalities: __________________________________________
  • Likely localization: ________________________________________________________
  • Immediate actions / referrals: ______________________________________________
  • Plan / follow‑up: ___________________________________________________________

Optional Add‑Ons (when indicated by symptoms)

  • Higher‑sensitivity visual field mapping (detailed central/peripheral to red)
  • Formal acuity testing with calibrated charts/occluder and pinhole
  • Quantified vestibular testing beyond bedside VOR
  • Photodocument optic discs if indicated

Sign‑off

Examiner signature: __________________________ Date: __________________

Graph View

Backlinks