OCEX CN Testing Part 2

Difficulty swallowing can also indicate a problem with CN IX/CN X. To test for Mild dysphagia- Give the Pt a cup of about 150mL of water- Normally, the Pt should swallow the water in less than .... seconds?

15 sec - at a rate greater than 10ml/s

To perform a Weber's test first obtain a ..... Hz tuning fork? Then tell the patient: 'I am going to do another hearing test by placing this tuning fork on your head/forehead and asking you about what you hear and obtain .....? Hold the tuning fork by the .... and set the tines vibrating by striking with a .... hammer, or against a .... area or pulling on both ends of the tinenes, then place the vibrating tuning fork on the .... of the vertex of the skull or the .... of the forehead, keeping the tines in the orientation shown in the figure below, Then Ask the patient 'Do you hear the sound ..... in both ears?'- Normally the answer should be 'yes' but if the sound lateralizes (i.e., is heard louder on one side), an auditory deficit is implied?

512 Hz Consent Stem Tendon Bony (Wrist, Elbow or Knee) Midline Midline Equally

In Conductive hearing loss, the sound lateralizes to the ..... (affected/unaffected) side? In Sensorineural hearing loss, the sound lateralizes to the ..... (affected/unaffected) side? To determine the nature of the deficit uncovered by Weber's test (i.e., conductive, or sensorineural loss), ..... test should be performed?

Affected Unaffected Rinne's

CN VII (Facial) provides Taste from the ..... of the tongue? Taste from the ..... of the tongue and the ... palate and ..... is done by CN IX and, most likely, CN X, respectively?

Anterior 2/3 Posterior 1/3 Soft Epiglottis

The Light reflex radiates from the Tip of the Malleus to the Periphery in the ....-..... quadrant?

Anterior-Inferiror 13.Gently move the speculum to reveal as much of the malleus as possible.Look for any perforations of the tympanic membrane. 14.The central part of the pars tensa is tented inwards at the level of the tip of malleus and is called the umbo.

To Perform caloric (vestibulo-ocular reflex) testing in the unconsciousness patient- Inspect the ..... canal to ensure the tympanic membrane is intact and remove any impacted cerumen (ear wax)? Next, make sure that the Pt is in ..... position with the head elevated to 30°- This ensures that the horizontal semicircular canal is in the ..... plane and that the maximal response can be elicited- . With the canal in this orientation, significant convection currents arise in the ..... due to warming or cooling? Next, Irrigate the ....... meatus with 20-100mL warm water over a period of about 30s using a large syringe with catheter attached? The warm water should cause the specific gravity of the endolymph near the external auditory meatus to ..... , allowing it to 'rise' and flow to bend the .... towards the ......?- This will .... the hair cells on that side? Allow about 5 minutes for the canal and endolymph to return to normal temperature

Auditory Supine Vertical Endolymph External Auditory - Water should be above body temperature (the presumed temperature of the endolymph) but below 48°C Decrease Cilia Kinocilium Depolarize

After Weber's test to check if the hearing loss is Conductive or Sensorineural Rinne's test has to be performed- First- Tell the patient: 'now I am going to place the tuning fork on the .... behind your ear and then beside your ear and . I will be asking you to tell me when you stop hearing the sound of the tuning fork each time, Second- .Set the 512Hz tuning fork vibrating and, holding it by the stem, place it behind the patient's ear, making firm contact with the bony .... process?- Then Ask the patient 'please tell me when you stop hearing the sound'. This process tests .... conduction with the vibration propagating directly to the cochlea and bypassing the outer and middle ear?- Note the time it takes for the patient to stop hearing the sound. Time noted = ..... conduction? Next, When the patient has indicated that they no longer hear the sound, and without stopping the tuning fork from vibrating, bring it next to the ......?- This tests .... conduction and involves the outer, middle and inner ear? Next, Ask the patient 'do you hear the sound again?' Normally the patient will hear the sound again due to middle ear amplification, next Ask the patient 'please tell me when you stop hearing the sound' ?Note the time it takes for the patient to stop hearing the sound, Time noted + .... conduction = ..... conduction? Finally, repeat for the opposite ear.

Bone Mastoid Bone Bone External Acoustic Meatus Air Bone Air

Bitterness is better detected by the taste receptors tied to CN .... and ....?

CN IX CN X

In the Corneal reflex test the Sensory part is done by CN ..... and the Motor part is done by CN .....?

CN V (Trigeminal) CN VII (Facial) - innervates the Opercularis occuli

The Jaw-Jerk reflex test the Sensory part is done by CN ..... and the Motor part is done by CN .....?

CN V3 (Mandibular) CN V3 (Mandibular)

What is the CN involved in testing Facial Expression? What are the 5 Muscles tested in the test of Facial expression?

CN VII (Facial) 1- Frontalis 2- Orbicularis oculi 3- Buccinator 4- Orbicularis oris 5- Platysma

To test the Orbicularis oculi muscle Ask the Pt to .... their eyes and keep them ..... as you try to open the eyes with your thumbs?- This will prove difficult in the absence of orbicularis oculi weakness?

Close Closed

In the Corneal Reflex test In the absence of specific symptoms, if no blink is observed, ensure that the Pt is not wearing ....?

Contact Lenses Note the sensory arm of CN V can also be assessed by testing the 3 divisions V1, V2 and V3 for nociception ( see SG1001), thermoception and touch using a wisp of cotton. The corneal reflex pathway can be found in Haines, figure 8-27 (9th ed)

A UMN lesion will result in weakness in the ..... (ips/cont) ..... of the face while ..... of the face will be preserved? In an UMN the forehead ..... will be preserved?

Contralateral Lower 1/2 Upper 1/2 'upper spares upper' Wrinkling

CN IX and CN X can also be evaluated by testing the .... reflex? This test causes discomfort to the Pt and is not routinely performed- Unless history taking discloses some evidence of ..... or ...... it may be omitted from the exam?

Dysarthria (voice sounding hoarse or nasal, for example) Dysphagia (Pt reports problems swallowing)

What are the Steps involved in the Corneal Reflex testing?- 1- Use a fine wisp of cotton or tissue rolled to a point and touch the Pt's ..... with the wisp and ask the Pt to look up and away, - With the Pt's consent, you may gently hold the ..... open to avoid touching the eyelashes, 2- Approaching from the side, bring the wisp of cotton in towards the lateral edge of the .... of the adducted eye, 3- An approach from the front of the eye may allow CN .... to mask the normal response, as the Pt may see the wisp before it contacts the cornea Observe for the .... and .... responses (blink)?

Eyeball Eyelids Cornea CN II Direct and Consensual

To Elicit an Optokinetic Nystagmus using OKN tape- After the Pt is seated comfortably in a chair, hold an optokinetic tape about 35 cm from the .... and pull the tape slowly and steadily first in one direction and then the other? Next, Ask the Pt to follow the images on the tape without moving the .....? Then Observe and explain the motion of the .... as the tape passes?

Eyes Head Eyes

What are the Steps involved in Assessing Taste sensation?- 1- Prepare samples representing the major taste qualities for example, bitter (tonic water), sour (citrus/vinegar), sweet (sugar), salty (salt), 2- 2- Ask the Pt to close their .... and protrude the .....?, 3- Apply a small amount of the test substance to the ....-..... of the tongue one side of the tongue, 4- Ask the Pt to identify the taste quality? 4- Ask the Pt to rinse the mouth. Proceed to test other side, 5- Repeat steps 2-4 to test the other taste qualities.

Eyes Tongue Anterior 2/3 Eyes Tongue Anterior 2/3

The Normal result of Rinne's test is Air conduction ..... than Bone conduction? In Conductive hearing loss, ..... conduction > ..... conduction and in Sensorineural hearing loss .... conduction > ..... conduction but either the total times are reduced or AC=BC=0)?

Greater In other words, the sound is heard longer by AC than by BC, with AC being about twice as long as BC BC > AC AC > BC

To test the Platysma muscle ask the patient to .... or pull the corners of the mouth ......? Longitudinal folds of skin in the .... should be obvious when Platysma contracts?

Grimace Downwards Neck

What are the Steps involved in the Jaw-Jerk Reflex?- 1- Ask the Pt to ....-way open the jaw and .... it, 2- Place the index finger on the tip of the ..... (chin, on the midline) and tap your finger gently but briskly with a reflex hammer, 3- The Normal response is ..... (movement/no movement) or only slight ..... of the mouth ?

Half Relax Mandible - The hammer strike should be directed downward to open the mouth as the masseter muscles stretch. No movement Closure

In the testing of the function of the SCM Instruct the patient as follows: I will place my hand on your left Cheek and Please try to turn your ..... to the left as I try to resist your .... movement.? Have him/her turn head to the left against your hand. Student should apply pressure on the cheek in the direction opposite to that which the patient is attempting to turn their head (resistance) and then Test the opposite side.

Head Head

In the Whisper test first ask the patient if they have experienced any changes in your ..... recently?, then Tell the patient 'I would like to test your hearing today' and obtain ......? Then tell the patient: 'I am going to stand behind you and whisper ...... (number) words or numbers and ask them to repeat the words (or numbers) back? Stand behind the patient and occlude the patient's external ear canal by pressing on the ..... of one ear then At a distance of approximately 60cm / 2 feet, whisper words or numbers on the side of the patient's ..... ear? Then repeat for the other ear?

Hearing Consent 3 - Choose two syllable words or two-digit number Tragus Non-occluded Normal response: Patient repeats all words / numbers 6.

In a LMN lesion the entire ..... (ips/cont) ..... of the face tends to be affected?

Ipsilateral Half

An .... (LMN or UMN) lesion will result in difficulty raising the shoulder ipsilaterally and turning the head contralaterally.

LMN There is considerable debate as to whether the UMN innervation of spinal accessory nucleus is bilateral, primarily contralateral or primarily ipsilateral. It seems currently accepted that the pool of motor neurons in the nucleus which innervates SCM receives bilateral hemispheric innervation (with maximal input from the ipsilateral hemisphere), whilst the pool which innervates trapezius receives only contralateral innervation. It follows then that an UMN lesion on the right will affect trapezius on the left, with SCM on the left only mildly affected, if at all.

What is the Innervation of the Muscles of Mastication?

Mandibular branch of CN V ie CN V3

What are the Steps involved in Assessing the Muscles of Mastication?- 1- Observe the skin over the ..... muscles. Concavity or asymmetry suggests atrophy and may therefore indicate an .... (UMN or LMN) lesion, 2- With the Pt's consent, palpate both ..... muscles and then Ask the Pt to clench their .... so that the jaw is tightly closed, 3- Note any asymmetry of bulk and tone

Masseter LMN Masseter Teeth Note that the temporalis muscles are also innervated by CN V. They may be tested by applying the procedure outlined in steps 1-4

In the Jaw-Jerk reflex, the Normal response is .... movement or only slight ..... of the mouth evidenced by an upward jerk of the Mandible? An Exaggerated jaw-jerk reflex suggests a ..... lesion occurring Rostral to the .... motor nucleus?

No Closure UMN Trigeminal

Both the .... reflex and .... testing (vestibule-ocular reflex) are primarily useful in comatose patients and test the vestibular apparatus and vestibular division of CN VIII? Both procedures are expected to stimulate vestibulo-ocular reflexive movements of the eyes, the underlying circuitry of which relies on intact functioning of parts of the medulla, pons and midbrain- therefore, the tests can be used to assess .... function in the comatose patient? If the expected conjugate horizontal eye movements are observed, the indication is that the lesion producing coma is ..... the brainstem? Deficits in oculocephalic/vestibulo-ocular eye movements suggest a brainstem lesion that could be the cause of .....?

Oculocephalic Caloric (vestibule-ocular reflex) Brainstem Above Coma However, it is important to note that these deficits may be unrelated to the cause of coma - for example, a Pt may have pre-existing vestibular disease, or may have taken ototoxic drugs or vestibulo suppressant drugs, such as barbiturates.

What are the Steps involved in Examination of the Ear canal and Ear drum?- 1- Use an .... with the largest ear speculum that the canal will accommodate, 2- Position the Pt's head for comfortable viewing through the otoscope, 3- Grasp the .... of the ear firmly but gently with the free hand and pull it upward, backward and slightly away from the head to straighten the ear ......, 4- Hold the otoscope handle between the .... and ..... and Brace the hand against the Pt's face, 5- Insert the otoscope gently into the ......, direct it .... and ..... (through any hairs to ensure a clear view through the ear canal), 6- 6- In the Ear canal Note any discharge, foreign bodies, redness of the skin or swelling (cerumen may obscure the view). The skin of the canal is often thickened, red and itchy in otitis externa.?

Otoscope Tragus Canal Thumb and Fingers Ear canal Down and Forward - through any hairs to ensure a clear view through the ear canal). The sides of the ear canal can be quite sensitive, necessitating efforts to minimize pressure via the otoscope

To Perform the Gag reflex test - first Ask the Pt to open the mouth and tilt the head back slightly. A pen torch may be shone into the mouth to aid visualization of the palatal arches- Next, touch the .... on one side and then the other with a tongue depressor?-Symmetrical elevation of the palate should be noted? The afferent arm of the gag reflex is primarily CN .... and the efferent arm is CN ....?

Pharynx CN IX CN X Imagine a Pt who, when asked to say 'Ahh', shows palatal elevation on the right and uvular deviation to the right. In addition, the gag reflex in the Pt is bilaterally normal. Localize the lesion?

To test the Buccinator muscle ask the Pt to .... out their ....?

Puff Cheeks Apply pressure to the cheeks with the fingers. Inspect for any leakage of air (note that air may leak due to weakness in either buccinator or orbicularis oris

To test the Orbicularis oris muscle ask the patient to .... the lips, .... and .....?- there should be symmetrical ..... of the lips?

Purse Whistle Smile Retraction

In Examination of the Eardrum/Tympanic membrane the shape of the Eardrum is a ..... tent? We should look for a .... reflex? For Ear orientation: 4- 6 o'clock position in the .... ear and for the .... ear between 6-8 o'clock

Round Light Right Left Note the color and contour. The cone of light will help aid in landmarking. A red bulging drum can indicate purulent otitis media. - The pars tensa forms most of the tympanic membrane. Its periphery is thickened to form a fibrocartilaginous ring called the annulus tympanicus

The Spinal Component of CN XI supplies ...... and .... muscles?

SCM (Sternocleidomastoid) Trapezius 1- Explain procedure to the patient. (e.g. I am going to assess the strength of your muscles by having you do certain movements with your shoulders and neck. I will also be applying gentle pressure to resist these movements). 2- Obtain consent (Are you ok with this?) 3- Ask patient to expose the area to be tested (e.g. would it be ok for you to take off your top for me to examine you?)

In the testing of the function of the Trapezius Instruct the patient as follows: shrug your ..... and try to stop me from pushing them down, then With patient's ..... shrugged , observe for any asymmetry? Place hands on both shrugged ..... and apply pressure downwards as patient attempts to keep them shrugged? Compare both sides for deficits.

Shoulders Shoulders Shoulders

To examine Elevation of the Palate and test motor function of CN IX and CN X- Ask the Pt to say Ahhh and then Shine the penlight into the mouth and inspect the .... palate, ... and .....?

Soft Uvula Pharynx

To perform Oculocephalic reflex testing:-the Pt should be in ..... position, The Examiner, standing behind the head of the Pt, holds the Pt's eyes open and briskly rotates the head to one side- Conjugate horizontal eye movements in the direction ..... to the head turn are expected?- . The vestibulo-ocular reflex circuitry drives this movement of the eyes. Within several seconds, the eyes return to the resting position. 3. Note that this maneuver should not be attempted in cases of .... trauma?

Supine Opposite e.g. head rotated right, eyes move left Cervical

In the Examination of the Palate- the palate should elevate ......, the Uvula should usually remain on the ..... and the Pharynx should constrict ..... like curtains closing?

Symmetrically Midline Medially Note that an asymmetrically hanging uvula does not always indicate pathology. The most important observation from this test is symmetrical elevation of the palate.

The Malleus causes ..... of the Eardrum? The Upper portion of the Right malleus occupies the .... o'clock position, with the lower portion of the malleus extending slightly below the midpoint of the tympanic membrane towards .... o'clock position? . The upper portion of the Left malleus occupies the .... o'clock position, with the lower portion of the malleus extending slightly below the midpoint of the tympanic membrane towards .... o'clock position?

Tenting 1 7 11 5

To test hypoglossal nerve (CN XII): Ask the Pt to open their mouth and inspect the .... as it lies in the floor of the mouth?- Assess for atrophy, asymmetry and/or fasciculation (twitches, usually at the side of the tongue)? Then Ask the patient to protrude their .... and Check for deviation, atrophy or asymmetry?

Tongue Tongue

In Inspection of the External Ear we look for Deformities, lumps, or skin lesions in the auricle (and surrounding tissue), ear canal orear drum can indicate a pathology- To Inspect each Auricle and the surrounding tissue we can use the .... test?- in this test we would move the .... up and down and press the ....?

Tug Auricle Tragus Press firmly behind the ear. Tenderness behind the ear may be present in otitis media that has spread to the mastoid.

The .... (UMN or LMN) innervation of the hypoglossal nucleus is mostly contralateral, as shown above- Therefore, following a .... lesion, the protruded tongue may deviate contralaterally?

UMN UMN An LMN lesion will result in deviation of the tongue towards the side of the lesion.

Gross hearing is assessed using the ..... test, then the Weber's and Rinne's tests may be used to characterize any hearing loss?

Whisper

To test the Frontalis muscle Ask the Patient to ..... the forehead or .... the eyebrows and .....?

Wrinkle Raise Frown