Cranial nerves examination – Bell’s palsy

Location: You are an final year student in neurology outpatient clinic

Patient: 55 year old patient

Please examine this patient’s cranial nerves. Do not examine the visual nerves (II, III, IV, VI). Assume these are normal.
– Please provide a running commentary whilst you are examining
– After 6 minutes you will be asked a series of questions by the examiner

You are a 60 year old patient who has come to a neurology outpatient clinic.

Please feel free to stop the examination if the candidate causes pain or discomfort to yourself.

When the candidate examines your facial movements, show this photo:

Otherwise the examination is normal.

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Clarifies who they are talking to
Asks patient for preferred name

Étique Examination étique
Washes hands
Exposes patient appropriately
Patient positioned sitting
Treats patient with dignity and respect

Inspection General inspection
Other signs of neurological conditions
Look around the bed (e.g. for mobility aids, NBM signs, glasses, hearing aids)

I - Olfactory I - Olfactory
Ask patient if they have noticed any change in smell

V - Trigeminal V - Trigeminal
Inspect for temporalis/masseter muscle wasting
Tests sensation over ophthalmic, maxillary and mandibular distributions of the trigeminal nerve
Temporalis and masseter muscle power
Says they would consider testing corneal reflex and jaw jerk

VII - Facial VII - Facial
Inspect for facial asymmetry
Test facial motor function
Says they would consider testing taste (anterior two thirds tongue)

VII - Facial - pathology photo_camera When the candidate examines the patient's facial movements, show this photo
Identifies left sided facial nerve palsy
Identifies LMN lesion due to involvement of whole face

VIII - Vestibulocochlear VIII - Vestibulocochlear
Crude hearing test
Weber’s test
Rinne’s test

IX, X - Glossopharyngeal, Vagus IX, X - Glossopharyngeal, Vagus
Inspects palate and uvula symmetry
Assesses speech
Assesses cough
Assesses swallow
Says would consider gag reflex and taste (posterior third of tongue)

XI - Accessory XI - Accessory
Inspects for sternocleidomastoid/trapezius muscle wasting
Tests sternocleidomastoid power
Tests trapezius power

XII - Hypoglossal XII - Hypoglossal
Inspects relaxed tongue
Assesses tongue movements/power

Closing Closing examination
Invites patient to get re-dressed
Washes hands

Patient Patient score
Candidate did not cause any pain to patient
Candidate was polite throughout examination

Question What is the diagnosis?
Left LMN facial nerve palsy

Question What are the possible causes?
Bell's palsy
Ramsay Hunt syndrome
Acoustic neuroma
Lyme disease
Nerve infiltration (e.g. TB, sarcoid, lymphoma)
Parotid tumour/surgery

Question How is Bell's palsy managed?
Short course of glucocorticoids
Aciclovir not usually given as unproven efficacy
Eye care to prevent corneal injury (e.g. artificial tears, tape eye shut when sleeping

Submit your answers to get your score.

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