00:01
Next up, we'll do the 8th cranial nerve,
which is the vestibulocochlear nerve.
00:05
Now this has two components the vestibular
component and the cochlear component.
00:09
And we're going to do
the latter part first.
00:11
Grossly, we just want to assess hearing
by simply the finger rubbing test.
00:16
So I'm just going to do this,
can you hear this on both sides?
Quick way to establish that the person
does not have any gross hearing loss.
00:23
If there was any asymmetry when
we did that simple maneuver,
or if the patient's reporting
the problem with hearing,
we would then move on to perform
the Weber and Rinne tests
with a tuning fork.
00:35
Ideally, you want to use a
512, you could also use a 256.
00:39
Patients who are older
oftentimes will lose the ability
to hear higher
pitches like a 512.
00:45
And that's sort of a normal
part of aging is presbycusis
that loss of those
very high pitches.
00:51
Both of these tests are designed to
distinguish between conductive hearing loss
versus sensory
neural hearing loss.
00:59
And conductive hearing loss would be
if he even had a lot of wax in his ears
that was occluding the
external acoustic meatus
than the sound that I make out here is
simply not going to get to the eardrum,
or if there's a problem
with the perforated eardrum
or if there's a problem with
the ossicles of the bones
that are magnifying the
sound and transferring it
or passing it on to the sensory
nerve to the cochlear nerve.
01:22
So conductive hearing loss
versus sensorineural hearing loss
that's what we use
these these tests for.
01:28
I always remember which one
of these tests is the Weber.
01:31
The Weber test is
going to be up here.
01:33
Weber starts with a W,
and that's a symmetric letter.
01:36
And so I can remember I'm starting
in the middle of his forehead.
01:38
And we'll do that now
by making a loud sound.
01:43
Which side do you hear that,
the most on or is it pretty much the same?
A little harder.
01:48
Sure.
01:53
Both.
01:54
Great.
01:54
So if you had a problem with
conductive hearing loss,
again, let's say that his left
ear was completely full of cerumen
and he was unable to get any sound moving
to his sensory nerve, his cochlear nerve,
his cochlear nerve on the left
would be starving for information,
and so would amplify its
sensitivity to sound.
02:14
And so when I put
this on his forehead,
he would lateralized
to the left,
if he had a conductive
hearing problem,
he would try and his left cochlear would
be amplifying its detection of sound,
even though it's vibrating
through his skull.
02:28
In contrast,
if he had a sensory neural problem,
let's say on the left,
where the nerve was out,
perhaps due to like a schwannoma,
or a viral labyrinthitis,
something that's causing
damage to the nerve itself,
then when I put this on his forehead,
he would lateralize to the right,
because the left sensory
input is not functioning,
the detector is not functioning.
02:51
So this test doesn't tell us
what the cause of the problem is,
because you need to do the
next step in this test.
02:57
And that's the Rinne exam.
02:59
The Rinne exam is
performed as follows.
03:04
Can you hear that?
Yes.
03:06
Let me know when
you stop hearing it.
03:22
Stop.
03:23
Can you hear it now?
Yes.
03:25
Great.
03:26
So what we've done there is
we've used his mastoid process,
which is where I've put the head of this
tuning fork to test for bone conduction.
03:37
Bone conduction is essentially
seeing if the sensory nerve
is still able to
gather information.
03:42
Whereas when I hold the
tuning fork out here,
this is air conduction,
which relies upon the,
again the machinery of hearing.
03:52
If, under normal circumstances,
air conduction should be
better than bone conduction.
03:59
Because in general, the ears were designed
to magnify information coming from sound.
04:05
And that's what the ossicles and
dependent membrane they're designed to do,
as opposed to getting sound just
from vibrations on your skull,
which is what I'm testing
with bone conduction.
04:14
So again,
if his ear is full of cerumen,
he's going to have
decreased air conduction,
because the sound of
vibrations from the air
is just not going to
penetrate past there.
04:25
So when I did this test,
and waited till he could no
longer hear via bone conduction,
when I would bring the
tuning fork out here,
he would not have
been able to hear it.
04:33
And then I would know,
especially if the Weber test
had localized to the left side
that his problem is a
conductive hearing loss problem.
04:41
So those are the two tests
that we use to really dive in
and identify conductive versus
sensorineural hearing loss.
04:49
All right, with that we can move
on to Cranial Nerves IX and X.
04:53
So cranial nerve IX is the
glossopharyngeal nerve,
cranial nerve X is the vagus nerve
and we're going to do them together.
05:00
The vagus nerve has a lot
of other things that it does
in terms of the
autonomic nervous system.
05:05
But for the purposes of
the bedside physical exam,
we're really focusing on its role
in terms of regulating swallowing.
05:12
So these different nerves are
difficult to distinguish their actions
when we're looking at
the swallow reflex.
05:19
But they are going to help us,
we can identify that they're both
out or not using these maneuvers.
05:24
So let me first
grab my pen light,
my otoscope light.
05:29
So the glossopharyngeal
and vagus nerves
are going to help with
elevation of the soft palate.
05:34
So let's take a look.
05:36
Say 'ah'.
05:37
Ah.
05:38
Great, we can see that there's
symmetry between the arches
and the back there is
soft palates going up,
we also see that his
uvula is also midline.
05:46
In a patient for whom there
was evidence of a symmetry
and one side is not going
up the way that it should.
05:51
We could then test
the gag reflex,
which you can either do with a Q-tip swab
and just touch the back of the throat
or tickle the uvula to make sure
that the gag reflex is intact.
06:02
All right, we're on the homestretch
with the cranial nerve exam,
we're on cranial nerve XI.
06:06
This is the accessory nerve.
06:07
And this nerve innervates
two important muscles,
and it's the sternocleidomastoid
and the trapezius muscles.
06:13
To test those, I'm just going
to have you turn your head
to the left against resistance.
06:18
Great.
06:18
And keep in mind that him
turning his head to the left
is actually the function of his
right sternocleidomastoid muscle
which you could see
was tensing up there,
and then I'll have you turn
your head to the right.
06:29
Great and that's his left
sternocleidomastoid muscle shown there,
and then the muscles of the trapezius
are operating to lift his head
is elevate his head,
or laterally flex
his head as well
depending upon the orientation
of his head at the time.
06:43
So next up is the
12th cranial nerve,
the last one,
this is the hypoglossal nerve
and it's simply tested by having the
patient stick your tongue out please
and move it from side to side.
06:53
Put your tongue back.
06:54
A patient who has a defect
in the 12th cranial nerve
on the left will actually
deviate their tongue
towards the affected side
because that nerve is designed
to make the tongue
muscle pushed out.
07:06
So if it's not working,
it's going to end up
being dominated by the
right hypoglossal nerve
and the musculature which will push
the tongue off to the off to the left.