For the 3rd (ocolomotor), 4th (trochlear), and 6th (abducens) cranial nerves, eyes are observed for symmetry of movement, globe position, asymmetry or droop of the eyelids (ptosis), and twitches or flutters of globes or lids. Conus Medullaris Syndrome vs Cauda Equina Syndrome : Anatomical basis and Mnemonic, Handtevy Method : Emergency Drug Dose by Age, Total Contact Cast (TCC) Principles and Technique, A case of child with Mucopolysaccharidosis : Hunter Syndrome, Ectrodactyly or Lobster-claw syndrome : A Case Report, A Case of Neonatal Umbilical Infection leading to Septic Shock, Partial Exchange transfusion for Neonate with Polycythemia, Alpha and Beta Adrenergic Receptors : Mnemonics, Ask the patient to wrinkle his/her forehead, Asymmetry as he/she cannot wrinkle his forehead on the side of palsy in LMN palsy, Ask the patient to close his/her eyes forcibly while you try to open the eyelids with your fingers. Patient has different sized or reactive pupils bilaterally. Rarely, a venous loop may compress the nerve at its root entry zone into the brain stem. Before Function: Eye movement: Innervates extrinsic eye muscles that enable most movements of the eye and that raise the eyelid. Verywell Health's content is for informational and educational purposes only. Patients report seeing double images, one above and slightly to the side of the other, and the eyes do not adduct normally. Have you noticed any recent alteration to eating, swallowing, speech (articulation) or tongue function? See Figure \(\PageIndex{4}\), The acronym PERRLA is commonly used in medical documentation and refers to, pupils are equal, round and reactive to light and accommodation., Test sensory function. Cranial nerve 7 controls movement of the face, and it also has a role in sensation behind the ear and in making tears and saliva. The second cranial nerve or the optic nerve is responsible for visual acuityENROLL IN OUR COURSE: http://bit.ly/PTMSKGET OUR ASSESSMENT BOOK http://bit.. Download the cranial nerve examination PDF OSCE checklist, or use our interactive OSCE checklist. Appendix 2 gives a summary of the test procedures in a face-to-face consultation. With our video tutorials, you can learn a topic in less than 30 minutes. Test eye movement by using a penlight. and lead them to targeted physical examination and appropriate triage. Gaining knowledge and understanding of the CNs function and potential reasons for impairment is likely to increase the performance of testing. Have you noticed any recent alteration to your vision or unsteadiness? What are the 12 cranial nerves? Functions and diagram - Medical News Today Hope it helps someone. Cranial nerves and their functions (Diagonal lines Sensory function Smell/Hearing; Horizontal lines Motor and sensory function of the eyes; Vertical lines Motor and sensory function of the face/jaw/throat/tongue; Crossed lines Motor function of the head/neck/shoulders). Ask patient to smile, raise eyebrows, puff out cheeks. Emergency clinicians often encounter patients with the triad of pinpoint pupils, respiratory depression, and coma related to opioid overuse. Facial movements include blinking, opening the eyes, raising the eyebrows, smiling, puffing out the cheeks, and pursing the lips. Check all EOMS (H-test). Cranial nerve 7 has many branches, which lead to the small muscles of the face, glands of the eyes and mouth, and sensory fibers behind the ear. Sometimes these injuries can lead to permanent facial weakness. official website and that any information you provide is encrypted A) Inspection: Observe: Face at rest for any facial asymmetry Any facial tics, symmetry of eye blinking or eye closure During smiling In palsy: However, absence of this finding does not exclude central causes. See Figure \(\PageIndex{7}\), Test motor function. Cranial Nerve 2 | Optic Nerve Assessment for Physiotherapists Required fields are marked *. Cranial nerves, their functions and examination (Diagonal lines Sensory function Smell/Hearing; Horizontal lines Motor and sensory function of the eyes; Vertical lines Motor and sensory function of the face/jaw/throat/tongue; Crossed lines Motor function of the head/neck/shoulders). The stapedius reflex test is a type of hearing test that audiologistsspecialists who study hearing loss, balance problems, and related disordersuse to assess damage to the seventh cranial nerve. Ask them to move their arm toward the midline (whilst still wagging the finger), instruct them to tell you when they first see the movement of the finger. Less common causes include compression by tumors, arteriovenous malformation, aneurysm, and MS (Khan et al., 2017). The left and right cranial nerve 7 are symmetric in structure and function. Methods: This paper summarizes the functions, potential impairments of the nerves, associated conditions, and basic skills involved in cranial nerve examination. Test the right sternocleidomastoid muscle. Table: Testing Cranial Nerves - Merck Manuals Consumer Version It can be stressful to not be able to move the muscles of your face the way you want to, and its distressing to see that your face appears lopsided. The other ear is assessed similarly with a different combination of numbers and letters. Knapstad MK, Nordahl SHG, Skouen JS, et al. The patient is considered to have passed the screening test if they repeat at least three out of a possible six numbers or letters correctly. Patient hears whispered words or finger snaps in both ears; patient can walk upright and maintain balance. Cranial nerve 7, which is also called the facial nerve, controls movement of the face, including the forehead, eyelids, cheeks, mouth, and jaw. Tongue is midline and can be moved without difficulty. Reflex: sensory element of corneal reflex (rarely used). This may affect every day function e.g. Next, the nerve forms the geniculate ganglion (a ganglion is a collection of nerve cell bodies). The eye may be slightly adducted when the patient looks straight ahead. Pupils should be round and bilaterally equal in size. In a face to face-to-face consultation, the sensory component is tested using a cotton wool ball and blunt tip needle sequentially, while comparing sides (see Figure 7). A 44 year old male hobby cyclist (former professional) attended his regular physiotherapy clinic, 24hours after sustaining an acute onset, of right sided ear pain (described like someone hammering a nail into his ear), fronto-lateral headache, momentary double vision and mild neck pain. He has published several papers on this topic. Within the facial canal, three important events occur: Firstly the two roots fuse to form the facial nerve. It is referred to as atrophy of the optic nerve. He has been a regular key note speaker at numerous courses and conferences in the UK and Worldwide since 2002. (see Figure 8). Webers test (fork is placed on the vertex of the head). These symptoms can be caused by a health problem involving cranial nerve 7 or by a condition affecting the brain, such as a stroke (a blockage of blood flow or bleeding in the brain) or a tumor. Heidi Moawad is a neurologist and expert in the field of brain health and neurological disorders. meningioma: II: Optic . He denied suffering headaches and reported that he had never suffered this type of pain before. When you visit the site, Dotdash Meredith and its partners may store or retrieve information on your browser, mostly in the form of cookies. It originates in the pontomedullary region. Repeat this on either side, at shoulder height, above the head and below the chin. Vestibular disorders can result in nystagmus because the vestibular system and the oculomotor nuclei are interconnected read more . Other problems that can affect cranial nerve 7 include trauma, which can be a result of an accident, a dental condition, or a surgical complication. Rehabilitation to improve facial nerve function after an impairment or injury can include physical therapy or electromyographic feedback techniques. Rinnes test (Figure 2a and 2b): The tuning fork is struck and placed on the mastoid process. The whispered voice test is a simple test for detecting hearing impairment if done accurately. May affect one OR both eyes . The Cranial Nerve Assessment for Nurses | Health And Willness Alan Taylor is a physiotherapist, educator and writer. l am bellys palsy patient about one month what should I do to recover from this facial nerve. While the upper face receives bilateral UMN innervation, the lower face receives only contralateral UMN innervation. He is a qualified Chartered Physiotherapist, and an honorary Fellow of the UKs Musculoskeletal Association of Chartered Physiotherapists. Continue to test the sternocleidomastoid by placing your hand on the patients forehead and pushing backward as the patient pushes forward. Both pupils should constrict in reaction to bright light. fundoscopy. Ask the patient to open and close their mouth several times while observing muscle symmetry. Ask patient to open mouth flatten tongue and say Aaaaaaaaah, observe for symmetrical elevation of the soft palate and central ascent of the uvula. However, with the development of modern imaging, the clinical examination has been reduced [2]. Each ear is tested individually. The signs and symptoms of infranuclear lesions differ based on the site of the lesion: At or just above the stylomastoid foramen: It causes Bells palsy which presents as loss of motor functions of all muscles of facial expression resulting in the deviation of mouth toward the normal side, inability to shut the mouth and eye and accumulation of food in the vestibule of mouth flattening of expression lines. Test the anterior 2/3's of the tongue (CN VII) by alternately placing two to three familiar liquids on each side of the anterior 2/3's of the tongue (pictured to the right). 2023 Dotdash Media, Inc. All rights reserved, Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. The facial nerve can be damaged due to trauma, inflammation, infections, or disease. Symptoms are hemi-facial paresis of the upper and lower face. However, there are many other conditions that can affect cranial nerve 7, and Bells palsy is often a diagnosis of exclusionmeaning that other causes of cranial nerve 7 weakness often need to be ruled out before a diagnosis of Bells palsy is made. Thank you in advance =). Cranial nerve testing (Proceedings) - dvm360 Facial Nerve: Function, Anatomy & Branches - Cleveland Clinic Whether the palate elevates symmetrically when the patient says "ah" is noted. The .gov means its official. Where can I get help for myself or my family. Ask if it feels strong. If you develop any symptoms of cranial nerve 7 impairment, its important that you get prompt medical attention. 2022;16:666173. doi:10.3389/fnins.2022.666173, Kamalden TMIT, Yusof ANM, Misron K. A review of delayed facial nerve paresis as complication following total endoscopic ear surgery. Function: Eye movements (abduction). Lower CN lesions should be considered in cases of neck pain/head ache, neuralgic pain, disturbed speech, swallowing, coughing, deglutition, sensory dysfunctions, taste, or autonomic dysfunctions, dysphagia, pharyngeal pain, cardiac or gastrointestinal compromise, or weakness of the trapezius, sternocleidomastoid, or the tongue muscles [11]. The Epley canalith repositioning maneuver can be done for both sides to help confirm the diagnosis of BPPV. As such, some of the CNs have motor functions, some have sensory functions, and some have mixed functions (see Table 1). UMN vs LMN Facial Nerve Palsy If the subjective examination (see Table 3.) This mechanism is considered increasingly common due to the widespread use of bariatric surgery and strict vegetarian or vegan diets. In a face-to-face consultation you can vigorously rub the fingers together near to each ear with the patients eyes closed. Damage to this nerve can cause facial weakness, as well as insufficient tears and saliva, a diminished sense of taste, and decreased sensation behind the ears. Overview What are the cranial nerves? how to test cranial nerve 5, Take a cotton ball and touch it to three areas illustrated below on the face bilaterally.When the patient feels you touch each area with the cotton ball, tell them to say "yes". When performing a comprehensive neurological exam, examiners may assess the functioning of the cranial nerves. Cranial nerve disorders: clinical manifestations and topography, A system based approach to risk assessment of the cervical spine prior to manual therapy, Baylor University Medical Center Proceedings, Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review, Dunsford J. Note any side to side differences. Tingling sensation, pain, twitching, etc. See Table \(\PageIndex{1}\) for a comparison of expected versus unexpected findings when assessing the cranial nerves. Use OR to account for alternate terms He has devised and taught over 100 one-day and two-day courses in these areas. Cranial Nerves Chart C) Sensory function testing (Taste test): Differentiating UMN (Supranuclear) and LMN (Nuclear and Infranuclear) Facial nerve palsy: Causes of Unilateral and Bilateral Facial Palsy: 1. Look at this figure to understand https://epomedicine.com/medical-students/applied-anatomy-of-facial-nerve/#Supranuclear_pathways. If hoarseness is noted, the vocal cords are inspected. Their functions . It may be helpful to use a cheat sheet, in clinics where this type of testing is only performed occasionally. Asymmetry of facial movements is often more obvious during spontaneous conversation, especially when the patient smiles or, if obtunded, grimaces at a noxious stimulus; on the weakened side, the nasolabial fold is depressed and the palpebral fissure is widened. In some situations, you might also have electromyography (EMG) or a nerve conduction study (NCV) to test the function of the muscles and nerves. Patient has inability to shrug shoulders or turn head against resistance. How to Test the Corneal Reflex The corneal reflex test can be done while you are awake. In a face-to-face consultation, the motor component is assessed by examining the function of the temporalis, masseteric and pterygoid muscles. 5th Cranial nerve. Patient swallows and speaks without difficulty. This is important for nurses, nurse practitioners, and other medical professionals to know how to test cranial nerves and what cranial nerve assessment abnormalities may indicate.This becomes especially important when evaluating potential new strokes. Temporary anosmia may result from inflammatory responses in relation to infection. From the brain stem, which is at the back of the neck, the nerve winds around toward the face. Your healthcare provider might do this during an office medical visit or during an eye appointment by gently placing a clean object (like the soft tip of a cotton swab) on your eye. Ask patient to say Aaaaaaaaah, observe for symmetrical elevation of palate and uvula. Eye closure will also usually be impaired (and may be "wide open"). An unexpected finding is involuntary shaking of the eye as it moves, referred to as, Test bilateral pupils to ensure they are equally round and reactive to light and. Also, because problems with cranial nerve 7 can affect a person's ability to blink, damage may result to the conjunctiva (the surface of the white part of the eye) or the cornea (the surface of the colored part of the eye and the pupil). Conversely, in physiotherapy, the suggestion is, that this is not routine and furthermore, there appears to be a perception that these skills are the domain of medical physicians, and somehow outside the skill set of physiotherapists. Yes, the eyes can be closed in upper motor neuron lesion of facial nerve. Rarely, this palsy may result from aneurysms, tumors, or MS (Kung and Van Stavern, 2015). Subtle CN palsy is a known be a pre-ischemic feature of carotid artery dissection due to anatomical proximity of the lower cranial nerves (IX, X and XII) to the carotid sheath. Ischemic optic neuropathy due to reduced blood flow to the optic nerve, may be linked to atherosclerosis, or arteritis e.g. Your email address will not be published. Upper part of the face have bilateral representation, Thank you for pointing out, the correction has been made. A direct response is the constriction that occurs when the pupil is exposed to light. Sufferers may exhibit signs of diminished muscle mass,fasciculations, and partialparalysisof the SCM and trapezius muscles, resulting in an asymmetric neckline. In cases of severe visual impairment light perception should be tested using a small flashlight. This facilitates hearing and equilibrium. The ability to move the eye in all other directions is controlled by CN III. Place your hands on the patients shoulders and press down as the patient elevates or shrugs the shoulders and then retracts the shoulders. Terms and conditions Comment policy Cookies and Privacy policy Sitemap Youtube. Using a penlight, approach the patient from the side, and shine the penlight on one pupil. Forehead wrinkle is the one clinical feature that can differentiate the origin of unilateral facial weakness. Roger Kerry is Associate Professor in the Faculty of Medicine and Health Sciences at the University of Nottingham, UK. Injury can occur secondary to blunt or direct trauma during sports injuries (Bordoni et al., 2020). Neck pain associated with clinical symptoms in dizzy patientsA cross-sectional study. Test pupillary reaction to light. The two 7th Cranial Nerves (CN VII) are located on either side of the brainstem, at the top of the medulla. Found this while looking up what my neuro-ophthalmologist was talking to me about. Air can be made to escape from the mouth more easier on the week side. Instructions for assessing each cranial nerve are provided below. Vestibular function can be evaluated by testing for nystagmus Nystagmus Nystagmus is a rhythmic movement of the eyes that can have various causes. bhilai C.G. Use to remove results with certain terms CN VII is the facial nerve. What are the muscles of facial expressions? In this process, electrical impulses of the facial muscles are measured and displayed, and the person learns what stimulates movement. Introduction to the Neurologic Examination. He has published several papers on this topic and presented about this topic on congresses. It is arguable that the BP findings alone were enough to triage the patient. Far vision is tested using the Snellen chart. Assessment CN VII Assessment CN VII Where is the 7th Cranial Nerve located? CN subjective questions (Diagonal lines Sensory function Smell/Hearing; Horizontal lines Motor and sensory function of the eyes; Vertical lines Motor and sensory function of the face/jaw/throat/tongue; Crossed lines Motor function of the head/neck/shoulders). The tongue is carefully inspected for signs of atrophy, asymmetry or fasciculation. Test the sense of taste by moistening three different cotton applicators with salt, sugar, and lemon. The cranial nerve exam is a type of neurological examination. Treatment with oral steroids may speed up recovery. In a face-to-face consultation, ask the patient to close both eyes tightly while you try to force open each eye to test strength. Function: Movement and function of the tongue. Ask the patient to face away from you and observe the shoulder contour for hollowing, displacement, or winging of the scapula and observe for drooping of the shoulder. Bells palsy is the most common condition that affects cranial nerve 7. A tongue blade can be used to touch one side of the posterior pharynx, then the other, and symmetry of the gag reflex is observed; bilateral absence of the gag reflex is common among healthy people and may not be significant. Observe and palpate (if face to face) the size and contraction of the masseter. See Figure \(\PageIndex{1}\)[1] for an image of a nurse performing an olfactory assessment. It has nine components. The ability to smell is tested by asking the person to identify items with very specific odors (such as soap, coffee, and cloves) placed under the nose. I have Idiopathic Intracranial Hypertension, and its affecting not only the 7th cranial nerve, but others as well. Aneurysms of the internal carotid artery or a fracture to the atlas bone may compress the nerve leading to ischaemic damage. If you have a condition affecting cranial nerve 7 function, its important that you get medical attention. In a face-to-face consultation, the patient should read from a Snellen chart at 3040 cm. Anisocoria or differences in pupillary size should be noted in a dimly lit room. Question: #Physiotherapists #PhysicalTherapists Were you taught cranial nerve testing at University? Alternative charts are available for children or adults who cant read letters in English. Note any side to side differences or reduction in the visual field. A function based approach to order and testing (Diagonal lines Sensory function Smell/Hearing; Horizontal lines Motor and sensory function of the eyes; Vertical lines Motor and sensory function of the face/jaw/throat/tongue; Crossed lines Motor function of the head/neck/shoulders. Exercise, headache, and factors associated with headache in chronic whiplash: analysis of a randomized clinical trial. Protocols are easy to use, efficient in use of time and reduce the chance of missing something significant. Function: Taste (posterior 1/3 of tongue); Somatosensory information from tongue, tonsil, pharynx; control of some of the muscles used in swallowing. Ask patient to swallow. Although the scale and distribution of this knowledge deficit remains to be quantified in full, the authors are aware of as yet unpublished data from surveys in Italy and the UK, that are indicative of a shortfall in education and skills in this area of neurological examination. These three nerves are tested together as the control movement of the eye. Because the 8th (vestibulocochlear, acoustic, auditory) cranial nerve carries auditory and vestibular input, evaluation involves, Hearing tests Evaluation Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss ( 1). Nystagmus secondary to BPPV has the following nearly pathognomic characteristics: Usually, vertical (upward-beating) nystagmus when the eyes are turned away from the affected ear and rotary nystagmus when the eyes are turned toward the affected ear, Nystagmus that fatigues when the Dix-Hallpike maneuver is repeated. damn i am happy with the description link. If a left sided facial weakness is caused by an injury to the right cerebral cortex (e.g., stroke), the duel innervation of the forehead will result in facial weakness below the forehead, with preservation of bilateral forehead wrinkle and eyelid closure (may have mild weakness but the eye will not be "wide open". Some of these movements are voluntary (on purpose) and some are involuntary (not on purpose). No potential conflict of interest was reported by the author(s). This may be considered if the nerve is injured. When downward gaze is attempted, the superior oblique muscle may cause the eye to adduct slightly and rotate. Observe the response of the lighted pupil, which is expected to quickly constrict. Brief fine amplitude nystagmus at end-lateral gaze is normal. Ent omf and head neck ca resident 2nd year. See Figure \(\PageIndex{8}\), Test sensory function. Each has a different function responsible for sense or movement. The numerator of the fractions on the chart indicate what the individual can see at 20 feet, and the denominator indicates the distance at which someone with normal vision could see this line. While mild eyelid closure problems can occur with stroke (Upper Motor Neuron problem), a "wide open lid" favors a CN VII cause versus stroke. The consensual or indirect response refers to the simultaneous constriction of the opposite pupil. By Heidi Moawad, MD May be secondary to nerve infarction, encephalopathy, trauma, infection, increased intracranial pressure, vasculitis, or may be idiopathic (Kung and Van Stavern, 2015). Normally, the eyes stay focused on the object (via the vestibular ocular reflex). Ask him to smile or show his upper teeth. It is essential to have proper knowledge of anatomy to understand this section of clinical examination of facial nerve. CN I-olfactory-Smell. Both pupils should react in the same manner to light. Accessibility StatementFor more information contact us atinfo@libretexts.org. Stand 1 foot in front of the patient and ask them to follow the direction of the penlight with only their eyes. Walker, H. K. Cranial nerve XI: The spinal accessory nerve. History includes location read more is also done. Ask the patient to open their mouth and say Ah and note symmetry of the upper palate. Osazone Test: Principle, Procedure, and Results, Bials Test: Principle, Reagents, Procedure and Results, Clinical Tests For Examination Of Oculomotor, Trochlear & Abducent Nerves, To Demonstrate The Olfactory Sensations On A Given Subject, Photoelectric Colorimeter: Working Principle, Use and Applications, Clinical Tests For Examination Of Trigeminal Nerve (5th Cranial Nerve), Differential Leukocyte Count Procedure And Results, Creatine Kinase Test by IFCC Kinetic Method:Principle, Procedure, Results, Lactate Dehydrogenase Test: Principle And Procedure. Legal. Bilateral eye blink is an important protective response. This causes paralysis (weakness) of some facial movements. Check resisted head rotation (sternocleidomastoid) and shoulder elevation (trapezius upper fibers). These signals help you smell, taste, hear and move your facial muscles. Freed B, Coker C, Steele R, Marolt C, Motzko M, Creamer BA, Dennis JF. It is however, important that clinicians are aware that there is little or no specific data available to support the diagnostic accuracy (i.e. Special Instructions or Considerations Federal government websites often end in .gov or .mil. Mechanisms: Characterized by episodes of unilateral brief, excruciating pain which occur spontaneously or are precipitated by stimulation of the verve by chewing, swallowing, coughing, talking, yawning, or sneezing. May follow blunt trauma such as a road traffic collision or a head injury in sport. Dysfunction is characterised byflaccid paralysis/weakness of the ipsilateral tongue musculature. Note any side to side differences. Neck pain and associated symptoms are common conditions that lead to pain, impairments, disability and a considerable economic burden [4]. Function: Somatosensory information (touch, pain) from the face and head; Motor function chewing. If there is unilateral weakness present, the tongue will point to the affected side due to unopposed action of the normal muscle. If nystagmus changes direction (eg, from one side to the other when, for example, when the direction of gaze changes), it is probably central. He has been a regular key note speaker at numerous courses and conferences worldwide. The facial nerve: Starts in your brainstem. Facial Paralysis: Causes, Symptoms, and Treatment, 13 Reasons for Uncontrollable Lip Twitching, Moebius Syndrome: Symptoms, Diagnosis, and Treatment, Communicating branches of the facial nerve: Descriptions and clinical considerations, Design and evaluation of a custom-made electromyographic Biofeedback system for facial rehabilitation, A review of delayed facial nerve paresis as complication following total endoscopic ear surgery. When performing these tests, examiners compare responses of opposite sides of the face and neck. However to date, there is no published data on the scale of the issue. The association between neck pain and headache manifestations including, facial pain, jaw pain, muscular dysfunction, visual/balance disturbances, and dizziness has been well documented and debated in the physiotherapy world for decades in a range of domains [57]. This will allow clinicians to pick up on subtle clues that may be offered by patients during the subjective examination (e.g. In: Jorquera Moya M, Merino Menndez S, Porta Etessam J, et al. See Figure \(\PageIndex{15}\)[18] for an image of assessing the hypoglossal nerve. Overview of Neuro-ophthalmologic and Cranial Nerve Disorders, Neuro-ophthalmologic and Cranial Nerve Disorders. An official website of the United States government. . Have you noticed any recent alteration to your ability to eat or chew? Watch for smooth movement of the eyes in all fields. The https:// ensures that you are connecting to the Those who have learned the nerves in order may prefer to test that way. An attempt to protrude the tongue results in deviation of the tongue toward the weak side because of the unopposed actions of the intact genioglossus muscle. Current evidence suggests that common viral causes are: Herpes simplex virus infection (most common), Herpes zoster. Instead the eyeball rolls up. Extraocular movements controlled by these nerves are tested by asking the patient to follow a moving target (eg, examiners finger, penlight) to all 4 quadrants (including across the midline) and toward the tip of the nose; this test can detect nystagmus and palsies of ocular muscles. The vascular team were of the opinion that this was an exercise-induced dissection and may have been linked to his (previously unknown) elevated blood pressure. It has been suggested that CN examination should be an integral part of that process [13]. Then reverse the procedure to test the left sternocleidomastoid. The pain seeps and elicits burning sensations to my entire face, neck and sporadic pain down my back.
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