1. Cranial Nerve Evaluation Acoustic Neuroma and the Facial Nerve
Alyssa Capeling
Sara Holaly
Shawn McGinley
Kathy Olson

2. Outline Overview of cranial nerves
Cranial nerves affecting speech and hearing
Acoustic Neuroma
Cranial nerve VII
Function
Course and innervation
Evaluation
Overview
Case study
Case history
Audiologic assessment
Facial muscule evaluation
Taste
Treatment options
Summary
References

3. Cranial Nerve Function
Love, R.J. & Webb, W.G. (2001). Neurology for the speech language pathologist (4th ed.). Boston, MD: Butterworth-Hinemann.

4. Cranial Nerve Function
Fix, J.D. (2000). High-yeild neuroanatomy (2nd ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

5. Cranial Nerves on the Web

6. Cranial Nerves for Speech and Hearing
Cranial Nerve V: Trigeminal
Function: mastication and sensation (pain, temperature, propioception, and touch) to face, teeth, gums, anterior 2/3 of tongue, part of external ear canal, and tympanic membrane
Also helps with flattening and tensing the soft palate for eustacian tube opening and anterior and superior movement of the larynx
Testing:
Motor: feel masseter muscle as the patient bites down then relaxes; have the patient open/close jaw against resistance, have the patient move jaw laterally against resistance
Sensory: firmly stroke cotton swab across different areas of the face and tongue with the patient’s eyes closed

7. Cranial Nerves for Speech and Hearing
Cranial Nerve VII: Facial
Function: controls movements of facial expression (wrinkle forehead, close eyes, close mouth, pull back corners of mouth, pull down corners of mouth), taste on anterior tongue, stapedious reflex, controls lacrimal gland, sublingual gland, submadibular gland, and secretory glands of mouth and nasal cavity
Also helps to move larynx up and back
Testing:
Motor: wrinkle forehead, look up at ceiling, close eyes as tightly as possible, pucker lips, smile
Sensory: have patient distinguish between different tastes with eyes closed and tongue out of mouth
More detail later

8. Cranial Nerves for Speech and Hearing
Cranial Nerve VIII: Vestibulocochlear
Function: sound sensitivity, maintain equilibrium
Testing:
Hearing: audiologic testing
SLP may do screening, and neurologist may use tuning forks to test acuity and lateralization
Audiologists perform complete diagnostic testing
Equilibium: patient interview (may complain of tinnitus and/or dizziness)
Audiologists may perform ENG (electronystagmography) testing and ABR (Auditory Brainstem Response) testing
ENTs may order MRIs (magnetic resonance imaging)

9. Cranial Nerves for Speech and Hearing
Cranial Nerve IX: Glossopharyngeal
Function: helps to clear the pharynx during swallowing via dialation of the pharynx and elevation of the larynx; controls taste on the posterior 1/3 of the tongue, assists with pharyngeal gag, activates and regulates secretion from the parotid gland
Testing:
Difficult to distinguish from CN X
Sensory: test gag reflex by rubbing posterior pharyngeal wall
Motor: swallowing assessment

10. Cranial Nerves for Speech and Hearing
Cranial Nerve X: Vagus
Function: controls muscles of phonation and swallowing, innervates cardiac and smooth muchles of esophagus, stomach, and intestine, mediates sensation of visceral muscles of pharynx, larynx, epiglottis, throax, and abdomen, controls taste in pharynx and epiglottis, controls intrinsic muscles of larynx, controls palatal function
Recurrent laryngeal branch: intrinsic muscles of larynx except cricothyroid
Superior laryngeal branch: innervates cricothyroid
Testing:
Palatal function: view at rest and during /a/, test gag reflex
Laryngeal function: lanyngoscopy, voice assessment including sustained /a/, perceptial assesssment of pitch and loudness, cough vs coup, stress testing (counting), may do instrumental analysis,

11. Cranial Nerves for Speech and Hearing
Cranial Nerve XI: Spinal Accessory
Function: help turn, tilt, rotate, forward/backward movement of head, raise the sternum, shrugging the shoulders
Testing: have patient move head against resistance, have patient shrug shoulders while you push down

12. Cranial Nerves for Speech and Hearing
Cranial Nerve XII: Hypoglossal
Function: controls shortening, narrowing, elongating, and flattening of tongue via innervation of intrinsic muscles of tongue, controls tongue protursion, retraction, drawing up and back via innervation of the extrinsic tongue muscles, and assists with elevation of the hyoid
Testing: look at the tongue at rest to look for atrophy, look for fasiculations and involuntary movement, have the patient protrude tongue, move it up and down, corner to corner, test strength using resistance during movement, listen to production of /t/, /d/, /t⌠/, /d3/, l/, /n/, /i/, /j/, /k/, /g/

13. Acoustic Neuroma
Definition: “…a benign tumor of Schwann cells that affects the vestibulocochlear nerve (CN VIII).” (Fix, 2000, p. 81)
May also effect CN V and CN VII
Symptoms: unilateral hearing loss, tinnitus, vertigo, nystagmus, nausea, vomiting
If damage to CN VII: facial weakness, loss of corneal reflex
If damage to CN V: paresthesia and loss of corneal reflex
Diagnosis: MRI, ENG, and ABR
Treatment: Surgical removal
Full recovery is possible with small tumors
If not diagnosed early, may become large and lead to damage of CN VII and/or the brainstem during removal

14. Function of CN VII
General Sensory:(afferent) carry sensation from the skin of the concha of the auricle, and posibly supplement sensation from the wall of the EAM and the external surface of the tympanic membrane
Special Sensory: (afferent) taste sensation from the anterior two-thirds of the tongue
Branchial Motor: (efferent) supplies muscles of facial expression and the stapedius, stylohyoid, and posterior belly of the digrastic muscles
Visceral Motor: (parasympathetic efferent) for stimulation of the lacrimal, submandibular, and sublingual glands as well as the mucous membrane of the nose and hard and soft palates

15. Branches of CN VII that Supply Muscles of the Face and Neck
Muscles Supplied
Nerve to Stapedius
Stapedius
Nerve to Posterior Belly of Digastric
Posterior Belly of Digastric
Nerve to Stylohyoid
Stylohyoid
Termoral
Frontalis, Occiptalis, Orbicularis Oculi, Corrugator Supercilli, Procerus
Zygomatic
Obicularis Oculi
Buccal
Buccinator, Obicularis Oris, Nasalis, Labator Labii Superioris, Levator Labii Superioris Alaeque Nasi, Zygomaticus Major and Minor, Levator Anguli Oris
Mandigular
Orbicularis Oris, Mentalis, Depressor Anguli Oris, Depressor Labii Inferioris, Risorius
Cervical
Platysma
Posterior Aurical
Occipitalis

16. General Examination Compnents of the Facial Nerve
1. Function of the muscles of facial expression
2. Taste from the taste buds
3.Somatic sensation from the external ear
4. Function of the stapedius
5. Secretomotor innervation of the lacrimal and salivary glands

17. Case Study Patient: E. O. Age: 68 Prior Medical History
Onset of hearing loss: January 1986
Diagnosis of Acoustic Neuroma: June 2002
Date of Surgical Tumor Removal: July 31,2002
Speech Tx history:
In patient acute care: primary focus swallowing
In patient rehab: primary focus oral motor exercises
Home Health (4 weeks): Oral motor exercises and swallowing strategies
Out patient: Oral motor exercises, speech articulation, electrostimulation of facial muscles by physical therapy

18. Cranial Nerve VII The Facial Nerve

20. Case Study Reported symptoms: Immediately post surgery
Unable to swallow – PEG tube removed in September
Unable to speak due to facial weakness
Severe drooping of left side of face, “crooked mouth”
Tongue felt “frozen and spotty”
Unable to blink eye
Ocassional blurriness
Balance disturbances
Decreased tearing in left eye
Improvements 3 months post surgery
Increased facial movement
Easier to eat/swallow
Improved speech

21. Acoustic Reflex Testing
The Acoustic Reflex: A bilateral contraction of the stapedius muscles in response to loud sounds (80 dB SPL or above for people with normal hearing)
Testing is conducted at 500 Hz, 1000 Hz, and 2000 Hz by using a 226 Hz probe tone to measure changes in immittance
Purposes of the Acoustic Reflex:
protection from loud sounds
Attenuates low frequency sounds and helps with our perception by reducing bodily noise.

22. A c o u s t I c R e f l e x P a t h w y s

23. Acoustic Reflex Responses
Shawn’s Response Levels
Right Ipsilateral (Stimulus and Probe Right) 85 dB SPL
Right Contralateral (Stimulus Right, Probe Left) 90 dB SPL
Left Ipsilateral (Stimulus and Probe Left) 85 dB SPL
Left Contralateral (Stimulus Left, Probe Right) 90 dB SPL
E.O.’s Response Levels
Right Ipsilateral: Present at expected levels
Right Contralateral: Absent
Left Ipsilateral: Absent
Left Contralateral: Absent
Patient with Left Facial Nerve Disorder Only
Right Contralteral: Absent
Left Contralateral: Present at expected levels

24. Examing the Function of the Muscles of Facial Expression
Task
Occipitofrontalis
Raise eyebrows
Orbicularis Oculi
Close eyes tightly
Obicularis Oris
Approximate lips
Zygomaticus Minor
Protrude upper uip (pucker)
Lebator Anguli Oris
Lift upper border of lip on left
Zygomaticus Major
Raise later angles of lips (smile)
Buccinator
Approximate & compress lips (clinician can’t open)
Mentalis
Rase and protrude lower lip (pout)
Temporalis Masseter
Close jaw tightly
Pterygoid Lateralis and Medialis left
Move jaw laterally to the left
Pterygoid Lateralis and Medialis right
Move jaw laterally to the right

25. Examing the Function of the Muscles of Facial Expression: Zygomaticus Major

26. Examing the Function of the Muscles of Facial Expression: Zygomaticus Minor

27. Examing the Function of the Muscles of Facial Expression

29. Examing Taste from the Taste Buds
Four basic modalities of taste
Sweet vs. salty
Bitter and sour
Protrude tongue
One side swabbed with solution
point to taste modality
Other side swabbed
Compared with first side
Rinse with water
Repeat with next taste

31. Treatment Options Oral Motor Exercises Articulation Drill
Occupational and Physical Therapies
Surgical Options

32. Summary Cranial Nerves for Speech and Hearing Acoustic Neuroma
Facial Nerve
Case Study

33. References
Bhatnager, S.C. & Andy, O.J. (1995). Neuroscience for the study of communication disorders. Baltimlore, MD: Williams & Wilkins.
Facial Nerve. (n.d.). Retrieved October 22, 2002, from
h_n/cn/cn1/cn7.htm
Fix, J.D. (2000). High-yeild neuroanatomy (2nd ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Garrison, D. W. (1986). Cranial nerves: A systems Approach. Springfield, IL: Charles C. Thomas.
Love, R.J. & Webb, W.G. (2001). Neurology for the speech language pathologist (4th ed.). Boston, MD: Butterworth-Hinemann.
Nelson, M.A. & Hodge, M.M. (2000). Effects of facial paralysis and audiovisual information on stop place identification [electronic version]. Journal of Speech, Language, and Hearing Research, 43,
Neuroscience for Kids – Cranial Nerves. (n.d.). Retrieved September 6, 2002, from
chudler/cranial.html.
Pauwels, L.W., Akesson, E.J., Stewart, P.A., Spacey, S.D. (2002). Cranial nerves in health and disease (2nd ed.). Hamilton, Ontario: BC Decker Inc.
Wiederholt, W.C. (1995). Neurology for the non-neurologists (3rd ed.). Philadelphia, PA: W.B. Sanders Company.
Yokoyama, T., Nishizawa, K., Sugiyama, K., & Yokota, N. (1999). Intraoperative evoked facial muscle responses and recovery process of the facial nerve in acoustic neuroma surgery [electronic version]. British Journal of Neuroscience, 13,