Figure 13.3). Most of us have had temporary V3 loss, at the dentist.
Motor V lesions are unusual. Look at the centre line of incisor teeth, upper and lower. See if the lower incisors remain central or move laterally as the jaw opens against slight resistance. Then assess the jaw jerk.
VII: Facial
A complete LMN facial palsy affects all facial muscles on one side. Upper motor neurone (UMN) weakness affects the lower face; this spares blinking and forehead wrinkling. In early UMN facial weakness a hint of slowing of a blink, or grimace is all that may be seen, sometimes with dissociation between voluntary and involuntary movement.
Make suggestions:
Frontalis: ‘look upwards’ produces furrowing of the brow.
Orbicularis oculi: ‘screw up your eyes tightly’
Alae nasae: ‘wrinkle your nose’
Orbicularis oris: ‘now try to whistle gently’
Risorius: ‘… and now please show me your teeth’
Platysma: ‘tension the skin of your neck’.
Involuntary movements (e.g. myokymia, fasciculation and slight hemifacial spasm): illuminate the face well. Finally, as a practical point, gradual emergence of patchy facial weakness is distinctly unusual in Bell’s palsy.
VIII: Auditory
Testing is unnecessary when there is no problem. With some hearing loss, note distance at which a whisper is heard. Rinne & Weber tests are now felt to be of doubtful value.
My approach: occlude gently both external auditory meati with the tips of each index finger. Rustle with each middle finger the skin/hair over the mastoid – a measure of bone conduction. If there is marked difference between each side, sensorineural loss is usually present. Any suspicion of a CPA lesion: MRI and audiometry.
VIII: Vestibular
Dizziness, vertigo and nystagmus: Chapter 15. Gait & stance, Romberg & Unterberger tests. Common error: over‐diagnosis of nystagmus. A few beats at extremes of lateral gaze is normal. Nystagmus must usually be sustained, within binocular gaze to be pathological.
IX and X: Glossopharyngeal and Vagus
Take both together. Observe uvula & fauces saying ‘Aaah’. Look for saliva pooling, food, palate/uvula deviation.
Voice sounds ‘wet’ in early bulbar weakness (Chapter 13)
Listen to a cough
Watch patient begin to drink, if safe – spluttering, pooling.
An isolated IXth – almost impossible to identify – causes impaired unilateral pharynx sensation.
XI: Accessory
Trapezii and sternomastoids: scapula winging, weak shoulder shrugging and head turning,
XII: Hypoglossal
Tongue: wasting and deviation to weak side when protruded. Speed and amplitude diminished in pyramidal lesions and Parkinson’s. Fibrillation: diagnose fibrillation only when tongue rests within mouth; twitching occurs in normal people when protruded.
Gait and Movement Disorders
Assess gait:
Normal, symmetrical, without limp
Spastic – narrow‐based, stiff, toe‐scuffing
Hemiparetic
Extrapyramidal – shuffling, festinant (hurrying), with poor arm swinging, slow
Apraxic – with gait ignition failure, with walking difficulty but preserved ability to move legs rapidly on a bed or seated
Ataxic
High stepping, foot drop, myopathic, antalgic, neuropathic
Otherwise unusual – dystonia, chorea or myoclonus, or apparently theatrical.
Do not miss subtleties – early chorea, a little dystonia. A video on a phone is helpful.
Motor System
Techniques are important.
Posture of Outstretched Upper Limbs
Ask the patient to extend arms symmetrically, palms uppermost and then close the eyes.
Drift with pronation/descent towards midline is a cardinal sign of an early pyramidal lesion.
Postural tremor, chorea, pseudochorea and asterixis become apparent. Rest tremor diminishes.
Apply gentle downward wrist pressure and release: rebound – a cerebellar lesion.
Fatiguability: inability to maintain the arm outstretched.
Inspect arms, hands, nails.
Non‐organic problems: often aimlessly waving around.
Tone
Distinguish between akinetic‐rigidity and spasticity.
Extrapyramidal lead pipe rigidity is detectable throughout all passive movements. Take the hand through slow, extension, flexion, rotation movements. This elicits early stiffness in wrist and forearm muscles and cogwheeling. Stiffness becomes more evident when the opposite limb is moved actively a.k.a. synkinesis. By contrast, in spasticity, the early pronator catch or beats of ankle clonus will only become apparent if sought by brisk movements – quickly supinating the forearm or dorsiflexing the ankle: slow movements can miss these signs. A catch of increased tone at an ankle precedes sustained clonus.
Power, Muscle Bulk, Consistency
MRC 0–5 Power Grades:
5: Normal
4: 4+, 4− Active movement against
