What is being assessed by having a patient puff out their cheeks, stick out their tongue, raise both arms, and close their eyes, likely as part of a neurological examination to evaluate cranial nerve function?

Cranial Nerve Examination Components

The combination of puffing cheeks, sticking out the tongue, raising both arms, and closing eyes is assessing multiple cranial nerves and motor function as part of a comprehensive neurological examination. This specific set of tests evaluates facial nerve (VII), hypoglossal nerve (XII), motor strength, and coordination.

Specific Tests and Their Neurological Significance

1. Puffing Cheeks

• Assesses: Facial nerve (cranial nerve VII)
• Function tested: Motor innervation of facial muscles
• Clinical significance:
  • Evaluates the integrity of facial muscles and their innervation
  • Weakness or asymmetry may indicate facial nerve palsy or paralysis 1
  • Important for detecting conditions like Bell's palsy, stroke, or other neurological disorders affecting facial movement

2. Sticking Tongue Out

• Assesses: Hypoglossal nerve (cranial nerve XII)
• Function tested: Motor control of tongue muscles
• Clinical significance:
  • Evaluates tongue movement and symmetry
  • Deviation of the tongue toward one side indicates hypoglossal nerve weakness on that side 1
  • Tongue fasciculations or atrophy may suggest lower motor neuron disorders 2

3. Raising Both Arms

• Assesses: Motor strength and coordination
• Function tested: Upper extremity motor function and symmetry
• Clinical significance:
  • Evaluates for pronator drift (a sign of upper motor neuron dysfunction)
  • Asymmetry may indicate hemiparesis from stroke or other neurological conditions
  • Tests antigravity movement and motor strength 2

4. Closing Eyes

• Assesses: Facial nerve (cranial nerve VII)
• Function tested: Orbicularis oculi muscle function
• Clinical significance:
  • Inability to close eyes completely (lagophthalmos) indicates facial nerve weakness
  • Important for detecting peripheral vs. central facial nerve lesions 1
  • Critical for corneal protection - inadequate closure can lead to exposure keratitis 2

Clinical Applications

Neurological Disorders Assessment

• This combination of tests is commonly used in rapid neurological screening, particularly for:
  • Stroke evaluation (facial weakness, arm drift)
  • Cranial nerve assessment in neurological examinations
  • Brain death determination protocols 3, 4

Distinguishing Central vs. Peripheral Lesions

• Central lesions (upper motor neuron):

  • May preserve forehead movement while affecting lower face
  • Often accompanied by other neurological signs

• Peripheral lesions (lower motor neuron):

  • Affect the entire hemiface including forehead
  • As seen in Bell's palsy 1

Surgical Monitoring

• These tests are particularly important in monitoring cranial nerve function:
  • Pre and post-surgical evaluation for head and neck procedures
  • Intraoperative cranial nerve monitoring during vestibular schwannoma surgery 2
  • Assessment after skull base surgeries or trauma

Important Clinical Considerations

• Combined deficits: The presence of both facial weakness and tongue deviation should raise suspicion for lesions affecting multiple cranial nerves, possibly indicating a skull base lesion or brainstem pathology 1

• Pediatric assessment: In children, these tests help identify motor delays and neuromotor dysfunction that may indicate developmental issues 2

• Documentation: Pre- and post-operative cranial nerve examination is recommended before and after surgical intervention or radiotherapy for patients with head and neck pathologies 2

• Protection measures: In cases of facial nerve palsy with inability to close the eye, corneal protection should be prioritized to prevent exposure keratitis 2

This combination of simple tests provides valuable information about multiple neurological systems and is an efficient component of the neurological examination, allowing clinicians to quickly assess for significant neurological dysfunction that could impact morbidity, mortality, and quality of life.