Makindo Medical Notes

Related Subjects: |OSCE Eye Exam |OSCE Ear Exam |OSCE Abdominal Exam |OSCE Testicular Exam |OSCE Inguinal Exam |OSCE Upper limb Neurology |OSCE Lower limb Neurology |OSCE Face Neurology

Don't forget to look at the pupils. If there is hemifacial weakness have a quick look to see if arm on same side is weak too and if forehead and eye spared which may suggest a stroke. Remember a facial nerve weakness causes difficulty closing the eye and not ptosis.

Introduction

• Wash your hands thoroughly before beginning the examination.
• Introduce yourself, confirm the patient’s name, date of birth, and explain the purpose of the exam.
• Obtain informed consent and ensure the patient is comfortable in a well-lit, private setting.
• Explain that you will be testing both sensory and motor functions of the face, assessing pupillary responses, and looking for signs of specific neurological conditions.

Key Areas to Assess

• Trigeminal Nerve (CN V): Sensory examination of its three divisions (V1, V2, V3) and motor assessment of the muscles of mastication (V3). However not a common cause of good neurological signs.
• Facial Nerve (CN VII): Motor examination of the muscles of facial expression. With Bell's palsy there may be unilateral weakness with inability to close the eye and drop of angle of mouth and slow eye closing on the affected side and Bell's sign. If the eye and forehead closing is not affected then consider facial weakness is more likely related to a stroke and patient may have ipsilateral upper limb weakness.
• Pupillary Function: Evaluation of pupil size, symmetry, and light reflexes (direct and consensual) to ensure normal function. A complete IIIrd nerve will cause a complete unilateral ptosis and eye will be down and out and pupil dilated.
• Horner’s Syndrome: Horner's syndrome with a very small pupil and very mild ptosis is one to watch for. Look for signs such as mild ptosis (drooping eyelid), miosis (constricted pupil), and anhidrosis (absence of sweating which is not usually examined for but do mention) which indicate sympathetic dysfunction.
• Additional Conditions: Recognize features suggestive of neuromuscular dystrophies and Parkinson's disease affecting facial expression.

Examination Techniques

• Sensory Testing (CN V): Use light touch (cotton wisp) and pinprick (disposable pin or neurotip) over the V1, V2, and V3 distributions.
• Motor Testing (CN V & VII): Ask the patient to perform facial movements such as raising eyebrows, closing eyes tightly, smiling, and puffing out the cheeks.
• Pupillary Testing: Observe the pupils for size, shape, and reactivity to light (both direct and consensual responses). Verify that they are round, equal, and reactive (PERRLA).
• Horner’s Syndrome Assessment: Look for subtle signs like ptosis, miosis, and reduced sweating on one side of the face.
• Corneal Reflex: Lightly touch the cornea to test the afferent limb (via V1) and the efferent response (via CN VII).

Table: Major Nerves Involved in the Neurological Examination of the Face

Additional Considerations: Neuromuscular Dystrophies & Parkinson’s Disease

• Facial Dystrophies: In conditions such as myotonic dystrophy, patients may exhibit facial muscle weakness, ptosis, and a characteristic long, thin face with a drooping mouth. Observation of reduced facial expression and muscle wasting can be a clue to an underlying dystrophy.
• Parkinson’s Disease: Patients typically present with a masked, hypomimic face (reduced facial expression) along with bradykinesia. Look for reduced blinking, a fixed facial expression, and any tremor or rigidity that may affect the facial muscles.

Closure

• Thank the patient for their cooperation.
• Provide a brief summary of your findings and explain any further investigations or management plans if necessary.
• Wash your hands again and document your examination findings clearly.