Table 1.

Performing an Examination of the Cranial Nerves via Telemedicine^a

Cranial Nerve	Virtual Assessment
CN I	Given that CN I is seldom examined, abnormalities in smell can be screened for in the patient’s history. If the physician wishes to examine it, they can have patients identify familiar smells with their eyes closed. This can be done with the help of an assistant who presents the odours to the patient.
CN II	Physician should instruct patients to bring their eyes closer to the camera. Observe the pupils, noting symmetry and size. To test the pupillary light reflex, physician can ask patient to close their eyes for a few seconds then open them, noting appropriate constriction. Similarly, the patient or assistant can use a flashlight. Assess visual fields by asking patient to cover each eye and describe what they see. Physician can print out the NIH stroke scale cards and present them to patients, testing for visual defects. Red desaturation can be tested by holding up a red object in front of patients.
CN III, IV, VI	Physician should have the patient gaze in the 9 cardinal positions, with a brief pause at each position, looking for nystagmus and ptosis. Assess for saccades by having the patient alternate their gaze between two extremes of their screens.
CN V	Physician should observe the clenching and releasing of the jaw. Ask for areas of facial numbness or tingling.
CN VII	Physician should have the patient smile, show teeth, raise their eyebrows, squeeze eyes shut and purse their lips, observing for asymmetry.
CN VIII	Physician should assess the patient’s hearing ability by speaking to them in their normal voice. Assistant may test finger rub and note any asymmetry.
CN IX and X	Physician should watch for vocal abnormalities such as hoarseness. Physician can ask patients to open their mouth, say “ah” and assess for appropriate palatal elevation.
CN XI	Physician should ask patients to shrug their shoulders and rotate their neck.
CN XII	Physician should ask patients to stick out their tongue, noting any unilateral deviation, atrophy or fasciculations.

Notes: ^aData from Verduzco-Gutierrez et al.¹⁸ Al Hussona et al¹⁹ and from an American Headache Society video by Dr. J. Robblee.²⁰

Abbreviations: CN, cranial nerve;  NIH, National Institutes of Health.