Cranial nerve examination — a facial droop
PLAB 2 & PRES 3 · neurology · medium · 10 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mrs Sarah Whitfield, 47, noticed this morning that the right side of her face has drooped. She is frightened that she has had a stroke. Please perform a cranial nerve examination. Present your findings to the examiner, then discuss the likely diagnosis, your management plan, and how you would reassure her.
What examiners look for
Forehead, forehead, forehead. The single distinction this station exists to test: the forehead receives bilateral upper motor neurone supply, so a stroke spares it; a facial nerve lesion takes the whole face, forehead included. Test eyebrow raising and eye closure on every facial droop. A lower motor neurone facial weakness is a finding, not a diagnosis. Bell palsy earns the label only after the examination has excluded company: other cranial nerve deficits, limb signs, vesicles in the ear (Ramsay Hunt), a parotid mass and a history suggesting Lyme disease. The small muscles tell the anatomical story. Stapedius weakness makes ordinary sounds painfully loud (hyperacusis); chorda tympani involvement blunts taste on the anterior two-thirds of the tongue; both place the lesion inside the facial canal and support Bell palsy over a cortical cause. Eye closure is the urgent clinical problem, not the droop. An eye that cannot close dries out and its cornea ulcerates — lubricants, ointment and night-time taping belong in every management plan, and marking schemes reward them before steroids. Steroids are time-critical: prednisolone helps most when started within 72 hours. A candidate who books a routine review in two weeks has missed the treatment window even if their diagnosis is right. Prognosis is genuinely reassuring and should be given plainly: most people with Bell palsy recover completely, usually over weeks to a few months. Honest reassurance — "this is not a stroke, and here is the examination evidence" — is itself a marked skill. Sequence and economy matter: the cranial nerves have a fixed order for a reason. Candidates who jump straight to the face and never test the other eleven nerves may find the lesion but fail the station. If anything does not fit — bilateral weakness, a slow onset over weeks, recurrence, or no recovery — say so and refer. Knowing the edges of the common diagnosis is what separates a safe candidate from a lucky one.
Guideline references
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