👁️ Clinical Pearl: Always look at the pupils. 🙂 If hemifacial weakness is present → check the arm on same side. 🧠 Forehead sparing = think stroke. 😮 Difficulty closing the eye (not ptosis) = facial nerve palsy.

👋 Introduction

🧼 Wash hands before starting.
Introduce yourself, confirm patient’s name & DOB.
Explain purpose: testing motor + sensory function of the face, including pupils.
Gain consent, ensure comfort, privacy, and good lighting.

🔑 Key Areas to Assess

CN V (Trigeminal): Sensory in 3 divisions + motor to mastication. (Rarely gives “classic” neuro signs but important in OSCE).
CN VII (Facial): Motor to muscles of expression. – Bell’s palsy 👉 whole face weak, cannot close eye, mouth droop, Bell’s sign. – Stroke 👉 forehead spared, look for limb weakness.
Pupillary Function: Assess size, symmetry, light reflexes. – Complete CN III palsy 👉 full ptosis, dilated pupil, eye “down and out”.
Horner’s Syndrome: Subtle triad 👉 mild ptosis, small pupil (miosis), anhidrosis.
Other Conditions: Masked facies in Parkinson’s, wasting in myotonic dystrophy.

🩺 Examination Techniques

Sensory (CN V): Light touch (cotton) + pinprick over V1, V2, V3. Compare sides.
Motor (CN V & VII): Ask to raise eyebrows, close eyes tight, smile, puff cheeks. Look for asymmetry, drooping, weakness.
Pupils: Inspect for size/shape, test direct & consensual light reflexes. Check for RAPD if suspected.
Horner’s: Look closely for subtle ptosis + constricted pupil. Mention sweating loss (though not usually examined).
Corneal Reflex: Touch cornea lightly → afferent CN V, efferent CN VII.

📊 Table: Major Nerves in Facial Examination

Nerve	Division/Area	Function Tested	Technique
CN V (Trigeminal)	V1 (Ophthalmic)	Sensory: Forehead, scalp, eyelid, nose. Corneal reflex.	Light touch + pinprick. Corneal reflex with cotton wisp.
	V2 (Maxillary)	Sensory: Lower eyelid, cheek, upper lip.	Light touch + pinprick.
	V3 (Mandibular)	Sensory: Jaw, chin. Motor: mastication.	Touch chin + ask to clench teeth.
CN VII (Facial)	Entire face	Motor: facial expression. (Taste ant. 2/3 tongue)	Ask to smile, frown, close eyes, puff cheeks.

🧠 Additional Considerations

Neuromuscular Dystrophies: Myotonic dystrophy → long thin face, drooping mouth, ptosis, weak eye closure.
Parkinson’s Disease: Masked facies (hypomimia), reduced blinking, rigidity, tremor.

✅ Closure

Thank patient, redress, maintain dignity.
Summarise findings and suggest further tests if needed (neuroimaging, neurophysiology).
🧼 Wash hands again and document carefully.

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OSCE Neurological Examination Face