cranial nerve small group discussions 2014 (1)

8/10/2019 Cranial Nerve Small Group Discussions 2014 (1)

1/20

Cranial Nerve Small Group Discussions

Case #1 Trigeminal Neuralgia

Patient 57-year-old emale complains o rig!t-sided acial pain

"istory - Patient co pain on t!e rig!t side o t!e ace$ %!ic! is intermittent innature& 'egan ( %ee)s ago& Descri*es t!e pain as s!arp in nature$ occurringseconds at a time or a*out (+ minutes and t!en resolves& T!e pain is severeand distressing to !er to s!e came to t!e ,D& S!e denies ever$ toot!ac!e$pro*lems %it! t!e T.$ earac!e$ loss o eyesig!t$ *lurred vision$ !alos$ s!ootersor loaters$ drainage rom t!e ears$ tinnitus$ trauma$ ras!es$ etc& S!e too) !ernapro/en and tried acetaminop!en %it!out relie& Don0t tell t!em t!is unless t!eyas) *ut s!e does !ave triggers touc!ing t!e mid c!ee) and c!e%ing&

S 12373 42 12 4&4 degrees

P"/6edical llnesses mild osteoart!ritis$ !ypot!yroidismedications synt!roid$ napro/en P8NSurgery none

SocialTo*acco denies,T9" rarelyD9: denies

P!ysical6",,NT :TNC$ P,8;$ sclera anicteric$ T0s clear$ no drg rom nose$mucous mem*ranes moist$ p!aryn/ clear$ opens and closes mout! easily$ teet!aligned$ no tenderness over t!e teet! %!en percussed %it! tongue *lade$ notenderness over t!e T.$ no tenderness over t!e temporal artery

Nec) nec) is supple$ no masses$ no t!yroidomegaly$ no *ruits$ nolymp!adenopat!y

Neuro totally intactS)in no ras!es

8est o p!ysical e/am is normal

Trigeminal neuralgiaT. disease9dontogenic inection9ttis media

:cute glaucoma"erpes >oster


2/20

?es6:neurysm

Tumorultiple sclerosis

Does trigeminal neuralgia occur more oten in emales or males=

@emales

Presence o triggersC!e%ing

'rus!ing t!e teet!S!aving8ig!t side

a/illary and mandi*ular divisions o t!e nerve Asee pictureB8arely t!e op!t!almic division

No particular time o day *ut rarely during sleep

:re any diagnostic testing reuired=

No& 9nly i t!ere is a real neurological deicit$ %!ic! t!ere s!ouldn0t *e

"o% do you %ant to treat t!is=

Carama>epine AtegretolB !as *een used since t!e 1+0s& T!e eectiveness%as *ased on uncontrolled studies& T!ere is a !ig! rate o spontaneousremission in t!is condition&


3/20

:re t!ere ot!er treatments or t!is condition=

P!enytoin$ *acloen$ valproate sodium$ lamotrigine$ ga*apentin !ave all *eentried *ut no s!o%n to *e more eective t!an car*ama>epine

edication inEections F Cryot!erpy to a*late t!e nerve *ut recurrence iscommon and main complication is acial anest!esia

Destruction o t!e trigeminal ganglion *y percutaneous procedures- many ris)s

9pen surgical management decompression o t!e nerve %it! or %it!out partiala*lation 4+ 5 eective

Disc!arge %it! a %ee)s %ort! o carma*a>epine A1++mg *idB and pain

medication& "ave patient ollo% up %it! neurologist&


4/20

Trigeminal nerve ganglion and *ranc!es
http://upload.wikimedia.org/wikipedia/commons/9/99/Gray778_Trigeminal.png


5/20

Case #3 Sc!%annoma

Patient 24-year-old emale complains o ringing in t!e let ear %it! decreased!earing %!ic! *egan a*out 5 %ee)s ago&

"istory - S!e !as noticed mild let-sided intermittent !eadac!es recently %it!ullness in t!e let ear or t!e last 3 years *ut s!e didn0t t!in) muc! o it until s!elost !er !earing& S!e denies trauma$ ever$ acial paralysis$ vertigo$

S 1344 43 12 4& degrees

P"/6edical llnesses deniesedications occasional acetaminop!enSurgery appendectomy as a c!ild

Social

To*acco 1 ppd per day or many years,T9" occasionallyD9: denies

P!ysical6",,NT :TNC$ P,8;$ sclera anicteric$ T0s clear$ decreased !earing

let ear A can *e c!ec)ed %it! a tuning or) or a %atc! A!ard to do %it! a digital%atc! or any sound made on eac! side testing *ot! earsB$ no drg rom nose$mucous mem*ranes moist$ p!aryn/ clear$ opens and closes mout! easily$ teet!aligned$ no tenderness over t!e teet! %!en percussed %it! tongue *lade$ notenderness over t!e T.$ no tenderness over t!e temporal artery

Nec) nec) is supple$ no masses$ no t!yroidomegaly$ no *ruits$ nolymp!adenopat!yNeuro totally intactS)in no ras!es


ery e% diseases cause asymmetrical sensorineural !earing loss

esti*ular sc!%annomaeniere0s disease A alt!oug! t!e tinnitus is usually intermittent and t!ese patients!ave true vertigoBeningioma usually causes acial palsy or trigenimal nerve a*normality


6/20

:udiogram Aa*out 15 o patients %ill !ave normal audiograms and t!ereores!ould !ave t!e ollo%ing test even i t!eir audiogram is normalB

Gadolinium-en!anced 8 Sc!%anomas are very small and gro% very slo%ly&CT does not !ave t!e necessary sensitivity to ind t!e small lesions&

:symmetrical sensorineural !earing lossHnilateral tinnitus continousm*alance"eadac!e@ullness in t!e ear9talgia

@acial nerve %ea)ness

@emales:verage age6 2 54 years

2 years

Surgical removalStereotactic radiation a*lation

S!ould you do t!e 8 emergently=

Pro*a*ly don0t need to since it is a slo% gro%ing tumor

T!en !o% s!ould t!is patient *e !andled=

Disc!arge$ no meds@ollo% up %it! otolaryngology or neurosurgery or audiogram and 8 pro*a*lycould tal) to t!em *eore disc!arge and arrange or t!e 8 *eore *eingevaluated&


7/20

Case #( 8amsay "unt

Patient 57-year-old male complains o let-sided acial %ea)ness$ %!ic! %aspresent %!en !e a%o)e t!is :&

"istory - Patient !ad a *urning type pain in t!e let ear or 3 days or %!ic! !etoo) acetaminop!en %it! some relie& "e noticed a e% small vesicles and i !e*ro)e t!em$ t!ere %as clear luid&

edications !ydroc!olorot!ia>ide$ enalaprilSurgery !ernia repairSocial

To*acco denies,T9" occasionallyD9: denies

P!ysical6",,NT :TNC$ P,8;$ sclera anicteric$ rig!t T clear$ small clear

colored vesicles on t!e pinna o t!e let ear$ auditory canal and tympanicmem*rane Asee picB$ no drainage rom nose$ mucous mem*ranes moist$ p!aryn/

clear$ drooping o t!e let side o t!e ace$ una*le to raise let eye*ro%$ teet!aligned$ no tenderness over t!e temporal arteryNec) nec) is supple$ no masses$ no t!yroidomegaly$ no *ruits$ no

lymp!adenopat!yNeuro intact e/cept or acial %ea)nessS)in no ras!es


'ell0s Palsy$ etiology is 8amsay-"unt Syndrome


8/20

:ntiviral alt!oug! controversial alacyclovir 1+++ mg *id or 1+ days or amiciclovir *ecause *ot! !ave *etter a*sorption t!an acyclovir& Start %it!in 1%ee) o symptoms&


9/20


10/20


11/20


12/20

Case #2 9ptic Neuritis ultiple Sclerosis

Patient 34-year-old emale complains o *lurred vision and pain in t!e rig!t eye

"istory - Patient *e!ind t!e rig!t eye %it! *lurred vision& T!e pain *egan 3 (

days prior to admission and progressively *ecame %orse& T!e pain is dull innature$ constant and does not radiate& Today s!e noted t!at s!e could not seeclearly out o t!e rig!t eye& S!e denies trauma$ ever$ !eadac!e$ vomiting$ ever$cold symptoms$ nec) pain$ c!est pain$ coug!$ s!ortness o *reat!$ a*dominalpain$ vomiting$ dysp!agia$ dysp!asia$ ot!er ocal neuro deicits&

S 1172 7( 12 4&4 degreesisual acuities let eye 3+3+ and rig!t eye 3+5+

P"/6edical llnesses denies

edications i*uproenSurgery removal o cyst on t!e ovarySocial

To*acco denies,T9" sociallyD9: denies

P!ysical6" :TNC, - Pupillary lig!t reaction is decreased in t!e rig!t eye and a relative

aerent pupillary deect A8:PDB$ %!en loo)ing a red card s!e states t!at it is

am*er$ undal e/am see pic Apale optic dis)B& A"ave t!em demonstrate !o% toc!ec) aerent pupil response %it! t!e s%inging las!lig!t test&


13/20

'ranc! 8etinal :rtery 9cclusion Central 8etinal :rtery 9cclusion

Glaucoma$ :ngle Closure$ :cute

"erpes Simple/

eningioma$ 9ptic Nerve S!eat!

9cular aniestations o Syp!ilis

9ptic Neuropat!y$ :nterior sc!emic

9ptic Neuropat!y$ Compressive

Sarcoidosis Sudden isual ;oss

T!yroid 9p!t!almopat!y

To/icNutritional 9ptic Neuropat!y

C'C

eryt!rocyte sedimentation rate

t!yroid unction tests

8 not speciically designated to *e done emergently *ut it does give t!ediagnosis& Hsually %ould spea) to a neurologist and as) a*out doing t!e 8&See t!e picture&

C'C is normal$ ,S8 75$ TS" and T2 are normal

9t!er tests not done in t!e ,D - antinuclear anti*odies$ angiotensin-convertingen>yme$ rapid plasma reagin$ and mitoc!ondrial DN: mutation$ CS@ evaluation$among ot!er tests

9ptic neuritis&

9ptic neuritis


14/20

mpaired color vision$ dysc!romatopsia$ is al%ays present in optic neuritis$c!aracteri>ed *y a reduced vividness o saturated colors& n color terminology$

Saturation reers to t!e purity o color$ and desaturation is t!e degree to %!ic! acolor is mi/ed %it! %!ite& Some patients s!o%n a red target c!aracteri>e t!esensation Ks dar)er$ i&e& red is s!ited to%ard am*er$ %!ereas ot!ers say t!ecolor is *leac!ed or lig!ter$ i&e& red is s!ited to%ards orange& n t!e a*sence o amacular lesion$ color desaturation is a !ig!ly sensitive indicator o optic nervedisease&

9nly 1(

:utoimmune disease$ pat!logical T cells caused to activate *y a trigger& nitiatesan inlammatory response Avery comple/B demyelinates t!e nerves&

"o% do you %ant to treat t!is patient=

T!e 9ptic Neuritis Treatment Trial A9NTTB %as a careully perormed randomi>edclinical trial and yielded useul inormation& Despite t!e 9NTT$ t!e treatment o

optic neuritis A9NB remains some%!at controversial&

L(7$ (4M

@rom a visionstandpoint$ o*servation %it!out steroid treatment versus intravenous steroidtreatment s!o%ed no dierence in ultimate visual outcome at t!e 5-year mar)& L(M

T!e 9NTT s!o%ed strong evidence against t!e use o oral steroids in isolation int!e treatment o 9N$ *ecause oral steroids alone caused an increased rate orecurrence o 9N&L2+M ntravenous steroids Amet!ylprednisolone 35+ mg id or ( d%it! oral steroid taperB decreased t!e s!ort-term ris) o development o S inpatients %it! CNS %!ite matter plaues$ *ut !ad no long-term protective *eneitrom S& ntravenous steroids do little to aect t!e ultimate visual acuity inpatients %it! 9N$ *ut t!ey do speed t!e rate o recovery& Some cliniciansadvocate intravenous steroids in patients %it! severe visual loss or *ilateral

visual loss&

ntravenous steroids are sometimes administered in an outpatient setting or at!ome& :dmission to t!e !ospital is recommended or t!e duration o !ig!-doseintravenous steroid treatment *ecause o t!e potential ris) o serious adverseeects rom t!is treatment&


15/20

Patients %it! neuromyelitis optica AN9B oten respond to intravenousmet!ylprednisolone& Plasma e/c!ange !as *een used in patients %it! nosigniicant improvement %it! steroids&L21$ 23M


16/20


17/20

A case of acute optic neuritis. A. 1.5 Tesla, contrast-enhanced spin echo T1-

weighted, fat-suppressed coronal MRI through the orbits shows enlargement and

contrast enhancement of the left optic nerve in the retrobulbar portion arrow!. ".#oronal spin echo T1-weighted, fat-suppressed MRI of the same patient shows

enlargement and contrast enhancement of the nerve in a parasagittal obli$ue

section arrow!.


18/20

Case #5 D Cranial Nerve Palsy

Patient 57-year-old male complains o drooping o t!e rig!t eyelid %!ic! *egant!is morning

"istory - Patient states t!at !e *egan to !ave an ac!ing type pain in t!e rig!teye Alocated retro*ul*ar and supraor*italB& 9nset %as acute& S!ortly ater%ards$!e noticed dou*le vision and drooping o t!e let eyelid& "e denies recent coldsymptoms$ trauma$ ever$ ot!er ocal neurological deicits&

S 13473 72 13 4&2 degrees

P"/6edical llnesses !ypertension$ dia*etes A 35 yearsBedications !ydroc!olorot!ia>ide$ enalapril$ metormin$ glipi>ideSurgery denies

Social To*acco denies,T9" rarelyD9: denies

P!ysical6",,NT :TNC,ye - mild drooping o t!e rig!t eyelid$ can close eye$ P,8;$ no pupillary

deect$ ,9 una*le to move rig!t eye superiorly or medially$ i t!e eit!er eye iscovered$ t!en t!e diplopia diasappears$ t!e anterior c!am*er is normal dept!$sclera is noneryt!ematous$ undus is clear$ i pressures are c!ec)ed - 13

,NT Ts clear$ no drainage rom nares$ p!aryn/ clearNec) supple$ nontender$ no lymp!adenopat!y$ no t!yroidomegaly


TraumaTumorerte*ro*asilar isc!emia

:neurysmntracranial !emorr!ageDia*etic cranial mononeuropat!y diagnosis o e/clusion


19/20

C'C - normalC!emistry normal e/cept or *lood sugar %!ic! is 3478 Aeasiest test to eliminate all t!e ot!er etiologies ot!er%ise a plain

CT o t!e *rain ollo%ed *y a CT angiogram needs to *e perormedB

Can move eye inerioralaterally

Can not move t!e eye laterally&

"o% does dia*etes cause t!is mononeuropat!y=

s!cemia due to small vessel damage o t!e vessels to t!is cranial nerve&T!is e/plains t!e pain o t!e condition& T!e center o t!e nerve is aected moret!an t!e perip!ery& So %it! t!e oculomotor nerve$ t!e movement o t!e eye isaected *ut t!e pupillary response is preserved&

T!ere is no speciic treatment or t!is condition to reverse it& :ter t!e ot!eretiologies are ruled out$ t!an s!ould treatment is to relieve t!e symptoms& Treatt!e pain& NS:Ds are used to treat t!e pain& @ not enoug!$ t!en narcotics can*e given& A%!ile %aiting or t!e diagnostic tests$ NS:Ds s!ould not *e givenuntil ntracranial !emorr!age is ruled outB& To allo% t!e patient to see$ patc! t!eaected eye& 8emem*er$ t!e patient can not drive due to t!e patc!ing or t!edou*le vision$ not operate !eavy mac!inery$ or clim* in !ig! places& Hsually t!econdition resolves over ( to mont!s&


20/20

!ttp6emedicine&medscape&comarticle11423-overvie%

cranial nerve small group discussions 2014 (1)

Documents