Clinical Correlations- Exam 2 Flashcards
Scalp Laceration
- Loss of structural support
- Aponeurosis tone loss
- Profuse bleeding
- Staples used to close wound
Peri-Orbital Ecchymosis
(Scalp Infection)
- Infection spread via Emissary Veins causing Meningitis (inflammation of intracranial structures)
- Occipitofrontalis muscle inserts onto skin, allowing infection to enter eyelids and nose
Calvaria Fracture
Four types:
- Simple Linear (most common)
- Depressed
- Comminuted
- Basilar
Berry (Saccular) Aneurysm
Vessels are weakest at their branching points
- Berry aneurysm at the Posterior Cerebral Artery can impinge CN III and affect pupillary constriction
- Aneurysm may rupture causing a Subarachnoid bleed
Uncal Herniation
Epidural bleed increases intracranial pressure causing Uncus to be pushed through the Tentorium Cerebelli
-Affects CN III leading to a fixed, non-dilated pupil
Arnold-Chiari Malformation
Hernation of the Cerebellar Tonsil through the Foramen Magnum
- Caused by a neural tube development disorder (Spina Bifida)
- May cause Hydrocephalus by closing off the 4th Ventricle
Hydrocephalus
Excess CSF accumulation causing Ventricles to dilate
-Imbalance of reabsorption (or blockage) within the Ventricular system
Treated with a Ventriculoperitoneal Shunt to draw CSF out of Ventricles and into the abdomen
Papilledema
Swelling of CN II and the Optic Disc due to increased intracranial pressure from:
- Hydrocephalus
- Tumor
- Trauma
- Intracranial Hypertension
Symptoms:
-Headache, Vision Loss, Blindness
Treatment:
-Optic Nerve Sheath Fenestration
Middle Cerebral Artery (MCA) Stroke
-Most common stroke (approximately 50% of cases)
Complete MCA Syndrome:
Losing sensation/movement on the opposite side of the body from where the Brain was injured
- Contralateral hemiplegia (paralysis)
- Contralateral hemianesthesia (sensory)
Orbital Blowout Fracture
Anterior trauma to the Orbital Rim
-Involves Maxillary bone
Blowout occurs medially and inferiorly
-Causes Eye to drop down into maxillary sinus
Symptoms:
- Double vision
- Eye drooping
- Protruding eye
Glaucoma
Leading cause of blindness in the world
Causes:
- Obstruction to aqueous humor outflow
- Build up of fluid in anterior chamber increases pressure on the Eye and CN II
Symptoms:
- Blurry vision
- Severe eye pain
- Halo’s around the eyes
Can damage CN II and lead to permanent vision damage
H Test
Testing Individual Eye Muscles
Following movements of the examiners finger, the pupil is moved in H-patterns to test individual extraocular muscles and the integrity of their nerves
- Only the actions of the medial and lateral rectus are tested starting from the primary position
- Other muscles must be tested from an abducted or adducted position
Occulomotor Nerve Palsy
Injury to CN III
-Lateral Rectus and Superior Oblique unaffected, all other muscles are paralyzed
-Characterized by a dilated, non-reactive pupil that is fixed laterally (“Down and Out”)
Pupillary Light Reflex
Rapid contriction of the pupil due to light
-When light enters one eye, both pupils constrict
Pathway:
- CN II
- CN III
- Ciliary ganglia
- Short ciliary nerves
- Pupil constriction
Trochlear Nerve Lesion
Lesion of CN IV leads to paralysis of Superior Oblique causing the extorsion of the Eye
Symptoms:
- Vertical diplopia
- Weakened downward gaze
Treatment:
-Head tilted to opposite side of affected eye to compensate for extorsion
Abducent Nerve Lesion
A lesion to CN VI causes paralysis of the Lateral Rectus muscles
- Affected eye cannot move laterally
- Affected eye stays adducted at rest
Horner’s Syndrome
Interruption of the Cervical Sympathetic Trunk manifested by the absence of sympathetically stimulated functions on the same side of the face as the lesion (ipsilateral)
Can be caused by a Pancoast Tumor
-Tumor of the apex of the lung which compresses the Cervical Sympathetic Trunk
Symptoms:
- Miosis (constricted pupil)
- Ptosis (drooping eyelid)
- Annhydrosis (absence of sweating)
Inferior Alveolar Nerve Block
Anesthetizes:
- Mandibular nerve
- Skin/mucous membrane of the lower lip
- Labial alveolar mucosa and gingiva
- Skin of the chin
Dens Fracture
Fracture of the Dens and/or part of the C2 vertebral body
-Caused by hyperextension of the cervical spine with the head of C1 forced backwards
Common in:
- Elderly falls
- Traumatic accidents
Type 1: Fracture of only the apex of the Dens
Type 2: Fracture of the Dens where it meets the vertebral body
Type 3: Fracture of the Dens that extends into the vertebral body
Hangman’s Fracture
Bilateral fracture of the Pars Interarticularis of C2 with C2/C3 subluxation (misalignment)
- Hyperextension injury where the head is snapped upwards and backwards
- Severe subluxation can impinge the upper cerivcal spinal cord leading to injury
Congenital Torticollis
Damage to the Sternocleidomastoid during gestation that leads to fibrosis (shortening) of the muscle
-Head tilts towards (and face tilts away from) the affected side
Treatments:
- Gentle stretching
- Infant stimulation to encourage movement
- Torticollis collar
Erb’s Point (Cervical Plexus Block)
Site for regional anesthesia
-Located in the posterior triangle of the neck
Carotid Endarterectomy
Removal of atherosclerotic plaque from the Carotid Arteries (usually at bifurcation)
Nerves to protect during procedure:
- CN IX
- CN X (Superior Laryngeal Nerve branch)
- CN XI
- CN XII
Central Line Placement
Catheter placed into vein to administer medication/fluids or measure central venous pressure
Vein commonly used:
- Internal Jugular Vein
- Subclavian Vein
- Femoral Vein
-Precautions must be taken to not pierce the Common Carotid Artery
Retropharyngeal Abcess
Swelling of retropharyngeal space due to spread of upper respiratory/oral infection
Symptoms:
- Difficulty swallowing
- Difficulty breathing
Treatment:
- IV antibiotics
- Intubation
- Surgical abcess drainage
Thyroidectomy
Surigcal removal of part or all of the Thyroid gland
Hypothyroidism:
- Low energy
- Weight gain
- Feeling cold
Hypoparathyroidism:
-Low blood calcium leading to muscle spasms and tremors
Surgical complication:
-Injury to Recurrent Laryngeal Nerve leading to a monotone voice and trouble breathing
Tracheotomy
Incision between the 3rd and 4th Tracheal rings to establish a long-term airway
Risks:
-Dependant on the size/position of Thyroid and its vasculature
Cricothyrotomy
Incision through the Cricothyroid membrane to establish an emergency airway
CSF Rhinorrhea
Fracture to the Cribiform plate may damage CN I
-Since CN I is covered by meninges, damage to it will cause a leak of CSF into the nose
Clinical presentation:
-Blood from the patient’s nose will have a “halo” around it indicating the presence of CSF
Hypoglossal Nerve Lesion
Paralysis of the tongue muscles on the side of the lesion
- Deviation of protruded tongue towards the affected side
- “Lick you lesion”
Tongue will appear wrinkled and shrunken due to atrophy
A. Cingulate (Subfalcine) Herniation
Intracranial pressure pushes Cingulate Gyrus underneath the Falx Cerebri
-Can impinge both Anterior Cerebral Arteries causing an infarction
B. Uncal Herniation
Increased intracranial pressure pushes the Uncus through the Tentorial Notch
-Can impinge CN III and the Posterior Cerebral Artery
C. Central Herniation
Increased intracranial pressure pushes the Temporal lobe down through the Tentorial Notch
-Can obstruct the Cerebral Aqueduct and cause Hydrocephalus
Communicating Hydrocephalus
Issue with reabsorption at the Arachnoid Granulations
-CSF can flow through ventricles normally but cannot leave the skull
Non-Communicating (Obstructive) Hydrocephalus
Issue with a blockage of CSF
Corneal Reflex
Examiner tries to ellicit a blink by touching cotton to the Cornea
Afferent: Absence of reflex indicates a lesion to Nasociliary branch of CN V1
Efferent: Absence of reflex indicates a lesion to CN VII which innervates the Orbicularis Oculi
Trigeminal Neuralgia (Tic Douloureux)
Sensory disorder of the sensory root of CN V due to demyelination
Symptoms:
- Sudden attacks of excruciating, lightning-like jabs of facial pain
- Initiated by touching a trigger point or by eating
- Can be caused by pressure from an aberrant artery (artery pressing on Trigeminal ganglia)
- CN V2 most affected, then CN V3, and least affected is CN V1
Gag Reflex
Sensory (Afferent): CN XII
-General sensation to posterior 1/3 of the tongue, tonsils, oropharynx, soft palate
Motor (Efferent): CN X
-Triggers a reverse peristalsis to the central visceral tube, esophagus, stomach, and duodenum
Transmucosal Absorption
-Quick drug administration
- Nitroglycerin is a vasodilator
- Treatment for Angina Pectoris
-Thin mucosa allows drug to enter Deep Lingual Veins in less than one minute
Epistaxis (Nosebleeds)
Causes:
- Infection
- Hypertension
- Dry mucosal membrane
- Trauma to Kiesselbach area
Fracture of the Cribiform Plate
(Lesion to CN I)
- Anosmia (loss of smell)
- CSF rhinorrhea
Fracture involving Optic Canal
(Lesion to CN II)
-Loss of pupillary constriction
Pressure on optic pathway
(Lesion to CN II)
Visual field defect
Laceration or intercerebral clot in the Temporal, Parietal, or Occipital lobes of the Brain
(Lesion to CN II)
Visual field defects
Pressure from Uncal Herniation
(Lesion to CN III)
- Dilated pupils
- Ptosis
- Eyes turn “down and out”
- Pupillary reflex on side of lesion is lost
Fracture involving Cavernous Sinus
(Lesion to CN III)
- Dilated pupils
- Ptosis
- Eyes turn “down and out”
- Pupillary reflex on side of lesion is lost
Stretching of nerve during its course around the Brainstem
(Lesion to CN IV)
Inability to look down while affected eye is adducted
Fracture of the orbit
(Lesion to CN IV)
Inability to look down while the eye is adducted
Injury to Trigeminal branches in the roof of the Maxillary Sinus
(Lesion to CN V)
- Loss of pain and touch sensations
- Paresthesia
- Mandible deviation to side of lesion with gaping mouth
Pathological processes affecting the Trigeminal Ganglia
(Lesion to CN V)
- Loss of pain and touch sensations
- Paresthesia
- Mandible deviation to side of lesion with gaping mouth
Fracture involving Cavernous Sinus/Orbit
(Lesion of CN VI)
- Eye fails to move laterally
- Diplopia on lateral gaze
Laceration or contusion in Parotid region
(Lesion to CN VII)
Paralysis of facial muscles
Fracture of Temporal bone
(Lesion to CN VII)
- Paralysis of facial muscles
- Dry cornea
- Loss of taste
Intracranial hematoma
(Lesion to CN VII)
- Paralysis of facial muscles
- Forehead wrinkles because of loss of innervation to Frontalis muscle
Tumor of nerve
(Lesion to CN VIII)
- Tinnitus
- Progressive unilateral hearing loss
Brainstem lesion
(Lesion to CN IX)
- Loss of taste to posterior 2/3 of tongue
- Loss of palate sensation on affected side
Deep laceration of neck
(Lesion of CN IX)
- Loss of taste to posterior 2/3 of tongue
- Loss of palate sensation on affected side
Brainstem lesion
(Lesion to CN X)
- Sagging of soft palate
- Uvula deviation
- Paralysis of vocal cord (hoarse voice)
Deep laceration to the neck
(Lesion to CN X)
- Sagging of soft palate
- Uvula deviation
- Paralysis of vocal cord (hoarse voice)
Laceration of the neck
(Lesion to CN XI)
- Drooping of shoulder
- Paralysis of Sternocleidomastoid
- Paralysis of Trapezius
Basal Skull fractures
(Lesion to CN XII)
Protruded tongue deviates toward the affected side
