Cranial Nerve Palsies Flashcards by Ellie C

What can cause a cranial nerve palsy?

Tumours

Trauma

Ischaemia

Infections

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Clinical features of olfactory nerve palsy

Ansomia

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Test for olfactory nerve palsy

Identification of certain smells e.g. peppermint, coffee

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Aetiology of olfactory nerve palsy

Trauma to lateral and occipital regions

SOLs

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Aetiology of optic nerve palsy

Ischaemic optic neuropathy

Inflammation: MS, sarcoidosis, viral infections

Trauma

Tumours (e.g. optic nerve glioma, pituitary adenoma)

Raised ICP (e.g. hydrocephalus)

B12 deficiency

Drugs: sildenafil, amiodarone, ethambutol

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Clinical features of optic nerve palsy

Impaired vision

Complete transection → ipsilateral blindness and loss of direct pupillary reflex

Papilloedema (raised ICP)

Compression (e.g. tumour) → optic atrophy

Pituitary oedema → compression of optic chiasm → bitemporal hemianopia

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Test for optic nerve palsy

Visual field test

Visual acuity test

Fundoscopy (e.g. papillitis)

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Aetiology of oculomotor nerve palsy

Ischaemic stroke

Aneurysm of posterior communicating

Transtentorial herniation

Cavernous sinus thrombosis

Diabetic cranial mononeuropathy

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Clinical features of oculomotor nerve palsy

motor portion

Paralytic squint

Adduction weakness

Down-and-out gaze (exotropia + hypotropia)

Ptosis

Horizontal diplopia (worsens when head turned away from side of the lesion)

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Clinical features of oculomotor nerve palsy

sensory portion

Absence of pupillary reaction

Prominent motor dysfunction and sparing of pupil in ischaemic lesions due to vascular disease

Severely impaired pupillary reaction with relatively spared motor function in compression lesions

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Aetiology of trochlear nerve palsy

Microvascular damage (diabetes, hypertension, arteriosclerosis)

Cavernous sinus thrombosis

Trauma

Congenital fourth nerve palsy

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Clinical features of trochlear nerve palsy

Extorsion of the eye (inability to depress and abduct the eyeball simultaneously)

Diplopia

Mild hypertropia and excyclotorsion

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Aetiology of trigeminal nerve palsy

Tumour

Vascular compression

Oral surgery

Inflammation of the nerve

Cavernous sinus thrombosis

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Clinical features of trigeminal nerve palsy

Ophthalmic nerve (CNV1): absent corneal reflex, loss of sensation in ipsilateral forehead

Maxillary nerve (CNV2): loss of sensation in ipsilateral midface

Mandibular nerve (CNV3): anaesthesia of ipsilateral lower third of face and anterior 2/3s of tongue, paresis of muscles of mastication

Tenso tympani branch: hearing impairment

Trigeminal nerve nuclei: ipsilateral weakness of muscles of mastication and/or ipsilateral loss of sensation

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Aetiology of abducens nerve palsy

Trauma

Pseudomotor cerebri

Cavernous sinus thrombosis

Space-occupying lesion causing downward pressure (e.g. tumour)

Diabetic neuropathy

Congenital: Duane syndrome

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Clinical features of abducens nerve palsy

Horizontal diplopia worsens when looking at distant objects

Esotropia: medial deviation of affected eye at primary gaze

Inability to abduct eye (will rotate head to look at the side)

What is the most common ocular cranial nerve palsy?

Vestibulocochlear nerve palsy

Aetiology of vestibulocochlear nerve palsy

Bacterial meningitis (most common cranial nerve palsy)

Lyme disease

Tumour (e.g. acoustic neuroma, neurofibromatosis type 2)

Basilar skull fracture

Clinical features of vestibulocochlear nerve palsy

Sensorineural hearing loss

Vertigo

Horizontal nystgamus

Motion sickness

Tests for vestibulocochlear nerve palsy

Audiometry

Vestibular function - electronystagmography, rotation test

CT/MRI

Aetiology of glossopharyngeal nerve palsy

Idiopathic

Compression of nerve by a blood vessel

Clinical features of glossopharyngeal nerve palsy

Loss of gag reflex (afferent limb)

Loss of carotid sinus reflex

Sensory loss over soft palate, upper pharynx, and posterior third of tongue (inc. loss of taste)

Mild dysphagia

Glossopharyngeal neuralgia (throat and ear pain)

Test for glossopharyngeal nerve palsy

Diminished or absent gag response

Loss of taste in posterior third of the tongue

Aetiology of vagus nerve palsy

Trauma

Diabetes

Inflammation

Aortic aneurysms

Tumours

Surgery (e.g. recurrent nerve injury during thyroidectomy)

Clinical features of vagus nerve palsy

Flaccid paralysis and ipsilateral lowering of soft palate → nasal speech & deviation of uvula away from lesion Dysfunction of pharyngeal muscles → dysphagia, aspiration Loss of gag reflex (efferent limb) and/or cough reflex (afferent limb) Recurrent laryngeal nerve injury: Lesion of one nerve: unilateral vocal cord paralysis → dysphonia (hoarseness) Lesion to both nerves: bilateral vocal cord paralysis → aphonia and inspiratory stridor Gastroparesis Cardiovascular dysfunction e.g. tachycardia

Test for vagus nerve palsy

Diminished/absent gag and/or cough reflex Saying “ahhh” will cause uvula to deviate away from affected side Indirect laryngoscopy - vocal cord possibly in paramedian or intermediate position Water swallow tests - coughing, choking or dysphonia Increased resting heart rate Gastroparesis on endoscopy

Aetiology of accessory nerve palsy

Iatrogenic Most commonly from surgical resection of cervical lymph nodes

Clinical features of accessory nerve palsy

Paresis, atrophy and/or asymmetry of SCM Paresis, atrophy and/or asymmetry of the trapezius muscle → ipsilateral shoulder drooping and lateral winging scapula

Test for accessory nerve palsy

Possibly asymmetrical neckline Shrug shoulders → weakness during elevation of ipsilateral shoulder Turn head from side to side → weakness turning head towards contralateral side

Aetiology of hypoglossal nerve palsy

Tumours Trauma Dissection of internal carotid artery

Clinical features of hypoglossal nerve palsy

Atrophy Fasciculation of the tongue on the side of the lesion

Test for hypoglossal nerve palsy

Signs of unilateral lower motor neurone damage: tongue atrophy, fasciculations, asymmetry Tongue deviates to side of lesion due to weakness of ipsilateral muscles

What is Bell's palsy?

An acute, unilateral, idiopathic, facial nerve paralysis

Clinical features of Bell's palsy

LMN facial nerve palsy - forehead affected UMNL “spares” the upper face Post-auricular pain Altered taste Dry eyes Hyperacusis

Management of Bell's palsy

Oral prednisolone within 72hrs onset Eye care - artificial tears/lubricants

What is Horner's syndrome?

Ptosis and meiosis with or without anhydrosis

Aetiology of Horner's syndrome

Pancoast tumour (affecting sympathetic nerve supply) Stroke Carotid artery dissection