Medicine Neurology 2 Flashcards

Question

Migraine can be categorised into four main types:

Answer 1

* Migraine without aura * Migraine with aura * Silent migraine (migraine with aura but without a headache) * Hemiplegic migraine

Answer 2

* **Premonitory** or ****prodromal stage (can begin several days before the headache) * **Aura** (lasting up to 60 minutes) * **Headache** stage (lasts 4 to 72 hours) * **Resolution** stage (the headache may fade away or be relieved abruptly by vomiting or sleeping) * **Postdromal** or **recovery** phase

Answer 3

* Usually unilateral but can be bilateral * Moderate-severe intensity * Pounding or throbbing in nature * Photophobia (discomfort with lights) * Phonophobia (discomfort with loud noises) * Osmophobia (discomfort with strong smells) * Aura (visual changes) * Nausea and vomiting

Answer 4

* Sparks in the vision * Blurred vision * Lines across the vision * Loss of visual fields (e.g., scotoma)

Answer 5

**Sensation** changes may include tingling or numbness. **Language** symptoms include dysphasia (difficulty speaking).

Answer 6

The main feature of hemiplegic migraines is **hemiplegia** (unilateral limb weakness). Other symptoms may include **ataxia** (loss of coordination) and **impaired consciousness.**

Answer 7

autosomal dominant

Answer 8

stroke or TIA.

Answer 9

* Stress * Bright lights * Strong smells * Certain foods (e.g., chocolate, cheese and caffeine) * Dehydration * Menstruation * Disrupted sleep * Trauma

Answer 10

****Patients may develop strategies for managing symptoms, often retreating to a dark, quiet room and sleeping. Medical options for an acute attack are: * **NSAIDs** (e.g., ibuprofen or naproxen) * **Paracetamol** * **Triptans** (e.g., sumatriptan) * **Antiemetics** if vomiting occurs (e.g., metoclopramide or prochlorperazine) Opiates are **not** used to treat migraines and may make the condition worse.

Answer 11

Triptans are used to abort migraines when they start to develop. They are 5-HT receptor agonists (they bind to and stimulate serotonin receptors), specifically 5-HT1B and 5-HT1D.

Answer 12

Triptans (e.g., sumatriptan) are taken as soon as a migraine headache starts. They should halt the attack. If the attack resolves and then reoccurs, another dose can be taken. If it does not work the first time, another second dose should **not **be taken for the same attack

Answer 13

The main contraindications relate to risks associated with vasoconstriction, for example, **hypertension, coronary artery disease or previous stroke, TIA or myocardial infarction.**

Answer 14

* Propranolol (a non-selective beta blocker) * Amitriptyline (a tricyclic antidepressant) * Topiramate (teratogenic and very effective contraception is needed)

Answer 15

* Pizotifen * Candesartan * Sodium valproate * Monoclonal antibodies (e.g., erenumab and fremanezumab)

Answer 16

* Cognitive behavioural therapy * Mindfulness and meditation * Acupuncture * Vitamin B2 (riboflavin)

Answer 17

**Prophylactic triptans **(e.g., frovatriptan or zolmitriptan) are an option for menstrual migraines. Symptoms tend to occur two days before until three days after the start of menstruation. Regular triptans may be taken during this time.

Answer 18

Cluster headaches are severe and unbearable **unilateral** headaches, usually centred around the eye.

Answer 19

They are called cluster headaches as they come in clusters of attacks and then disappear for extended periods. For example, a patient may suffer 3-4 episodes a day for weeks or months, followed by a pain-free period lasting several years. Attacks last between 15 minutes and 3 hours.

Answer 20

A typical patient is a 30-50 year old male smoker. They may have triggers, such as alcohol, strong smells or exercise.

Answer 21

Cluster headaches cause severe pain. They are sometimes called “suicide headaches” due to their severity. Associated symptoms are typically unilateral: * Red, swollen and watering eye * Pupil constriction (miosis) * Eyelid drooping (ptosis) * Nasal discharge * Facial sweating

Answer 22

Triptans (e.g., subcutaneous or intranasal sumatriptan) High-flow 100% oxygen (may be kept at home)

Answer 23

**Verapamil** is the first line for prophylaxis (to prevent attacks).

Answer 24

* Occipital nerve block * Prednisolone (e.g., a short course to break the cycle during clusters) * Lithium

Answer 25

Encephalitis means inflammation of the brain. This can be the result of infective or non-infective causes. Non-infective causes are autoimmune, meaning antibodies are created that target brain tissue.

Answer 26

The most common viral cause is **herpes simplex virus (HSV)**. In children the most common cause is **herpes simple type 1 (HSV-1)** from cold sores. In neonates it is **herpes simplex type 2 (HSV-2)** from genital herpes, contracted during birth.

Answer 27

Other viral causes include **varicella zoster virus (VZV)** associated with **chickenpox, cytomegalovirus** associated with **immunodeficiency**, Epstein-Barr virus associated with **infectious mononucleosis, enterovirus, adenovirus and influenza virus**. It is important to ask about vaccinations, as the **polio, mumps, rubella and measles viruses** can cause encephalitis as well.

Answer 28

* Altered consciousness * Altered cognition * Unusual behaviour * Acute onset of focal neurological symptoms * Acute onset of focal seizures * Fever

Answer 29

* **Lumbar puncture**, sending cerebrospinal fluid for viral PCR testing * **CT scan** if a lumbar puncture is contraindicated * **MRI scan** after the lumbar puncture to visualise the brain in detail * **EEG recording** can be helpful in mild or ambiguous symptoms but is not always routinely required * **Swabs** of other areas can help establish the causative organism, such as throat and vesicle swabs * **HIV** testing is recommended in all patients with encephalitis **Contraindications** to a **lumbar puncture** include a GCS below 9, haemodynamically unstable, active seizures or post-ictal.

Answer 30

Intravenous antiviral medications are used to treat the suspected or confirmed underlying cause: * **Aciclovir** treats **herpes simplex virus (HSV)** and **varicella zoster virus (VZV)** * **Ganciclovir** treat **cytomegalovirus (CMV)** **Repeat lumbar puncture** is usually performed to ensure successful treatment prior to stopping antivirals **Aciclovir** is usually started empirically in suspected encephalitis until results are available. Other viral causes have no effective treatment and management is supportive. **Followup, support and rehabilitation** is required after encephalitis, with help managing the complications.

Answer 31

* Lasting fatigue and prolonged recovery * Change in personality or mood * Changes to memory and cognition * Learning disability * Headaches * Chronic pain * Movement disorders * Sensory disturbance * Seizures * Hormonal imbalance

Answer 32

Cauda equina syndrome is a **surgical emergency** where the nerve roots of the cauda equina at the bottom of the spine are compressed. It requires emergency decompression surgery to prevent permanent neurological dysfunction. However, even with immediate decompression, patients may still not regain full function.

Answer 33

* Sensation to the **lower limbs, perineum, bladder** and **rectum** * **Motor innervation** to the **lower limbs** and the **anal** and **urethral sphincters** * **Parasympathetic** innervation of the **bladder** and **rectum**

Answer 34

* Herniated disc (the most common cause) * Tumours, particularly metastasis * Spondylolisthesis (anterior displacement of a vertebra out of line with the one below) * Abscess (infection) * Trauma

Answer 35

* Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus) * Loss of sensation in the bladder and rectum (not knowing when they are full) * Urinary retention or incontinence * Faecal incontinence * Bilateral sciatica * Bilateral or severe motor weakness in the legs * Reduced anal tone on PR examination TOM TIP: A common way people ask about saddle anaesthesia when taking a history is to ask, **“does it feel normal when you wipe after opening your bowels?”**

Answer 36

* **Immediate hospital admission ** * **Emergency MRI scan** to confirm or exclude cauda equina syndrome * **Neurosurgical input** to consider **lumbar decompression surgery**

Answer 37

When a **metastatic lesion** compresses the **spinal cord** (before the end of the spinal cord and the start of the cauda equina), this is called **metastatic spinal cord compression (MSCC).** This is different to cauda equina, which specifically refers to compression of the cauda equina.

Answer 38

back pain and motor and sensory signs and symptoms. A key feature is back pain that is worse on coughing or straining.

Answer 39

MSCC is an **oncological emergency** and requires rapid imaging and management. There are specialist MSCC coordinators who should be involved early to coordinate the imaging and treatment of patients with MSCC.

Answer 40

* High dose dexamethasone (to reduce swelling in the tumour and relieve compression) * Analgesia * Surgery * Radiotherapy * Chemotherapy

Answer 41

Cauda equina presents with lower motor neuron signs (reduced tone and reduced reflexes). The nerves being compressed are lower motor neurons that have already exited the spinal cord. When the spinal cord is being compressed higher up by metastatic spinal cord compression, upper motor neuron signs (increased tone, brisk reflexes and upping plantar responses) will be seen

Answer 42

Benign essential tremor is a relatively common condition associated with older age. It is characterised by a **fine tremor** affecting all the **voluntary muscles**. It is most notable in the hands but can affect other areas, for example, causing a **head tremor, jaw tremor and vocal tremor.**

Answer 43

* Fine tremor (6-12 Hz) * Symmetrical * More prominent with voluntary movement * Worse when tired, stressed or after caffeine * Improved by alcohol * Absent during sleep

Answer 44

Parkinson’s disease Benign essential tremor Multiple sclerosis Huntington’s chorea Hyperthyroidism Fever Dopamine antagonists (e.g., antipsychotics)

Answer 45

There is no definitive treatment for benign essential tremor. The tremor is not harmful and does not require treatment if it is not causing functional or psychological problems. Medications that may improve symptoms are: * **Propranolol** (a non-selective beta blocker) * **Primidone **(a barbiturate anti-epileptic medication)

Answer 46

Motor neurone disease is a term that encompasses a variety of specific diseases affecting the motor nerves. Motor neurone disease is a progressive, eventually fatal condition where the motor neurones stop functioning.

Answer 47

There is no effect on the sensory neurones. Sensory symptoms suggest an alternate diagnosis.

Answer 48

Amyotrophic lateral sclerosis (ALS) is the most common and well-known type of motor neurone disease. Stephen Hawking had amyotrophic lateral sclerosis.

Answer 49

**Progressive bulbar palsy** is the second most common form of **motor neurone disease**. It primarily affects the muscles of talking and swallowing (**the bulbar muscles**).

Answer 50

Other types to be aware of are **progressive muscular atrophy and primary lateral sclerosis.**

Answer 51

Both Motor neurone disease involves a progressive degeneration of both the upper and lower motor neurones. The **sensory neurones** are spared.

Answer 52

Muscle wasting Reduced tone Fasciculations (twitches in the muscles) Reduced reflexes

Answer 53

Increased tone or spasticity Brisk reflexes Upgoing plantar reflex

Answer 54

The typical patient is a late middle-aged (e.g., 60) man, possibly with an affected relative. There is an insidious, progressive weakness of the muscles throughout the body, affecting the limbs, trunk, face and speech. The weakness is often first noticed in the upper limbs. There may be increased fatigue when exercising. They may complain of clumsiness, dropping things more often or tripping over. They can develop slurred speech (dysarthria).

Answer 55

The diagnosis needs to be made very carefully. It is based on the clinical presentation after excluding other conditions. It should only be made by a specialist when there is certainty. The diagnosis is often delayed, causing stress.

Answer 56

There are no effective treatments for halting or reversing the progression of the disease. **Riluzole** can slow the progression of the disease and extend survival by several months in ALS. **Non-invasive ventilation (NIV) **can be used to support breathing when the respiratory muscles weaken.

Answer 57

Patients with motor neurone disease tend to die of respiratory failure or pneumonia.

Answer 58

Huntington’s disease (also called Huntington’s chorea) is an autosomal dominant genetic condition that causes progressive neurological dysfunction. It is a trinucleotide repeat disorder involving a genetic mutation in the** HTT** gene on chromosome **4**, which codes for the huntingtin (HTT) protein.

Answer 59

* Fragile X syndrome * Spinocerebellar ataxia * Myotonic dystrophy * Friedrich ataxia

Answer 60

Huntington’s chorea displays something called genetic **anticipation**. Anticipation is a feature of **trinucleotide repeat disorders**, where successive generations have more **repeats** in the gene, resulting in: * Earlier age of onset * Increased severity of disease

Answer 61

Huntington’s chorea presents with an insidious, progressive worsening of symptoms. It typically begins with **cognitive, psychiatric or mood problems,** followed by the development of movement disorders: * Chorea (involuntary, random, irregular and abnormal body movements) * Dystonia (abnormal muscle tone, leading to abnormal postures) * Rigidity (increased resistance to the passive movement of a joint) * Eye movement disorders * Dysarthria (speech difficulties) * Dysphagia (swallowing difficulties)

Answer 62

Diagnosis is made by genetic testing via a specialist g**enetic centre** and involves pre and post-test counselling. There are currently no treatment options for slowing or stopping the progression of the disease

Answer 63

Huntington’s chorea is a progressive condition. Life expectance is around 10-20 years after the onset of symptoms. As the disease progresses, patients become more frail and susceptible to illness (e.g., infections, weight loss, falls and pressure ulcers). Death is often due to **aspiration pneumonia**. Suicide is also a common cause of death

Answer 64

Myasthenia gravis is an **autoimmune** condition affecting the **neuromuscular junction**. It causes **muscle weakness** that **progressively worsens with activity** and **improves with rest. **

Answer 65

Myasthenia gravis affects men and women at different ages, typically affecting women under **40** and men over **60.**

Answer 66

There is a strong link with **thymomas** (thymus gland tumours). 10-20% of patients with myasthenia gravis have a **thymoma**. 30% of patients with a **thymoma** develop myasthenia grav

Answer 67

**Acetylcholine receptor (AChR)** antibodies are found in most patients with myasthenia gravis. These antibodies bind to the **postsynaptic acetylcholine receptors**, blocking them and preventing stimulation by acetylcholine. The more the receptors are used during muscle activity, the more they become blocked. There is less effective stimulation of the muscle with increased activity. With rest, the receptors are cleared, and the symptoms improve.

Answer 68

* Muscle-specific kinase (MuSK) antibodies * Low-density lipoprotein receptor-related protein 4 (LRP4) antibodies

Answer 69

MuSK and LRP4 are important proteins for the creation and organisation of the** acetylcholine receptor.** Destruction of these proteins leads to inadequate **acetylcholine receptors.**

Answer 70

The symptoms most affect the proximal muscles of the limbs and small muscles of the head and neck, with: * Difficulty climbing stairs, standing from a seat or raising their hands above their head * Extraocular muscle weakness, causing double vision (diplopia) * Eyelid weakness, causing drooping of the eyelids (ptosis) * Weakness in facial movements * Difficulty with swallowing * Fatigue in the jaw when chewing * Slurred speech

Answer 71

* Checking for a thymectomy scar * Testing the forced vital capacity (FVC)

Answer 72

Antibody tests look for: * AChR antibodies (around 85%) * MuSK antibodies (less than 10%) * LRP4 antibodies (less than 5%) A **CT** or **MRI** of the thymus gland is used to look for a thymoma. The **edrophonium test** can be helpful where there is doubt about the diagnosis.

Answer 73

Patients are given intravenous **edrophonium chloride** (or neostigmine). Normally, **cholinesterase enzymes** in the **neuromuscular junction** break down **acetylcholine**. Edrophonium blocks these enzymes, reducing the breakdown of acetylcholine. As a result, the level of acetylcholine at the neuromuscular junction rises, temporarily relieving the weakness. A positive result suggests a diagnosis of myasthenia gravis.

Answer 74

* **Pyridostigmine** is a cholinesterase inhibitor that prolongs the action of acetylcholine and improves symptoms * **Immunosuppression** (e.g., prednisolone or azathioprine) suppresses the production of antibodies * **Thymectomy** can improve symptoms, even in patients without a thymoma * **Rituximab** (a monoclonal antibody against B cells) is considered where other treatments fail

Answer 75

Myasthenic crisis is a potentially life-threatening complication of myasthenia gravis. It causes an acute worsening of symptoms, often triggered by another illness, such as a respiratory tract infection. Respiratory muscle weakness can lead to respiratory failure. Patients may require **non-invasive ventilation** or **mechanical ventilation**. Treatment is with **IV immunoglobulins **and **plasmapheresis.**

Answer 76

Lambert-Eaton myasthenic syndrome is an **autoimmune** condition affecting the **neuromuscular junction**, similar to **myasthenia gravis**. The symptoms tend to be more insidious and less pronounced than myasthenia gravis. In most cases, it is a **paraneoplastic syndrome** occurring alongside **small-cell lung cancer (SCLC)**. It can occur as a primary autoimmune disorder without the presence of SCLC.

Answer 77

**Lambert-Eaton myasthenic syndrome** results from antibodies against **voltage-gated calcium channels.** These antibodies may be produced in response to **small-cell lung cancer (SCLC) **cells that express **voltage-gated calcium channels**. They target and damage voltage-gated calcium channels in the **presynaptic membrane** of the **neuromuscular junction**. **Voltage-gated calcium channels **are responsible for assisting in the release of **acetylcholine** into the **synapse** of the **neuromuscular junction**. Acetylcholine travels across the **synapse** and attaches to **receptors** on the **postsynaptic membrane**, simulating **muscle contraction**. When the **voltage-gated calcium channels** are destroyed, less acetylcholine is released into the synapse, resulting in a weaker signal and reduced muscle contraction.

Answer 78

The key presenting features are: * **Proximal muscle weakness,** causing difficulty climbing stairs, standing from a seat or raising the arms overhead * **Autonomic dysfunction**, causing dry mouth, blurred vision, impotence and dizziness * **Reduced or absent tendon reflexes** Signs and symptoms improve after periods of muscle contraction, which is the reverse of what is seen in myasthenia gravis. Reflexes may be absent in a rested patient but be present when testing immediately after the patient maximally contracts the associated muscles. Equally, muscle strength may improve after use.

Answer 79

Excluding underlying malignancy (e.g., small-cell lung cancer) is essential. **Amifampridine** works by blocking v**oltage-gated potassium channels** in the **presynaptic membrane**, which in turn prolongs the depolarisation of the cell membrane and assists calcium channels in carrying out their action. Other options include: * Pyridostigmine (cholinesterase inhibitor) * Immunosuppressants (e.g., prednisolone or azathioprine) * IV immunoglobulins * Plasmapheresis

Answer 80

Charcot-Marie-Tooth disease is an **inherited disease** that affects the peripheral motor and **sensory neurones.** It is also known as **hereditary motor and sensory neuropathy**. There are various types, with different genetic mutations and pathophysiology, causing myelin or axon dysfunction. The majority of mutations are inherited in an **autosomal dominant** pattern. Symptoms usually start to appear before the age of 10 but can be delayed until 40 or later.

Answer 81

* High foot arches (pes cavus) * Distal muscle wasting causing “inverted champagne bottle legs” * Lower leg weakness, particularly loss of ankle dorsiflexion (with a high stepping gait due to foot drop) * Weakness in the hands * Reduced tendon reflexes * Reduced muscle tone * Peripheral sensory loss

Answer 82

Peripheral neuropathy refers to reduced sensory and motor function in the peripheral nerves, typically affecting the feet and hands (“stocking-glove” distribution). It is a characteristic feature of Charcot-Marie-Tooth.

Answer 83

A – Alcohol B – B12 deficiency C – Cancer (e.g., myeloma) and Chronic kidney disease D – Diabetes and Drugs (e.g., isoniazid, amiodarone, leflunomide and cisplatin) E – Every vasculitis A common OSCE scenario is to examine a patient with peripheral neuropathy. Charcot-Marie-Tooth is a relatively common condition with good signs and stable patients, making it popular in OSCEs. Look for the other features of the condition, suggest the diagnosis, and then run through the ABCDE mnemonic to indicate the other possible causes of peripheral neuropathy.

Answer 84

There is no cure or treatment to prevent it from progressing. Management is supportive, with input from various members of the multidisciplinary team: * **Neurologists** and geneticists to make the diagnosis * **Physiotherapists** to maintain muscle strength and joint range of motion * **Occupational therapists** to assist with activities of living * **Podiatrists** to help with foot symptoms and suggest insoles and other orthoses to improve symptoms * **Analgesia** for neuropathic pain (e.g., amitriptyline) * Orthopaedic surgeons for severe joint deformities

Answer 85

Neurofibromatosis is a genetic condition that causes nerve tumours (neuromas) to develop throughout the nervous system. These tumours are benign but can cause neurological and structural problems.

Answer 86

Neurofibromatosis type 1 is more common than neurofibromatosis type 2

Answer 87

The neurofibromatosis type 1 gene is found on chromosome **17**. It codes for a protein called neurofibromin, which is a **tumour suppressor protein**. Mutations in this gene are inherited in an autosomal dominant pattern.

Answer 88

C – Café-au-lait spots (more than 15mm diameter is significant in adults) R – Relative with NF1 A – Axillary or inguinal freckling BB – Bony dysplasia, such as Bowing of a long bone or sphenoid wing dysplasia I – Iris hamartomas (Lisch nodules), which are yellow-brown spots on the iris N – Neurofibromas G – Glioma of the optic pathway

Answer 89

Neurofibromas may be seen on the skin. They are skin-coloured, raised nodules or papules with a smooth, regular surface. A single skin neurofibroma without other features does not indicate neurofibromatosis. **Two or more** are significant. A **plexiform neurofibroma** is a larger, irregular, complex neurofibroma containing multiple cell types. A single plexiform neurofibroma is significant.

Answer 90

Diagnosis is based on the diagnostic criteria. Genetic testing can be helpful. There is no treatment for the underlying disease process. Management involves monitoring, managing symptoms and treating complications.

Answer 91

* Migraines * Epilepsy * Renal artery stenosis, causing hypertension * Learning disability * Behavioural problems (e.g., ADHD) * Scoliosis of the spine * Vision loss (secondary to optic nerve gliomas) * Malignant peripheral nerve sheath tumours * Gastrointestinal stromal tumour (a type of sarcoma) * Brain tumours * Spinal cord tumours with associated neurology (e.g., paraplegia) * Increased risk of cancer (e.g., breast cancer and leukaemia) **TOM TIP:** The two unique complications worth remembering for NF1 are malignant peripheral nerve sheath (MPNST) and gastrointestinal stromal tumours (GIST).

Answer 92

The neurofibromatosis type 2 gene is found on chromosome **22**. It codes for a protein called merlin, a **tumour suppressor protein **important in Schwann cells. Schwann cells provide the myelin sheath that surrounds neurones of the peripheral nervous system. Mutations in this gene lead to **schwannomas** (benign tumours of the Schwann cells). Inheritance is also autosomal dominant.

Answer 93

Neurofibromatosis type 2 is particularly associated with **acoustic neuromas,** which are tumours of the auditory nerve that innervates the inner ear.

Answer 94

neurofibromatosis type 2

Answer 95

Facial nerve palsy refers to isolated dysfunction of the facial nerve and presents with unilateral facial weakness.

Answer 96

The facial nerve exits the brainstem at the **cerebellopontine** angle. On its journey to the face, it passes through the **temporal** bone and **parotid **gland.

Answer 97

It then divides into five branches: Temporal Zygomatic Buccal Marginal mandibular Cervical

Answer 98

* Facial expression * Stapedius in the inner ear * Posterior digastric, stylohyoid and platysma muscles

Answer 99

taste from the anterior 2/3 of the tongue.

Answer 100

* Submandibular and sublingual salivary glands * Lacrimal gland (stimulating tear production)

Answer 101

Patients with new-onset **upper** motor neurone facial nerve palsy need immediate management as a possible stroke. In contrast, patients with **lower** motor neurone facial nerve palsy can be managed less urgently.

Answer 102

Each side of the forehead has **upper motor neurone** innervation by both sides of the brain. However, each side of the forehead only has **lower motor neurone** innervation from one side of the brain.

Answer 103

Each side of the forehead has **upper** motor neurone innervation by both sides of the brain. However, each side of the forehead only has **lower** motor neurone innervation from one side of the brain.

Answer 104

Cerebrovascular accidents (strokes) Tumours

Answer 105

Pseudobulbar palsies Motor neurone disease

Answer 106

Bell’s palsy is a relatively common condition. It is idiopathic, meaning there is no apparent cause. It presents with a unilateral lower motor neurone facial nerve palsy. Most patients fully recover over several weeks, but recovery may take up to 12 months. A third are left with some residual weakness.

Answer 107

If patients present within 72 hours of developing symptoms, NICE clinical knowledge summaries (updated 2023) recommend considering prednisolone as treatment, either: * 50mg for 10 days * 60mg for 5 days followed by a 5-day reducing regime, dropping the dose by 10mg per day Patients also require **lubricating eye drops **to prevent the eye from drying out and being damaged. If they develop pain in the eye, they need an ophthalmology review for exposure keratopathy. The eye can be taped closed at night.

Answer 108

varicella zoster virus (VZV)

Answer 109

unilateral lower motor neurone facial nerve palsy.

Answer 110

Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior two-thirds of the tongue and hard palate.

Answer 111

Treatment is with aciclovir and prednisolone. Patients also require lubricating eye drops.

Answer 112

Otitis media Otitis externa HIV Lyme disease

Answer 113

* Diabetes * Sarcoidosis * Leukaemia * Multiple sclerosis * Guillain–Barré

Answer 114

Acoustic neuroma Parotid tumour Cholesteatoma

Answer 115

Direct nerve trauma Surgery Base of skull fractures