Neuro with eyelid/facial abnml

Question 0

Parkinson’s

Answer 0

Apraxia of eyelid opening

Other findings on this patient’s history and exam suggest Parkinson disease including numerous square wave jerks and difficulty with balance and gait. Other neuro-ophthalmic features seen in Parkinson disease include convergence insufficiency, blepharospasm (which can occur along with and be difficulty to distinguish from apraxia of eyelid opening), dry eye, and decreased blink rate.

Question 1

Neurosarcoidosis

Answer 1

Neurosarcoidosis develops in a minority (5-10%) of sarcoid patients and frequently involves the facial nerve. Neuro-sarcoid also very commonly involves the optic nerve (cranial nerve 2) via a number of different mechanisms including papilledema due to meningeal infiltration around the brain OR optic nerve perineuritis related to optic nerve sheath infiltration OR optic nerve infiltration.

The combination of uveitis and facial nerve palsy should always raise concern for Lyme disease and sarcoidosis.

Question 2

psp

Answer 2

Progressive supranuclear palsy can appear similar to Parkinson disease (eyelid apraxia) but would be expected to affect vertical saccades as a predominate early feature of the disease.

Question 4

Apraxia of eyelid opening

Answer 4

Apraxia of eyelid opening associated with?
Shy Drager syndrome
Parkinson’s / Huntington’s disease (extra-pyramidal disease)
Progressive supranuclear palsy
Wilson’s disease

Si/Sx: when pt closes eyes, he can not re-open them easily. Patient struggles using frontalis contraction to open his eyelids. Once open, his superior eyelids are only slightly ptotic.

Question 5

Essential blepharospasm

Answer 5

Unclear etiology; ?bilateral basal ganglia
Absent during sleep

Treatment: Botox

Question 6

Blepharospasm w/ oral-facial grimacing?

Answer 6

Meige syndrome (oral-facial dystonia with chin thrusting, lip pursing, tongue movements)

Question 7

Hemifacial spasm

Answer 7

Unilateral CN7 root compression at CPA
Occurs during sleep
MRI to r/o ectatic vessel or CPA tumor
Treatment: Botox, Jannetta procedure*

*vessel is mobilized a sponge like material is placed between the nerve and the offending blood vessel

Question 8

Facial myokymia

Answer 8

unilateral CN7 nucleus
Facial muscle fasciculations
Glioma in children; MS in adults

Question 9

Lid myokymia

Answer 9

Unknown etiology/location

Question 10

Trigeminal Neuralgia

Answer 10

“Tic Doloureaux”
Compression of CN V root (superior cerebellar artery aneurysm or tumor)
Treatment: carbamazepine or surgery
(e.g. Janetta procedure)

Question 11

Ramsay Hunt syndrome

Answer 11

VZV infection of CN7
Mastoid / preauricular pain
Treatment: acyclovir + prednisone
Poor prognosis for recovery

Question 12

Melkersson-Rosenthal syndrome

Answer 12

Recurrent facial paralysis with facial swelling and lingua plicata (tongue furrowing)