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P2 Head, Neck and Neuro > Schwannoma, ear and cranial nerves > Flashcards

Schwannoma, ear and cranial nerves Flashcards

1
Q

Define the term tinnitus.

A

Perception of sounds in the absense of external auditory stimulus

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2
Q

What three things cause tinnitus.

A
  1. Hearing loss
  2. Sounds produced by adjacent structures
  3. Other disease processes
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3
Q

What sounds can be produced by tinnitus

A
  • Ringing of the ears
  • Hissing
  • Roaring
  • Buzzing
  • Humming sound
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4
Q

Which two ways can tinnitus be defined?

A
  • Objective tinnitus
  • Subjective tinnitus
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5
Q

What is objective tinnitus?

A

Sound is potentially detectable by another observer

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6
Q

What are the causes of objective tinnitus?

A

Vascular abnormalities or neuromuscular disorders- sounds generated by turbulent blood flow conducted into auditory system - pulsatile

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7
Q

What is subjective tinnitus

A

Noise perception when there is no noise stimulation in the cochlear

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8
Q

What can cause transient tinnitus in normal people?

A
  • Aspirin
  • Nicotine
  • Coffee
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9
Q

What is the suggested pathophysiology of tinnitus?

A
  • Abnormal firing of auditory receptors
  • Dysfunction of cochlear neurotransmitters function or ionic balance
  • Alterations in central processing of the signal
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10
Q

Define vertigo.

A

Illusion of motion associated with disorders of vestibular function

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11
Q

Define objective and subjective vertigo?

A

Objective - person is in motion and environment is stationary Subjective - person is stationary and environment is in motion

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12
Q

What are some differential diagnoses of vertigo?

A
  • Light-headedness
  • Syncope
  • Faintness
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13
Q

Vertigo can be caused by peripheral and central vestibular problems, what is the difference between them?

A
  • Peripheral - severe in intensity, and episodic
  • Central - mild and consistent
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14
Q

Describe motion sickness.

A

Normal physiological vertigo caused by repeated rhythmical stimulation of vestibular system

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15
Q

Symptoms of motion sickness

A

Vertigo

Malaise

Nausea

Vomiting

Autonomic symptoms: lowered BP, tachycardia, sweating

Hyperventilation - can causes pooling of blood in lower extremities

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16
Q

What is the pathology of Ménière’s disease?

A

Excessive accumulation of endolymph in the membranous labyrinth - increases with the distention of the scala media until the membrane ruptures Cochlear organs degenerate

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17
Q

What is the ‘triad’ of Ménière’s disease?

A
  • Vertigo
  • Tinnitus
  • Hearing loss
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18
Q

What are the suggested mechanisms that may cause Ménière’s disease?

A
  • Increased endolymph production
  • Decreased production of perilymph accompanied by a compensatory increase in endolymph sac
  • Decreased endolymph absorption- caused by malfunction of endolymph sac or blockage of endolymphatic pathways
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19
Q

Name five things which are thought to cause Ménière’s disease.

A
  • Viral and bacterial agents - syphilis
  • Trauma
  • Immunological - Allergies
  • Metabolic derangements
  • Vascular disorders
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20
Q

What is Ménière’s disease characterized by?

A

Fluctuating episodes of tinnitus, feeling of ear fullness, violent rotatory vertigo

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21
Q

What happens to hearing loss as Ménière’s progresses?

A

Stops fluctuating and progressively worsens

Both ears become affected

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22
Q

What happens to the vertigo as the Ménière’s progresses?

A

Episodes of vertigo diminish and disappear although the person may be unsteady

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23
Q

List the differential diagnoses of Ménière’s disease

A

ENT causes

  • acoustic neuroma
  • otitis media
  • earwax
  • too toxic drugs

Intracranial pathology

  • vertebrobasilar insufficiency
  • tumours
  • migraine

Systemic illness

  • Anaemia
  • hypothyroidism
  • DM
  • autoimmune disease
  • syphilis
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24
Q

What is a schwanomma of the vestibulocochlear nerve?

A

Benign Schwann cell tumour affecting CN VIII

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25
Q

How does a schwanomma cause unilateral sensorineural hearing loss?

A

Compresses the cochlear nerve, interferes with the blood supply to the nerve and cochlear

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26
Q

What genetic problem is thought to cause tumour growth in schwannoma?

A

Tumour suppressor gene abnormality on chromosome p22 (schwanomma protein)

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27
Q

How do patients with a schwannoma present?

A

Decreased hearing Episodes of vertigo

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28
Q

What does unilateral hearing loss do to your hearing?

A

Leaves you unable to localise sound

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29
Q

Which other nerves are likely to become affected if the tumour grows too big - and what problems will that cause?

A

Facial nerve

  • nystagmus
  • slowed blink
  • altered taste
  • altered tearing

Trigeminal - facial numbness

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30
Q

What is the differential diagnosis for a schwannoma?

A
  • Meningioma
  • Epidermoid
  • Facial nerve schwannoma
  • Trigeminal schwannoma
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31
Q

Where does the vestibulocochlear nerve arise?

A

Vestibular nuclei

  1. superior and lateral
  2. medial and inferior

Cochlear nuclei (auditory component) - dorsal-lateral medulla

  1. posterior
  2. anterior
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32
Q

Where does the vestibulocochlear nerve leave the cranium?

A

Through the internal acoustic meatus

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33
Q

Where do the two parts of the vestibulocochlear merge when travelling back to the brain?

A

Inside the petrous part of the temporal bone

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34
Q

What does the vestibular nerve (vestibular ganglion) supply?

A
  • Three semi-circular ducts
  • Utricle
  • Saccule
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35
Q

How does the cochlear nerve innervate the cochlear?

A

Enters the base of the cochlear and passes up through the modiolus - branches pass through lamina of modiolus to innervate receptors on spiral organ

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36
Q

Describe what a neoplasm is

A

Abnormal mass of tissue with uncoordinated growth - growth persists excessively after cessation of the initial stimuli

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37
Q

Describe the growth pattern of a benign tumour.

A
  • Expansive
  • Capsule
  • Localised
  • Slow
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38
Q

Describe the growth pattern of a malignant tumour.

A
  • Infiltrative
  • No capsule
  • Metastasis
  • Rapid
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39
Q

What effects can a slowly enlarging space occupying lesion have on the brain or spine

A

Atrophy of adjacent brain or spinal tissue

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40
Q

What effects can a rapidly enlarging space occupying lesion have on the brain or spine

A

Rise in pressure in affected compartment from the normal level of

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41
Q

What clinical signs can be seen when a space occupying lesion distorts the meninges and blood vessels?

A

Headache

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42
Q

What clinical signs can be seen when a space occupying lesion compresses the optic nerve

A

Papillodema

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43
Q

What clinical signs can be seen when a space occupying lesion distorts the medulla?

A

Vomiting

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44
Q

What clinical signs can be seen when a space occupying lesion compresses the occulomotor nerve

A

Pupillary constriction and then dilation

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45
Q

What clinical signs can be seen when a space occupying lesion causes traction of the abducens nerve?

A

Abducens palsy - false localising sign

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46
Q

What clinical signs can be seen when a space occupying lesion compresses the posterior cerebral artery?

A

Occipital infarction

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47
Q

What clinical signs can be seen when a space occupying lesion causes traction on brainstem arteries?

A

Fatal infarction of brainstem/heamorrhage

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48
Q

What are the two layers of the dura mater called?

A
  • Endocranial layer
  • Meningeal layer
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49
Q

Where is an intracranial venous sinus located?

A

In certain areas, the dura mater splits into its two layers to enclose venous channels

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50
Q

Where does venous drainage leave the skull?

A

Jugular foramen

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51
Q

What is the relation between the inferior sagittal sinus and the flax cerebri?

A

Located in the lower margin of the fall

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52
Q

Which two veins join to become the straight sinus - and where does this sinus run?

A
  • Inferior sagittal sinus and the great cerebral vein
  • Runs in the junction between the falx and the tentorium cerebelli
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53
Q

Which transverse sinus does the superior sagital sinus drain to?

A

Right

54
Q

Which transverse sinus does the inferior sagittal sinus drain to?

A

Left

55
Q

Which sinus does the internal carotid artery, the three nerves that supply the eye muscles and V1 + V3 branches of the trigeminal nerve pass?

A

Cavernous sinus

56
Q

How can schwannoma removal surgery cause other nerve problems?

A

Vestibulocochlear and facial nerve share a common cause through the internal auditory canal. This proximity means the facial nerve is easily damaged during surgery = facial palsy

57
Q

How does facial palsy present?

A
  • Weakness of muscles of facial expression and eye closure
  • Face sags
  • Face drawn to opposite side when smiling
  • Corneal and conjunctiva damage because the eye is open all the time
  • Mild dysarthria
  • Difficulty eating
58
Q

What can occur in very severe cases of facial palsy?

A

Loss of taste over anterior tongue Intolerance to high-pitched or loud noises

59
Q

How to distinguish between facial palsy and a lower motor neuron.

A

In lower motor neuron disease - Patient can’t wrinkle forehead because the final common pathway to the muscles is destroyed Lesion must be in pons or outside the brainstem

60
Q

How to distinguish between facial palsy and an upper motor neuron.

A

In upper motor neuron disease - upper facial muscle are partially spared (other pathways in brainstem) - appear to be different pathways for voluntary and emotional movement - face sagging is less obvious

61
Q

What is the treatment for Meniere’s disease?

A

Symptomatic relief - antiemetics, diuretics and anticholinergics Lifestyle changes: stop smoking, low-sodium diet, stress management, caffeine elimination Surgical: shunts to drain excess endolymph, removal of portion of vestibulocochlear nerve and destruction of the membraneous labyrinth

62
Q

What are the 2 branches of the Vestibulocochlear nerve and where do they form?

A

Vestibular branch Cochlear branch - within the acoustic meatus

63
Q

Where does the Vestibulocochlear nerve attaches to the brainstem?

A

At the cerebellopontine angle - most laterally of all the nerves

64
Q

Where do the secondary neurons of the vestibulocochlear nerve pass to?

A

Bilaterally to the midbrain, medial geniculate bodies and to the auditory cortex in the upper part of the temporal lobe

65
Q

What are the clinical features of Schwannoma?

A

Unilateral sensorineural hearing loss, intermittent dizziness and facial numbness Headaches, coordination difficulties, obstructive hydrocephalus May be life threathening

66
Q

Describe hydrocephalus

A

Accumulation of cerebrospinal fluid (CSF) within the brain. This typically causes increased pressure inside the skull.

67
Q

How can you test vestibulocochlear nerve?

A

Tuning fork tests and audiometry to distinguish between external and middle ear deafness and inner ear nerve deafness Others - electrical neurophysiological testing - Caloric test

68
Q

Describe the basis of the caloric test

A

Irrigating the external acoustic meatus with warm and cold water, convection currents affect the lateral semi-circular duct which provokes nystagmus (jerky eye movements), duration measured and compared to normal subject

69
Q

What is Bell’s palsy?

A

Unilateral lower motor lesion affecting face - forehead not wrinkled - eyeballs rolls up, eyelid does not close - flat nasolabial fold, paealysis of lower face

70
Q

What is the treatment of acoustic schwannoma and its symptoms??

A

Cerebreal oedema - managed with steroids, intravenous or oral dexamethasone Epilepsy - anticonvulsants Oral alkylating agents (chemo) - Vincristine, procarbazine and temozolomide Surgery - can be removed, but 10% mortality rate

71
Q

What is tarsorrpathy and when is it used?

A

Surgical procedure in which the eyelids are partially sewn together to narrow the eyelid opening - done to protect the eyes eyes, associated pain with them drying up

72
Q

Name the 4 stages of Schwannoma

A

Intracanalicular Cisternal Compressive Hydrocephalus

73
Q

What does the olfactory nerve do?

A

Sensory - sense of smell

74
Q

What does the optic nerve do?

A

Sensory - sight

75
Q

What does the occulomotor nerve do?

A

Motor - eyelid movement - eyeball movement (medial, superior and interior rectus and inferior oblique) - pupillary constriction - accommodation of lens for near vision

76
Q

What does the trochlear nerve do?

A

Motor- eyeball movement (superior oblique)

77
Q

What does the trigeminal nerve do?

A

Both sensory and motor - sensory to the face (opthalamic, maxillary and mandibular) - motor to the muscles of mastication (masseter, temporalis, pterygoids)

78
Q

What does the abducens nerve do?

A

Motor- movement of eyeball (lateral rectus)

79
Q

What does the facial nerve do?

A

Both - sensory to skin of external ear and anterior tongue - motor to muscles of facial expression and helps secrete saliva and tears

80
Q

What does the vestibulocochlear nerve do?

A

Sensory- hearing and equilibrium

81
Q

What does the glossopharyngeal nerve do?

A

Both sensory and motor - motor is for swallowing and speech and secretion of saliva - sensory: carotid body and sinus; tonsils, pharynx and taste for posterior tongue

82
Q

What does the vagus nerve do?

A

Both sensory and motor innervation - swallowing and speech - parasympathetic innervation

83
Q

What does the accessory nerve do?

A

Motor - sternocleidomastoid and trapezius -movement of head and shoulders

84
Q

What does the hypoglossal nerve do?

A

Motor- movements of the tongue

85
Q

What are the layers from skin to brain?

A

Skin Aponeurosis Periosteum Bone Meninges - dura, arachnoid an pia

86
Q

What are the layers of the bone of the skull?

A

Outer table - cortical compact bone, thick and tough Diploe - the spongy cancellous bone separating the inner and outer layers of the cortical bone Inner table - cortical bone, thin, dense and brittle

87
Q

What is a vault?

A

Something resembling arched dome

88
Q

What is Crista galli?

A

Upper part of the perpendicular plate of the ethmoid bone, which rises above the cribriform plate The falx cerebri attaches to the crista galli The olfactory bulbs of the olfactory nerve lie on either side of the crista galli on top of the cribriform plate

89
Q

What is the exit of the olfactory nerve?

A

Cribriform plate

90
Q

What is the exit of the optic nerve?

A

Optic canal

91
Q

What is the exit of the oculomot nerve?

A

Superior orbital fissue

92
Q

What is the exit of the trochlear nerve?

A

Superior orbital fissure

93
Q

What is the exit of the trigeminal nerve?

A

V1 Opthalmic - Superior orbital fissure V2 Maxillary - foramen rotundum V3 Mandibular - Foramen ovale

94
Q

What is the exit of the Abducens nerve?

A

Superior orbital fissure

95
Q

What is the exit of the facial nerve?

A

Internal Acoustic meatus

96
Q

What is the exit of the Vestibulocochlear nerve?

A

Internal acoustic meatus

97
Q

What is the exit of the glossopharyngeal nerve?

A

Jugular foramen

98
Q

What is the exit of the Vagus nerve?

A

Jugular foramen

99
Q

What is the exit of the Spinal Accessory nerve?

A

Jugular Foramen

100
Q

What is the exit of the Hypoglossal nerve?

A

Hypoglossal canal

101
Q

Which cranial nerves originate in forebrain?

A

Olfactory and optic

102
Q

Which cranial nerves originate in midbrain?

A

Oculomotor and trochlear

103
Q

Which cranial nerves originate in Pons?

A

Trigeminal, Abducens, Facial, Vestibulocochlear

104
Q

Which cranial nerves originate in Medulla?

A

Glossopharyngeal Vagus Spinal Accessory Hypoglossal

105
Q

Where does the olfactory nerve terminate?

A

In the olfactory sensory neurons embedded in the olfactory epithelium - upper part of the nasal cavity

106
Q

How do you test olfactory nerve?

A

Give odor samples to smell, test one nostril at a time Control test: ammonia - it is an irritant causing pain and can be still detected by the nasal mucosa

107
Q

Which nerve provides somatosensory innervation to the nasal cavity?

A

Trigeminal V1 and V2

108
Q

What are the signs that oculomotor is not functioning?

A

Ptosis Outward and slightly downward deviation of the eye Dilated and fixed pupil

109
Q

What are the signs that trochlear is not functioning?

A

Torsitional diplopia (double vision) Compensatory tilted head

110
Q

What are the signs that abducens is not functioning?

A

Reduced abduction Positioned medially

111
Q

How do you test eye movements?

A

Subject sits upright Hold head still with one hand Observe normal position and lack of spontaneous movements Eye movement: - moving object to be followed by eyes - H shape

112
Q

Whar are the 3 main divisions of the trigeminal nerve?

A

V1 - ophtalmic V2 - Maxillary V3 - Mandibular

113
Q

What are the branches of the trigeminal nerve that pass through the foramina of the fronta normalis?

A

Supra-orbital nerve Infra-orbital nerve Mental nerve

114
Q

How do you test trigeminal nerve?

A

Sensory innervation of skin: The skin areas in the 3 divisions with a piece of cotton Motor function: - clench teeth - open the mouth - jaw jerk reflex

115
Q

How do you test the facial nerve?

A

Motor function: - Raise eyebrows - frown -smile - puff out their cheeks Cornea reflex - wisp the cornea with sterile cotton

116
Q

Which large glands are innervated by the facial nerve?

A

Sublingual and Submandibular

117
Q

How do you test the vestibulocochlear nerve esp. hearing?

A

Whisper voice test - whisper postero laterally to the person starting at arms length - needs to repeast at least 3/6 numbers Audiometry

118
Q

What are the classic physiological tests of vestibulocochlear nerve?

A

Rinne test - test of air vs bone conducting sound - vibrating fork behind the mastoid bone - when the subject cant hear it move it to the outer ear canal Weber test - test of symmetrical inner ear function - vibrating fork to the midline of forehead

119
Q

What are the tests for glossopharyngeal and vagus nerves?

A

Speech Swallowing Observe - the position of the palate and the uvula Symmetrical position and movements of uvula Gag reflex - back of the throat is touched with a tongue blade

120
Q

What is the test for accessory spinal nerve?

A

Place your arms firmly on the shoulders of your subject and ask them to raise shoulders

121
Q

What is the test for Hypoglossal nerve?

A

Stick tongue out - tip will deviate to the weak side - check movements in all directions

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P2 Head, Neck and Neuro (11 decks)

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