Session 13 - Lecture 1 - Review Flashcards
2 - Themes of the Lecture
• Clinical Signs Involving the Eye
• Autonomics-sympathetic innervation to head and neck
• Arterial blood supply to head and neck
• Cranial nerve routes and branches: facial nerve
- Facial nerve lesion (LMN) vs stroke (UMN)
• Radiological investigations in head and neck pathology
• Embryology
“1. lots of things that can present with eye signs ties in nicely with H&N.
2. Autonomics – minus the sympathetic innervation to the H&N – tricky.”
3 - Eye signs
Top: https://www.youtube.com/watch?v=x0w_VDQ0Tv4
What is the diagnosis?
In which direction would diplopia be worse?
What could be a possible cause?
Bottom: Painful, swollen ++ temp 39○C; painful to move eye Right eye: VA 6/12 Left eye VA 6/6 What is the diagnosis? Explain why the clinical findings described have arisen:
Top:
What is the diagnosis?
R abducens nerve palsy
In which direction would diplopia be worse?
to her R side (lateral gaze)
What could be a possible cause?
- raised ICP (S.O.L)
- stroke (brainstem) - would expect other neurology
- microvascular / ischaemic damage (neuropathy)
Bottom: Painful, swollen ++ temp 39○C; painful to move eye Right eye: VA 6/12 Left eye VA 6/6
What is the diagnosis? orbital cellulitis (post-septal)
Explain why the clinical findings described have arisen:
- increased swelling due to inflammation / infection IN orbit
- increased pressure –> pushes eyeball forward (proptosis)
- pressure + involvement of CNII –> decreased VA
“Top left (clip): lady having a cranial nerve exam. First things to think – which is the problem eye – then muscle, which nerve. Remember we always record things from the pts perspective – so either the pts left or pts right – not ours. Which direction from a pain perspective would she complain of worsening diplopia, and think of a possible cause.
1a. Abducens nerve - Bc which muscle is weak? The lateral rectus in her right eye – so it’s a right abducens nerve palsy.
1b. If you were doing her eye test - she’d complain of worsening diplopia looking to her right – whichever direction correlates to the muscle that’s weakened – so if right lateral rectus then if she turns her gaze to the right side, then her diplopia will get worse.
1c. Generally, causes – raised ICP. Why might she have raised ICP? Does she look like someone who’s come in with a head injury? Could be a space occupying lesion looks like a tumour. Could be a head injury - underlying lesion that hasn’t been picked up like epidural. Increased ICP isn’t a diagnosis itself there has to be other reasons for that. Could possibly be a stroke – would expect other signs if it were a brainstem stroke but yes possibly a stroke. Another one – cavernous sinus necrosis – potentially, bc abducens nerve runs through that – complaining of a headache, apoptosis in the eyes – could be thinking along lines of cavernous sinus. Something that’s even more likely is diabetes - vascular cause for a cranial nerve 6 lesion is diabetes. Know these diseases can affect blood vessels – tiny tiny blood vessels, that supply the kidneys and the eye – also supply nerves, including CN – CN6, 3 oculomotor and trochlear nerve can be affected by diabetes – vascular causes for a lesions.
Bottom: Painful, v swollen right eye, got a temperature, what do we think of the visual acuity (VA) as being measured? Right eye has worst VA – 6/12 means at 6m you’re reading letters that are big enough to be read at 12m so you’re VA is poorer - 6/6 is good – means you can read text at the size it should be. VA measured via the Snellen chart.
2a. Periorbital or orbital cellulitis – periorbital is pre-septal and orbital cellulitis is post-septal cellulitis so which one is it? Post-septal, orbital? Why is it orbital cellulitis – bc VA affected in the eye, anything else – painful movements, tells you there’s something moving the extraocular eye – preseptal are inside orbital cavity, fever but could you get fever in periorbital cellulitis – yes bc it’s cellulitis – in front of septum, in skin around orbit, could still get slight temperature – skin infection – but if in front of septum it’s not going to be involved in the orbital structures inside the orbit. So eye movements shouldn’t be painful or impaired if infection is in front of the orbital section.”
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