Session 8: Integrated Case Studies Flashcards
The image below is a coronal section through the primary motor cortex. Which area of the primary motor cortex is responsible for conscious control of left half of the face and arm?
E and F
Patient comes in with facial nerve palsy.
What muscle(s) is affected to account for the appearance by the eye?
Orbicularis oculi meaning the patient can’t close his eye.
Facial nerve palsy.
What muscle(s) is affected to account for the appearance by the mouth?
Zygomatic major and minor
Risorius
Orbicularis oris
What might the doctor have asked the patient to do to test the integrity of the facial nerve?
General facial expression
Alteration of taste
Dryness of eyes
Dryness of mouth
Hearing
Why might the doctor examine the parotid gland in a patient presenting with facial nerve palsy?
Facial nerve runs through the parotid gland. If there is pathology it can cause impingement and irritation of the nerve.
What are the three branches of the facial nerve that arise within the petrous temporal bone?
Greater petrosal nerve
Chorda tympani
Nerve to stapedius
Why might a patient with a facial nerve lesion complain of sensitivity to loud noises (hyperacusis)?
Palsy of stapedius which prevents excessive noise forming.
Give two reasons why the patient’s eye might be at risk of drying and injury as a result of a facial nerve lesion.
How could this be managed?
Corneal reflex not working
Can’t blink leading to drying out
Lacrimal glands which are innervated by parasympathetics from chorda tympani are not working.
Less protection to foreign bodies.
Eye drops and eye patch
Why might the doctor also want to examine the ear more closely?
Acute otitis media and cholesteotomas which can cause facial nerve palsy.
Also Ramsay-Hunt syndrome which is shingles of the facial nerve presenting in the external ear.
Name three conditions involving structures or areas of the ear that can present with otalgia.
Acute otitis media
Otitis externa
Perichondritis
Which nerves are involved in innervating structures of the external and middle ear (those carrying general sensory afferent)?
Glossopharyngeal (middle ear + oropharynx + tonsils)
Trigeminal via auriculotemporal
Vagus nerve (ear + larynx + laryngopharynx)
C2, C3
To explore a potential cause for referred pain to the ear the presence of pathology in which other areas of the head and neck should be determined?
Mouth
Tonsils
Lymph nodes
Cancers
The doctor enquires about the presence of red flags and also examins the oropharynx and palpates for cervical lymphadenopathy.
What are red flags and what might these have been in this patient’s case?
In case it is cancer
Weight loss
Changing/hoarse voice
Lumps
Difficulty swallowing
Ear pain
Why did the doctor examine the oropharynx and palpate the cervical lympadenopathy?
Shared sensory with glossopharynx nerve.
What features on palpation of a lymph node would be indicative of metastatic involvement?
Immobile
Non-tender
Hard
Irregular
What do you think could be the underlying diagnosis and what would be the appropriate next step for the GP to take in managing this patient?
Referral to ENT
What is the likely diagnosis?
Left ear?
Acute otitis media
(Fever, bulging, runny nose)
What features in the girl’s history and examination of the tympanic memrbane led to your diagnosis?
Bulging and red tympanic membrane
Why is this condition more common in young children that in adults?
Because the eustachian tube is shorter and more horizontal in children. That makes it easier for pathogens to make their way up there from the nasopharynx.
What are the most common pathogens involved in causing acute otitis media?
Viral (most common)
Streptococcus pneumoniae
Haemophilus influenzae
What condition has now developed?
Mastoiditis
Explain with reference to the anatomy of the ear, how the original infection was able to spread leading to the condition seen in the above image?
Middle ear has a connection (aditus->mastoid antrum-> mastoid air cells)
Infection can travel here and settle in the mastoid air cells.
Name two other anatomical structures within the skull which can in any patient be affected by the spread of infection from the middle ear?
Temporal lobe
Sigmoid sinus -> thrombosis of sigmoid sinus
Dura -> meningitis
