BELLS PALCY

Is chracterised by an acute paralysis of the face related to in inflammation and

swelling of the facial nerve within the facial nerve within the facial canal or at the
stylomastoid foramen. Is is usually unilateral, rarely bilateral, and may occur
repetitively. In some, a family history of the condition is evident. But associated with
viral infections, e.g herpes simplex and varicella zoster. Endemics of Bells palsy
occur sporadically
Symptoms :

Ipsilateral mastoid precedes weakness over 48 hour period

Impairment of taste, hyperacusis and salivation
Lacrimanatiom is seldom affected
bells palsy phenomenon (normak eyeball movement on eye closure)

diagnosis :

based on typical presentation and exclusion of middle ear disease,

diabetes, sacroidosis and lyme disease

treatment :

during the stage protect the exposed eye during sleep

prednisolone given in high dosage in the acute stage (40-60mg per day for 5

days)
antiviral yherapy acyclovir is currently under evaluation
eye care

OTHER FACIAL NERVE DISORDERS

ramsay hunt syndrome

herpes zoster infection of geniculated (facial) ganglion causes sudden severe
facial weakness with typical zoster vesicular eruption within the external

ausditory meatus
deafness may result from VIII involvement. Neve V-XII are affected
antiviral agent may help
hemifacial spasm
this condition is characterized by unilateral clonic spasm beginning in the
orbicularis oculi and preading to involve other facial muscle, the etiology
remains unknown but irritation from an adjacent blood vessel may cause
demyelination an short circuiting with the nerve.
CT/MR scan of the posterior fossa sxclude the presence of cerebellar pontine
angle lesion and may show an actatic basilar artery
Anxiolytics and carbamazepine may produce some benefit ut are of no lasting
value

DEAFNESS, TINNITUS AND VERTIGO

Deafness :
1. conductive deafness : failure of sound conduction to the cochlea
2. sensorineural deafness : failure of action potential production due to disease
of the coclea, coclear nerve or cochlear central connection
3. pure word or cortical deafness : a bilateral or dominant posterior temporal
lobe lesion produce a filure to understand spoken language despite preserved
hearing
tinnitus : a sensation of noise of ringing, buzzing, pulsing, hissing or singing quality
vertigo : an illusion of oratory movement due to disturbed orientation of the body in
space
clinical examination : examination of the external auditory meatus, tymphanic
membrane and eye movements and webers and rinnes test
cause of deafness :

conductive (wax) : infection, trauma and tumors

sensorineural : (choclear) like congenital infection trauma and drugs
(retrocochlear)
lie
acoustic
neuroma,
meningoma,
epidermoid/dermoid

Cause of vertigo :

labyrinthine like trauma, benign positional vertigo, meniere disease and

drugs
vestibular nerve like vestibular neuronitis, cerebellopontin angle tumors
central associated with other brain stem symptoms

cause of tinnitus :
any lesion causing deafness may also cause tinnitus
DISORDER OF THE LOWR CRANIAL NERVES
NINTH CRANIAL NERVE

disorders of the glossopharyngeal nerve

glossopharyngeal palsy from either medullary or nerve root lesion does not
sccur in isolation. When associated with X and XI cranial nerve lesions, this

constitutes with jugular foramen syndrome

glossopharyngeal neuralgia
short, sharp lancinating of pain, identical to trigeminal neuralgia in nature but
affecting of posterior part of the pharynx or tonsillar area. The pain radiates
towards the ear and is triggerd by swallowing. Reflex bradicardia or syncope

occur due to stimulation of vagal nuclei by discharge from dlossopharyngeal.

As with trigeminal neuralgia, carbamazepin often provides effective relief
TENTH CRANIAL NERVE
Disorders of the vagus nerve cause :

palatal weakness
pharyngeal weakness
laryngeal weakness

ELEVENTH CRANIAL NERVE

The supranuclear connections act on the ipsilateral sternomastoid and on the
contralateral trapezeus. This result in :

- head turning away from the relevant

hemisphere during a seizure

-

head turning towards the relevant hemisphere with cerebral

infarction

unilateral lower motor neurone weajness produce a lower shoulder in the affected
side and weakness in turning the head to the opposite side
TWELFT CRANIAL NERVE
A lesion of the hypoglossal nerve results in atrophy and deviation of the tongue to
the weak side
-

basal base
basal skull

tumor

and

bone

lesion,

basal

meningitis,

carcinomatous

meningitis, glomous jugulare tumor

brain stem
infraction, meyelination, motor neuron disease, syringobulbia, poliomyelitis,
intrinsic tumor
neck
penetrating injury, neck operations, tumours
recurrent laryngeal nerve lesion
mediastinal disease, operative damage, aortic aneurysm
systemic causes
diabetes, meningovasculat syphilis, sarcoidosis, sle
jugular foramen syndrome
ession involving the ix, x and xi cranial nerve
collet sicard syndrome
lesion unvolving IX, X, Xi and XII cranial nerves
villaret syndrome

lesion of the retropharyngeal space involing the IX, X, XI and XII cranial nerve
and the cervical sympathetic
SYMTOMS AND SIGN CEREBRAL DYSFUNGTION

damage to midline structure

vermis
result in : disturbance of equilibrium with unsteadiness on standing, walking
and even sitting. The patient gait is board based and reeling. Eye closure

does not affect alance (are Romberg test) test of vestubar function
damage to hemisphere structures
always produse sign ipsilateral to the side of the lession
result in : loss of the normal capacity to modulate fine voluntary movements
eye movements
nystagmus results dorm diseade affecting cerebrall connections to the
vestibular nuclei
disturbance of speech
dysarthria
titubations
is a rhythmic nodding tremor of the ehad from side ro and fro, usually
associated with distal limb tremor
head tlit
involuntary movements

NYSTAGMUS
May result from :
- retinal disease
- ;anyrinth disease
- Disorder affecting the cerebellum
1) Retinal or ocular nystagmus
Rapid, pendular, increased when looking to side, persistent throught lifetime
Occur I congenital cataract, congenital macular defect, albinism
2) Vestibular nystagmus
Slow phase to side of lesion, quick or fast phase to normal side, rotator
component often present, turning eye away from the side of the lesion,
vertigo sccompanies nystagmus
Occur in acute labutinthine disease, menieres disease, vestibular neuronitis,
vascular disease
3) Positional nystagmus
After a delay of several second, nystagmus develops often with a rotator
component. Woth repeated testing, the nytagmus fatigue
4) Central nervous system

Occurs in vascular disease, semyelinatiom, neoplasm, nutritional disease,

alcohol intoxications and drug toxicity
5) Ataxic nystagmus
CETEBRAL ANEURYSMS MANAGEMENT FOLOWING SAH
Methods of aneurism repair
Direct clipping of the aneurysm neck : wrapping, ballon embolisation, coil
embolisationa dn trapping
Prevention of cerebral ischaemia
Calcium antagonist, avoidance of antihypertensive, high fluid intake, plasma volum
expansion, hypertensive therapy, brain protective agents
TREMOR
Is rhythmic involuntary movement normally affecting the limbs

The rate (slow 4-6hz), rapid (6-12 Hz)

The amplitude (fine or coarse)
The distributin : head, trunk and limbs
Associated feature e.g disorder of gait or balance

MYOCLONUS
Is a shock like contraction of muscle which occur irregularly and asymetriclly.
Pathopysiology
The presice nature of myoclonus re,ains unclear. Several forms exist, some clearly
related to epilepsy, other may be associated with demage to inhibitory mechanism
in the brainstreem reticulate formation. Myoclonus may results from pathological
changes affecting a variety of different site inclusing te motor cortex, cerebellum
and sponal cord
Clinical features
Movements whwn repetitive vary between 5-60/minute. The mucles of the face, oral
cavity and limbs are preferentially affected
Cause
Progressive In myoclonus, metabolic disease asosiated, miscellaneous disorders,
degenerative disease, epileptic disorders
Treatment

Benzodiazepine drugs such as clomazepam may suppres myoclonic movements,

piracetam and levadopa or dopamine agonist are also used