Sixth nerve palsy: Difference between revisions
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==Background== | ==Background== | ||
* Also called 6th cranial nerve (CN VI) | *Also called 6th cranial nerve (CN VI) | ||
* Most common ocular nerve palsy | *Most common ocular nerve palsy | ||
* Innervates the ipsilateral lateral rectus muscle controlling eye abduction | *Innervates the ipsilateral lateral rectus muscle controlling eye abduction | ||
* Esotropia of the affected eye due to the unopposed action of the medial rectus muscle, innervated by the oculomotor nerve (CN III) <ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref> | *Esotropia (eye moves inward) of the affected eye due to the unopposed action of the medial rectus muscle, innervated by the oculomotor nerve (CN III) <ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref> | ||
==Clinical Features== | ===Causes=== | ||
*Nuclear lesion | |||
**Congenital, [[MS|demyelinating]], [[CVA|ischemia]], traumatic | |||
*Inflammatory | |||
**[[Vasculitis]] | |||
**[[Sarcoidosis]] | |||
**[[Systemic lupus erythematosus]] | |||
*Infectious | |||
**[[Lyme disease]] | |||
**[[Syphilis ]] | |||
**[[Tuberculosis]] | |||
**[[Meningitis ]] | |||
*Orbital lesions | |||
**Neoplastic | |||
**Inflammatory | |||
**Infectious | |||
==Clinical Features== | |||
===History=== | ===History=== | ||
*May complain of:<ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref><ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> | |||
*''[[Diplopia]]'' (frequent complaint) upon attempting lateral gaze and ''esotropia'' at rest | |||
* | **May have a ''head turn'' to help correct their diplopia | ||
*May have a | *[[Vision loss]] | ||
*Vision loss | *[[Hearing loss]] | ||
*Hearing loss | *Symptoms of [[vasculitis]], most commonly [[giant cell arteritis]] (headache, tenderness of the scalp, jaw claudication, reduced visual acuity, tinnitus, fever_ | ||
*Symptoms of vasculitis, most commonly [[giant cell arteritis]] (headache, tenderness of the scalp, jaw claudication, reduced visual | *+/- history of [[diabetes]], [[hypertension]], [[stroke]], [[fever]], and [[headache]] | ||
* | |||
===Examination=== | ===Examination=== | ||
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**Check deep tendon reflexes and strength to exclude corticospinal tract involvement | **Check deep tendon reflexes and strength to exclude corticospinal tract involvement | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* ''Increased intracranial pressure (ICP)'': Because of its position and intracranial length, increased ICP from any cause can lead to injury and dysfunction | *''[[Elevated ICP|Increased intracranial pressure (ICP)]]'': Because of its position and intracranial length, increased ICP from any cause can lead to injury and dysfunction | ||
* ''Vascular'': Aneurysm, central venous thrombosis | *''Vascular'': Aneurysm, central [[venous sinus thrombosis]] | ||
* ''Inflammatory'': Post-viral, demyelinating, | *''Inflammatory'': Post-[[viral syndrome|viral]], [[MS|demyelinating]], [[sarcoidosis]], [[giant cell arteritis]], Miller-Fisher Syndrome variant of [[Guillian-Barre Syndrome]] | ||
* ''Neoplastic'': Lesions in the cerebellopontine angle. In children – pontine glioma | *''Neoplastic'': [[brain tumor|Lesions]] in the cerebellopontine angle. In children – pontine glioma | ||
*''Degenerative/deficiency'': Vitamin B deficiency, Wernicke-Korsakoff | *''Degenerative/deficiency'': [[vitamin B12 deficiency|Vitamin B deficiency]], [[Wernicke-Korsakoff syndrome]] | ||
*''Idiopathic'': Post-lumbar puncture, status-post surgery involving head | *''Idiopathic'': Post-[[lumbar puncture]], status-post surgery involving head | ||
*''Infection'': [[Meningitis]], [[lyme disease]], [[syphilis]] | *''Infection'': [[Meningitis]], [[lyme disease]], [[syphilis]] | ||
*''Congenital'': Rare to find true congenital sixth nerve palsy | *''Congenital'': Rare to find true congenital sixth nerve palsy | ||
*''Autoimmune'': [[Myasthenia Gravis]] | *''Autoimmune'': [[Myasthenia Gravis]] | ||
*''Trauma'': Especially if a torsional head motion or medial wall [[orbital fracture]](with entrapment of the medial rectus muscle | *''[[head trauma|Trauma]]'': Especially if a torsional head motion or medial wall [[orbital fracture]] (with entrapment of the medial rectus muscle | ||
*''Endocrine'': Diabetic cranial mononeuropathy - the incidence of palsy in the 3rd, 6th, and 7th cranial nerves is significantly higher in patients with [[diabetes]]<ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref><ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> <ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/26314216</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/17157701</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/11555800</ref> | *''Endocrine'': [[diabetic neuropathy|Diabetic cranial mononeuropathy]] - the incidence of palsy in the 3rd, 6th, and 7th cranial nerves is significantly higher in patients with [[diabetes]]<ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref><ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> <ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/26314216</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/17157701</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/11555800</ref> | ||
== | ==Evaluation== | ||
===Work-up=== | ===Work-up=== | ||
*POC glucose | *Workup will depend on suspected etiology, may include | ||
*CBC | **POC glucose | ||
*BMP | **CBC | ||
*ESR | **BMP | ||
*Lyme | **ESR | ||
*RPR ( | **Lyme titer | ||
*Lumbar puncture | **RPR (if suspect syphilis) | ||
*Antinuclear antibody test | **[[Lumbar puncture]] to exclude meningitis, Guillain-Barré | ||
*CT head: | **Antinuclear antibody test | ||
*MRI: indicated for brainstem findings on the exam and to exclude pontine glioma in children and in adults where the abducens nerve palsy does not improve<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref> | **[[CT head]]: exclude acute bleed or mass | ||
**[[brain MRI|MRI]]: indicated for brainstem findings on the exam and to exclude pontine glioma in children and in adults where the abducens nerve palsy does not improve<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref> | |||
==Management== | ==Management== | ||
* | *Treat by underlying etiology | ||
*Consider neuro/optho consult | |||
*Children: Can be treated with alternating patching to decrease probability of developing amblyopia in the affected eye | *Children: Can be treated with alternating patching to decrease probability of developing amblyopia in the affected eye | ||
*[[Giant cell arteritis]]: | *Adults: Lenses can be fogged with clear tape, paint, or nail polish to decrease diplopia. Neurology can prescribe Fresnel prisms as an alternative. | ||
*[[Giant cell arteritis]]: treat with [[prednisone]] or intravenous [[Methylprednisolone]]. | |||
==Disposition== | ==Disposition== | ||
*Dispo appropriate to etiology | *Dispo appropriate to etiology | ||
* | *Truly isolated cases: often benign, can be followed up by neurologist for serial exams | ||
*Surgery: If patient does not improve within 6 months after treatment and serial check-ups, surgery may be required<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref> | *Surgery: If patient does not improve within 6 months after treatment and serial check-ups, surgery may be required<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref> | ||
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{{Reflist}} | {{Reflist}} | ||
[[Category: | [[Category:Ophthalmology]] | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Symptoms]] |
Revision as of 15:39, 23 October 2019
Background
- Also called 6th cranial nerve (CN VI)
- Most common ocular nerve palsy
- Innervates the ipsilateral lateral rectus muscle controlling eye abduction
- Esotropia (eye moves inward) of the affected eye due to the unopposed action of the medial rectus muscle, innervated by the oculomotor nerve (CN III) [1]
Causes
- Nuclear lesion
- Congenital, demyelinating, ischemia, traumatic
- Inflammatory
- Infectious
- Orbital lesions
- Neoplastic
- Inflammatory
- Infectious
Clinical Features
History
- May complain of:[1][2]
- Diplopia (frequent complaint) upon attempting lateral gaze and esotropia at rest
- May have a head turn to help correct their diplopia
- Vision loss
- Hearing loss
- Symptoms of vasculitis, most commonly giant cell arteritis (headache, tenderness of the scalp, jaw claudication, reduced visual acuity, tinnitus, fever_
- +/- history of diabetes, hypertension, stroke, fever, and headache
Examination
- Excluding paresis of the other cranial nerves
- Check ocular muscle movements
- Check for papilledema
- Test pupillary response
- Test ocular motor nerves (CN III, IV, and VI)[3][4]
- Trace a full H-pattern with finger and have the patient follow the finger only with their eyes
- Patients with abducens nerve palsy are unable to move the affected eye laterally
- In order to avoid diplopia, patients will turn their heads away from the lesion so that both eyes are looking sideways
- Check deep tendon reflexes and strength to exclude corticospinal tract involvement
Differential Diagnosis
- Increased intracranial pressure (ICP): Because of its position and intracranial length, increased ICP from any cause can lead to injury and dysfunction
- Vascular: Aneurysm, central venous sinus thrombosis
- Inflammatory: Post-viral, demyelinating, sarcoidosis, giant cell arteritis, Miller-Fisher Syndrome variant of Guillian-Barre Syndrome
- Neoplastic: Lesions in the cerebellopontine angle. In children – pontine glioma
- Degenerative/deficiency: Vitamin B deficiency, Wernicke-Korsakoff syndrome
- Idiopathic: Post-lumbar puncture, status-post surgery involving head
- Infection: Meningitis, lyme disease, syphilis
- Congenital: Rare to find true congenital sixth nerve palsy
- Autoimmune: Myasthenia Gravis
- Trauma: Especially if a torsional head motion or medial wall orbital fracture (with entrapment of the medial rectus muscle
- Endocrine: Diabetic cranial mononeuropathy - the incidence of palsy in the 3rd, 6th, and 7th cranial nerves is significantly higher in patients with diabetes[1][2] [3][4][5][6][7]
Evaluation
Work-up
- Workup will depend on suspected etiology, may include
- POC glucose
- CBC
- BMP
- ESR
- Lyme titer
- RPR (if suspect syphilis)
- Lumbar puncture to exclude meningitis, Guillain-Barré
- Antinuclear antibody test
- CT head: exclude acute bleed or mass
- MRI: indicated for brainstem findings on the exam and to exclude pontine glioma in children and in adults where the abducens nerve palsy does not improve[3][4]
Management
- Treat by underlying etiology
- Consider neuro/optho consult
- Children: Can be treated with alternating patching to decrease probability of developing amblyopia in the affected eye
- Adults: Lenses can be fogged with clear tape, paint, or nail polish to decrease diplopia. Neurology can prescribe Fresnel prisms as an alternative.
- Giant cell arteritis: treat with prednisone or intravenous Methylprednisolone.
Disposition
- Dispo appropriate to etiology
- Truly isolated cases: often benign, can be followed up by neurologist for serial exams
- Surgery: If patient does not improve within 6 months after treatment and serial check-ups, surgery may be required[3][4]
See Also
External Links
References
- ↑ 1.0 1.1 1.2 Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546
- ↑ 2.0 2.1 Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013
- ↑ 3.0 3.1 3.2 3.3 Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013
- ↑ 4.0 4.1 4.2 4.3 Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins
- ↑ http://www.ncbi.nlm.nih.gov/pubmed/26314216
- ↑ http://www.ncbi.nlm.nih.gov/pubmed/17157701
- ↑ http://www.ncbi.nlm.nih.gov/pubmed/11555800