UKMLA: Neurology

Bell’s Palsy: What is it?

Bell’s palsy is an idiopathic syndrome that causes damage to the facial nerve leading to a lower motor neuron facial palsy

It can occur at any age, with a peak incidence in the age group of 15-45 years.

Bell’s Palsy: What are the clinical features?

• Acute onset of unilateral lower motor neuron facial weakness

• Forehead is NOT spared→ if spared, it is more likely to be stroke

• Hyperacusis

• Altered taste

• Dry eyes and mouth

• Loss of taste in anterior 2/3 of tongue (Facial nerve VII supplies this)

Bell’s Palsy: What is the investigation?

• Diagnosis is mainly clinical

• Otoscopy, FBC, ESR, CRP, Viral serology for HSV-1, EBV or VZV as varicella zoster is more associated with Ramsay-hunt syndrome

• Imaging

Bell’s Palsy: What is the management?

• All patients presenting within 72 hours of the onset of symptoms should be administered oral steroids → prednisone 50mg 1x a day for 10 days after which the dose is tapered.

• Ocular lubricants for dry eyes

• Eye patch to prevent corneal exposure

• Aciclovir may be given too

• 70-80% will recover!!!

Bell’s Palsy: What are the managements of other palsy’s?

• Corticosteroids for Bell's Palsy

• Antiviral agents for Ramsay Hunt syndrome.

• Antibiotics for Lyme disease and basal meningitis

Erb’s Palsy: Which nerve roots are damaged?

C5-C6 nerve roots→ due to child birth

Klumpke’s Palsy: Which nerve roots are damaged?

C8-T1 nerve roots → due to axillary radiotherapy e.g. for breast cancer

Erb’s Palsy: What are the clinical features?

• Dermatomal sensory loss in the C5-6 distribution

• "Waiter's tip" sign: Characterised by shoulder adduction, elbow extension, forearm pronation, and wrist flexion.

Klumpke’s Palsy: What are the clinical features?

• Dermatomal sensory loss in the C8-T1 distribution

• Weakness of the SMALL intrinsic muscles of the hand

• Potential ipsilateral Horner's syndrome if T1 involvement occurs→ ptosis of eyes

Brachial Plexus Injury: What is the investigation?

EMG (nerve) and MRI studies

Brachial Plexus Injury: What is the management?

• Physiotherapy

• NSAIDS and analgesia

• Nerve graft surgery after watchful waiting

Headaches: What are cluster headaches?

Severe unilateral headache due to trigeminal nerve activation→ common in middle-aged men

Headaches: What are the risk factors for cluster headaches?

Risk factors include:

• Male gender

• Age more than 30

• Alcohol consumption

• Prior brain surgery or trauma

• Family history

Headaches: What are the symptoms of cluster headaches?

• Severe pain

• Patient’s rock or sway to distract from pain

• 15 minutes - 3 hours duration

• Occurs up to 8 times a day

• Most patients will have attacks for weeks to months then have remission for a number of months to years

• Patients may also express suicidal ideation during the attacks

• Lacrimation

• Nasal congestion

• Red eye + eye pain

Headaches: What is the management of cluster headaches?

• Acute→ 100% oxygen therapy + subcutaneous or nasal sumatriptan

• Prevention→ verapamil, topirimate and lithium

Headaches: What is the most common type of primary headache disorder?

Tension headaches

Headaches: What is the classification of tension headaches?

• Infrequent→ less than 1 day of headache per month

• Frequent→ 10 episodes in 15 days, for longer than 3 months

• Chronic→ more than 10 episodes in 15 days, for longer than 3 months

Headaches: What are the features of tension headaches?

• Bilateral, non-pulsatile pain

• Tight, pressure sensation

• Scalp is tender

Headaches: What is the management of tension headaches?

• Analgesia

• Stress management

• Massages and relaxation

Headaches: What are migraines?

• A headache characterised by unilateral, pulsating pain and aura→ visual or sensory changes

• Lasts 4-72 hours

Headaches: What are the symptoms of migraines?

• Aura afterwards

• Unilateral, throbbing pain

• Photophobia

• Phonophobia

• Nausea and/or vomiting

Headaches: How can triggers for migraines be tracked?

Headache diary

Headaches: What is the management of migraines?

• Avoid triggers e.g. sleep on time and eat good food

• Triptans→ contraindicated in patients with iscahemic heart disease

• Anti-emetics → metoclopramide

• Females of child-bearing age shouldn’t take COCP due to risk of stroke

Headaches: What are the contraindications for sumatriptan?

Contraindicated in patients with ischaemic heart disease

Headaches: Which drug is used for the prophylaxis of cluster headaches?

Verapamil

Headaches: Which drug is used for the prophylaxis of migraines?

1. Propanol → NOT FOR ASTHMATICS

2. Topiramate

3. Amityrptyline→ FOR WOMEN WHO CAN CONCIEVE, NOT FOR PEOPLE WITH DIAVETES

Headaches: Which drug is used for the prophylaxis of migraines in adolescents or asthmatics?

Topiramate

Headaches: Which drug is used for the prophylaxis of migraines in women on child-bearing age?

Amitriptyline (as topiramate is teratogenic)

Headaches: What is the complication of regular migraine medications?

Medication overuse headaches if you use the medication more than 10-15 days a month

Headaches: What is the acute management of a migraine?

Ibuprofen 400mg, aspirin 900mg or paracetamol 1g

Ocular Palsy: What are the signs of third nerve palsy?

• Down and out pupils

• Ptosis

• Fixed pupil dilation

• Aneurysm in circle of Willis

• Commonly caused by diabetes

Ocular Palsy: What are the signs of fourth nerve palsy?

Paralysis of trochlear nerve which controls superior oblique muscle causes:

• Upwards and inwards pupil

• Head tilt

• Double vision in the vertical plane

• Trochlear nerve palsy is caused by diabetes and ocular trauma

Ocular Palsy: What are the signs of sixth nerve palsy?

The eye fails to ABduct due to paralysis of the abducens nerve. It may be medially deviated at rest, and diplopia worsens when the patient is asked to look horizontally away from the midline on the side of the lesion

Ocular Palsy: What is the management?

• Prismatic glasses for diplopia

• Strabismus surgery

• Spontaneous recovery is also possible!!