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Benign Abducens Nerve Palsy

Benign Sixth Nerve Palsy Syndrome


Presentation

  • The aim of our study was to present the largest single-center series of patients with the longest period of follow-up to confirm the benign nature of this entity.[ncbi.nlm.nih.gov]
  • , and Management; Carotid Cavernous Fistulas: Epidemiology, Clinical Presentation, and Management.[books.google.com]
  • In contrast, high-grade stereopsis was present in all other patients (positive Lang I Stereotest).[nature.com]
  • Case Report A healthy 11-month-old girl without a history of any medical problem presented to the pediatric department with an acute-onset esotropia in the left eye due to sixth nerve palsy.[healio.com]
Falling
  • These children continue to "fall through the cracks" of our medical education system.[books.google.com]
  • (Inability to look down can lead to falling down stairs.) Multiple sclerosis (MS) often presents with optic neuritis in which there is pain on eye movement and alteration or loss of vision. Diplopia can occur.[patient.info]
  • Nonphysiologically active paraganglia have a negative chromaffin reaction, and the glomus jugulare falls into this group.[karger.com]
  • One primary type of generalized seizure is tonic-clonic seizures, in which an individual loses consciousness without warning, falls, and stiffens, because of muscle contractions.[britannica.com]
Severe Pain
  • Neither parents nor their children reported severe pain associated with palsy. However, some discomfort was found in the children teething and/or undergoing infection.[nature.com]
  • In a variant called cluster headache, severe pain is felt in and around one eye that lasts approximately an hour and frequently wakes the patient in the early morning.[britannica.com]
Malaise
  • […] context of IIH. [1] Children with intracranial hypertension secondary to steroid administration or following infections like mycoplasma, have demonstrated signs that suggest a posterior fossa lesion, including ataxia, facial palsy, nuchal rigidity, malaise[neurologyindia.com]
  • Typical symptoms of encephalitis include the onset, over hours or days, of headache, fever, stiffness of the neck, drowsiness, and malaise.[britannica.com]
Turkish
  • To our knowledge, this is the first Turkish patient reported.[healio.com]
Pneumonia
  • Other uncommon etiologies include Mycoplasma pneumoniae infection, Chlamydia pneumoniae infection, and Lyme disease. 1,3,4 Benign recurrent abducens nerve palsy is a rare condition of unknown etiology.[healio.com]
  • Benign isolated abducens nerve palsy in mycoplasma pneumoniae infection. Pediatr Neurol 1998; 18 : 71–72. 9. Knapp CM, Gottlob I. Benign recurrent abducens (6th) nerve palsy in two children. Strabismus 2004; 12 : 13–16. 10. Larsen PC, Gole GA.[nature.com]
  • Epstein-Barr, cytomegalovirus, varicella, herpes zoster ophthalmicus, Mycoplasma pneumoniae, Chlamydia pneumonia etc [8].[medresearch.in]
  • Cranial nerve palsies in Streptococcus pneumoniae meningitis. Pediatr Neurol. 1990;6(3):209–10. CrossRef PubMed Google Scholar 24. Sato K, Yoshikawa H. Bilateral abducens nerve paresis associated with anti-GQ1b IgG antibody.[link.springer.com]
Pertussis
  • In patient 12, occurrence of the palsy followed immunization (pertussis, diphtheria, tetanus, poliomyelitis and infant Haemophilus type B vaccine). In addition, palsies were found in three teething children (patients 6, 10, and 11).[nature.com]
  • Isolated abducens palsy has been reported after vaccination (measles, measles-mumps-rubella, diphtheria-tetanus-pertussis vaccines) and some documented infections i.e.[medresearch.in]
  • Abbreviations MMR Measles: Mumps, Rubella Hib: Haemophilus influenzae b AEFI: Adverse events following immunization dTap: Diphtheria-tetanus-acellular pertussis.[bmcinfectdis.biomedcentral.com]
Pharyngitis
  • Angiographic evidence of a blood supply from the external carotid artery system, especially the ascending pharyngeal artery, substantiates this diagnosis.[karger.com]
Torticollis
  • Conversely, early developmental disturbances of vision often disrupt ocular motor control systems, giving rise to complex disorders such as nystagmus, strabismus, and torticollis.[books.google.com]
  • AJNR Am J Neuroradiol 2001;22:196-9. [ PUBMED ] [ FULLTEXT ] This article has been cited by 1 Idiopathic intracranial hypertension presenting as stiff neck and torticollis Saifudheen, K. Neurology India. 2010; 58(6): 982 [Pubmed][neurologyindia.com]
  • Infants noted to have torticollis, or a sustained head tilt, may be referred to a pediatric ophthalmologist to be evaluated for a congenital fourth nerve palsy. Fourth nerve palsies can also be caused by head trauma, infection, or a brain mass.[willseye.org]
  • Focal dystonias include writer’s cramp, orofaciomandibular dystonia, and torticollis. Tics are similar to dystonia, but they consist of brief movements or utterances of unknown cause.[britannica.com]
Diplopia
  • Diplopia may be a complication after refractive surgery. Ocular lesions, including diplopia, can be amongst the presenting features of Creutzfeldt-Jakob disease (CJD), especially new variant CJD [ 4 ].[patient.info]
  • In other studies with smaller cohorts, the prevalence of diplopia is highly variable, ranging from 0 to 43%, and the diplopia is often accompanied by other symptoms or signs ( 8 – 10 ).[frontiersin.org]
  • Patients will have horizontal uncrossed diplopia which is greater at distance than at near. The diplopia is also worse in the direction of the palsied muscle and gets better in the contralateral gaze (incomitant).[eyewiki.aao.org]
  • Neuro-Ophthalmology Diplopia – Double Vision Diplopia, also known as double vision, occurs in one of two ways. The double vision is either present with one eye open (monocular diplopia) or only with both eyes open (binocular diplopia).[eye.uci.edu]
  • Cranial Nerve Muscle(s) Lesion(s) Oculomotor nerve (CN III) Extraocular muscles innervated by CN III are superior rectus (SR) infecrior rectus (IR) medial rectus (MR) inferior oblique (IO) Levator palpebrae superioris Ciliary muscle Sphincter pupillae Diplopia[medbullets.com]
Strabismus
  • Three children required strabismus surgery. None of the patients developed long-term recurrences or neurological abnormalities during a mean follow-up of more than 9 years.[ncbi.nlm.nih.gov]
  • In cases of subsequent acquired strabismus, with a constant angle of deviation, strabismus surgery may be required. References 1. Patel SV, Muyala S, Leske DA, Hodge DO, Holmes JM. Incidence.[nature.com]
  • Strabismus . 2004;12:13–16. doi:10.1076/stra.12.1.13.29015 [CrossRef] Wang CH, Chou ML, Huang CH. Benign isolated abducens nerve palsy in Mycoplasma pneumoniae infection.[healio.com]
  • Conversely, early developmental disturbances of vision often disrupt ocular motor control systems, giving rise to complex disorders such as nystagmus, strabismus, and torticollis.[books.google.com]
  • Augmented Hummelsheim procedure for paralytic strabismus. J Pediatr Ophthalmol Strabismus. 2000;37(4):189–95. quiz 226–187. PubMed Google Scholar 36. Couser NL, Lenhart PD, Hutchinson AK.[link.springer.com]
Strabismus
  • Three children required strabismus surgery. None of the patients developed long-term recurrences or neurological abnormalities during a mean follow-up of more than 9 years.[ncbi.nlm.nih.gov]
  • In cases of subsequent acquired strabismus, with a constant angle of deviation, strabismus surgery may be required. References 1. Patel SV, Muyala S, Leske DA, Hodge DO, Holmes JM. Incidence.[nature.com]
  • Strabismus . 2004;12:13–16. doi:10.1076/stra.12.1.13.29015 [CrossRef] Wang CH, Chou ML, Huang CH. Benign isolated abducens nerve palsy in Mycoplasma pneumoniae infection.[healio.com]
  • Conversely, early developmental disturbances of vision often disrupt ocular motor control systems, giving rise to complex disorders such as nystagmus, strabismus, and torticollis.[books.google.com]
  • Augmented Hummelsheim procedure for paralytic strabismus. J Pediatr Ophthalmol Strabismus. 2000;37(4):189–95. quiz 226–187. PubMed Google Scholar 36. Couser NL, Lenhart PD, Hutchinson AK.[link.springer.com]
Nystagmus
  • There was no evidence of nystagmus, and dilated funduscopy was unremarkable with no evidence of papilledema.[healio.com]
  • Conversely, early developmental disturbances of vision often disrupt ocular motor control systems, giving rise to complex disorders such as nystagmus, strabismus, and torticollis.[books.google.com]
  • […] usually benign, it may in some cases be the harbinger of an intracranial tumor such as cerebellar astrocytoma or pontine glioma29,526 or other pathology such as a Chiari 1 malformation.517 Absence of symptoms or signs such as headaches, papilledema, or nystagmus[guwsmedical.info]
  • Additional findings include slowing of abducting saccades and, in some cases, a dissociated adducting nystagmus in the other eye, reflecting central adaptation (1).[neuroophthalmology.ca]
Cranial Nerve Involvement
  • Cranial nerve involvement produces hoarseness and dysphagia.[karger.com]
  • nerve involvement; proptosis; disc edema; orbital pain; conjunctival injection Orbit Ipsilateral IIIrd, IVth, Vth cranial nerve involvement; proptosis; disc edema; orbital pain; conjunctival injection Uncertain Tumor; demyelination; hemorrhage; infarction[guwsmedical.info]
  • The probable mechanism of third nerve (and other cranial nerves) involvement seems to be compression in the subarachnoid space in the setting of raised ICP.[neurologyindia.com]
  • Despite successful local therapy, about 80% will die of metastatic cancer within 5 years. [8] Our case presented with diplopia as the only sign of the cranial nerve involvement and this presentation is rare even in cases with skull base metastases from[ijo.in]
Mydriasis
  • Isolated ptosis or mydriasis usually is not a sign of third nerve palsy. When complete, the eye may be deviated down and out.[medtextfree.wordpress.com]
  • Patients usually have dysphagia due to bulbar weakness and progress within a few days to generalized weakness with other ocular signs, notably accommodation paresis and ptosis, less commonly mydriasis.[neuroophthalmology.ca]

Workup

  • I will be having an MRI friday and a blood workup though I have never had diabetes, high blood pressure, or high cholesterol.[medhelp.org]
  • Discussion The differential diagnoses and workup of an isolated sixth nerve palsy usually depends on the age and the clinical circumstances of the patient.[dovepress.com]
  • Natural History and Clinical Workup Newborns may demonstrate a transient sixth nerve palsy that is frequently unilateral and occasionally accompanied by a temporary ipsilateral seventh nerve palsy.53,267,291,400 Simple observa- FIGURE 5-7.[guwsmedical.info]
  • For any patient who develops signs of aberrant regeneration, workup for a structural lesion is initiated, or repeated if previous workup has been carried out and no lesion found. Nonisolated Cranial Neuropathies MULTIPLE CRANIAL NEUROPATHIES.[medtextfree.wordpress.com]
  • The family opted for comfort measures and hospice care, hence further workup including onconeural antibodies were not pursued. He continued to deteriorate and subsequently expired.[karger.com]
Chlamydia
  • Other uncommon etiologies include Mycoplasma pneumoniae infection, Chlamydia pneumoniae infection, and Lyme disease. 1,3,4 Benign recurrent abducens nerve palsy is a rare condition of unknown etiology.[healio.com]
  • Epstein-Barr, cytomegalovirus, varicella, herpes zoster ophthalmicus, Mycoplasma pneumoniae, Chlamydia pneumonia etc [8].[medresearch.in]
Toxoplasma Gondii
  • Serological studies were negative for Mycoplasma pneumoniae , Epstein–Barr virus, cytomegalovirus, and Toxoplasma gondii . Her AchR Ab levels were negative. No beta-hemolytic streptococci were isolated in her throat culture.[healio.com]

Treatment

  • Modalities or Observation of Arteriovenous Malformations; Selection of Treatment Modalities or Observation of Dural Arteriovenous Malformations; Surgical Treatment of Cranial Arteriovenous Malformations and Dural Arteriovenous Fistulas; Anesthesia Considerations[books.google.com]
  • Management should include screening and treatment of amblyopia, as well as exclusion of a transition into concomitant non-paralytic esotropia.[nature.com]
  • Botulinum treatment of childhood strabismus. Ophthalmology . 1990;97:1434–1438. King AJ, Stacey E, Stephenson G, Trimble RB. Spontaneous recovery rates for unilateral sixth nerve palsies. Eye . 1995;9:476.[healio.com]
  • Treatment for diplopia depends on the underlying cause.[eye.uci.edu]

Prognosis

  • Cause and prognosis of nontraumatic sixth nerve palsy in young adults. Ophthalmology 2002 ; 109 : 1925 –8. 7. Sanders SK, Kawasaki A, Purvin VA. Long-term prognosis in patients with vasculopathic sixth nerve palsy.[cambridge.org]
  • Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol. 1992 May;113(5):489-96. 4. Rush JA. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases.[reviewofoptometry.com]
  • Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol. 1992;113(5):489-96. Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases.[reviewdiseasehandbook.com]
  • Although the prognosis for benign isolated abducens nerve palsy is usually excellent, possible complications have to be considered.[nature.com]
  • Prognosis The prognosis for sixth nerve palsy depends on the underlying etiology.[eyewiki.aao.org]

Etiology

  • Other uncommon etiologies include Mycoplasma pneumoniae infection, Chlamydia pneumoniae infection, and Lyme disease. 1,3,4 Benign recurrent abducens nerve palsy is a rare condition of unknown etiology.[healio.com]
  • Conversely, slowly progressive onset suggests a compressive etiology. Subacute onset suggests a demyelinating process as a possible etiology. Associated pain suggests a microvascular etiology.[eyewiki.aao.org]
  • Etiologic incidence and management of the third, fourth, and sixth nerve palsies. Ophthalmology 1980; 87 : 24–43. 5. Afifi AK, Bell WE, Menezes AH. Etiology of lateral rectus palsy in infancy and childhood. J Child Neurol 1992; 7 : 295–299. 6.[nature.com]
  • Etiology of Infranuclear Sixth Nerve Palsy.[guwsmedical.info]
  • This is followed by trauma, elevated intracranial pressure, inflammatory causes and post-viral etiologies. 1,2,7-9 - Intracranial neoplasm.[reviewofophthalmology.com]

Epidemiology

  • Articles in this issue include: Arteriovenous Malformations: Epidemiology and Clinical Presentation; Dural Arteriovenous Fistulas: Epidemiology and Clinical Presentation; Historical Perspective of Treatments of Arteriovenous Malformations and Dural Arteriovenous[books.google.com]
  • Epidemiology of idiopathic intracranial hypertension: A prospective and case-control study. J Neurol Sci 1993;116:18-28. [ PUBMED ] 4. Giuseffi V, Wall M, Siegel PZ, Rojas PB.[neurologyindia.com]
  • It is also an additive in many of the non-live vaccines the patient received in childhood without incident and extensive epidemiological studies have not found a link between neurological adverse events following immunization (AEFI) and additives or adjuvants[bmcinfectdis.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology

  • The exact pathophysiology is unknown, although hypotheses including autoimmune mechanisms and direct viral invasion could explain the pathophysiology behind immunization related nerve palsies.[bmcinfectdis.biomedcentral.com]
  • Pinealoma Para Myokymia of the superior oblique muscle (typically with brief episodic ocular movements that cause subjective visual shimmering, ocular trembling, and/or tilted vision) Entrapment of the trochlear nerve by a vascular loop (similar to the pathophysiology[merckmanuals.com]
  • The pathophysiology of recurrent painful ophthalmoplegic neuropathies remains unclear.[dovepress.com]
  • With advances in neuroimaging techniques and a growing understanding of the pathophysiology of IIH, it is mandatory to exclude other causes of increased ICP without ventriculomegaly or mass lesions, such as gliomatosis cerebri, meningitis, and intracranial[neurologyindia.com]
  • We discuss the reported causes of CPM in pregnancy, possible pathophysiologic mechanisms involved and the anatomic basis of the unique clinical presentation of sixth nerve palsy in our case.[annalsofian.org]

Prevention

  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • Occlusion may also prevent secondary contracture of the medial rectus muscle of the deviating eye.[healio.com]
  • Therefore, if close follow-up to resolution of the palsy or paresis is not possible, neuroimaging is recommended.24 Treatment Amblyopia prevention is always key in children younger than 7 to 9 years of age.[guwsmedical.info]
  • Occlusion using Bangerter filter or pirate patch can eliminate diplopia and confusion, prevent amblyopia or suppression in younger patients, and decrease the possibility of ipsilateral medial rectus contracture.[eyewiki.aao.org]
  • In younger patients, patching may be necessary to prevent or treat amblyopia. If a compensatory head posture allowing binocular fusion is present, patching may be optional unless there is a change in visual acuity or angle of deviation.[reviewofophthalmology.com]

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