Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (93 page)

Testing should be designed to rule out causes of underlying diseases, serology for herpes simplex, HIV, and other viruses; Borrelia; Ehrlichia; and other agents as appropriate by history. If collagen vascular disease is suspected, an ANA test may be of help. Bell palsy may occasionally present with a slight increase in cells in the CSF.

References

1.  Peitersen E. The natural history of Bell’s palsy.
Am J Otol.
1982;4:107.

2.  Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies.
Acta Otolaryngol Suppl.
2002;(549):4–30.

3.  Morgan M, Nathwani D. Facial palsy and infection: the unfolding story.
Clin Infect Dis.
1992;14:263.

4.  Markby DP. Lyme disease facial palsy: differentiation from Bell’s palsy.
BMJ.
1989;299:605.

5.  Bitsori M, Galanakis E, Papadakis CE, et al. Facial nerve palsy associated with Rickettsia conorii infection.
Arch Dis Child.
2001;85:54.

6.  Lee FS, Chu FK, Tackley M, et al. Human granulocytic ehrlichiosis presenting as facial diplegia in a 42-year-old woman.
Clin Infect Dis.
2000;31:1288.

7.  Levenson MJ, Ingerman M, Grimes C, et al. Melkersson-Rosenthal syndrome.
Arch Otolaryngol.
1984;110:540.

HEMIANOPSIA, BITEMPORAL

   Definition

Bitemporal hemianopsia is the loss of vision in the temporal fields due to a mass lesion causing compression of the optic chiasm.

   Clinical Presentation

Patients present with decreased vision in the temporal fields. The most common cause is pituitary adenoma (see eBook Figure 4-12), but any mass lesion may be causative, including metastatic tumor, sarcoidosis, Hand-Schüller-Christian disease, meningioma of sella (see eBook Figure 4-13), craniopharyngioma (see eBook Figure 4-14), and aneurysm of the circle of Willis.

Diagnosis is predominantly made by neuroimaging. Biopsy may help identify tumor type.

OPHTHALMOPLEGIA

   Definition

Internuclear ophthalmoplegia is an impairment of horizontal eye movement. There is weak adduction of the affected eye and abduction nystagmus of the contralateral eye. It is the result of a lesion in the medial longitudinal fasciculus.

   Clinical Presentation

Patients may present with a number of causative disorders including MS (approximately 30% of cases and most common in younger patients, also tends to be bilateral),
^1,2
cerebrovascular disorders (infarction is most common in older patients), infection, trauma, and tumor.

Diagnosis is based on physical findings and neuroimaging with MRI and specialized neural ophthalmologic techniques such as oculographic recording.
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The differential diagnosis includes oculomotor nerve palsy.

   Laboratory Findings

Testing is directed at identifying the causative disease. Tests to rule out DM, vasculopathies, multiple sclerosis, myasthenia gravis, hyperthyroidism, infection, and drug toxicities will be of help.
³

References

1.  Frohman EM, Zhang H, Kramer PD, et al. MRI characteristics of the MLF in MS patients with chronic internuclear ophthalmoparesis.
Neurology.
2001;57:762.

2.  Frohman EM, Frohman TC, O’Suilleabhain P, et al. Quantitative oculographic characterisation of internuclear ophthalmoparesis in multiple sclerosis: the versional dysconjugacy index Z score.
J Neurol Neurosurg Psychiatry.
2002;73:51.

3.  Keane JR. Internuclear ophthalmoplegia: unusual causes in 114 of 410 patients.
Arch Neurol.
2005;62:714.

OCULOMOTOR NERVE PALSY

   Definition

Oculomotor nerve palsy may result from lesions of the third cranial nerve (oculomotor nerve) anywhere along its path.

   Clinical Presentation

The diagnosis varies by patient age, type of diplopia, and lid involvement. The most common causes include intracranial aneurysm, ischemia, trauma, and migraine. Ischemic diabetic third nerve palsies are the most common etiology in adults. Traumatic third nerve palsy arises only from severe blows to the head. Ophthalmoplegic “migraine” has been reclassified as a cranial neuralgia by the International Headache Society in 2004.
¹

The differential diagnosis includes MS (may mimic pupil-sparing ophthalmoplegia) and orbital inflammation or fracture. The diagnosis rests on complete history, and neurologic exam and neuroimaging with MRI, MRA, or CTA to rule out aneurysm.
²

   Laboratory Findings

Laboratory testing can help in the diagnosis of diabetes and vasculopathies (glucose, hemoglobin A1c, sedimentation rate). Testing to exclude myasthenia gravis should be performed in younger patients.

References

1.  Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders.
Cephalalgia.
2004;24:1.

2.  Jacobson DM, Trobe JD. The emerging role of magnetic resonance angiography in the management of patients with third cranial nerve palsy.
Am J Ophthalmol.
1999;128:94.