2 pence (or euro cents) to add here...
Hmmm... speaking from limited experience, I'd scan her head fairly soon, I'd
just be worried about acute things that can knacker the 6th nerve along its
merry intra-cranial way. Really tiny pontine CVA's just knocking out the 6th
nerve nucleus and nothing else are probably too rare but a CT would show
this too.
If that were negative I guess it would be a toss up between demyelination
and one of the other very many causes of a mononeuritis (vasculitis et
cetera) or a lateral rectus muscle problem.
Okay, it could be migraine, but I'd sooner have a scan with the history of
headache.
Strangely enough Dr. Ryan, I admitted recently a woman with essentially the
EXACT same history - but this time, it was a paralyzed INFERIOR OBLIQUE, and
oh she was 60 odd years of age.
This lady I begged for a scan, with concern about the cavernous sinus and
orbits - which were clear, then the usual demyelination work up - unlikely
given her age, so it duly came back negative. Hadn't a clue what was going
on. Top differential at the time was an isolated occular muscle palsy...
Neurology couldn't give a specific diagnosis, so the opthalmology boys came
round, and sure enough they said, we know what it is, it's 'Brown's
syndrome'
What?
Apparently it's some sort of isolated occular myopathy ? inflammatory. And
it's idiopathic although 'NSAIDs may help'
Last I heard she was still seeing double looking in and up. (3 months).
Anyone else EVER see anything like that?
Robert Spykerman
----- Original Message -----
From: "John Ryan" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, October 09, 2001 10:22 PM
Subject: Isolated 6th nerve palsy
> A 48 year old, cigarette smoking, otherwise well, lady presents with a 3
day
> history of diplopia which was preceded by unilateral headache for 2 days,
> resolving with onet of diplopia. Examination reveals a marked lateral
> rectus palsy on the right side and she has already patched the eye to
> prevent diplopia. Examination is otherwise completely normal. Blood
sugar
> and BP normal, nothing to suggest demyelination or auto immune pathology.
>
> Would you ?
>
> 1) Arrange urgent CT
> 2) Arrange urgent MRI
> 3) Referr to neurology OPD, (next available appointment in a future era)
> 4) Discharge her telling her many of these resolve after 3 months (as per
> Tintanelli !)
> 5) Some other bright idea ?
>
> John Ryan
>
>
>
>
>
>
>
> Dr John Ryan
>
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