UNDERSTANDING
NEUROLOGY
Third Edition
Abdel-Latif Moussa Osman
M.D., D.P.M. & N., D.M.
Professor & Chairman
Departments of Neurology
Faculty of Medicine
Al-Azhar University
Winner of the State Prize in Medicine
CAIRO
2005
‫بسم هللا الرحمن الرحيم‬
‫اا َ بس َففِ الَ‬
‫س ف َْ ا‬
‫س ف َْ ا‬
‫"الَ ي ِّ‬
‫ا َع َ‬
‫الَياَ فِ َ َبففِ ا اَ َ‬
‫ُكل ف ُ هللا فَ اسس فِ ال ِّالس ُع اه ف َ ََِا لَ ََ فِ َ َبففِ ََ َ‬
‫الَ ف‬
‫الَ اي فِ َ ِّ ا‬
‫حففرا ال ََم فِ َ َح َم ال َف ُ َ‬
‫ت ُ َؤاخ ف انفَِ ن فَسففي َِ َ اع ا َ اخَاافَففِا َ بس فِ َ َعالَ ت َ اَمففَ َ‬
‫فن لَْال َففِا َ بس فِ َ َعالَ ت ُ ََ ِّم ال فِ َ َبففِ الَ َ‬
‫ا سففِ َعا ا سف افر لَ فِ َ‬
‫اَلففنينَ ِّبف ا‬
‫قَِل فاَ لَ فِ َ ب ف ا عا اا ف ُ َ‬
‫الَ االقَ او ِّم اال َكِفِّ ِّرين"‬
‫َعا ا َح ام َِا َ اف َ‬
‫بوالَفِ َ فَِ اف ا‬
‫صرفَِ َ‬
‫ا ا‬
‫(الْقرة ‪)286‬‬
‫ِس فيم ُك ُ‬
‫"‪ ...‬فَا َ سبِ س‬
‫ضا ‪"...‬‬
‫الزبَد ُ فَيَنه ُ‬
‫ث فِّ األ ا ِّ‬
‫َب ُجسَِ الءا َع َ سبِ َبِ يَ سَ ُع ال س َ‬
‫(الراد ‪)17‬‬
‫‪Therapeutics, Emergencies & Prescriptions‬‬
‫‪Twelfth Edition, 2004‬‬
‫‪All rights reserved. No part of this book may be reproduced in any form‬‬
‫‪or by any means, without written permission of the author.‬‬
‫‪ANDALOSIA FOR PRINTING‬‬
‫‪TEL: 4023508 / 0106696883‬‬
‫‪National Deposit No‬‬
‫‪ISBN: 4 – 090 – 257 – 977‬‬
To The Memory of
My Father & Mother
PREFACE TOS
This book is an attempt to make neurology an understandable task for medical students,
general practitioners, and specialists who are interested in this field.
Neurology is no more considered "the speciality for the diagnosis of unbeatable disease".
Many neurologic diseases have specific therapies. Among treatable neurologic disorders are
: migraine, epilepsies, bacterial meningitis, neurosyphilis, pernicious anemia with subacute
combined degeneration of the spinal cord, myasthenia gravis,... etc.
The book included twenty chapters discussing Neurology Sheet (History, Examination, &
Investigations); The Cranial Nerves; The Pyramidal System; Cerebrovascular Disorders;
Hydrocephalus; Brain Tumours; Extrapyramidal Syndromes; Disorders of the Cerebellum;
Disorders of the Spinal Cord & Cauda Equina; Disorders of Peripheral Nerves; Disorders of
Voluntary Muscle & Myoneural Junction; Speech Disorders; The Epilepsies; Coma; Demyelinating Diseases of the Nervous System; Deficiency Disorders of the Nervous System;
Congenital & Degenerative Disorders of the Nervous System; & Infections of the Nervous
System.
Without ample knowledge on neuroanatomy, neurophysiology, neuropathology, and
neurochemistry, one can never understand clinical neurology. For this reason, a hint on
neuro-anatomy, neurophysiology, & neuropathology is given prior to clinical reviewing of
the common neurologic disorders.
Many diagramatic illustrations were included to clarify difficult points and make them
easier to grasp.
I hope this book will offer a new viewpoint of the field of neurology.
Cairo, January
1992
Abdel LatifM. Osman
CONTENTS
Page
CHAPTER 1 : NEUROLOGY SHEET ..............................................................
1
(HISTORY. EXAMINATION, & INVESTIGATIONS ) ......... 3. 5.28
CHAPTER 2 : THE CRANIAL NERVES .........................................................
38
The Olfactory Nerve (I).............................................................
38
The Optic Nerve (II)..................................................................
38
The Oculomotor Nerve (III).......................................................
42
The Trochlear Nerve (IV)..........................................................
42
The Abducent Nerve (VI)..........................................................
43
The Trigeminal Nerve (V).........................................................
51
The Facial Nerve (VII)...............................................................
54
The Auditory Nerve (VIII).........................................................
57
The Glossopharyngeal Nerve (IX).............................................
59
The Vagus Nerve (X)................................................................
59
The Accessory Nerve (XI) .........................................................
61
The Hypoglossal Nerve (XII)....................................................
62
CHAPTER 3 : THE PYRAMIDAL SYSTEM...................................................
64
Hemiplegia.................................................................................
65
Pseudobulbar Palsy....................................................................
69
CHAPTER 4 : CEREBROVASCULAR DISORDERS .....................................
71
Cerebral Haemorrhage...............................................................
74
Subarachnoid Haemorrhage.......................................................
76
Cerebral Embolism ....................................................................
77
Cerebral Thrombosis..................................................................
77
Hypertensive Encephalopathy...................................................
79
Syndromes of the Cerebral Arteries ..........................................
80
CHAPTER 5 HYDROCEPHALUS .................................................................
84
CHAPTER 6 BRAIN TUMOURS ..................................................................
88
CHAPTER 7 EXTRAPYRAMIDAL SYNDROMES ......................................
105
The Parkinsonian Syndrome......................................................
105
Chorea.........................................—.......................................
110
Huntington's Chorea ..................................................................
112
Hemiballismus...........................................................................
112
Athetosis .................................................„.......„.........*.„.....„....
113
Torsion Dystonia .......................................................................
113
CHAPTER 8 : DISORDERS OF THE CEREBELLUM....................................
116
Manifestations of Neocerebellar Lesion in Man ........................
118
Causes of Cerebellar Ataxia ......................................................
118
Hereditary Ataxias ....................................................................
119
Types of Ataxia..........................................................................
121
CHAPTER 9 : DISORDERS OF THE SPINAL CORD & CAUDA EQUINA
122
Paraplegia...................................................................................
123
Transverse Myelitis ...........<..............................................„...„...
128
Cauda Equina Lesion ................................................................
128
Conus Medullaris Lesion ..........................................................
129
Epiconus Lesion.........................................................................
130
Neurogenic Bladder...................................................................
131
CHAPTER 10 : DISORDERS OF PERIPHERAL NERVES ..................................
Polyneuropathy..............................................................................
CHAPTER 11: DISC LESIONS & SPONDYLOSIS .............................................
Cervical Disc Lesions & Spondylosis ............................................
Lumbar Disc Lesions & Spondylosis .............................................
Causes of Wasting of Small Hand Muscles ...................................
The Carpal Tunnel Syndrome ........................................................
CHAPTER 12 : DISORDERS OF VOLUNTARY MUSCLE & MYONEURAL
JUNCTION....................................................................................
Muscular Dystrophies..................................................................
Myotonias......................................................................................
Myasthenia..................................................................................
CHAPTER 13 : SPEECH DISORDERS .................................................................
Aphasia (Dysphasia)..................................................................
Dysarthria (Anarthria).................................................................
Aphonia (Dysphonia)...................................................................
Mutism...........................................................................................
Speech Disorders in Childhood .....................................................
Apraxia ........................................................................................y.
Agnosia..........................................................................................
Disorders of the Body - Image ......................................................
CHAPTER 14 : THE EPILEPSIES ..........................................................................
CHAPTER 15 : HEADACHE, MIGRAINE & OTHER PAINFUL SYNDROMES
Headache.........................................................................................
Migraine........................................................................................
Causes of Facial Pain ..................................................................
CHAPTER 16 : COMA .............................................................................................
CHAPTER 17 : DEMYELINATING DISEASES OF THE NERVOUS SYSTEM
Acute Disseminated Encephalomyelitis ........................................
Neuromyelitis Optica (Devic's Disease)........................................
Multiple Sclerosis (M.S.)...............................................................
Diffuse Sclerosis (Schilder's Disease)...........................................
CHAPTER 18 : DEFICIENCY DISEASES OF THE NERVOUS SYSTEM.........
Beriberi..........................................................................................
Pellagra ..............„„..............................,.............................<...........
Subacute Combined Degeneration of the Spinal Cord..................
Folate Deficiency...........................................................................
CHAPTER 19 : CONGENITAL & DEGENERATIVE DISORDERS OF THE .....
NERVOUS SYSTEM....................................................................
Cerebral Palsy................................................................................
Congenital Diplegia (Little's Disease)...........................................
Motor Neurone Disease (Amyotrophic Lateral Sclerosis).............
CHAPTER 20 : INFECTIONS OF THE NERVOUS SYSTEM ..............................
Syphilis of the Nervous System (Neurosyphilis)...........................
Meningitis......................................................................................
Encephalitis ......^............................................................................
QUESTIONS & ANSWERS :..........................................................;.......................
REFERNCES :..........................................................................................................
Page
132
132
141
142
144
145
146
147
147
152
154
157
158
159
160
160
160
161
161
162
163
171
171
173
176
177
183
183
183
184
187
188
188
189
190
191
192
192
192
192
195
195
198
202
205
208
CHAPTER 1 NEUROLOGY
SHEET
HISTORY, EXAMINATION, & INVESTIGATIONS
HISTORY
I - Personal History :
*Name: ........................................... * Age : .......................... * Sex : .......................
* Occupation : ................................. * Address : .................... * Habits : ..................
* Marital state :................................. * Handedness : ....................................................
II - Complaint:
2;^;;^;;^^^;^^;^;;^^;^^^;^^;^^;^^;;^;^^^^^
3.......................................................................................................................................
in - Family History : 1 . Positive blood consanguinity between the parents.........................
2 . Similar condition in the family......................................................
IV - Past History :
(Trauma, fever. Syphilis, T.B., diabetes, otitis media, rheumatism, bilharziasis,... etc)
V - History of the present illness :
(1) Duration: .................................. (2) Onset: .................... (3) Course :...............
(4) Symptomatology (Chronologically); .......................................................................
(5) Inquiry about other important symptoms (Symptoms of increased ICT, Cranial nerve
affection. Motor, Sensory or Sphincteric troubles).
EXAMINATION
I - The Mental State :
(1) Attention : ................................... (2) Orientation (for Time, Space & Persons) .......
(3) Memory (for Recent & Remote events) ......................................................................
(4) Mood : ....................................... (5) Delusions & Hallucinations............................
II - Speech and Articulation :
m - Cranial Nerves :
Rt
Lt
- Olfactory :........................................................................................................................
- Optic (2nd): * Visual Acuity : ........................................................................................
* Visual Fields : ........................................................................................
* Fundus :..................................................................................................
- The 3rd. 4th and 6th :......................................................................................................
* Pupils......................................................................................................
* External Ocular Movements (Individual & Conjugate)..........................
* Nystagmus : .............................................................................................
- Trigeminal : * Motor (temporal muscles, masseters and ptery golds ) ...........................
* Sensory : ......................................:..........................................................
* Corneal Reflex........................................................................................
* Jaw jerk...................................................................................................
- Facial:
* Motor : Upper face :.......................................... Lower face:...............
*7a^.........................................................................................................
- Auditory (Sth); ..............................................................................................................
Cochlear: * Whispered Voice ............................................. * Watch test..............
* Rinne's test ....................................................... * Weber's test ..........
Vestibular : * Rotational test .................................................. * Caloric test.............
- Glossopharyngeal and Vagus (9th & Wth) : ..................................................................
* Movement of the palate and pharynx (on saying Ah ) ...........................
* Palatal and pharyngeal reflexes (gag reflex ) .......................................
* Vocal Cords......................................^......................................................
^
*Accessory (llth) : .........................................................................................................
* Trapezii ............................................................ * Sternomastoids ....
- Hypoglossal (12th ) : Tongue ........................................................................................
IV - The Motor System :
1 . Muscle Status and Deformities :................„...........„.....,.„.....................................„..
2 .Muscle Tone:..............................................................................................................
3 . Muscle Power:..........................................................................................................
4 . Involuntary Movements (including fasciculation ) :.................................„..............
V- The Sensory System :
1 . Superficial Sensations:
* Pain......................................................................................................
* Temperature...........................................................................................
* Touch ....................................................................................................
2 . Deep Sensations :
* Position Sense.........................................................................................
* Sense of Movement.................................................................................
* Vibration Sense......................................................................................
3 . Cortical Sensations :
* Stereognosis............................................................................................
* Graphoesthesia.......................................................................................
* Two Point Discrimination.......................................................................
* Sensory Inattention.................................................................................
Vi - The Reflexes :
[7.L. ;
* Biceps Jerk ........................................................A
* Supinator Jerk .....................................................
0 = Absent
* Triceps Jerk ........................................................ [ ± = diminished
* Finger Jerks ........................................................ ( + = normal
L.L.:
* Knee Jerk.............................................................
++ to ++++
* Ankle Jerk.......................................................... J = exaggerated.
* Clonus (ankle or patellar):.......................................................................
Abdominal Reflexes : ......................................................................................................
Cremasteric Reflex:........................................................................................................
Plantar Reflexes:................................... >t = flexor,
T = extensor
VII - Co - ordination :
1 . Finger - to - nose test ..................................................................................................
2 . Finger - to - finger test.................................................................................................
3 . Heel - Knee test...........................................................................................................
Viii-Gait:...............................................................................................................................
IX - Skull and Spine :.......................................................................,....................................
X- Signs of Meningeal irritation :
1 . Neck Stijfness .........................................:....................................................................
2 .Kernig's sign...............................................................................................................
3 . Straight Leg Raising (Lasegue's sign)......................................................................
XI - Palpation and Auscultation of Carotids : ......,......................•..............<.....................
XII - General Examination :
1 . Chest :...................................... 2 . Heart: .............................................................
3 . Abdomen : ............................... 4 . Glands :.............................................................
5 .Pulse : ..................................... 6 . Temperature : ..................................................
^.B.P.: ......................................
PROBABLE DIAGNOSIS & DIFFERENTIAL DIAGNOSIS :
1 . Clinical Diagnosis. ................... 2 . Etiological Diagnosis ......................................
3 . Anatomical Diagnosis .............. 4 . Pathological Diagnosis ....................................
INVESTIGATIONS:
* CSF :......................................... * Radiography : .....................................................
*EEG : ........................................ *EMG&NCV :.......„.........................................
* Blood: ....................................... * Urine : ................................................................
* Stools : ..................................... * Other Investigations : ........................................
HISTORY
A good history is of utmost importance for proper \ diagnosis of neurological problems.
History includes the following;
1- PERSONAL HISTORY:
Name & Address : to get acquainted with the patient.
Age : Certain neurological diseases have certain age incidence. For example, a brain stem
lesion of rapid onset, at the age of 20, is most likely demyelinating in origin, whereas, in the 60s, it is probably vascular (basilar artery insufficiency). A cerebellar tumour in children (below 12) is probably a medulloblastoma, in early twenties, an astrocytoma or ependymoma, between 35 & 50 usually a haemangioblastoma, above
50, probably a metastais.
Sex : As sex incidence is met with in many neurological conditions e.g. myasthenia gravis
affects females more than males, while myotonia atrophica affects males more than
females.
Occupation : Occupational diseases in neurology are well known. People dealing with
lead industries may present with lead polyneuropathy with bilateral wrist drop. Individuals dealing with insecticides may develop toxic encephalopathy, myelopathy or
neuropathy. Farmers with schistosomiais (bilharziasis) may develop hepatic failure
with hepatic coma, flapping tremors and/or ammoniacal encephalopathy. Also they
may develop bilharzioma anywhere in the CNS.
Habits : * Excessive tea, coffee and I or smoking are usually associated with anxiety, insomnia and tremors of the fingers.
* Alcoholism may lead to alchoholic neuropathy, delirium tremens with drug withdrawal convulsions, Korsakoffs syndrome with amnesia for recent events, confusion,
disorientation and confabulation.
* Opium and morphine addicts have pin - point pupils.
Handedness : Whether the patient is right - handed or left - handed. Usually in right handed people the left hemisphere is the dominant one.
Marital state : Whether the pt. is married or not. Repeated miscarriages of the female partner point to syphilis.
II - COMPLAINT : Should be written in the patient's own words.
m - FAMILY HISTORY : Ask about:
(a) Similar condition in the family.
(b) Blood consanguinity between the parents.
IV - PAST HISTORY :
Trauma, fever, syphilis, T.B., bilharziasis and anti - bilharzial treatment, otitis media,
diabetes, hypertension, rheumatism, operations and similar condition in the past.
V- HISTORY OF THE PRESENT ILLNESS :
1. Duration.
2. Onset:
* Sudden (in few minutes) as in traumatic and vascular lesions.
* Rapid (in few hours or days) as in demyelinating and inflammatory disorders.
* Gradual (in one week or more) as in degenerative and neoplastic lesions.
3. Course:
* Regressive (improving): as in traumatic, vascular and inflammatory lesions.
* Progressive (worsening): as in degenerative and neoplastic lesions.
* Fluctuant (relapses and remissions): as in demyelinating disorders and sometimes in
vascular lesions.
* Stationary course : may occur in post- inflammatory conditions. 4. Detailing of the
complaint (Symptomatology) in a chronological sequence of events. 5 . Then ask about
the following symptoms (if the patient does not mention them in his
complaint):
(a) Symptoms of increased intracranial tension :
i. Headache : its location, character, radiation, relation to posture, what aggravates it &
what reliefs it ?
ii. Vomiting : relation to meals, nausea, character. iii.
Diminution of vision or blurring of vision. iv.
Convulsions.
(b) Symptoms of cranial nerve affection :
i. Anosmia: in olfactory lesions e.g. olfactory groove meningioma. ii. Diminution of
vision: in optic nerve lesions. iii. Diplopia & squinting : in lesions of oculomotor nerves
(3,4 & 6). iv . Facial pain or paraesthesias & difficulty in mastication : in trigeminal
nerve lesions.
v . Accumulation of food beneath the cheek: in facial nerve lesions. vi. Tinnitus and
deafness : in irritative and paralytic lesions of the cochlear divsion of
the 8th nerve.
vii. Vertigo: in lesions of the vestibular nerve. viii. Dysarthria, dysphagia, nasal
regurgitation of fluids and hoarseness of voice : in
lesions of 9th, 10th and 12th. cranial nerves.
(c) Symptoms of motor system affection :
<. heaviness, weakness and paralysis. ii.
atrophy or wasting. iii. cramps and spasms.
(d) Symptoms of sensory system affection:
i. Pains and paraesthesias : character, distribution, radiation, what aggravates it & what
reliefs it. ii. Hypoesthesia or
anesthesia.
(e) Symptoms of sphincteric disturbances :
i. Constipation.
u. Impotence.
iii. Bladder disorders :
* Retention of urine : is met with in lower motor neurone (L.M.N.) lesions including
sensory atonic bladder, motor atonic bladder and autonomic bladder.
* Retention with overflow : is met with in the sensory atonic bladder and the autonomic bladder.
* Precipitency of micturition: is met with in partial lesion of the pyramidal tracts.
(f) Coma, convulsions and / or aphasia with the onset.
(g) Symptoms of chest trouble :
i. Pulmonary tuberculosis : may be associated with the following neurological corn
plications:
* Tuberculous meningitis.
* Pott's disease of the spine with or without Pott's paraplegia.
* Peripheral neuropathy as a complication of I.N.H. & cycloserine therapy.
* Tinnitus, vertigo and deafness as a complication of streptomycin and dihydrostreptomycin therapy.
ii. Suppurative lung syndrome: may be complicated by brain abscess or toxic encephalopathy.
iii. Bronchogenic carcinoma: may be complicated by :
* Encephalopathy, myelopathy, neuropathy and myopathy.
* Metastases may occur in the brain, spinal cord, cranial bones or spine. (h)
Symptoms of cardiac trouble :
;. Rheumatic heart disease and atril fibrillation (A.F.) u. Infective endocarditis, iii.
Myocardial infarction.
All may be complicated by embolic hemiplegia. iv . Syphilitic or atherosclerotic aortic
aneurysm may be associated with intracranical
aneurysms. (i) Symptoms of
gastrointestinal trouble :
* Pellagra and subacute combined degeneration of the cord (B 12 deficiency) may be associated with gastrointestinal symptoms such as diarrhea, dyspepsia, vomiting and glossitis.
* Carcinoma of the stomach or of the colon may give CNS metastases. (j) Miscellaneous
symptoms such as :
* Epistaxis (Nasopharyngeal tumours & leprosy).
* Swellings in the neck, axilla or groin (Sarcoidosis, reticulosis and carcinomata).
* Skin pigmentation (Von Recklinghausen's disease).
* Ulcers in the mouth, scrotum and genitalia (Behcet's syndrome).
EXAMINATION I - THE MENTAL STATE :
1. Attention (Cooperation): Whether the patient is attentive (cooperative), or inattentive.
2 . Orientation : Whether the patient is well - oriented or disoriented to (i) time. (ii) place &
(iii) persons.
3 . Memory : for recent events & remote events. We may get:
* amnesia (loss of memory) for recent events.
* amnesia for remote events, or
* amnesia for both recent and remote events. Memory can be tested by :
* Asking about events of the same day, the last week, months or years.
* Give the patient a name and address and ask him to repeat it afrer 5 minutes.
* Make him try simple calculations.
* Make him try serial subtraction of 7 from 100.
* Digit forward and digit backward tests : normally one can repeat 7 or 8 numbers forwards and 4 or 5 backwards correctly.
4 . Mood : Whether anxious, excited, depressed, apathetic or euphoric.
* Euphoria is met with in disseminated sclerosis (D.S.) and in some patients with frontal
lobe disease.
* Emotional incontinence with uncontrolable laughing or crying, is met with in pseudobulbar palsy.
5 . Delusions and Hallucinations :
Delusions are false beliefs, not corrected by proof or reasoning and not conforming with
the patient's education, or culture. They may be grandiose delusions, persecutory
delusions,.... etc.
Hallucinations may be:
* Visual hallucinations: unformed in occipital lobe lesions and formed in temporal lobe
lesions.
* Auditory hallucinations: are met with in temporal lobe lesions.
* Olfactory hallucinations: in temporal lobe lesions e.g. uncinate seizures. n - SPEECH
& ARTICULATION :
Common Speech Defects:
1 . Dysphasia (or aphasia): is the inability to formulate a meaningful speech (motor or
expressive aphasia), or inability to understand spoken or written words (sensory or
receptive aphasia). It is due to a lesion affecting one or more of the cortical speech
centres.
2 . Dysarthia (or anarthria): difficulty in articulation of words or phrases. It results from
diseases of the peripheral neuromuscular mechanisms of speech.
3 . Dysphonia (or aphonia): the pt. fails to produce sound or only whispers. It results
from diseases of the larynx and vocal cords or may be hysterical.
4 . Mutism: the patient does not try to speak. Usually psychogenic in origin.
Methods of Testing Speech Function :
(i) Ask the patient to name some
common objects e.g.a pencil,
a comb, a box of matches,... etc.
(li) Ask the patient some simple
questions (his name, age and address).
(Hi) Ask the patient to read a
short paragraph. (iv) Ask the
patient to write
his name and address. (v) Give
him some simple
calculations e.g. simple sums. (vi)
Ask the patient to repeat
some phrases. (yii) Ask the patient
to count to
30 or more and notice any fatigue
or nasal tonation.
Examination for Aphasia : Spoon-Pencil Test
(yiii) Ask him to subtract 7 from 100, then 7 from the answer and so on.
m - THE CRANIAL NERVES :
The Olfactory Nerve (1st): is tested by asking the patient to inhale a nonirritant substance
such as coffee, almonds, peppermint or chocolate. Each nostril is tested alone. Loss of the
sense of smell is called anosmia. * Causes of anosmia : are discussed later. The Optic
Nerve (2nd):
(a) Visual acuity is tested by :
i. Asking the patient to
count fingers at different distances. ii.
Using the Snellen's type
chart for testing distant vision.
^ ^ ^^ ^
(Olfactory)
iii. Using the Jaegar Type cards for near vision. Each eye is tested alone.
(b) The visual fields are tested by :
i. The confrontation method:
the patient and examiner
face each other, with a
yard distance in between.
The examiner covers his
right eye and the patient
covers his left eye and
keep fixing on the
examiner's pupil while
the examiner moves his
finger inwards midway
between the patient and
himself, in each of the 4
quadrants of the field.
Estimation of Visual Fields by Confrontation
The patient should say the moment he sees the moving finger. Then the other eye
is tested in the same way. The last step is done by uncovering both eyes and testing
their fields together, to detect the phenomenon of visual inattention which is met
with in parietal lobe lesions.
ii. Perimetry : is a more accurate charting of the peripheral fields of vision. iii.
Bjerrum screen : is used to detect central scotomata and to measure the blind spot.
* Types of field defects : are discussed later.
(c) Fundus examination (Ophthalmoscopy):
This may reveal normal fundi, papilloedema, or optic atrophy
* Causes of papilloedema : are discussed later.
* Causes of opric atrophy : are discussed later. The Oculomotor Nerves (3rd, 4th
and 6th.):
(a) Note the presence or absence ofptosis, squint, exophthalmos or enophthalmos.
(b) Look at the size, shape, equality and regularity of the pupils.
(c) The pupillary light reflex:
Throwing light to the side of one eye -»
constriction of the pupil of this eye
(direct reaction) and of the opposite one
(consensual reaction).
(d) The reaction to Convergence
andAccomodationfor near vision: The
pt. while fixing
a distant object, is asked to look at the
examiner's finger or a pencil placed
about 9 inches in front of the bridge
of the nose —> convergence of eyes and
constricion of the pupils. (e) Pupillary
Abnormalities :
(i) Miosis occurs in :
* sympathetic lesions.
*
pontine haemorrhage.
* opium and morphine addiction. * after miotics e.g. eserine and pilocarpine. (ii)
Homer's syndrome : Consists of ptosis, miosis, enophthalmos, anhydrosis and warmth
of one half of the face. It occurs in lesions of the superior cervical ganglion.
(iii) Mydriasis : occurs in :
* paralysis of the parasympathetic fibres (3rd nerve.)
* atropine and homatropine.
(iv) Loss of light reflex : can result from a lesion in its afferent loop (retina, optic nerve,
or chiasma) or in the efferent loop (the parasympathetic supply from the midbrain
running with the 3rd n.). Bilateral failure to react, with intact vision, indicates a
midbrain lesion.
(v) Loss of accomodation reflex: is met with in upper brain stem lesions (tumours or
encephalitis) or in Parkinsonism.
(vi) The Argyll Robertson Pupil: is a small irregular pupil, not reacting to light, reacting
to accomodation and responding poorly to mydriatics. Causes:
* Syphilis (tabes dorsalis).
* Encephalitis.
* Multiple sclerosis
* Midbrain tumours.
* Diabetes.
* Alcoholism.
* Post traumatic.
(f) Examine the isolated ocular movements in different directions by asking the patient to
look upward, downward, outward and inward by each eye separately.
(g) Examine Conjugate ocular movements in all directions, by testing the patient's upward,
downward and lateral gaze.
The Third, Fourth, and Sixth Cranial Nerves (Oculomotor, Trochlear, and Abducens)
(h) Test for Nystagmus : by asking the patient to fix an object e.g. the tip of a pencil,
placed in the midline and then moved to left, right, upwards and downwards. Lateral
deviation should be maintained for 5 seconds at least for the nystagmus to occur and to
be noticed.
When testing for lateral gaze nystagmus, do not force the limbus of the iris beyond the lacrymal
punctum to avoid "end point nystagmus.** Nystagmus at this point is usually abnormal.
* Causes of Nystagmus : are discussed later.
The Trigeminal Nerve (5th):
(a) Examine Superficial Sensations over the face (ophthalmic, maxillary and mandibular
divisions).
(b) The Corneal Reflex : touching the cornea with a piece of cotton wool -> bilateral
blinking, (afferent loop is the 5th. nerve, efferent loop is the 7th.n.). Lost comeal
reflex may be the earliest sign of 5th n. lesion e.g. in cerebellopontine angle tumours.
cavernous sinus aneurysms and tumours, and orbital fissure syndrome.
Testing the corneal reflex: with the patient looking to one side, bring a wisp of cotton (a few
strands pulled out from a cotton - tipped applicator) from opposite side and touch cornea. The
patient should blink.
(c) The Motor Function of the 5th nerve:
* Ask the patient to clench his teeth and palpate the temporal muscles and masseters.
* Ask the pateint to open his mouth, while placing your hand under the jaw and notice
any deviation (pterygoid weakness).
(d) The Jaw Jerk- Ask the patient to open his mouth slightly, then place your left forefinger
below the lower lip. Tapping the finger in a downward directionmay induce a
S^S^KT "^^ ^rk;Normally'the jaw jerk is weak or absent-lt" exaggerated in U.M N.L above the level
of the pons e.g. pseudobulbar palsy, motor neurone disease and multiple sclerosis
(MS),
"curune
The Facial Nerve (7th):
(a) Inspect the face of the patient, the wrinkles of the forehead, the nasolabial folds, mSv^
""^"^"ts of the mouth during talking or smiling, for any asym-
(b) Motor functions are examined as follows:
i. Ask the patient to wrinkle his forehead. « . Ask the patient to close his eyes
tightly and to resist attempts to open them
m .Ask the patient to show his teeth and to open his mouth and compare the naso labial tolds and the symmetry of movements in both conditions. iv. Ask the patient to
whistle and to blow out the cheeks. v. Try to make the patient smiles,
vi. Elicit the
glabellar reflex on both sides
(c) Taste sensation is examined over the anterior two thirds of the tongue by moistening
it (while protruded) with a little of sugar, salt, vinegar or quinine (fo testing: sweet, salt,
sour, and bitter tastes respectively).
(d) Secretory functions:
i. Giving the patient ammonia to inhale and
compare the flow of tears on the 2 sides. ii.
Placing a spiced substance on the tongue and
compare the flow of saliva. Facial Palsy may
be an upper motor neurone paralysis or a
lower motor neurone paralysis. It may be
unilateral or bilateral.
An upper motor neurone (U.M.N.) facial
weakness :
A lesion anywhere between the opposite
cortex and the facial nucleus in the pons SL deviation of the mouth to the opposite side
and obliteration of the nasolabial fold on the same side. U.M.N. facial weakness occurs
on the opposite side of the lesion.
A lower motor neurone facial weakness (L.M.N.L.) :
Due to a lesion between the nucleus in the pons and the muscle AL inability to close the
eye with upward turning of the eyeball on attempted closure, loss of blinking, loss of
wrinkling of the forehead, blunted nasolabial fold and deviation of the mouth to opposite
side. L.M.N. facial weakness occurs on the same side of the lesion.
* Causes of facial palsy : are discussed later.
The Auditory (Acoustic) Nerve (8th):
It has two parts:
(a) The cochlear nerve, (b) The vestibular nerve.
A- Examination of Hearing:
(i) Whispering test. (ii) Watch
test.
The Eighth Cranial Nerve
(Auditory Division)
(iii) Rinnes test'. Comparing
bone conduction and air
conduction, by placing a
striked
tuning fork on the
mastoid, then hold it near the external meatus. Normally air
conduction is better than bone conduction. In conductive deafness (middle
ear deafness) the reverse occurs.
_
While in perceptive deafness
(nerve deafness )both are
reduced, but air conduction
remains the better. (iv) Weber's
test: Placing the fork
central on the forehead . In
nerve deafness , the sound is
lateralized to the normal ea, but in
conductive deafness, it is
lateralized to the diseased ea
(v) Audiomctry : is a quantitative measurement of hearing using musical notes of varying pitch
produced by an electric oscillator. B - Tests of Vestibular Function:
1. The Rotational Test:
The patient is seated on a chair with his head supported and fixed. The chair is rotated
10 times in 20 seconds, then suddenly stopped.
Normally -> nystagmus, past - pointing, falling and vertigo.
2. The Caloric Test:
The ear is irrigated with water (250 ml, first at 30°C . and later at 44 °C) through the
external auditory meatus over a period of 40 seconds.
Rt.ear: * Nystagmus to the left on using cold water.
* Nystagmus to the right on using warm water. Lt. ear: * Nystagmus to the right
on using cold water.
* Nystagmus to the left on using warm water. N.B.: In patients with perforated
drum, air is used instead of water.
The response to caloric test may be lost or markedly diminished in Meniere's disease
and in vestibular nerve lesions e.g. acoustic neurinoma and vestibular neuronitis.
Caloric test; A. With the patient sitting in a chair with the head tilted to one side, inject 2 cc of ice
water in the external canal. B. Remove water, tilt head backwards 60°, and observe and time the
nystagmus. Quick movements will be directed away from the cold ear.
C - Electronystagmography:
Electrical recording of ocular movements is done to obtain a graphic record of nystagmus.
The Glossopharyngeal & Vagus Nerves (9 th& 10th):
The 9 th cranial nerve carries common sensation from the pharynx, tonsils, soft palate
& posterior third of the tongue, as well as taste sensation from the posterior 1/3 of the
tongue.
The vagus is motor to the palatal and pharyngeal muscles and to the vocal cords.
(a) Motor Functions:
Ask the patient to open his mouth and to say "Ah "and watch the movement of the palate,
uvula and the two sides of the pharynx.
* Unilateral palatal paralysis —> movement of the palate to the normal side on phonation.
* Unilateral pharyngeal paralysis —> movement of the pharynx towards the normal side
on phonation.
Both conditions are caused by L.M.N.L. of the vagus.
* Bilateral palatal and pharyngeal paralysis is usually associated with dysphagia, nasal
regurgitation and nasal tonation of speech and indicates pseudobulbar palsy (Bil.
U.M.N.L.), true bulbar palsy (Bil. L.M.N.L.) or motor neurone disease.
(b) Sensory Functions:
i. Common sensation: Touching the palate, pharynx, tonsil or the back of the tongue ->
gag reflex (contraction of the pharynx, elevation of the palate and retraction of the
tongue) (afferent = 9 th., efferent = 10 th.)
Pharyngeal reflex
ii. Taste : is tested on the posterior third of
the tongue using a galvanic current of 2- 4
mA. and touching the tongue with the
anode-> metallic taste. (c) The vocal cords: should be examined in patients with
hoarseness of voice. Normally
abduction of the cords occurs during inspiration and adduction occurs during phonation.
The Accessory Nerve(llth.):
It is the motor nerve to the upper part of the trapezii and to the stemomastoids.
(a) Trapezius:
The patient is asked to raise his shoulders (while he is sitting upright) and the examiner
tries to depress them forcibly (from behind).
Weakness of the trapezius results in drooping of the shoulder on the same side.
(b) Stemomastoids:
Ask the patient to turn his head to either side against resistance and palpate the stemo13
mastoid on the opposite side, then ask him to flex his head forwards against the resistance of your hand, being
placed on his forehead and compare the two stemomastoids