METHODICAL INSTRUCTION FOR STUDENTS OF THE 4 COURSE
MEDICAL FACULTY
LESSON № 3 (PRACTICAL – 6 HOURS)
Theme:
1. Midbrain. Anatomy and symptoms of lesion of Oculomotor (III, IV, VI) and I, II Cranial nerves. Methods of examination. Alternate syndromes
2. Pons. Symptoms of lesion of V, VII, VIII Cranial nerves. Alternate syndromes.
3. Medulla Oblongata. Symptoms of lesion of IX, X, XI, XII Cranial nerves and above nuclear tracts. Bulbar and pseudobulbar syndrome. Alternate syndromes.
Aim: Students should be able to find out symptoms of Cranial nerves lesions, to localize the pathological processes.
Professional orientation of students: Examination of Cranial nerves is essential to a complete study of the nervous system. In order to localize lesions within the brain stem one must know the location and function of the tracts and nuclei. The Cranial nerves’ lesions may result from different disease. Aneurysms of the internal carotid system, tumors, and inflammatory lesion in the region of the sella and pressure from herniation of the uncinate gyrus in expanding lesion oculomotor palsy. Different specialties must know the symptoms of lesion of Cranial nerves.
Methodology of Practical Class (9:00-12:00).
Algorithm of students’ communication with patients with pathology in subject (communication skills) :
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing
4. Find a contact with a patient, try to gain his/her confidence
5. Correct inquest, listening to the patient’s explanation.
6. Conversation accomplishment.
Physical methods of examination
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing
4. Find a contact with a patient, try to gain his/her confidence
5. Explain to the patient the nessessity of the examination and its aim, get his/her informed consent
6. Explain to the patient examination details, its safety and possible sensations
7. Prepare for the examination (clean, warm hands, ets.)
8. Explain to the patient results of his/her tests correctly and accesibly
9. Conversation accomplishment.
Work 1.
Midbrain. Anatomy and symptoms of III, IV, VI nerves’ lesions. Symptoms of I, II nerves lesion. Alternate syndromes.
Step I. Aim: Find out the symptoms of I, II, III, IV, VI nerves lesions. For this purpose it is necessary to examine the patient. Make the conclusion of the presence of nerves lesions symptoms.
Step II. Aim: To localize processes within the separate anatomic structures of brain stem. It’s necessary to use algorithm of differential diagnosis, which is described in methodological indication for students.
Step III. Aim: To do topical diagnosis and to explain it. To show in the topical diagnosis the leading syndrome and the section of lesion of brain stem.
Alternate midbrain syndrome:
Weber’s syndrome – a lesion in the base of the cerebral peduncle affects the root of the third cranial nerve and the corticospinal tract, producing Oculomotor nerve palsy and a contralateral hemiplegia.
Benedict’s syndrome – Oculomotor nerve palsy and a contralateral choreoatetosis and intention tremor.
Clod’s syndrome – Oculomotor nerve palsy and a contralateral cerebellar ataxia.
Work 2.
Pons. Symptoms of V, VII, VIII nerves lesions. Alternate syndromes.
Step I. Aim: Find out the symptoms of V, VII, VIII nerves lesions. For this purpose it is necessary to examine the patient.
Step II. Aim: To localize processes within certain anatomic structures of pons. With this aim it’s necessary to use algorithm of differential diagnosis, which is in methodological indication for students.
Step III. Aim: To put topical diagnosis and to explain it. To show in the topical diagnosis the leading syndrome and the section of lesion of brain stem.
Alternate pond’ syndromes:
Raymond syndrome – a lost of sensation on the face according to the segmental type on the side of the lesion both lost superficial sensation on a trunk and extremities on opposite side.
Miyar-Gubler syndrome – peripheral palsy of the facial muscles on the side of the lesion and a contralateral hemiplegia.
Fovill syndrome – peripheral palsy of the facial muscles and the external rectus eyes’ muscle on the side of the lesion and a contralateral hemiplegia.
Work 3.
Medulla Oblongata. Symptoms of IX, X, XI, XII nerves lesion. Bulbar and pseudobulbar syndrome. Alternate syndromes.
Summery:
|
Nerves |
Symptoms |
|
n. Glossopharyngeal n. Vagus |
the voice is hoarse or brassy; dysphagia and regurgitation of fluids through the nose; the testing of taste sensation on the posterior one third of the tongue; ipsilateral paralysis of the palatal, pharyngeal, and laryngeal muscles; bilateral lesion (dyspnea, apnea, periodic respiration – Cheyne-Stokes breathing) |
|
n. Accessory |
the patient can’t turn his head; the trapezium ridge is depressed; the scapula appears rotated; evidenced by difficulty in elevating the arm above the horizontal. |
|
n. Hypoglossal |
deviation of the protruded tongue toward the side of the lesion; dysarthria; |
Step II. To find out the character of paresis or paralysis (bulbar or pseudobulbar).To do it it’s
necessary to examine the patient, paying attention on such symptom:
|
Bulbar syndrome |
Pseudobulbar syndrome |
|
gag reflex is absent or decreased |
gag reflex is present |
|
the tongue is atrophic |
the tongue is not atrophic |
|
the pathologic oral reflexes is absent |
the pathologic oral reflexes are present |
|
paralysis is unilateral or bilateral |
paralysis is only bilateral |
|
may be (dyspnea, apnea, periodic respiration – Cheyne-Stokes breathing) |
— |
Make the conclusion for the presence of bulbar or pseudobulbar syndrome.
Bulbar syndrome produces the lesion of the n. Glossopharingeal, n. Vagus and n. Hypoglossal (nucleus or radix). Pseudobulbar syndrome produces the bilateral lesion of the tr. Cortical-nuclear.
Step III. Aim: To localize processes within certain anatomic structures of medulla oblongata. With this aim it’s necessary to use algorithm of differential diagnosis, which is in methodological indication for students.
Step IV. Aim: To put topical diagnosis and to explain it. To show in the topical diagnosis the leading syndrome and the section of lesion of brain stem.
Alternate intramedular syndromes:
Jackson’s syndrome – Hypoglossal nerve palsy on the site of the lesion and opposite hemiplegia.
Aweli’s syndrome – peripheral palsy of the palatal and laryngeal muscles on the site of the lesion and a contralateral hemiplegia.
Schmidt’s syndrome – peripheral palsy of the muscles (palatal, laryngeal, tongue and m. sternoclaidomastoideus, m. trapezius) on the site of the lesion and a contralateral hemiplegia.
Valenberg – Zakcharchenko’ syndrome – on the site of the lesion (nystagmus, Horner’s syndrome, peripheral palsy of the palatal and laryngeal muscles, a fallout of sensation on the face for the segmental type, cerebellar ataxia) and a contralateral hemiplegia, hemianestesia.
Individual Students Program.
You should be subjects prepared for the practical lesson using the existing textbooks and lectures. Special attention should be paid to the following:
Theme: 1. Midbrain. Anatomy and symptoms of III, IV, VI nerves’ lesions. Symptoms of I, II nerves lesion. Alternate syndromes.
1. Symptoms of Oculomotor nerve lesion on different levels:
a) lesion of cortical-nuclear tract;
b) lesion of nuclei in the midbrain (Weber’s and Benedict’s syndromes);
c) lesion of the nerve;
d) lesion of parasympathetic and sympathetic innervation of eyes (Horner syndrome).
2. Symptoms of Trochlear nerves lesion:
a)lesion of cortical-nuclear tract;
b) lesion of nucleus in the midbrain;
c)lesion of the nerve;
3. Symptoms of Abducens nerves lesion:
a)lesion of cortical-nuclear tract;
b) lesion of nucleus in the pons ( Fovill syndrome);
c)lesion of the nerve;
4. Symptoms of Olfactory nerves lesion:
a) lesions of neurons of the first order;
b) lesions of neurons of the second order;
c) lesions of neurons of third order;
d) lesion of cortex.
5. Symptoms of Optic pathway lesions on any level of defeat:
a) lesion of the Optic nerve;
b) lesion of the chiasm;
c) lesion of the optic tract;
d) lesion of the Thalamus;
e) lesion of the optic radiation;
f) lesion of the cortex of occipital lobe.
6. Examination of the retina and the disk:
a) «choked disk»;
b) «retrobulbar neuritis»;
c) primary optic atrophy;
d) secondary optic atrophy;
e) retinal emboli.
7. Symptoms of the cortical center for voluntary conjugate movement lesions.
Theme 2. Pons. Symptoms of V, VII, VIII nerves lesions. Alternate syndromes.
1. Symptoms of Facial (VII) nerve’s lesion;
e) lesion of tr. Cortical-nuclear;
f) lesion of tr. Nuclear-muscular;
g) lesion of n. Intermediate (Wrisberg).
2. Differential symptoms of Facial (VII) nerve lesion on different levels:
a) in the pons ( alternate syndromes of the Miyar- Gubler, the Fovill)
b) in the cerebellar-pontine angle;
c) in the facial canal of the temporal bone;
d) extra cranial lesion.
3. Symptoms of Trigeminal (V) nerve lesion:
a) symptoms of sensation part lesion;
b) symptoms of motor part lesion.
4. Differential symptoms of Trigeminal (Vth) nerve lesion on different levels:
a) lesion of the postcentral gyrus;
b) lesion of the capsule internal, the thalamus;
c) lesion of pons (alternate syndromes of the Raymond);
d) lesion of cerebellar-pontine angle;
e) lesion of the Gasserian ganglion;
f) lesion of three branches (the Ophthalmic, the Maxillar, the Mandibular).
5. Symptoms of Cochlear and Vestibular pathways lesion:
a) Cochlear division lesions;
b) Vestibular division lesion;
c) lesion in the cerebellar-pontine angle;
d) lesion of the nucleus in the pons;
e) lesion of the cortex of Temporal lobes.
Theme 3. Medulla Oblongata. Symptoms of IX, X, XI, XII nerves lesion. Bulbar and pseudobulbar syndrome. Alternate syndromes.
1. Symptoms of IX, X, XI, XII nerves lesion:
a) Lesion of Corticonuclear tract;
b) lesion of nuclei;
c) lesion of nerve.
2. Symptoms of XI nerve lesion:
a) lesion of nuclei;
b) lesion of nerve.
3. Symptoms of XII nerve lesion:
a) lesion of Corticonuclear tract;
b) lesion of nuclei;
c) lesion of nerve.
4. Alternating syndromes of the medulla oblongata:
a) Jackson, Awelis;
b) Schmidt, Valenberg – Zakcharchenko;
Seminar discussion of theoretical issues 12:30-14.00.
Test evaluation and situational tasks.
Tests
1. Name the symptoms of lesion of Oculomotor nerve.
2. Name the symptoms of lesion of Trochlear nerve.
3. Name the symptoms of lesion of Abducens nerve.
4. Describe the symptoms of lesion of Optic nerve.
5. Name the symptoms of lesion of Optic chiasm (all variants);
6. Name the symptoms of lesion of the Optic tract.
7. Name the symptoms of lesion: cuneus, gyrus lingualis, sulcus calcarinus;
8. Where is localized the cortex center of vision? Name the symptoms of lesion.
9. Describe the Horner syndrome.
10. Where is localized the cortex center of voluntary conjugate movements of head and eyes? Name the symptoms of lesion.
11. Where is localized the pons center of voluntary conjugate movements of head and eyes? Name the symptoms of this lesion.
12. Name the symptoms of lesion of the left olfactory bulb and olfactory tract.
13. Describe the Weber’s syndrome.
14. Describe the Benedict’s syndrome.
15. Methods of anopsia examination.
16. Methods of anisocoria examination.
17. Describe the Argyll-Robertson’s syndrome.
18. Describe the Raymond’ syndrome.
19. Name the symptoms of lesion of Facial nerve in the facial canal before and after the greater superficial petrosal nerve passage.
20. Differential diagnosis between lesion of the nuclei and the sensory root of the Trigeminal nerve.
21. Name the symptoms of lesion of the Facial nerve extracranial portion.
22. Name the symptoms of the cerebellopontine angle lesion.
23. Differential diagnosis of the nuclei and the extracranial portion of Facial nerves’ lesion.
24. Symptoms of central paralysis of the muscles of facial expression.
25. Symptoms of peripheral paralysis of the muscles of facial expression.
26. Describe the Miyar- Gubler syndrome. Where is the process localized?
27. Describe the Fovill syndrome.
28. Describe the anatomy of Acoustic nerve.
29. Symptoms of the Cochlear nucleus lesion.
30. Symptoms of the Vestibular nerve lesion.
31. Symptoms of the Ophthalmic nerve lesion.
32. Symptoms of the Maxillary nerve lesion.
33. Symptoms of the Mandibular nerve lesion.
34. Symptoms of the Gasserian ganglion lesion.
35. Name the symptoms of Facial nerves lesion in the facial canal before n. stapedius passage.
36. Name the symptoms of Facial nerves lesion.
37. Name the symptoms of Facial nerves lesion in the facial canal before Chorda timpani passage.
38. Symptoms of lesion of left part of the Pons.
39. Symptoms of lesion of the descending root of the Trigeminal nerves.
40. Name the symptoms of XI nerves lesion.
41. Name the symptoms of XII nerves lesion.
42. Name the symptoms of bulbar syndrome.
43. Name the symptoms of pseudobulbar syndrome.
44. Describe the symptoms of IX nerves lesion.
45. Describe the symptoms of X nerves lesion.
46. Differential sign of bulbar and pseudobulbar syndromes.
47. Describe
48. Name the pathologic oral reflexes.
49. Describe Awelis’ syndrome.
50. Describe Schmidt’s syndrome.
51. Describe Valenberg – Zakcharchenko’ syndrome.
Real – life situation to be solved:
1. The patient has bitemporal hemianopsia. Where is the process localized?
2. The patient has ptosis, miosis and enophthalmia in the left. Name the syndrome. Where is the process localized?
3. Describe the Weber’s syndrome. Where is the process localized?
4. The patient has acute diplopia when looking right. What nerve is damaged?
5. Describe the Miyar- Gubler syndrome.
6. Describe the Raymond’ syndrome.
7. The patient has a facial paralysis, impairment of taste. Where is the process localized?
8. Patient has prosoplegia, xerophtalmia, ageyzia of anterior 2/3 of tongue. What vegetative structures are damaged? Where?
9. Name the symptoms of bulbar paralysis.
10. In patient with the cranium basis rupture dysphagia and dysphonia symptoms appeared incisively. Objective: immovable left part of palate there is, no reflex from palate and left part of posterior gullet wall. The patient can’t raise his left hand upper then horizontal level and turn his head to the right side. What is damaged? Localize process.
11. In patient without dysfunction of swallowing, voice and language, reflex’s of oral automatism were found. What’s damaged?
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.
Student should know:
1. Symptoms of Facial (VII) nerve’s lesion.
2. Symptoms of VI -th nerve’s lesion.
3. Symptoms of VIII -th nerve’s lesion.
4. Symptoms of V-th nerve’s lesion.
5. Symptoms of І nerve’s lesion.
6. Symptoms of ІІ -th nerve’s lesion.
7. Symptoms of III -VI-th nerve’s lesion.
8. Symptoms of IX, X, XI, XII nerves lesion.
9. Alternating syndromes of the medulla oblongata.
Student should be able to:
1. To localize processes within certain anatomic structures of pons.
2. To localize processes within certain anatomic structures of midbrain
3. To put topical diagnosis and to explain it.
Correct answers of test evaluations and situational tasks:
1. When the patient has bitemporal hemianopsia the process is localized in the middle part of chiasma, in its crossed fibbers.
2. Horner syndrome.
3. The symptom of paralysis of III nerve (ptosis, squint, diplopia, midriasis, accommodation and convergation paralysis) on the lesion side and central hemiparalysis on the opposite side. The process is in legs of the brain.
4. Right Abducens nerve.
5. On the side of lesion process a facial paralysis, on another side extremities paralysis.
6. Alternative superficial hyposthesia.
7. Process is localized in cerebellopontine angle.
8. Lesion of n. petrosus major and chorda tympani in canalis nervi facialis.
9. Dysphagia, dysphonia, dysarthria, decreased gag reflex from posterior gullet wall.
10. N. Vagus, n. Glossopharyngeal, n. Accesorry on left side. The lesion is in the area of left jugular foramen.
11. Cortical-nuclear Tract.
Independent work of students 14:15-15:00
References:
А – Basic:
1. Basic Neurology. Second edition. John
2. Clinical examinations ieurology – Mayo clinic and Mayo foundation.- 4-th edition.- W.B. Saunders Company, Philadelphia, London, Toronto.- 1976.
3. WEB-site of tdmu.
Material for practical classes
В – Additional:
3. Neurology for the house officer.- 3-th edition.-Howard L. Weiner, MD and Lawrence P. Levitt, MD,- Williams &Wilkins.- Baltimore.- London.- 1980.
4. Van Allen’s Pictorial Manual of Neurologic Tests.- Robert L. Rodnitzky.- Third edition.-Year Book Medical Publishers, inc. Chicago London Boca Raton. – 1981.
Methodical instruction has been worked out by: dotsent N.R. Sokhor
Methodical instruction was discussed and adopted at the Department sitting
20.05.2013 . Minute № 9
Methodical instruction was adopted and reviewed at the Department sitting
