The recurrent laryngeal nerve lies close to the thyroid gland. It may be damaged in difficult surgical procedures, and this may produce unilateral spasm of the ipsilateral vocal cord to produce a hoarse voice.
Since the thyroidectomy and institution of thyroxine treatment, the patient has lost weight and has no further complaints.
A 33-year-old man was playing cricket for his local Sunday team. As the new bowler pitched the ball short, it bounced higher than he anticipated and hit him on the side of his head. He immediately fell to the ground unconscious, but after about 30 seconds he was helped to his feet and felt otherwise well. It was noted he had some bruising around his temple. He decided not to continue playing and went to watch the match from the side. Over the next hour he became extremely sleepy and was eventually unrousable. He was rushed to hospital.
When he was admitted to hospital, the patient’s breathing was shallow and irregular and it was necessary to intubate him. A skull radiograph demonstrated a fracture in the region of the pterion. No other abnormality was demonstrated other than minor soft tissue bruising over the left temporal fossa.
A CT scan was performed.
The CT scan demonstrated a lentiform area of high density within the left cranial fossa.
A diagnosis of extradural hemorrhage was made.
Fractures in the region of the pterion are extremely dangerous. A division of the middle meningeal artery passes deep to this structure and is subject to laceration and disruption, especially in conjunction with a skull injury in this region. In this case the middle meningeal artery was torn and started to bleed, producing a large extradural clot.
The patient’s blood pressure began to increase.
Within the skull there is a fixed volume and clearly what goes in must come out (e.g., blood, cerebrospinal fluid). If there is a space-occupying lesion, such as an extradural hematoma, there is no space into which it can decompress. As the lesion expands, the brain becomes compressed and the intracranial pressure increases. This pressure compresses vessels, so lowering the cerebral perfusion pressure. To combat this the homeostatic mechanisms of the body increase the blood pressure to overcome the increase in intracerebral pressure. Unfortunately, the increase in intracranial pressure is compounded by the cerebral edema that occurs at and after the initial insult.
An urgent surgical procedure was performed.
Burr holes were placed around the region of the hematoma and it was evacuated. The small branch of the middle meningeal artery was ligated and the patient spent a few days in the intensive care unit. Fortunately the patient made an uneventful recovery.
A 35-year-old man was involved in a fight and sustained a punch to the right orbit. He came to the emergency department with double vision.
The double vision was only in one plane.
Examination of the orbits revealed that when the patient was asked to look upward the right eye was unable to move superiorly when adducted. There was some limitation in general eye movement. Assessment of the lateral rectus muscle (abducent nerve [VI]), superior oblique muscle (trochlear nerve [IV]), and the rest of the eye muscles (oculomotor nerve [III]) was otherwise unremarkable.
The patient underwent a CT scan.
A CT scan of the facial bones demonstrated a fracture through the floor of the orbit (Fig. 8.293).
A careful review of this CT scan demonstrated that the inferior oblique muscle had been pulled inferiorly with the fragment of bone in the fracture. This produced a tethering effect, so when the patient was asked to gaze in the upward direction, the left eye was able to do so but the right eye was unable to because of the tethered inferior oblique muscle.
The patient underwent surgical exploration to elevate the small bony fragment and return the inferior oblique to its appropriate position. On follow-up the patient had no complications.