The lesion cannot be a primary oculomotor nerve [III] nuclear injury.
As both the pupillary reflexes and vision are affected, the lesion is likely to be along the course of the oculomotor nerve [III]. Medical conditions such as diabetes mellitus and vascular disease may produce an isolated oculomotor nerve [III] injury, but they are not associated with pain.
The lesion was caused by an aneurysm.
One of the commonest causes of a third nerve palsy is pressure on the nerve from a posterior communicating artery aneurysm, which lies parallel to the nerve on the anterior aspect of the brainstem. As the aneurysm abuts the outside of the oculomotor nerve [III], it involves the parasympathetic fibers, which lead to a predominance of the loss of pupillary function over general function.
The aneurysm was imaged with an angiogram.
The patient initially underwent CT and MRI scanning. Currently, the definitive test for assessment of aneurysms arising from the circle of Willis and its branches is a digital subtraction angiogram. The angiogram demonstrated the posterior communicating artery aneurysm. The patient underwent surgery and made an excellent recovery.
A 10-year-old boy was brought to an ENT surgeon (ear, nose, and throat surgeon) with epistaxis (nose bleeding). The bleeding was associated with his nose picking habit. However, the bleeding was profuse and on two occasions required hospital admission and nasal packing.
On inspection an indurated area was noted.
The typical findings are an indurated area in the anterior inferior aspect of the nasal septum (Kiesselbach’s area). This is a very vascular area that has a considerable number of veins, which are often traumatized during nose picking.
The patient underwent treatment.
Typical treatment is cauterization of these prominent veins in Kiesselbach’s area, which is usually performed by a simple local analgesia and the application of silver nitrate.
Unfortunately, the boy was involved in a fight the next day and again developed severe epistaxis, which again was difficult to control.
Not only is there a rich venous plexus around Kiesselbach’s area, but there is also a significant arterial supply, which is provided from the nasal septal branches of the posterior and anterior ethmoidal arteries and the branches of the greater palatine artery. These are supplemented from the septal branches of the superior labial artery.
In most cases treatment is conservative.
Conservative treatment usually involves packing the nasal cavity until bleeding has stopped and correcting any bleeding abnormality. In patients with bleeding refractory to medical treatment a series of maneuvers have been employed, including ligating the anterior and posterior ethmoidal arteries through a medial incision in the canthus orbit, or by ligating other major arteries supplying the nasal cavity. Unfortunately, many of these procedures fail because of the rich and diverse origin of blood supply to the nasal cavity.
Determination of the specific site of bleeding can be achieved radiologically.
By placing a catheter from the femoral artery through the aorta and into the carotid circulation the sphenopalatine artery can be easily cannulated from the maxillary branch of the external carotid artery. Bleeding can usually be demonstrated and the vessel can be embolized using small particles.
Fortunately in this young boy’s case, bleeding stopped after further medical management and he remained asymptomatic.
A 30-year-old woman came to her doctor with a history of amenorrhea (absence of menses) and galactorrhea (the production of breast milk). She was not pregnant and appeared otherwise fit and well.
Serum prolactin was measured.
Prolactin is a hormone produced by the pituitary gland and necessary for the production of breast milk postpartum. This hormone was markedly elevated.
Further clinical tests demonstrated visual field defects.
The patient went to see an optometrist who performed a visual field assessment and demonstrated a reduction in the lateral aspects of the normal visual fields. This was bilateral and symmetrical—a bilateral temporal hemianopia.