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[Emergency] ATLAS OF SIXTH-NERVE PALSY

These are atlases of Sixth-Nerve Palsy disease. This is a disease of the OPHTHALMIC CONDITIONS


Clinical Summary

The abducens nerve innervates the lateral rectus muscle and is the most common single muscle palsy, causing loss of abduction and resultant horizontal diplopia, worse in ipsilateral gaze. Associated findings are dependent on the location of the lesion. Within the pons, involvement of the corticospinal tract results in contralateral hemiparesis. The abducens has the longest intracranial course of any nerve, and therefore is vulnerable to stretching or compression secondary to elevated intracranial pressure, trauma, neurosurgical manipulation, and cervical traction. Also, any meningeal process (infectious, inflammatory, or neoplastic) can affect this portion of the sixth nerve. Aneurysmal compression is uncommon.

Prior to entering the cavernous sinus, the nerve crosses the petrous portion of the temporal bone. Trauma with temporal bone fracture can result in a combination of sixth- and seventh-nerve palsies. Cavernous sinus pathology is suggested by the involvement of the internal carotid artery, venous drainage of the eye and orbit, trochlear and oculomotor nerves, the first division of the trigeminal nerve, and the ocular sympathetics. Microvascular changes secondary to diabetes, hypertension, and giant cell arteritis can compromise function.

Management and Disposition

Associated signs and symptoms guide the ED workup. CT or MRI is indicated if brain stem or cavernous sinus involvement is suspected. Pathology localizing to the subarachnoid space should prompt consideration for CT scanning and subsequent spinal tap. In the elderly, an isolated sixth-nerve palsy is likely ischemic, transient, and not indicative of underlying neurologic disease. In these cases, a glucose and erythrocyte sedimentation rate is appropriate; these patients can be followed as outpatients provided close follow-up is arranged.

There is no treatment for the palsy itself except for patching the affected eye if diplopia is bothersome.

Pearls

1. An isolated sixth-nerve palsy is commonly due to microvascular disease, not an aneurysm.
2. Basilar skull fractures of the temporal bone are capable of producing a sixth-nerve palsy. 
3. A sixth-nerve palsy associated with a Horner is usually localized to the cavernous sinus, since sympathetic fibers, as they traverse from the internal carotid artery to the oculomotor nerve, may briefly accompany the abducens nerve. 

Sixth-Nerve Palsy

Sixth-Nerve Palsy

Sixth-Nerve Palsy
FIGURE 2.61 Sixth-Nerve Palsy. Loss of abduction of the left
eye is seen in lateral gaze.
  

REFERENCES
The Atlas of Emergency Medicine, Fourth Edition, 2016. 

COMMENTS

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CLINICAL ATLAS,118,DERMATOLOGY ATLAS,11,EMERGENCY ATLAS,44,HAEMATOLOGY ATLAS,23,HUMAN ANATOMY,1,MICROBIOLOGY ATLAS,66,PARASITOLOGY ATLAS,4,PATHOLOGY ATLAS,22,PEDIATRIC ATLAS,41,STDs,19,SUBCLINICAL ATLAS,116,
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Free Medical Atlas: [Emergency] ATLAS OF SIXTH-NERVE PALSY
[Emergency] ATLAS OF SIXTH-NERVE PALSY
These are atlases of Sixth-Nerve Palsy disease. This is a disease of the OPHTHALMIC CONDITIONS
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