case presentation Benign tumor surgery resulting into 7th nerve palsy and ptosis

1. BENIGN TUMOR SURGERY
RESULTING INTO 7TH NERVE
PALSY AND PTOSIS
MANAHAN, MACLESTER T.

2. INTRODUCTION
• BENIGN TUMORS ARE NONCANCEROUS GROWTHS IN THE BODY. UNLIKE
CANCEROUS TUMORS, THEY DO NOT SPREAD TO OTHER PARTS OF THE
BODY.
• BENIGN TUMORS CAN FORM ANYWHERE IN THE BODY.
• WHILE THE UNDERLYING CAUSES FOR TUMOR GROWTH CAN VARY, THE
PROCESS BY WHICH THEY GROW IS THE SAME. NORMALLY, CELLS IN
YOUR BODY WILL NATURALLY REFRESH THEMSELVES BY DIVIDING. THIS
ALLOWS FOR DEAD CELLS TO BE DISPOSED OF NATURALLY. IN THE CASE
OF TUMORS, DEAD CELLS MAY REMAIN BEHIND AND FORM A GROWTH
KNOWN AS A TUMOR. CANCER CELLS GROW IN THIS WAY AS WELL;
HOWEVER, UNLIKE THE CELLS IN BENIGN TUMORS, THEY ALSO INVADE
NEARBY TISSUE. OUT-OF-CONTROL GROWTH OF ABNORMAL CELLS
CAUSES DAMAGE TO THESE ADJACENT TISSUES AND ORGANS, AND CAN
LEAD TO CANCEROUS TUMORS IN OTHER PARTS OF THE BODY.

3. • NOT ALL BENIGN TUMORS NEED TREATMENT. IF YOUR TUMOR IS SMALL AND IS
NOT CAUSING ANY SYMPTOMS, YOUR DOCTOR MAY RECOMMEND TAKING A
WATCH-AND-WAIT APPROACH. IN THESE CASES, TREATMENT COULD BE MORE
RISKY THAN LETTING THE TUMOR BE.
• IF THE DOCTOR DECIDES TO PURSUE TREATMENT, THE SPECIFIC TREATMENT
WILL DEPEND ON THE LOCATION OF THE BENIGN TUMOR. TUMORS MAY BE
REMOVED FOR COSMETIC REASONS IF THEY ARE LOCATED ON THE FACE OR
NECK. OTHER TUMORS THAT AFFECT ORGANS, NERVES, OR BLOOD VESSELS ARE
COMMONLY REMOVED WITH SURGERY TO PREVENT FURTHER PROBLEMS.
• TUMOR SURGERY IS OFTEN DONE USING ENDOSCOPIC TECHNIQUES, MEANING
THE INSTRUMENTS ARE CONTAINED IN TUBE-LIKE DEVICES. THIS TECHNIQUE
REQUIRES SMALLER SURGICAL INCISIONS AND REQUIRES LESS HEALING TIME.
• IF TUMOR CANNOT BE SAFELY ACCESSED FOR SURGERY, RADIATION THERAPY
MAY BE USED TO HELP REDUCE THE SIZE OF THE TUMOR OR PREVENT IT FROM
GROWING LARGER.

4. • THE 7TH CRANIAL (FACIAL) NERVE IS LARGELY MOTOR IN FUNCTION (SOME SENSORY
FIBRES FROM EXTERNAL ACOUSTIC MEATUS, FIBRES CONTROLLING SALIVATION AND
TASTE FIBERS FROM THE ANTERIOR TONGUE IN THE CHORDA TYMPANI BRANCH). IT
ALSO SUPPLIES THE STAPEDIUS (SO A COMPLETE NERVE LESION WILL ALTER
AUDITORY ACUITY ON THE AFFECTED SIDE). FROM THE FACIAL NERVE NUCLEUS IN
THE BRAINSTEM, FIBRES LOOP AROUND THE 6TH NUCLEUS BEFORE LEAVING THE
PONS MEDIAL TO 8TH AND PASSING THROUGH THE INTERNAL ACOUSTIC MEATUS. IT
PASSES THROUGH THE PETROUS TEMPORAL IN THE FACIAL CANAL, WIDENS TO FORM
THE GENICULATE GANGLION (TASTE AND SALIVATION) ON THE MEDIAL SIDE OF THE
MIDDLE EAR, WHENCE IT TURNS SHARPLY (AND THE CHORDA TYMPANI LEAVES), TO
EMERGE THROUGH THE STYLOMASTOID FORAMEN TO SUPPLY ALL THE MUSCLES OF
FACIAL EXPRESSION, INCLUDING THE PLATYSMA.
• FACIAL NERVE PARALYSIS ALSO KNOWN AS BELL’S PALSY IS A COMMON PROBLEM
THAT INVOLVES THE PARALYSIS OF ANY STRUCTURES INNERVATED BY THE FACIAL
NERVE. THE PATHWAY OF THE FACIAL NERVE IS LONG AND RELATIVELY
CONVOLUTED, AND SO THERE ARE A NUMBER OF CAUSES THAT MAY RESULT IN
FACIAL NERVE PARALYSIS.
• PTOSIS IS THE MEDICAL TERM FOR A DROOPING EYELID. IT REFERS ONLY TO THE
UPPER EYELID; IT DOES NOT REFER TO LOWER EYELID SAGGING. UPPER EYELID
DROOPING CAN SOMETIMES AFFECT VISION IF THE DROOPING IS SEVERE. PTOSIS IS
NOT A DISEASE, BUT A SYMPTOM OF ANOTHER CONDITION THAT MUST BE

5. CASE HISTORY
• C.M, 70 YEARS OLD FEMALE FROM BAGONG BARRIO CALOOCAN CITY CAME TO
THE CLINIC FOR EYE EXAMINATION. SHE EXPERIENCED BLURRING OF VISION AT
FAR AND NEAR, DOUBLING OF VISION AT NEAR, GLARE AND TEARING.
• WHEN SHE UNDERGONE SURGERY DUE TO BENIGN TUMOR AT THE HEAD IN
2006, SHE HAD 7TH NERVE PALSY, PTOSIS AND HEARING DEFICIENCY.
• THE PATIENT ALSO HAS HYPERTENSION AND HAD A SURGERY FOR MYOMA THE
SAME YEAR SHE HAD A SURGERY FOR THE TUMOR.

6. VISUAL ACUITY
VASC FAR VASC NEAR VAPH
OD: 20/80 OD: 16/80 OD: 20/40
OS: 20/80 OS: 16/200 OS: 20/80
OU: 20/60 OU: 16/60

7. GENERAL OBSERVATION AND INSPECTION
OCULAR ADNEXA OD OS
LIDS/LASHES NO MASS DROOPING
SCLERA YELLOWISH YELLOWISH
CONJUNCTIVA CLEAR W/ TINY BLOOD
VESSELS
CLEAR W/ TINY BLOOD
VESSELS
CORNEA CLEAR CLEAR
IRIS DARK BROWN DARK BROWN
LENS CLOUDY WHITE CLOUDY WHITE

8. PRELIMINARY TEST
NPC 16/18
PUSH-UP AMPLITUDE 14CM= 7.14D
ALTERNATE COVER TEST ORTHOPHORIA
CORNEAL REFLEX SLIGHTLY NASAL
COLOR VISION 15/18
VISUAL FIELD FULL/ INTACT
DIRECT LIGHT REFLEX OU 2+
INDIRECT LIGHT REFLEX OU 2+
ACCOMMODATION OU CONSTRICTED
SWINGING FLASH LIGHT TEST (-) MARCUS GUNN
SUBJECTIVE REFRACTION
OD -0.25 SPH ADD 2.25
PLANO ADD 2.25

9. OPHTHALMOSCOPY
FOVEA AND BACKGROUND
(+) ROR

10. DIAGNOSIS
• PTOSIS
• BELL’S PALSY
• CATARACT
• HEARING DEFICIENCY

11. ASSESSMENT
• THE PATIENT EXPERIENCING BLURRING OF VISION AT FAR AND NEAR, DOUBLING
OF VISION AT NEAR, GLARE AND TEARING. BENIGN TUMOR SURGERY RESULT TO
FACIAL NERVE PARALYSIS OR BELL’S PALSY AND AFFECT OCULOMOTOR NERVE
RESULT TO PTOSIS.

12. MANAGEMENT
• CORRECTIVE LENSES TO AID IN THE PATIENTS
DISCOMFORT AT FAR AND NEAR.
• CATARACT EXTRACTION
• PTOSIS SURGERY IF NEEDED