Seale (1936) Oral sepsis as a cause of paralysis of the ocular nerve

Embed Size (px)

Citation preview

  • 8/10/2019 Seale (1936) Oral sepsis as a cause of paralysis of the ocular nerve

    1/2

    [KOYE1>IBER 28

    1936.

    779

    section of their motor upply, and noted

    that

    the

    extreme

    fineness

    of

    fibre

    of

    these muscles.

    and

    there

    fore po sibly

    greater permeabil ity,

    might ., throw

    light on the extremely difficult problem of the

    morphology of their nen'e supply.

    I may perhaps be

    pardoned

    for a more lengthy

    excerpt from

    Duke-Elder in consideration of

    causal relationships of t\\'o ca es I purpo e to descnbe

    presently.

    His

    whole paper,

    h O \ ~ e v e r ,

    is

    .\\ 01:th

    careful

    study. Perhaps those

    puzzhng

    t\\'ltchl11gs

    and

    spasmodic contractions

    of

    the orbicular is and muscles

    upplied by the facial nerve may

    be .

    a ~ c ~ U n t , e d

    for

    now. Duke-Elder suggest two posslblttles for

    the

    muscle peculiarities,

    .

    the anomalous physiolo.gica

    behaviour of these muscles seems to correlate Itselt

    with

    an

    anomalous nerve supply.

    It

    has long been

    known that in addition to the motor nerye endings

    derived from the third, fourth and sixth nerves. an

    extraordinary

    number

    0 f

    nerves

    of

    the sensory type

    are

    met

    with in these muscles

    ...

    '

    It

    has been

    suggested . . .

    that

    these fibres

    b e l O 1 ~ g

    to the sym

    pathet ic, but , to

    nlY

    mind. the suggestIon

    S

    based on

    no adequate evidence.

    Where

    the fibres come from

    is not known. It might be suggested that they come

    from the fifth. and in con idering thi nerve one at

    once thinks

    of

    its enigmatic mesencephalic root. , ' .

    In the second place. if the peculiarity is not

    neuro

    logical in orig-in, it

    is

    possible that it may he due to

    ome peculiarity

    of

    the muscle-fibres them eh'es.

    The

    fibre

    of

    these muscles are extremely fine and delicate.

    and it '

    is

    concei,'able that they possess a greater

    permeability than the fibres

    of o ther

    keletal mu. c1e.,

    It

    is thus po ible that choline act

    upon ordmary

    keletal mu

    c1e

    onlv after denervation. becau e by

    thi mean their

    p e n ~ l e a b i l i t y

    ha been increa ed,

    that

    it act upon the

    extrin

    ic muscle

    of

    the eye m

    normal c ircumstance and

    without

    any

    trauma

    becau e

    the permeability

    of

    their thin and delicate fibre is

    sufficiently great.

    ~ l o r e

    recent work on ocular disorders associated

    with the wisdom tooth i to be found in an article in

    the

    British J mwl Ophthalmology

    for

    July,

    1935.

    by C.

    Bowdler Henry,3 Hunterian

    Profe or

    Lecturer in Oral Surgery, Royal Dental

    Ho

    pltal.

    London. Here the very definite st atement

    is

    made

    that in

    certain case a per fec tly healthy but unerupted

    wisdom tooth

    may

    produce g r ~ v di tur.bances in the

    eyes which mu t be a cribed eIther to d l r ~ c t .

    p r ~ s

    u.:e

    on neighbouring nerve or to ome reflex IrrItatIOn:

    He had

    collected 700 cases

    of

    disorder

    of

    eruption

    of

    the

    third

    molar . and

    among

    these \\'ere

    eighteen

    contributed and thiry-two

    literature

    ca e in

    ~ ~ i c h

    was

    ome ocular ymptom.

    Iriti and

    Uyeltls were

    mentioned as

    the

    commonest eye troubles caused by

    thi condition,

    but

    neuralg-ia, twitching-- and

    ev.en

    g laucoma might be due to .it. One ca e quoted by hlJ11

    proved that

    the

    eye affectIOn was. caused

    by pre ure

    of

    the root

    of

    an

    unerupted

    \\ dom tooth on the

    infradental nerve.

    That oral sepsis a a cau e of ocular paralys is was

    not

    of

    much account

    in

    the

    mind of

    neurolog-i

    ts

    until

    ORAL SEPSIS.

    S,A.

    TYDSKlIIP vm]

    G N S ] [ ~

    r l

    ~ t p s i s

    as a < taus. of aral sis of

    xttrnal

    Brular

    .lRu.ults.

    By E.

    A. SL\LE, :'ILD. (DuBL.).

    GR.\HA:\fSTOWX.

    Before

    19

    2

    3 little

    attention

    had been paid to

    the

    condition of the

    mouth

    in the presence of eye trouble.

    In

    that

    year,

    at

    the

    annual meeting

    at Oxford of

    the

    Oxford

    Ophthalmolog-ieal Congre s. the chief

    J}lace

    was given to a discussion on the relationship

    of

    dental

    sepsis to disease

    of the

    eye.

    1

    The

    first

    paper

    wa

    read

    by ~ 1 r . W.

    :\ckland,

    of

    Bristol. followed

    by

    the veteran

    London ophthalmologist. :'Ilr. Wm.

    Lan

  • 8/10/2019 Seale (1936) Oral sepsis as a cause of paralysis of the ocular nerve

    2/2

    Examination howed a marked downward deviati

    of the left eye. with light outward direction.

    Vi ion of each eye equd and above s tanda

    Fundi normal: in fact. no thing wrong but the squi

    The Maddox tangent _cale howed the fal e ima

    2t feet above and a couple of inche to the r ight .

    From the hi tor)' and aeneral good health I w

    inclined to exclude

    lue,

    but a ked for a blo

    examination

    hould

    impro ement

    not follow attent

    to hi unsatisfactory oral condition.

    an

    irm

    [

    S A

    MEDIC

    JOURN L

    teeth were

    he

    I a ked Dr . Kaplan for a repor t and he wa

    goo

    enough to give one which is unusually full.

    Th

    report

    reads: On May 27 pre ented himself f

    relief

    of

    pain radiating along right mandible wi

    hi tory of an aching first lowe. molar ( righ t) of thr

    days' duration. The following teeth were timdin

    843

    21

    12

    3 - - 67

    7

    6

    53

    21

    12

    3457

    8

    '

    exhibited

    marked

    attrition. Considerable recession

    gums;

    deep pockets interdentally, which harbour

    food .particles: accumulation

    of

    tartar

    and

    chron

    general periodontitis present.

    ,

    In

    the

    mandipl

    right side-the first molar had

    an

    exposed pulp sole

    caused by attrition

    of

    the occlusal surface.

    The

    seco

    molar was non-vital. having been devitalized

    arsenic in 1934

    these two teeth were sensitive

    percussion, the

    pain

    radiating along the mandib

    The ornl mucosa in this area was inflamed, partic

    larly in the

    retromolar

    triangle distal to

    the

    seco

    lower molar, where a probe could be admitted betwe

    the flap of gum and the distal root of this tooth whi

    communicated with

    an

    unerupted

    third

    molar. Dire

    smears were

    taken

    from

    various oral

    areas.

    Examination

    of

    these smears

    showed a

    Vincen

    infection; Bac fllsiformis; Bac necrosis and taphyl

    cocci and streptococci.

    Dr. Kaplan observations are enlightening.

    H

    says: The case is one

    of

    general oral sepsis w

    incent 's infect ion. In addition, a condensi

    osteitis existed in the mandible in the area of

    devitali.zed econd molar and an impacted wisdo

    tooth.

    It

    is possible that the oral sepsi eau

    inflammation of

    the

    periodontal membrane of t

    unerupted

    molar and thi again reflex irritation in t

    inferior

    dental

    nen e-a

    the distal root wa in dire

    contact with the main nerve.

    The

    fai lure to

    g et

    f

    an:esthesia

    wa

    probably due to non-absorption

    of

    t

    solution throug-h the myelin sheath of that nerve, t

    result of degenerative change. With the removal

    the _econd molar and the resisting- bone anter io r

    the wisdom tooth opportunity for migration \\

    allowed. thereb,' relieving the main nerve fro

    pre sure.

    The

    clearing up

    of

    the oral ep i togeth

    with the removal of the teetl-i anterior to the

    \Vi

    do

    tooth has amel iora ted the general condi tion.

    The second ca e wa al 0 a man in the fiftie. e

    to

    me

    by Dr. Ca_tIe on Augu t 6 la t.

    He

    complain

    of

    double vi ion

    for

    even day, but aid it disappear

    for one day oon after it on

    et;

    it then gradually g

    worse.

    ORAL

    SEPSI

    .

    xecently I should like to show by quoting from

    an

    addre by Dr . James Collier delivered

    at

    the jubilee

    Congress

    of

    the Ophthalmological Society

    of

    the

    United Kingdom in 1930. The title

    of

    his paper was

    Oculomotor Palsies

    resulting from Infective and

    Toxic

    Proces es.

    4

    Diphtheria, polyneuritis, botulism

    and nronal

    intoxication, etc.,

    and

    the paralysis

    of

    myasthenia gravis were discussed, but no case of

    ocular

    paralysis mentioned

    as

    due to oral sepsis.

    ::\1r

    A. F. Mc =allan, in

    the

    ensuing debate,

    described a case

    of

    paresis

    of

    the inferior rectus

    muscle cured by removal of

    an

    impacted wisdom tooth.

    He

    said

    research work

    by dental surgeons

    and

    bacteriologists has shown that practically all un

    erupted

    and

    impacted teeth lead to infection

    of

    the

    surrounding tissues by streptococci of various kinds.

    As my search has not yielded any case

    of

    paralysis

    of

    the external rectus

    or

    superior rectus muscles due

    to oral

    sepsi,

    I now record one of each recently

    occurring in

    my

    practice.

    In

    both was

    marked sepsi ;

    ir:

    one

    an

    unerupted wisdom tooth.

    On

    ::\lay 26

    last

    I was consulted by a man in the

    middle fifties for a squint in the right eye of ten days'

    duration, It

    was

    first noticed when read ing on a long

    raih ay journey, and after some pain in the right side

    of

    the face and head.

    There was a very marked in fe rior t rabismus of the

    .eye-fully

    40 -wi th

    inability

    of

    movement beyond the

    mid-line.

    He

    felt quite well and was going to office

    as u ual. -

    0

    abnormali ty in the

    fundus o r

    elsewhere

    wa. detected and vision up to standard in each eye.

    I

    ordered

    a

    KI mixture

    and referred him to his

    physician fo r a general overhaul and blood examina

    tion. I also advi ed him to see his dentist as his mouth

    did not appear 1).ealthy. Dr.

    Drury

    report \\'a very

    sati

    fac tory: the

    \i\'a

    sermann

    negative. Between this

    consultation and the next on June I he saw hi dentist.

    Dr. . Lewi Kaplan. on

    May

    27. and after ome pre

    liminary

    treatment teeth were extracted. Block

    amesthe ia

    of

    the infer io r dental canal gave the usual

    en ation-Ios to the mid-line and to the ide of

    the

    tonglle

    and

    lip, but evere pain wa felt deep in the

    ja\\' \ \'hen the forrep was applied, The fir t molar

    was removed. bu t the crown

    of

    the second broken;

    operation tnpped on account of pain. Daily treat

    ment

    of

    the gllm was continued. and on June 9

    an

    X-ray taken

    of

    the region. An impacted and un

    erupted wi 'dom tooth wa revealed with root

    infringing on the mandibular canal and nene. The

    root were ub equently remo\'ed

    and

    free drainage

    allowed.

    I next

    saw

    him on June 8, when a definite improve

    ment in eye-movement wa percept ible, On June 17

    further

    marked improvement was recorded. the move

    ment ranging

    1-

    to 20

    beyond nud-l ine. but,

    of

    cour e. double vision still t roubl ing. On July I still

    better

    movement howed, though at 12 feet the double

    images

    of

    a candle

    were separated

    by

    about

    15 inche .

    When next

    examined, July 18, double vision wa com

    pletely gone

    and

    no abnormality detected,

    7

    80

    NOVEMBER

    28, 1936.]