Head and neck pain, part 1

Chapter 13 Head and neck pain, part 1



Case 13.1



History


Sandra is a 34-year-old secretary who presents with a 3 month history of headache. She believes that it is due to work and stress. She moved to the city 4 months ago, and is having problems with her landlord. At work, Sandra is responsible for compiling departmental reports, which requires her to spend most of her time working on a computer. Sandra is always working late in order to meet deadlines. The headache seems to be present early in the morning and can sometimes wake her, but often gets worse once she is at work. The pain is diffuse over the vertex and occipital region and has been worsening in recent weeks. Sandra denies any diplopia, dysarthria, dysphagia, nausea or vomiting and has no symptoms relating to her limbs.


Sandra has no history of sinus infections, does not wear glasses, and has regular eye tests organised through work, the last test being 10 months ago. She does not feel nauseous when she has a headache, and has no visual symptoms. She has been generally quite well, and is only taking paracetamol and codeine (combined) for her headache, although this does not seem to help. Sandra has been told by a co-worker that she probably does not drink enough fluid, because over the past year she has been having episodes of dizziness. She disagrees, stating that she drinks approximately 2 litres of water every day. She drinks approximately 1–2 glasses of wine a week, is a non-smoker and does not use any recreational drugs.


When asking Sandra questions, she says that she can’t hear very well and asks you to speak louder. On further questioning, she states that she has had a problem with her hearing in her left ear ever since an ear infection 5 years ago. After the initial infection, Sandra had ‘ringing’ in her ear which lasted for approximately 3 months. When this stopped, she noticed some deafness. Her medical practitioner told her this would resolve, but instead, it has worsened. This has resulted in Sandra not seeing her doctor for 4 years, because she feels that he did not diagnose her initial complaint correctly. Recently her hearing has worsened, and she says she has a sense of fullness in the left ear which she believes is due to wax. She says that when she has the time she will register at the surgery and see a doctor.


Sandra’s medical history is unremarkable except for a motor vehicle accident at the age of 24 where she was a passenger and the car was hit from behind whilst waiting at traffic lights. She sustained a whiplash injury and has had episodes of neck pain and headaches ever since. These have been successfully treated by spinal manipulative therapy. The last time she was treated was over a year ago.


Sandra’s last menstrual period was 2 weeks ago and she takes the combined oral contraceptive pill (COCP), and has not altered the brand since the age of 26. Sandra’s parents are alive and well, her father was diagnosed as a type 2 diabetic at the age of 55 and her paternal grandmother died of breast cancer age 62.



Questions



1. Using only this information, state the possible causes of Sandra’s headache. Justify your answers.

2. Why was Sandra asked about:
a wearing glasses and any recent eye exam

b visual symptoms

c method of contraception and length of time using it

d the location of the headache?

3. What do you need to examine in this patient?


Physical examination




Cranial nerve examination






















































I Not done
II In both eyes, mild papilloedema
Satisfactory visual acuity, no field deficits noted
Pupils equal in size, round and reactive to light bilaterally
Accommodation/convergence normal
III, IV, VI Full extra ocular movements, no diplopia
No ptosis
Accommodation/convergence normal
V Diminished corneal reflex on the left
Slight diminished pin-prick and soft touch sensation in V1–3 dermatome on the left
Jaw-jerk normal
Muscle strength 5/5
VII Muscles of facial expression strength 5/5
VIII Could not hear whispered word at 30 cm on the left; on right, 100 cm
Weber’s lateralises to the right ear
Rinne’s +ve on right (air conduction greater than bone conduction) but not heard on left
IX, X Mildly diminished gag reflex on left
Symmetric palate elevation on ‘Ahh’
Spinal XI Normal
X11 Normal


Questions



4. What information can you obtain from these findings? What other parts of her body would you have examined? Can you narrow your differential diagnosis?

5. Explain the significance of the following signs, in context of your differential diagnosis:
a mild papilloedema

b weakness of muscles of mastication

c diminished corneal reflex on the left

d Weber’s lateralises to right ear

e Rinne’s — not heard in the left ear

f mildly diminished gag reflex and symmetrical palate elevation.

6. Sandra is referred to a medical practitioner. What investigations do you think would be ordered? Why?


Investigations


On magnetic resonance imaging (MRI) scan, coronal view, a high signal area was detected measuring approximately 16 mm in diameter in the cerebellopontine angle. This extends into the internal auditory meatus and indents the pons. Axial view confirmed the presence and size of the lesion.



Questions



7. What is the most likely diagnosis, based on these results? Justify your answer.

8. Are any further investigations required?

9. What is the cause of papilloedema?

10. Explain the development of the pathology which you diagnosed in question 7. Explain the symptoms associated with its growth.

11. What are other causes of cerebellopontine angle tumours? How would these symptoms differ from those experienced by Sandra?


Case 13.2



History


Gloria is a 54-year-old artist and part-time retail worker who has recently come to your practice complaining of mild temporal headaches and ringing in the ears. The headaches have been present for approximately 6 months, are bilateral, and are described as constant, with a visual analogue scale (VAS) of 6 out of 10. They began in tandem with the tinnitus. There is no prodrome, photophobia or phonophobia associated with the headaches. The tinnitus is described as transient at this time. She has had a very stressful month with financial and family difficulties. In the past, these issues have caused her to have similar symptoms, but without the ear complaint. She denies grinding her teeth. She complains of being ‘out of breath’ and having palpitations. She reached menopause 4 years ago.


Although she is legally blind, she is able to undergo her daily activities without fuss. Her visual disturbance is genetic in aetiology, and has been present since infancy. Gloria is under regular management by an ophthalmologist. She has consulted him regarding the headaches and tinnitus, and he reassured her that they are unrelated to her eyes, and that it was probably stress related.


Gloria enjoys a bottle of wine with her meal and lives alone. She has regular check-ups with her medical practitioner, and is otherwise healthy as she walks to and from work for 2 hours every weekday.



Questions



1. Using only this information, state the possible causes of Gloria’s headaches. Justify your answers.

2. What additional questions must you ask in order to determine the cause of her problem?

Gloria does not believe that her hearing has diminished recently. Gloria has not had any episodes of vertigo or light-headedness, nor any other neurological symptoms. She does not suffer from nausea or vomiting.


The dyspnoea and palpitations generally occur when she is feeling stressed. Gloria does not wake up breathless at night, she sleeps with only one pillow, and has never had any chest pain.


There is no family history of ear disorders. She had a grommet tube placed in her left ear at the age of 2, which fell out naturally after 9 months. As a teenager, she enjoyed the loud music experienced at live concerts on a weekly basis. Gloria also tried scuba diving on her honeymoon many years ago, but was unable to dive beyond a depth of 2 metres due to pain in the ears.

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Head and neck pain, part 1

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