ACTIVIDAD N°42 GRADO: 5TO DE PRIMARIA

Instabilities come from both the vagal and the sympathetic systems, and it is not always easy to separate them. The principal signs we see during our consultations are indicated below. Some vagal signs are, paradoxically, common to those of the sympathetic system.

Who has not seen patients or friends suffer a vagal attack with sudden intense pallor, just before a severe fall? More often than not, it is the fall that causes a problem, rather than the vagal attack.

Here is a summary of the principal signs of vagotonia:

— despondency, lassitude, exhaustion — sadness, even melancholy

— withdrawal

— feeling discouraged

— tendency towards depression — lack of will

— hypochondria

• digestive:

— over-production of hydrochloric acid — gastro-esophageal refl ux

— disturbance of cardiac rhythm — lipothymia (fainting)

• ocular:

— miosis

• respiratory:

— pseudocardiac signs, sensations of stabbing intrathoracic pain, precordial pain, thoracic oppression

— bronchospasm.

22.3 MANIPULATION 22.3.1 At the ear

Refer to Chapter 25, which is devoted to the ear, for techniques for the auricle (cartilagi-nous pavilion) and the external acoustic meatus. The ear is a key place for vagus nerve manipulation, especially because of the effects on the superior ganglion and tension on the dura mater of the posterior cerebral fossa.

22.3.2 At the neck In the carotid trigone

There are so many neurovascular structures in the neck that we will try to simplify the approach to the vagus nerve. It is in the carotid trigone that we can most easily contact and manipulate the nerve (Figs 22.6 and 22.7).

The nerve is found in company with its superior laryngeal branch, between the inter-nal carotid artery and the interinter-nal jugular vein. Note that, at the lateral part of the base of the triangle, one can also palpate the acces-sory nerve. This technique involves very light gliding induction. It is much more of a caress than a compression. This highly reactive area requires the utmost fi nesse (Fig. 22.8).

Always compare the two sides and apply the technique to the most sensitive zone,

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Hypoglossal nerve Vagus nerve

Internal jugular vein Hyoid bone

Common carotid

Sternocleidomastoid muscle

Fig. 22.6 The vagus nerve in the carotid trigone.

feeling for the visco-elasticity of the nerve and modulating the “return” of the nerve during manipulation.

Superior laryngeal nerve

The superior laryngeal nerve is an impor-tant collateral of the vagus nerve (Fig. 22.9).

From a mechanical perspective, it is directly connected to the inferior vagal ganglion (plexiform ganglion).

Search for the nerve in the lateral thyrohy-oid region, where it follows a slightly descend-ing horizontal course. It pierces the thyrohyoid membrane about 1 cm in front of the tuber-cle of the greater horn of the hyoid bone, lying about 2.5 cm from the median line, to reach the interior of the larynx.

Position yourself at your patient’s head, moving just slightly forward of the side oppo-site the nerve to be treated. With the thumb of your caudal hand, push the hyoid bone in the opposite direction (Fig. 22.10).

With the index fi nger of your cranial hand, gently examine the tissues along the greater horn of the hyoid bone, searching for the nerve in the thyrohyoid space. The superior

laryngeal nerve feels like a small cord parallel, or sometimes slightly caudal, to the greater horn. It is always a little sensitive and occa-sionally triggers a small cough refl ex.

Manipulate the nerve where it perforates the thyrohyoid membrane, a little caudal and in front of the tubercle of the greater horn of the hyoid. Work in induction without over-compressing the nerve. At the end of the maneuver, you may gently stretch the nerve in a caudal direction.

Carotid trigone

The carotid trigone (see Fig. 22.7) is represented by a triangle formed:

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•

•

The trigone has a caudal summit and a cephalic base. The structures within the trigone are:

•

•

•

Vagus nerve

22

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Stylohyoid muscle

Anterior belly of the digastric muscle Posterior belly of the

Digastric muscle

Anterior belly of the omohyoid muscle Sternal head of the

sternocleidomastoid muscle

Inferior constrictor muscle of the pharynx Clavicular head of the

sternocleidomastoid muscle

Sternocleidomastoid muscle

Fig. 22.7 Carotid trigone.

Fig. 22.8 Manipulation of the vagus nerve in the carotid trigone.

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Superior laryngeal nerve

Superior laryngeal artery

Thyrohyoid membrane

Fig. 22.9 Localization of the superior laryngeal nerve.

Indications

In addition to the general indications for the vagus nerve, its manipulation at the neck addresses these structures in particular:

• pharynx

• trachea

• esophagus

• heart.

We treat many problems of the esophago-cardio-tuberosity junction. In such cases we combine treatment of the vagus nerve at

the neck with subcostal mobilization of the hiatal area.

22.3.3 At the hiatal area

As we have seen, the vagus nerves pass through the esophageal aperture of the diaphragm, on either side of the esophagus. Remember that the left-hand side of the liver lies in front of the gastro-esophageal junction. We can obtain an effect on the vagus nerve by mobiliz-ing either the liver or the esophago-cardio-tuberosity junction.

Vagus nerve

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205 Fig. 22.10 Manipulation of the superior laryngeal nerve.