Category Archives: Oral Pathology

Molar incisor hypomineralization (MIH)

Clinical appearance of enamel hypomineralization of systemic origin affecting one or more permanent first molars (PFM) that are frequently associated with incisors


  • Oxygen shortage + low birth weight
  • Parental risks – infection, maternal psychological stress
  • Complications during delivery
  • Respiratory diseases and oxygen shortage of ameloblasts
  • Children born with poor general health
  • Childhood febrile disease


  • Demarcated opacities
  • Post eruption breakdown

Criteria for MIH severity:

Differential diagnosis

Challenges in treatment:

  • Sensitivity and rapid development of caries
  • Limited co-operation of a young child
  • Difficulty achieving anesthesia – enamel is porous so exposed dentine results in chronic pulp inflammation
  • Repeated marginal breakdown of restorations


  • Early – Stainless steel crowns
  • Moderate – Restoration
  • Late – Extract PFM
  • Fissure sealants
  • Topical fluoride – toothpaste, fluoride varnish, fluoride gel

Dental fluorosis

Dental fluorosis

Developmental disturbance of dental enamel, caused by successive exposure to high concentrations of fluoride – 1.5 mg/l (1.5 ppm) in drinking water – during tooth development , leading to enamel with lower mineral content of increased porosity


Direct inhibitory effect on enzymatic action of ameloblasts leading to defective matrix formation and subsequent hypomineralization

Clinical features:

Generalized discoloration and pits

Fluorosis index

Management: Depends on severity

  • Bleaching
  • Composite restorations
  • Veneers
  • Full crowns

Chronological hypoplasia (Linear enamel hypoplasia)

A well demarcated area of enamel hypoplasia corresponding with the period of crown formation of permanent teeth (between birth and 6 years) due to nutritional defects eg. rickets, childhood diseases etc. that may cause temporary ameloblast dysfunction

Chronological hypoplasia (Linear enamel hypoplasia)

Radioanalysis of impacted teeth

Canine localization

  • Parallax in horizontal plane: Two IOPA or USO + IOPA
  • Parallax in vertical plane: OPG (↑8°) + USO (↓65-70°) to horizontal plane
  • SLOB: Same Lingual Opposite Buccal
  • If in line with arch, will not move
  • Can do CBCT

Third molars

X-rays used:

  • IOPA – difficult due to gagging
  • OPG
  • Oblique lateral view
  • Lower/upper oblique occlusal view – buccolingual position
  • CBCT

1. Angulation

Angulation of impacted molar

2. Crown

  • Size
  • Shape
  • Dental caries
  • Resorption

3. Roots

  • Number of roots
  • Shape
  • Stage of development
  • Curvature – favorable/unfavorable
Impacted tooth root curvature - favorable/unfavorable

4. Relation to ID canal

5. Depth of tooth in alveolar bone

a. CBCT measurement tools

b. Winter’s lines method

  • 1st line (white): Occlusal surface of 1st and 2nd molar
  • 2nd line (amber):
    • Crest of interdental bone between 1st and 2nd molar
    • Extending distally along internal oblique ridge
    • Indicates amount of investing bone surrounding the tooth
  • 3rd line (red):
    • Perpendicular line dropped from white line to point of application
    • Measured from amber line to point of application
    • If red line > 5mm – difficult extraction
Winter's lines third molar impacted

c. Using roots of 2nd molar

Impacted third molar, use second molar relation

6. Buccal or lingual obliquity

  • Determine line of tooth in horizontal plane
  • Buccal obliquity – Crown inclined towards cheek
  • Lingual obliquity – Crown inclined towards tongue
  • Use:
    • Lower oblique occlusal
    • Lower 90° occlusal view

7. Others

a. Surrounding bone

  • Position of ascending ramus to determine access of tooth and the overlying bone
  • Density of bone
  • Evidence of pericoronal infection

b. Lower 2nd molar

  • Crown – Condition of restoration, caries, resorption
  • Root – Number, shape, periodontal status, condition of apices

Fractures and trauma

Classification of dentoalveolar injuries

Injuries to dental hard tissues and pulp

  • Enamel infraction – incomplete crack of enamel, no loss of tooth structure
  • Enamel fracture – loss of tooth structure involving enamel only
  • Enamel dentine fracture – loss of enamel and dentine, pulp not involved
  • Complicated crown fracture – crown fracture involving pulp
  • Complicated crown root fracture – enamel, dentine, cementum involved and pulp exposed
  • Uncomplicated crown root fracture – pulp not exposed
Ellis and Davey's classification of tooth fracture

Injuries to periodontal tissues

  • Concussion – injury to tooth supporting structure. Pain on percussion and no bleeding or displacement
  • Subluxation – increased tooth mobility due to traumatic injury to PDL tissues, no displacement
  • Extrusive luxation – partial displacement from socket
  • Intrusive luxation – intrusion into socket with socket fracture
  • Lateral luxation – displacement in horizontal plane with fracture of alveolar socket
  • Avulsion – complete displacement of tooth from socket

Injuries to alveolar bone

  • Comminution of alveolar socket wall
  • Fracture of alveolar socket wall – fracture confined to lingual/palatal or facial socket wall
  • Fracture of alveolar process ± alveolar socket
  • Fracture of basal mandibular or maxillary bone ± alveolar socket

Other injuries

  • Soft tissue injuries – laceration, imbedding foreign body in lips
  • Swallowing/inhaling avulsed tooth
  • Iatrogenic injury:
    • During extraction damage to adjacent teeth, fracture of associated jaw
    • Perforate root apex or side of root during endodontic treatment

Radiographic investigation

  • Two x-rays perpendicular or in different angles in vertical plane (IOPA, USO)
  • OPG
  • CBCT
  • Chest/abdomen x-ray if tooth aspirated/swallowed
  • Reproducible views for follow up evaluation

Classification of mandibular fractures

Anatomical site of fracture and associated radiographic investigation

Anatomical sites of mandible

1. Condylar neck:

NB: Intracapsular fracture of bone → Bleeding within joint cavity (hemarthrosis)→ Bone fragments with high osteogenic potential → Organization of hematoma within joint → Conversion to fibrous tissue → Then to bone (Ankylosis)

2. Coronoid process:

3. Ramus:

4. Angle

5. Body:

6. Canine region:

7. Symphysis:

Nature and complexity of fracture

  • Simple fracture – no communication with external environment, not breached overlying skin/mucosa
  • Compound fracture – communication with external environment, due to break in overlying skin and mucosa
  • Comminuted fracture – several broken bone fragments
  • Complex fracture – involves injury of vital structure eg. nerve, major blood vessel, joint
  • Greenstick fracture – in children, one side of cortex is broken and opposite side is spared

Etiological agent

  • Trauma
  • Iatrogenic – during extraction or enucleation of large cyst
  • Pathologic – neoplasm, cyst, osteomyelitis
  • Contrecoup fracture – fracture due to indirect force

Effect of action of muscles of mastication:

  • Favourable/unfavourable
  • Horizontal/vertical

Midfacial fractures

Le Fort fractures

Le Fort I

  • Horizontal force delivered above the level of teeth (to the maxilla)
  • Bilateral detachment of alveolar process and palate
  • Involves pterygoid process of sphenoid bone
  • ± Nasal septum
  • Unilateral or bilateral
  • The fracture separates the maxilla from pterygoid plates and nasal and zygomatic structures
  • Clinical:
    • Extraoral:
      • Swelling of upper lip
      • Soft tissue laceration
      • Open mouth due to displaced dentoalveolar portion epistaxis
    • Intraoral:
      • Malocclusion
      • Mobile dentoalveolar portion
      • Dull sound on percussion
      • Ecchymosis of maxillary buccal sulcus

Le Fort II

  • Pyramidal subzygomatic fracture of the maxilla
  • Separation of maxilla and attached nasal complex from the orbital and zygomatic structures
  • Clinical:
    • Extraoral:
      • Ballooning of face
      • Lengthening of face
      • Circumorbital ecchymosis
      • Subconjunctival hemorrhage
      • Epistaxis
      • Diplopia
      • Enophthalmos
      • CSF rhinorrhea
      • Step deformity in lower border of orbit
      • Intact zygomatic bone and arch
    • Intraoral:
      • Malocclusion
      • Anterior open bite
      • Mobility of the maxilla
      • Ecchymosis of sulcus

Le Fort III

  • High level suprazygomatic fracture of central and lateral parts of face
  • Most severe
  • Extensive soft tissue injury
  • “Floating” component is almost entire face
  • Clinical:
    • Extraoral:
      • Ballooning of face
      • Lengthening of face
      • Bilateral circumorbital ecchymosis – “racoon eyes”
      • Bilateral subconjunctival hemorrhage
      • Flattening of cheeks
      • Epistaxis
      • Diplopia – due to edema, hematoma, restrictive motility disorder (mechanical), cranial nerve injury
      • Enophthalmos
      • CSF rhinorrhea
    • Intraoral:
      • Malocclusion
      • Anterior open bite
      • Mobility of the maxilla, mandibular interference
      • Ecchymosis of sulcus
      • Obstructed airway – soft palate rests on posterior dorsum of tongue

Zygomatic complex fractures

Zygomatic complex fracture

Naso-orbito-ethmoid (NOE) complex fractures

Naso-orbito-ethmoid (NOE) complex fractures
  • Signs and symptoms:
    • Occular injury
    • Epiphora
    • Saddle nasal deformity – pushed between the eyes
      • Reduced nasal projection and height
      • Flattened nasal dorsum
      • Septal deviation/dislocation
    • Cerebrospinal fistula
    • Airway obstruction
    • Epistaxis
    • Frontal sinus involvement
    • Telecanthus – Increased distance between inner corners of the eyelids (medial canthi), while interpupillary distance is normal. Occurs due to displacement of bone fragments
  • Examination:
    • Airway
    • Anosmia (loss of smell)
      • CSF rhinorrhea
      • Loss of dorsal support
    • Ocular examination
    • Ophthalmology consultation
    • Intercanthal distance: Rule of thirds: intercanthal distance equal palpebral fissure width
      • Female: 32-33mm
      • Male: 33-34mm
  • Complications of NOE fractures:
    • Facial deformity
    • Telecanthus
    • Epiphora
    • Anosomia
    • Meningitis
  • Management:
    • Reattatchment and repositioning of the medial canthal tendon is key. Restore intercanthal distance
    • Nasolacrimal duct repair
    • Plating bone pieces
    • Transnasal wiring
    • Primary bone grafting for dorsal nasal support
    • Soft tissue adaptation
    • CSF leak – chemoprophylaxis to prevent disease

Objectives of fractures

  • Establish occlusion
  • Anatomic reduction
  • Ensure continuity with bone
  • Esthetic

Soft tissue cysts

Dermoid cyst:

  • Etiology: Epithelial tissue implanted into another structure
  • Commonly: Face, inside skull, lower back, ovaries
  • Clinical: Mature skin with sweat glands, hair follicle, sebum, blood, fat, bone, cartilage, nails, teeth
  • Benign, solitary, expand slowly due to accumulation of epithelial debris and glandular secretion
  • Non tender
  • Can rupture


Epidermoid cyst: Lined with stratified squamous epithelium, no skin appendages, don’t rupture


Branchial (lymphoepithelial) cyst:

  • Rare
  • Upper lateral neck, anterior border of sternocleidomastoid muscle
  • Etiology: Developmental
  • Clinical: Asymptomatic, soft, 1-10cm, fluctuant swelling
  • Lab: Histopathology
  • Management: Surgical removal
  • Differentials: Dermoid cyst, lymphadenopathy, sialadenitis, salivary gland tumor


Thyroglossal duct cyst:

  • Central neck
  • Moves when swallowing
  • Between hyoid and thyroid
  • Management:


Cystic hygroma/ lymphangioma:

  • Anterior and posterior triangle of neck
  • Etiology: Developmental
  • Clinical: Birth to 3 years, large cystic spaces, large soft swelling of neck
  • Management: Surgical removal for esthetic and respiratory problems
  • Differentials: Branchial cyst, lymphadenopathy, parotitis, submandibular sialadenitis


Thymic cyst

Soft tissue radiopacities and dystrophic calcifications

Calcification is soft tissues i.e. heterotopic ossification

1. Dystrophic calcification

  • Degenerated, diseased, dead tissue
  • Normal calcium and phosphate levels
  • Localized to site of injury (trauma, infection, inflammation) eg. cysticercosis parasite

a. Chronically inflamed cysts – eg. Residual cyst

b. Calcified lymph nodes

c. Tonsillar calculi (tonsilloliths)

  • Repeated inflammation enlarges tonsillar crypts
  • Incomplete resolution of organic debris (bacteria, pus, epithelial cells, food) – nidus for calcification


d. Arterial calcifications: Arteriosclerosis – calcium deposits (atheromatous plaque) in medial coat of vessel

2. Idiopathic calcification (calcinosis)

  • Deposit calcium in normal tissues
  • Normal calcium and phosphate levels

a. Chondrocalcinosis: Calcium phosphate crystals build up in joints – irritation – inflammation – cartilage damage

b. Sialoliths

c. Phleboliths – intravascular thrombi form due to venous stagnation – mineralize

d. Rhinoliths

e. Antroliths

3. Metastatic calcification

  • Minerals precipitate into normal tissues due to higher than normal calcium levels
  • Bilateral and symmetrical

a. Ossification of stylohyoid ligament

  • Classic eagle syndrome – cranial nerve impingement
  • Carotid artery syndrome – impingement of carotid vessels

b. Osteoma cutis: In skin, acne of long duration, in a scar, chronic inflammatory dermatosis

c. Myositis ossificans

  • Fibrous tissue and heterotrophic bone form in muscles interstitial tissues, tendons and ligaments
    • 1. Localized MO – acute/chronic trauma, heavy muscular strain, in occupation or sports, muscle injury from multiple injections (dental LA)
    • 2. Progressive MO – AD, rare, early infancy, males
  • High calcium levels: Hyperparathyroidism, hypercalcemia, malignancy
  • High phosphate levels: Chronic liver failure

Maxillary sinus radiology

1. Inflammatory

a. Retention cyst – Mucosal gland blocked

NB: Antral cysts

  • From mucous glands:
    • Asymptomatic
    • Disappear spontaneously
  • Odontogenic cysts:


b. Mucocele

  • Sinus opening in nasal passage blocked (allergy/cold)
  • Sinus filled with thick viscous fluid
  • Radiology: Clouding/opacification of whole sinus, sclerotic border still intact
  • If bacterial infection – destroy sclerotic wall


c. Sinusitis

  • Acute x chronic x hypersensitive
  • Rhinogenic x odontogenic
  • Periapical inflammation of premolar or molar
  • Long oroantral communication
  • Pain + percussion sensitivity
  • Histology:
    • Respiratory epithelium → squamous metaplasia
    • Thickened basal membrane
    • Infiltrate:
      • Acute – neutrophils
      • Chronic – lymphocytes + plasma cells
      • Hypersensitive – eosinophils
  • Radiology
    • Mucosa lining thickened – opaque thickening on sclerotic border
    • Long standing – forms polyps (sessile/pedunculated) within sinus
    • Picture


d. Pneumatization

  • Sinus enlarges :
    • Edentulous
    • Chronic recurrent sinusitis
  • Roots may look like are in sinus
  • Enlarging sinus develops compartments


e. Fungal infection

  • Aspergillus/mucor
  • Grow in nasal passage and sinus of immune compromised
  • Bone destruction, sclerotic border disappear
  • Differential diagnosis: Sinus carcinoma


f. Mucositis

  • Sinus mucosa thickens due to long standing periapical infection/unsuccessful RCT


2. Foreign bodies in sinus

  • Displaced root fragments in antrum after unsuccessful extraction + form oroantral fistula
  • External objects inhaled into sinus
  • Foreign bodies may calcify – laminated opacities in sinus (anthrolith) or nasal passage (rhinolith)

Oroantral communication

  • After extraction of premolar or molar
  • Nose blowing test
  • Root or tooth in sinus
  • Prolapse of antral mucosa


3. Sinus fracture

  • Le Fort fracture of lateral sinus wall
  • Blow out fracture of ventral orbital wall:
    • Trap door sign – fracture wall bone fragments project down from roof of sinus
    • Fluid level in sinus
    • Polyp like mass hanging from roof of sinus


4. Sinus neoplasia

a. Sinus osteoma – Well circumscribed opacity in sinus

b. Giant cemento-ossifying fibroma – enlarges and obliterated sinus

c. Sinus carcinoma – destroy sinus wall, opacification of sinus

d. Others:

  • Squamous cell carcinoma
  • Advanced stage – local spread
  • Nose obstruction, nose bleeding
  • Paresthesia of infraorbital nerve
  • Visual disturbances
  • Poor prognosis


Radiology of lesions

Radiolucent lesions

A. Periapical radiolucency

B. Pericoronal radiolucency (impacted teeth)

C. Unilocular radiolucency

D. Unilocular radiolucency with ragged and poorly defined borders

E. Multilocular lesions

F. Multiple separate radiolucency

  • COD – early
  • Histiocytosis X – well defined, non corticated, punched out no jaw expansion, no root resorption, therefore floating teeth
  • KCOTUL/ML – Anterior posterior direction, radiopaque margin, no roots resorbed
  • Metastatic tumors of the jaw – moth eaten
  • Multiple myeloma – punched out, non corticated radiolucency

Mixed Radiopaque radiolucent lesions

Radiopaque lesions

A. Periapical radiopacity

B. Discrete and diffuse multifocal radiopacities

C. Generalized radiopacity

Distinctive radiological features

Cottonwool appearance:

Moth eaten appearance:

Pain and neuromuscular diseases (facial paralysis)

PAIN is an unpleasant sensory/emotional experience associated with actual or potential tissue damage or described in terms of such damage

It is described by duration, site, distribution, type

1. Acute pain – sudden onset, obvious cause, identifiable pathology, responds to analgesics, and treatment of the pathology, associated with the emotions of fear and apprehension.

2. Chronic pain – insidious onset, no evident cause or readily identifiable pathology, responds poorly to analgesics, patient depressed

Physiology of pain:

  • Nociceptive stimuli (inflammation, infection, trauma, chemicals, thermal stimulus, biochemical stimulus)
  • Acts on peripheral pain receptors (non myelinated nerve fibres).
  • The impulse transmitted in form of a chemical transmitter substance across the synaptic cleft & an electric potential along the neuron.
  • Pain is perceived centrally causing peripheral release of endorphins (endogenous morphines)
  • From small interneurons that block the presynaptic release of the chemical pain transmitter (substance P) = tolerance

Gate control theory of pain:

  • Spinal gates at dorsal horn – at each segment of spinal cord
  • Heat, touch and pain impulse compete for the gate – therefore non painful stimulus blocks transmission of noxious stimulus
  • Modulated by substantia gelatinosa (SG) in the dorsal horn
  • Which then influences the first central transmission cells (T cells)
  • SG – modulating gate – permits only one type of impulse to pass through
  • Larger nerves eg. touch receptors carry impulse to brain quicker and get through gate, blocking nociceptors
  • Therefore use massage and heat therapy to inhibit pain sensation

Causes of facial pain and headaches

1. Local causes:

  • Dental or oral disease
  • Referred pain
  • Upper respiratory tract lesions
  • Neck lesions
  • Ocular lesions/ defective vision
  • Trauma

2. Neurologic causes:

  • Trigeminal neuralgia
  • Glossopharyngeal neuralgia
  • Herpetic neuralgia
  • Intracranial disease

3. Psychogenic causes:

  • Tension headaches
  • Atypical facial pain
  • Temporomandibular pain dysfunction syndrome

4. Vascular causes:

  • Migraine
  • Migranous neuralgia
  • Temporal arteritis

5. Systemic causes:

  • Severe hypertension
  • Drugs (vinca alkaloids etc)

Diagnostic features of conditions presenting with orofacial pain

Common diseases in this list need to be ruled out before diagnosis of rare conditions

1. Acute osteomyelitis:

  • Causative lesion – carious tooth/PDL disease, and bone swelling
  • Moth eaten appearance only manifests when approx 30% of bone undergoes osteolysis

2. Acute pulpitis:

  • Sensitivity to temperature extremes and sugary foods
  • ↑ pain at night or when lying down.
  • Vitalometry – indicates that the pulp is still vital
  • Percussion sensitivity – indicates apical spread

3. Apical abscess:

  • Non vital tooth with fistula, parulis or extra oral drainage tracts
  • This may be acute (with febrile presentation) or chronic

4. Cracked tooth syndrome:

  • Apico-occlusal crack which does not show up on x-ray
  • Pain on mastication
  • Lateral pressure on the inclines of the cusp causes pain

5. Cluster headaches:

  • Seasonal headaches with acute episodes in the evenings + ipsilateral conjunctival
    reddening and nasal discharge

6. Internal derangement of TMJ meniscus/ capsule adhesions

7. Myalgia of masticatory muscles:

  • Pain and spasm of muscles of mastication – marked by a trigger point on one or more of these muscles (masseter, medial and lateral pterygoids, temporalis)
  • Usually found in patients with a history of jaw clenching on anxiety

8. Otitis media:

  • Unilateral hearing impairment and bulging, perforated, red or purulent tympanic membrane

9. PDL abscess:

  • Expression of pus from the PDL pocket of a vital tooth
  • Characterized by presence of calculus and alveolar bone damage
  • If the tooth is non vital, it’s a perio-endo lesion

10. TMJ capsulitis/ synovitis/ arthritis:

  • Pain over the joint
  • Limited mouth opening or deviation on opening
  • Crepitus on palpation of the TMJ – indicates bone erosions – secondary to arthritis

11. Neuralgia (Trigeminal, Glossopharyngeal or Postherpetic):

  • Pain of neural origin, paroxysmal pain
  • Distinct trigger zone on skin/ in mouth
  • Middle aged or old patients, female patients
  • Trigeminal neuralgia is called ‘Tic Doloureux’ when it is accompanied by spasms of the muscles of facial expression

Classical trigeminal neuralgia:

  • Sudden unilateral, severe, brief, stabbing, recurrent pains in the distribution of trigeminal nerve branches
  • Pain is paroxymal
  • Provoked by light touch
  • Confined to trigeminal distribution
  • Unilateral
  • Lasts from few seconds to 2 minutes
  • Etiology: Intracranial compression of nerve by vasculature/foramina (osteopetrosis)
  • Diagnosis: History, CT scan, MRI, LA during an attack attenuates the pain instantly
  • Management: Carbamazepine, cryotherapy, vascular decompression

12. Atypical facial pain:

  • No known organic cause (diagnosis of exclusion)
  • Described by the patient in vague terms, treated as a symptom of depressive illness
  • It is also called psychogenic pain

13. Myofascial pain dysfunction syndrome (MPDS)

The diagnostic protocol for acute facial pain

Is the contributing lesion clinically visible (intra- and extra-oral examination for caries, PDL
disease, swellings, erosions, joint sounds, radiographic changes)?

− Is it accompanied by fever (a sign of acute disease)?

− Pulp or PDL: Abscess or osteomyelitis
− Mucosal lesions: Viral vesiculo-ulceration
− Facial swelling: Cellulitis or space infection
− Salivary swelling: Mumps or obstructive sialadenitis
− TMJ or mid ear: Infectious capsulitis or otitis media

If NO:

1. Dull or episodic aches:

Dull and episodic aches in jaws, TMJ and saliva

2. Constant ache:

  • Teeth or jaws:
    − Atypical facial pain
    − Myalgia of muscles of mastication
  • TMJ: Temporomandibular myalgia

3. Acute episodic ache:

  • Short term (seconds): Trigeminal neuralgia
  • Long term (minutes): Cluster headaches

NB: Manage pain and re-evaluate in 1 wk to eliminate an organic source eg cracked tooth

4. Chronic episodic ache:

  • Teeth or jaws:
    − Atypical facial pain
    − Myalgia of muscles of mastication
    − Cardiogenic (one of the signs of hypertension)
    − Vasogenic (migraine)
  • TMJ: Myalgia

Facial paralysis

UMN lesion: Lesion of the neural pathway above the anterior horn cell of spinal cord, or motor nuclei of the cranial nerves

LMN lesion: Affects nerve fibers traveling from anterior horn of spinal cord or cranial motor nuclei to the relevant muscles

Difference between upper and lower motor neuron lesions

1. Bell’s palsy: Picture

  • LMN paralysis of the face – due to inflammation in the stylomastoid canal
  • Reversible in 80% of cases
  • Management: Corticosteroid therapy

2. Ramsay Hunt syndrome:

  • Severe facial palsy – due to herpes zoster infection of the geniculate ganglion of the facial nerve
  • In hereditary craniofacial malformation

3. Tardive dyskinesia: Picture

  • Complication of longterm treatment with phenothiazines or butyrophenones
  • Clinical: Involuntary facial movements

4. Horner’s syndrome: Picture

  • A series of signs and symptoms – secondary to trauma to the cervical sympathetic trunk
  • Clinical: Miosis (papillary constriction), ptosis (drooping eyelids), facial anhidrosis (loss of sweating) and occasionally enophthalmos

5. Adie’s pupil: Unilateral dilatation + very slow light reflex – due to syphilis. Picture

6. Argyll-Robertson pupil: Picture

  • Failure of light reflex, but dilation for accommodation.
  • Also seen in neurosyphillis + other conditions affecting the Edinger Westphal nucleus eg diabetes mellitus, sarcoidosis, encephalopathies, midbrain tumors, trauma and amyloidosis