Recurrent cranial nerve palsies in diabetes mellitus

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Abstract
Reports on three diabetic patients who had recurrent cranial nerve palsies are presented. In none was the diabetes under good control at the time of nerve involvement. The third, sixth, seventh, and fourth nerves were affected in decreasing order of frequency. The first patient had a syndrome of the cavernous sinus characterized by a complete right external ophthalmoplegia from which he recovered, only to have a similar paralysis on the opposite side. The second had first a right seventh, then a left seventh nerve paralysis and subsequently an incomplete left third nerve palsy. The third had multiple, alternating complete and incomplete extraocular palsies affecting chiefly the third but possibly also the fourth and sixth nerves. The pupils were of average size and retained their reactivity in every case in which the oculomotor nerve was affected. This suggests that the accountable lesion is within the substance of the nerve, so situated as to spare the superficially lying, small pupilloconstrictor fibers. The rapid onset and early recovery are compatible with a vascular etiology. It is postulated that the pathogenesis is a specific vascular disease of the vasa nervorum, permitting transitory edema and ischemia of the affected nerves to occur, in the presence of abnormal metabolites. Although recurrent cranial nerve palsies occur in several diseases, the incidence seems especially high in diabetes mellitus. Since the oculomotor nerve is most often affected, it is suggested that, in the absence of myasthenia gravis or other identifiable disease, one should first suspect diabetes in a patient presenting with a third nerve palsy but with pupillary sparing.

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