Cheek Numbness Research Articles

A Case Report on the Short-Term Recurrence of Low-Grade Fibromyxoid Sarcoma in the Maxillary Sinus.

Low-grade fibromyxoid sarcoma (LGFMS) represents an exceptionally rare soft-tissue tumor, challenging to diagnose, and notorious for relentless recurrence and proliferation postsurgical resection. Primary symptoms of LGFMS include nasal congestion and rhinorrhea, accompanied by cheek numbness and distension. In this article, we report the diagnosis and treatment of a case of low-grade LGFMS originating in the maxillary sinus (MS). A 64-year-old male diagnosed with LGFMS of the left MS, undergoing 3 surgeries over a 1-year period with subsequent local recurrence. Following inconclusive postoperative pathology after the initial surgery, the patient experienced recurrence 2 months postsurgery, necessitating a second operation, which confirmed the LGFMS diagnosis pathologically. Radiation therapy commenced 1 month after the second surgery; however, recurrence transpired 6 months later, leading to a third operation. Subsequently, recurrence occurred again 8 months post third surgery, with the patient currently undergoing targeted therapy. This case underscores the distinct characteristics and therapeutic challenges inherent in LGFMS through the narrative of diagnosis and progression of LGFMS originating in the MS.

Bleach-Induced Chemical Sinusitis and Orbital Cellulitis Following Root Canal Treatment

The authors describe an unusual case of chemical sinusitis and orbital cellulitis secondary to a sodium hypochlorite accident in a patient who had just undergone root canal treatment. The patient presented with acute, progressive symptoms of unilateral maxillary sinusitis, facial cellulitis and orbital cellulitis which began hours after root canal treatment on the ipsilateral side. He was admitted to hospital under the care of the Otorhinolaryngology team and reviewed regularly by the Ophthalmologists. He underwent Endoscopic Sinus Surgery during his hospital stay. The intraoperative findings revealed necrotic sinus mucosa and slough within the involved maxillary sinus, which were suggestive of chemical burn injury induced by the highly alkaline sodium hypochlorite solution used during root canal treatment. He was treated postoperatively with regular nasal toilet, culture-directed antibiotics and topical ocular pressure-lowering eyedrops. He displayed a slow recovery with eventually no orbital sequelae, but experienced persistent cheek numbness three months post-injury. Severe chemical sinusitis with orbital cellulitis secondary to sodium hypochlorite accident is a rare complication of root canal treatment, with potentially severe consequences. It can present with symptoms similar to complicated acute bacterial sinusitis. Otorhinolaryngologists and dental surgeons should maintain a high index of suspicion when managing a patient post-root canal treatment with symptoms of unilateral sinusitis, facial cellulitis, orbital cellulitis and even airway compromise. This would allow prompt intervention before sight or life-threatening complications set in.

Comparison of conventional and extended middle meatal antrostomy for the treatment of antrochoanal polyps

ObjectiveThe objective was to compare the recurrence rate and complications between endoscopic middle meatal antrostomy (MMA) and extended MMA for the treatment of antrochoanal polyps (ACPs).Methods and materials95 ACPs were prospectively enrolled to undergo MMA (n = 48) or extended MMA (n = 47). The recurrence rate and complications were compared between these groups.ResultsAll patients completed 24 months of follow-up. The recurrence of ACP was demonstrated by only endoscope at 6 and 12 months postoperatively but at 24 months postoperatively by endoscope and CT. Rates of recurrence of ACP differed between groups and significance at postoperative month 6 (7/48 patients in the MMA group and 0/47 patients in the extended MMA group, P = 0.02), month 12 (16/48 vs. 2/47, P < 0.01) and month 24 (21/48 vs. 3/47, P < 0.01). No MMA closure was found in any group, 19.15% (9/47) patients complained of cheek numbness in the extended MMA group, however, no major complications were observed in both groups.ConclusionsExtended MMA via antidromic extended medial wall of MS may effectively reduce the recurrence of ACP with lower complications.

662 Bilateral Vocal Cord Paralysis and Cranial Polyneuropathy: A Rare Presentation of Ramsay Hunt Syndrome

Abstract Case Presentation A 61-year-old gentleman with chronic lymphocytic leukaemia presented with right sided disseminated vesicles, otalgia, hearing loss, facial weakness, dysphagia, hoarseness, breathlessness, and stridor. In the preceding 48 hours he had two A&amp;E presentations with only right otalgia, facial weakness, throat tightness and mild breathlessness. Cranial nerve (CN) examination demonstrated right cheek numbness and absent jaw jerk reflex (CNV), right grade 6 lower motor neuron facial palsy (CNVII), impaired hearing (CNVIII), dysphonia, dysphagia, and asymmetric palate elevation (CNIX and X). Fibreoptic nasendoscopy (FNE) demonstrated bilateral vocal cord palsy. He was diagnosed with Ramsay Hunt syndrome (RHS) and disseminated herpes zoster (HZ) requiring intubation and ventilation, intravenous steroids, aciclovir, antibiotics and a prolonged intensive care admission. He was discharged after three months. Eight months later, he has a long-term tracheostomy, gastrostomy, and live-in carer. Discussion This is the only case found in the literature of RHS and associated bilateral vocal cord palsy with cranial polyneuropathy requiring a long-term tracheostomy. It highlights the significant morbidity attached with RHS complications, particularly in a patient with underlying malignancy. Awareness of these rare and potentially life-threatening complications should be raised to avoid investigation and treatment delay. HZ should be considered in patients with CNVII palsy and otalgia, with or without vesicles. Clinicians should perform full CN examination including FNE to assess for cranial polyneuropathy. RHS can present without vesicles, making it indistinguishable from Bell's Palsy. Therefore, we should consider treating Bell's Palsy with aciclovir. Furthermore, multidisciplinary management of disseminated HZ is essential.

Extended middle meatal antrostomy via antidromic extended medial wall for the treatment of fungal maxillary sinusitis

ObjectiveThe objective of this study was to compare the long-term results of extended middle meatal antrostomy (MMA) and MMA combined with inferior meatal antrostomy (IMA, combined approach) for the treatment of fungal maxillary sinusitis (FMS).Methods and materialsA retrospective analysis including 90 patients with non-invasive FMS was treated with endoscopic extended MMA via antidromic extended medial wall (extended MMA group), or with both MMA and IMA (combined approach group). The recurrence rate, operation time, and complications were evaluated at postoperative 12 and 36 months.ResultsOf the 90 patients, 52 patients were in the extended MMA group and 38 patients in the combined approach group. CT revealed the thin medial wall or bone defect in 63.33% (57/90) patients. The mean operation time in the extended MMA group was significantly shorter than that of combined approach group (42.5 ± 6.5 vs 57.4 ± 4.9, P < 0.01). At postoperative 12 months postoperatively, the recurrence rate was 3.85% (2/52) in the extended MMA group and 0.0% (0/38) in the combined approach group, the difference wasn’t significant (X2 = 0.618, P > 0.05). The recurrence rate wasn’t increased during the follow-up period over time in both groups.13.5% (7/52) patients complained of cheek numbness in the extended MMA group, 60.5% (23/38) patients complained of cheek numbness and epiphora in 5.3% (2/38) patients in the combined approach group, the difference was significant (X2 test, P < 0.01). However, no major complications were observed in both groups. In addition, IMA closure was observed in 4 (10.5%) in the combined approach group at 12 months postoperatively and in 9 (23.6%) at 36 months postoperatively.ConclusionsExtended MMA via antidromic extended medial wall may effectively prevent the recurrence and reduce the complications of FMS, IMA wasn’t necessary for the treatment of FMS in most cases.

Mucormycosis in COVID-19 pandemic and its neurovascular spread.

PurposeRhinocerebral mucormycosis is a rapidly progressive angioinvasive fungal infection commonly seen in diabetics. In the COVID-19 pandemic we have witnessed a sudden surge in these cases. We aimed to evaluate the disease presentation, patterns of spread, and any association with the COVID-19 virus.MethodsThis prospective study was conducted on mucormycosis patients operated between March and July 2021. The diagnosis was confirmed either on KOH staining, fungal culture or histopathological examination.ResultsThirty one cases (21 males, 10 females) with a mean age of 53.3 years were included, of which 9 (29.1%) were COVID positive on presentation, 17 (54.8%) were post-COVID, while 5 (16.1%) had radiological evidence of COVID sequelae. Most common symptoms were cheek numbness (87.1%), headache (83.9%), visual disturbances (77.4%), and palate involvement (58.1%). Blackening of turbinates was uncommon (22.6%). Ethmoid sinus was involved in all patients. Pterygopalatine fossa involvement was present in 77.4%, and was accurately diagnosed on contrast enhanced MRI scan. There were 8 (25.8%) deaths, while the remaining are discharged or under treatment.ConclusionAn increase in the incidence of mucormycosis in the COVID-19 pandemic is probably due to a compromise in host immunity along with a synergistic effect in thrombotic microangiopathy. Spread of infection to the soft tissues of the infratemporal fossa, orbit or palate occur via neurovascular structures rather than by bone erosion. The pterygopalatine fossa is involved in most individuals.

Endoscopic treatment of ectopic teeth in the maxillary sinus.

BackgroundEctopic teeth in maxillary sinus is rare and are usually removed via sub-labial trans-canine fossa approach (SLCFA). The aim of our study was to present our experience with extraction of ectopic teeth in the maxillary sinus via transnasal endoscopic approach (TEA). Material and Methods Rhinologists were asked to share their experience in the management of ectopic teeth in the maxillary sinus. Data were reviewed retrospectively. Results Eleven cases were reported in 10 patients from 2010 to 2019, six males and four females with a mean age of 33.5 +/-17 years (range 16 to 61). Seven patients complained of sinonasal symptoms, two were diagnosed incidentally during routine dental work-up, and one had oro-antral fistula. In eight patients, a cyst coexisted within the maxillary sinus. Teeth were located arbitrarily within the sinus. All cases were operated by TEA. One patient had self-limited periorbital emphysema, one had transient cheek numbness, and one had early post-operative bleeding that stopped after endoscopic cauterization. Long-term follow-up revealed good clinical outcomes. ConclusionsTransnasal endoscopic removal of ectopic teeth from the maxillary sinus is a feasible and rational approach when SLCFA is contraindicated. Key words:Ectopic teeth, dentigerous cyst, endoscopic sinus surgery, Caldwell-Luc.

Is there an ideal time to repair orbital floor fractures?

Introduction: Orbital fractures often involve the orbital floor. They can be isolated or involve multiple orbital walls, also in conjunction with other facial fractures. Common symptoms include diplopia, enophthalmos, hypoglobus and cheek numbness. Repair of orbital trauma is believed by many specialists to be time sensitive, where outcomes can be significantly affected by timing and delays. We wanted to evaluate our outcomes in relation to timing.

THE DRUNKEN HAIR: INTRODUCING IN VIVO DEMONSTRATION OF INCREASED BLOOD ALCOHOL CONCENTRATION TEMPORARY DISRUPTING HUMAN HAIR FOLLICLES EMISSION OF ELECTROMAGNETIC RADIATION

The human hair consists of a follicle a.k.a root penetrating the skin and an outer skin structure commonly called the shaft. The hair follicle has been classified as a miniorgan having its own cells divisions; aging stages and also demonstrated to be an energy emitter in the form of electromagnetic radiation. The intent of this manuscript is to introduce documentation from in vivo experiments showing the deleterious effect of alcohol consumption on the previously documented hair follicle intrinsic and orderly emission of energy a.k.a. Electromagnetic Radiation (EMR). This was possible by a minor modification of a tabletop optical microscopy technique introduced in 2015 and designed to display plant and animals tissue EMR. In vitro control experiments had shown that a drop of white wine covering a human hair follicle placed on a glass slide caused what appeared to be a disruption on the hair follicle EMR emissions; the addition of chemicals to the wine during manufacturing could have caused that effect. The answer could lie in an in vivo alcohol drinking approach by increasing only the blood alcohol concentration (BAC). In this manuscript two in vitro and two in vivo are presented where the author, a non-alcohol drinker, purposely and during fasting underwent two binge-drinking episodes aimed to increase his BAC and investigate its impact on hair follicles. Several black beard hair samples were plucked via tweezers as controls; additional samples were also plucked and processed at approximately peak alcohol physical symptoms such cheek numbness and dizziness which occurred between 35 and 45 minutes post two episodes of wine or wine and beer binges. Images and video-recordings are presented.

Endoscopic combined middle and inferior meatal antrostomies approach in treatment of maxillary sinus inverting papilloma.

IntroductionEndoscopic medial maxillectomy is currently the most commonly used endoscopic approach to the maxillary sinus inverting papilloma. The possible complications of this procedure include epiphora, crusting and empty nose syndrome. Another method, a prelacrimal recess approach, enables preservation of the nasolacrimal duct and inferior nasal turbinate, but offers limited possibility of postoperative endoscopic follow-up.AimTo evaluate the combined middle and inferior meatus antrostomy approach to treat the maxillary sinus inverting papilloma.Material and methodsA retrospective assessment of the medical records of consecutive patients operated on due to the maxillary sinus inverting papilloma in a single centre was performed.ResultsFourteen patients operated on using combined antrostomies, with a follow-up of 2 years, are presented. In 2 patients, the tumor involved the prelacrimal recess. One of these patients was successfully operated on using combined antrostomies. In the second patient combined antrostomies were accompanied by a prelacrimal recess approach. None of the 14 patients had intraoperative complications. No recurrence was observed. No drying, empty nose syndrome, lacrimation, floppy turbinate or mucus recirculation was observed. Two patients complained of permanent cheek numbness. Follow-up endoscopy was easily performed with a rigid endoscope through both antrostomies in all patients except one.ConclusionsCombined antrostomies appear effective to treat the maxillary sinus inverted papilloma. They are associated with minimal invasiveness and complications and enable easy endoscopic follow-up. In patients with prelacrimal recess involvement, it can be supplemented by the prelacrimal recess approach or, if needed, converted to an endoscopic Denker procedure.

Surgery for juvenile nasopharyngeal angiofibroma with lateral extension to the infratemporal fossa

The study aimed to assess the usefulness of skull base surgery for large juvenile nasopharyngeal angiofibroma (JNA) with lateral extension to the infratemporal fossa. Eleven cases were enrolled for this study, and the mean age was 17.7 years old (range: 8-32). Six out of 11 cases underwent surgery as an initial treatment, and the other five underwent secondary surgery after initial surgery or radiotherapy in other institutions. The range of extension of tumor, feeding arteries, surgical approach, and treatment outcome were estimated. All tumors originated from the sphenopalatine foramen. Based on the imaging study, there was extension to the cavernous sinus observed in eight cases, as well as to the middle cranial fossa (8), orbit (4), and anterior cranial fossa (1). These tumors were diagnosed as Andrews' Stage IVa (3) and IVb (8). However, infiltration into the cavernous sinus was observed in one case only during surgery. Ten tumors were separated carefully from the cavernous sinus or dura and were accurately diagnosed as Stage IIIb. In all cases, the main arterial feeders of the JNAs were branches of the external carotid artery, which were embolized prior to surgery. However, 10 cases were also fed by branches of the internal carotid artery (branches of the ophthalmic artery), in which these arteries could not be embolized. Coronal skin incision (1) and a facial dismasking flap (9) were used, and in one case, wide lateral skin incision with temporary incision of the facial nerve was applied. The orbito-zygomatic approach and its modification was applied to all the cases. Fronto-lateral craniotomy was applied in four cases and lateral craniotomy in seven cases. Total resection was achieved in 10 cases and subtotal resection in one case. No mortality was noted in this series. Temporal trismus was observed in all cases which subsided gradually. Cheek numbness and facial palsy were observed in three and two cases, respectively. Coupled with craniotomy, tumor removal was successfully carried out in 11 patients with JNAs, which showed large lateral extension. Our surgical strategy is a safe and effective approach for the removal of JNAs with infratemporal fossa extension.

Endoscopic Transnasal Approach to the Infratemporal and Upper Parapharyngeal Tumors: Indications and Outcomes

Objectives: Describe the endoscopic transnasal approach to the infratemporal fossa (ITF) and upper parapharyngeal region (UPR), and analyze the indications and outcomes of this surgical technique in the management of the tumors localized in this critical area. Methods: Retrospective review of patients with benign and malignant tumors arising in or extending to the ITF and UPR, treated from 2002 to 2012 at a single institute. The tumors were surgically resected using an endoscopic transnasal transmaxillary transpterygoid approach, combined with a posterior septotomy to improve the controlateral maneuverability of surgical instruments. Results: Thirty-one consecutive patients with benign tumors (20 juvenile nasopharyngeal angiofibromas, 2 extracranial trigeminal schwannomas, 2 meningiomas, and 1 cavernous hemangioma) and malignancies (2 adenoid-cystic carcinoma, 1 mucoepidermoid carcinoma, 1 squamous-cell carcinoma, 1 adenocarcinoma, and 1 recurrence of chondrosarcoma after chemo-radiation therapy) were treated with curative intent. A gross-total resection was achieved in 28/30 patients. Major complications were observed in 1 case (intra-operative internal carotid artery blowout), and minor complications (postoperative palate and/or cheek numbness) were observed in 4 cases. Postoperatively, the 5 primitive malignancies received intensity-modulated radiotherapy. Mean follow-up was 30 months for malignancies and 54 months for benign tumors. All patients are now alive without recurrences, with stable intracranial persistence of disease in 2 cases (1 meningioma and 1 adenoid-cystic carcinoma). Conclusions: The purely endoscopic transnasal technique may provide a minimally-invasive and safe approach to resect selected tumors involving the ITF and UPR. Larger case series and longer follow-up are needed to validate the reproducibility and efficacy of this technique.

A Systematic Review of the Endoscopic Management of Orbital Floor Fractures

To determine the safety and efficacy of the endoscopic management of isolated orbital floor fractures. A systematic review was performed using electronic databases. Studies investigating the reconstruction of isolated orbital floor fractures using an endoscopic approach were considered for inclusion. Two investigators independently reviewed all results. Study quality was assessed using the Methodological Index for Nonrandomized Studies scale. Primary outcomes were the resolution of diplopia and enophthalmos. Secondary outcomes were postoperative complications, including blindness, paresthesias, sinusitis, infection, conversion to external approach, and need for revision surgery. Nine studies capturing 172 patients met the inclusion criteria for systematic review. Two studies were comparative and 7 were case series. Study quality was poor, lacking prospective data and reliable assessment of outcomes. Strong reviewer agreement was observed (intraclass correlation, 84%; 95% CI, 35%-96%). Diplopia resolved in 102 of 118 patients (86%) and enophthalmos resolved in 41 of 43 (95%). No complications of blindness, sinusitis, or conversion to external approach were reported. Thirteen patients (8%) had transient cheek numbness. Two patients (1%) required revision surgery. Reconstruction of isolated orbital floor fractures through an endoscopic approach appears to be safe and effective. High-level evidence prospectively comparing endoscopic and external approaches, however, is lacking.

The Case Files

The Case Files

Estrogen inhibits expression of P2Y&lt;SUB&gt;2&lt;/SUB&gt; mRNA in human breast cancer cell line MCF-7

Objective:To report our experience on endoscopic nasal lateral wall dissection approach for treatment of refractory benign maxillary sinus diseases.Methods:The data of 8 patients,who had relapsing maxillary diseases 2 to 4 times after maxillary sinus or ethmoid sinus surgery,were retrospectively analyzed.The patients included 6 males and 2 females,with an average age of(55±14) years(41-69 years).Under general anesthesia the operation started from an incision in front of the inferior turbinate(IT),then the lacrimal duct(LD) was dissected to form a IT-LD flap.The flap was placed inwardly and the maxillary sinus lesion was removed under endoscope.The inferior antrostomy was performed when necessary.The possibility of maxillary sinus malignant lesions was ruled out by postoperative pathology.Results:Postoperative pathological findings confirmed that the lesions were all benign.The follow-up period ranged from 6-14 months.Five patients were cured and 3 were improved 6 months after operation.There were no complications such as cheek numbness,epiphora,orbital hemorrhage,visual disorder or cerebrospinal fluid rhinorrhea during follow-up.Conclusion:The endoscopic nasal lateral wall dissection approach provides a wider vision field and allows for a thorough removal of maxillary sinus lesions,while reserving the LD and IT.

Carcinoma ex pleomorphic adenoma of soft palate with cavernous sinus invasion

BackgroundCarcinoma ex pleomorphic adenoma (CXPA) is an aggressive salivary gland malignancy and rare in minor salivary gland. A soft palate CXPA initially presenting as direct cavernous sinus (CS) invasion is very rare.Case PresentationA 60-year-old male had a 3-month history of a small soft palatal mass with progressing left cheek numbness, proptosis, and disturbed vision. Biopsy of soft palatal tumor showed pleomorphic adenoma. Magnetic resonance imaging showed a tumor involving left maxilla, and extended from pterygopalatine fossa, inferior orbital fissure to CS. Excision of tumor revealed CXPA. Adjuvant concomitant chemo-radiation therapy (CCRT) was given. The tumor recurred 5 months later in left CS which was re-treated with CCRT. The disease status was stable at 2 years after the diagnosis of CXPA.ConclusionWe present this case to emphasize that patients with symptoms such as facial numbness, proptosis and disturbed vision should be carefully investigated for lesions invading CS by perineural spread.

Endoscopic nasal lateral wall dissection approach for benign lesions of maxillary sinus

Objective:To report our experience on endoscopic nasal lateral wall dissection approach for treatment of refractory benign maxillary sinus diseases.Methods:The data of 8 patients,who had relapsing maxillary diseases 2 to 4 times after maxillary sinus or ethmoid sinus surgery,were retrospectively analyzed.The patients included 6 males and 2 females,with an average age of(55±14) years(41-69 years).Under general anesthesia the operation started from an incision in front of the inferior turbinate(IT),then the lacrimal duct(LD) was dissected to form a IT-LD flap.The flap was placed inwardly and the maxillary sinus lesion was removed under endoscope.The inferior antrostomy was performed when necessary.The possibility of maxillary sinus malignant lesions was ruled out by postoperative pathology.Results:Postoperative pathological findings confirmed that the lesions were all benign.The follow-up period ranged from 6-14 months.Five patients were cured and 3 were improved 6 months after operation.There were no complications such as cheek numbness,epiphora,orbital hemorrhage,visual disorder or cerebrospinal fluid rhinorrhea during follow-up.Conclusion:The endoscopic nasal lateral wall dissection approach provides a wider vision field and allows for a thorough removal of maxillary sinus lesions,while reserving the LD and IT.

Epithelioid Malignant Peripheral Nerve Sheath Tumor in the Infraorbital Nerve

Epithelioid malignant peripheral nerve sheath tumors are rarely found in cranial nerves. This report describes one such tumor originating from the infraorbital nerve in a 55-year-old man who presented with diplopia and right cheek numbness. Imaging showed a mass along the floor of the right orbit, which was excised. Histology suggested melanoma or carcinoma. Immunohistochemical staining was positive for S-100 and negative for HMB-45 and cytokeratin. Four other cases from the literature involving cranial nerves are discussed.

Numb cheek syndrome as the first manifestation of anti–Hu paraneoplastic neuronopathy

Sirs: Unilateral numb cheek syndrome (NCS) has rarely been described as the first manifestation of malignancy due to neoplastic involvement of the trigeminal nerve, more specifically the maxillary branch [1, 2]. NCS as the first symptom of subacute paraneoplastic sensory neuronopathy has, to the best of our knowledge, never been reported. We present this case because its rarity led to a diagnostic delay of several months. A 47-year-old man presented with a one month history of numbness in the left cheek, both inner and outer surfaces. The area of numbness corresponded with the mandibular division of the left trigeminal nerve (V3). His medical history was unremarkable. Neurological examination was normal including the left V3 area. As the main part of the cheek is innervated by the buccal nerve we considered that our patient had a mandibular sensory neuropathy probably due to compression or infiltration of the nerve by local malignancy, as seen in other types of trigeminal mononeuropathy [3]. Ancillary investigations including contrast enhanced brain MRI, thorax CT and extensive laboratory examinations of the blood and urine were normal. Cerebrospinal fluid (CSF) examination revealed mild lymphocytic pleocytosis, slightly elevated protein of 0.69 g/l (0.2–0.5) and no malignant cells or oligoclonal bands. Although intracranial malignancy could not be ruled out an expectant policy was chosen by the patient. Two months later he complained of slightly unsteady gait. A second MRI of the brain and skull base was normal. Another 4 months later he noticed numbness of his left hand and foot. Neurological examination showed only left sided facial hypalgesia. Nerve conduction studies were consistent with a non uniformly distributed, predominantly axonal, sensorimotor neuropathy, most pronounced in the left extremities. Repeated conventional CSF examination only showed an increased protein level of 0.86 g/l. Anti-Hu antibodies in CSF were detected with indirect immunofluorescence and Western blotting techniques. A second thorax CT and whole body PET-scan eventually showed a solitary lesion in the right hilus, which proved to be a metastasis of an anaplastic small cell carcinoma on histological examination. Although the primary tumour remained unrevealed, a paraneoplastic multifocal mainly sensory neuronopathy associated with presumed primary small cell lung carcinoma was diagnosed and combined chemotherapy started. Fifteen months after the initial complaint the primary tumour remained undetected and no metastases were found. The neuropathy progressed resulting in very severe sensorimotor neuropathy with asymmetric painful paresthesias, diffuse proprioceptive loss and weakness in all extremities. In patients with paraneoplastic anti-Hu associated neuropathy (AHN) involvement of the cranial nerves may be present but is very rarely the presenting symptom. AHN most commonly presents as a subacute sensory neuropathy, less frequently as a sensorimotor neuropathy [5, 6]. These neurological symptoms typically antedate the diagnosis of cancer and most commonly involve the extremities [4–7]. In 306 patients with malignancy and associated anti-Hu antibodies, 50 % of the patients had a sensory neuropathy [4–6]. Three of them had trigeminal nerve involvement, but in no one was cheek numbness described as the only presenting symptom. As initially no primary tumour was found, we did not consider AHN as a potential cause of the unilateral cheek numbness in our patient. The final diagnosis was reached because of the extension of the sensory symptoms and eventually the evidence of an asymmetric sensorimotor neuropathy. The diagnostic delay between the NCS and final diagnosis was 6 months, which lies within the range of reported diagnostic delays in AHN patients [4–7]. As early treatment of the underlying malignancy is the mainstay of treatment, we report this patient in order to add NCS to the list of presenting symptoms of AHN.

Application of endoscope in zygomatic fracture repair

The endoscope has been used to visualise the upper face and brow in aesthetic facial surgery which is performed without a coronal incision. We applied these principles to repair zygomatic fractures with the aid of a 4 mm, 30 degree telescope inserted through a small temporal incision. Fracture sites at the zygomatic arch and the zygomaticofrontal suture were exposed and fixed with miniplates under endoscopic control. This technique was used in 15 consecutive patients including 2 with isolated zygomatic arch comminuted fractures and 13 having displaced zygomatic fractures with segmental, displaced zygomatic arch fractures. Nine patients were men and six patients were women with a mean age of 35 years. Three patients had associated mandibular fractures. The periods of follow-up ranged from 3 to 22 months. Two patients developed transient frontal nerve palsy which recovered within 2 months. One patient had mild temporal hollowing on the side of the facial fracture. All patients achieved the adequate anatomic reduction and satisfactory malar symmetry. There has been no case of chewing problems, cheek numbness or progressive enophthalmos developing postoperatively. Application of the endoscope in zygomatic fracture repair minimises the scalp scar, avoids forehead numbness, provides a comfortable postoperative recovery and shortens hospital stay. Careful preoperative evaluation and proper surgical technique are mandatory for achieving optimal results in selected patients.