Facial Anesthesia Research Articles

The Trigeminal Trophic Syndrome: An Unusual Cause of Face Pain, Dysaesthesias, Anaesthesia and Skin/Soft Tissue Lesions

The trigeminal trophic syndrome is an unusual consequence of trigeminal nerve injury that results in facial anaesthesia, dysaesthesia and skin ulceration. Limited knowledge is available. The aim of this study was to increase the knowledge of this syndrome by performing a retrospective medical record review and case series report. Fourteen cases were identified. The female:male ratio was 6:1. Mean age of onset was 45 years (range 6-82). The cause was iatrogenic in most. Latent period to onset ranged from days to almost one decade. The majority (n = 12) had bothersome dysaesthesias. Most (n = 9) self-manipulated the face; a third (n = 5) did not. Most ulcers affected the second trigeminal division, mainly in the infraorbital nerve distribution. Neuropathic and/or neuralgic facial pain occurred in 50% (n = 7). Pain intensity was severe in most (n = 6). Gabapentin gave relief in two. To conclude, trigeminal trophic syndrome follows injury to the trigeminal nerve or its nuclei. For unclear reasons, most ulcerations follow infraorbital nerve distribution. Self-manipulation may contribute to ulcer development rather than being required. Gabapentin may help pain.

Anterior Inferior Cerebellar Artery Infarction Presenting With Sudden Hearing Loss and Vertigo

A peripheral origin is typically contemplated in a patient presenting with sudden hearing loss (HL) and dizziness without other neurologic manifestations. Although symptoms of anterior inferior cerebellar artery (AICA) infarction include sudden HL and vertigo, the clinical picture usually shows ipsilateral facial anesthesia or paralysis, Horner's syndrome, contralateral body anesthesia, or cerebellar dysmetria. A 68-year-old female patient developed sudden HL in the right ear and vertigo. A left-beating horizontal torsional nystagmus was observed, and caloric weakness in the right side was noted. Diffusion- and T2-weighted magnetic resonance imaging revealed cerebellar infarction in the right AICA territory. AICA infarction may present without obvious neurologic deficits, and an imaging study is advised in patients at high risk for vascular accidents.

MRI findings of malignant transformation of epidermoid cyst: case report

Malignant transformation of epidermoid cysts into squamous cell carcinoma (SCC) rarely occurs. A 67-year-old man initially presented with an 8-year history of right trigeminal neuralgia. His symptoms had changed into right facial anesthesia with right-ear hearing impairment 8 months before first consulting a neurosurgeon at our hospital. Results obtained using MRI suggested an epidermoid cyst in the right cerebellopontine angle, but showed atypical findings of a small enhancing nodule in the periphery and surrounding edema in the cerebellum and pons. Surgery was performed to remove the mass, but a small nodule was not reached. Despite stereotactic radiosurgery, the patient's clinical course deteriorated; he died 13 months after the first MRI examination. Autopsy revealed SCC originating from the epidermoid cyst. We present serial MRI and pathologic findings in the early and terminal phases of this patient.

A case of neurolymphomatosis involving cranial nerves: MRI and fusion PET-CT findings

Neurolymphomatosis (NL), or lymphomatous infiltration of peripheral nerves, is a rare neurologic manifestation that usually develops in patients with widespread systemic non-Hodgkin’s lymphoma (NHL) but may be the sole relapse site of NHL [1]. Cranial neuropathy is an unusual syndrome of NL that is sometimes difficult to diagnose using conventional imaging modalities. We report a patient with NL of cranial neuropathy in whom fusion F-fluoro-2-deoxyD-glucose (FDG) PET-CT aided in establishing the diagnosis of NL. A previously healthy, 66-year-old man presented with gastric lymphoma of CD20-positive, diffuse large B-cell phenotype. A thorough systemic evaluation revealed Ann Arbor stage IV NHL with multiple metastases in the neck and lung lymph nodes. Eight cycles of R-CHOP chemotherapy lead to complete remission. Three months later, he acutely developed left facial numbness, followed by rightsided peripheral facial palsy and diplopia. Over the next 2 weeks, he continued to deteriorate to the point of complete bilateral ptosis, bilateral facial hypesthesia, and severe dysarthria. On admission, he was alert and fully oriented. Neurologic examination was significant for 5-mm pupils unreactive to light, bilateral complete ptosis, remarkable extraocular movement limitations, bilateral facial anesthesia, and facial diplegia, consistent with bilateral third, fifth, and seventh nerve palsies. Brain MRI showed enlargement and enhancement of the cisternal segments of bilateral trigeminal nerves that was extending to the Meckel’s caves and cavernous sinuses, more pronounced in the left (Fig. 1a). Whole body fusion PET-CT was performed to assess the extent of relapse, showing increased FDG uptake along the bilateral trigeminal nerves and Meckel’s caves, stronger in the left (Fig. 1b). CSF analysis revealed 8 white cells/mm, markedly increased protein (340 mg/dl), and positive cytology for malignant lymphocytes. CSF tests for tuberculosis, virus, parasite, syphilis, and fungus were all negative. Finally, a diagnosis of NL involving multiple cranial nerves was made. Intense chemotherapy was scheduled but delayed due to bouts of serious infections. He could not recover from septicemia and multiple organ failure despite aggressive treatments, and finally he died two weeks later. Our patient’s MRI revealed enlargement and enhancement of trigeminal nerves, suggesting direct lymphomatous infiltration. However, these MRI findings are not specific for perineural spread of neoplastic diseases but can also be seen in various infectious and inflammatory processes. PET revealed increased FDG uptake in the trigeminal nerves and Meckel’s caves, probably representing lymphomatous infiltration of cranial nerves, subsequently confirmed with positive CSF cytology. J. H. Kim (&) AE J. H. Jang AE S.-B. Koh Department of Neurology, Guro Hospital, Korea University School of Medicine, 80 Guro-Dong, Guro-Ku, Seoul 152-703, Republic of Korea e-mail: jhkim.merrf@gmail.com J Neurooncol (2006) 80:209–210 DOI 10.1007/s11060-006-9164-7

Changes in the perioral muscle responses to cortical TMS induced by decrease of sensory input and electrical stimulation to lower facial region

Objective: To determine the changes in the motor cortex due to repetitive electrical stimulation and cutaneous anesthesia in lower facial region. Methods: A total of 11 subjects participated in the study of repetitive electrical stimulation, and 10 other subjects in the study of lower facial anesthesia. Facial nerve root and face associated cortical MEPs by transcranial magnetic stimulation (eight-shaped coil) were recorded from perioral muscles pre- and post- electrical stimulation and lower facial anesthesia. Cheek near to the corner of the mouth was transcutaneously stimulated by bipolar surface electrode giving repetitive electrical shocks at 5 Hz. Five percent lidocain/prilocain local anesthetic cream was applied to left or right lip-cheek region. Results: There was no significant change in perioral MEP responses after 10–30 min of 5 Hz electrical stimulation. We found a significant increase of amplitude in cortical MEP recordings during lower facial anesthesia especially in cases of cortical magnetic stimulations ipsilateral and contralateral to the anaesthetized side and in perioral recordings contralateral to the anaesthetized side. Conclusions: The present study demonstrates that topical anesthesia to the lower facial region leads to cortical modulation and fast plastic changes in both hemispheres that are directed to the normal side.

Meningioma involving Meckel's cave: transpetrosal surgical anatomy and clinical considerations.

Meningiomas originating in Meckel's cave (MC) are uncommon lesions that represent 1% of all intracranial meningiomas. Innovations in skull base surgery have enabled resection of these lesions with less morbidity, but require an intimate knowledge of both lesional pathology and regional microneuroanatomy. To review the surgical and clinical considerations involved in the management of MC meningiomas, we retrospectively reviewed data from patients who underwent transpetrosal resection of primary MC meningiomas between 1984 and 1998. Of 146 patients who underwent transpetrosal removal of meningiomas, 7 were believed to have tumors originating in MC. All 7 patients presented with trigeminal dysfunction, facial pain, and/or headache. Complete tumor removal was achieved in 5 of the 7 patients. Facial hypoesthesia or anesthesia, paralysis of cranial nerve VI, and ophthalmoplegia were among the postoperative complications encountered. Meningiomas of MC represent treatable lesions whose diagnosis requires prompt imaging of patients with trigeminal dysfunction and symptoms of facial pain and headache.

Effect of warming and buffering lidocaine on pain during facial anesthesia

In a double-blind study, room-temperature lidocaine was injected randomly into 1 eyelid of 40 patients during facial anesthesia. The other eyelid of the same eye received injection of warm lidocaine (group 1) or bicarbonate-buffered lidocaine (group 2). Based on a pain scale, warming or buffering lidocaine did not significantly reduce the amount of infiltration pain. Buffering lidocaine was effective in reducing the quality of pain, as judged by the patient's report of dominant pain.

SUPERSELECTIVE NEURECTOMY WITH PERIORBITAL PRIMARY RECONSTRUCTION FOR BLEPHAROSPASM: Case report

A 66-year old man with blepharospasm and ptosis of the brow was treated with a combined procedure in which the branches of the facial nerve were excised at the margin of the orbicularis, and the periorbital area was reconstructed simultaneously. The condition improved after the treatment with no occurrence of either oral complications or facial anaesthesia.

How to block and tackle the face.

Regional blocking techniques as noted in dentistry, anesthesia, and anatomy texts may result in inconsistent and imperfect analgesia when needed for facial aesthetic surgery. The advent of laser facial surgery and more complicated aesthetic facial procedures has thus increased the demand for anesthesia support. Surgeons should know a fail-safe method of nerve blocks. Fresh cadaver dissections are used to demonstrate a series of eight regional nerve-blocking routes. This sequence of bilateral blocks will routinely provide profound full facial anesthesia. Certain groupings of blocks are effective for perioral or periorbital laser surgery.

Conversion disorder after maxillofacial trauma and surgery

Three cases of conversion disorder are reported: one after orthognathic surgery and two after facial trauma. Two of the cases involved facial anesthesia and one case involved facial palsy. It was thought to be important to bring this phenomenon to the attention of oral and maxillofacial surgeons, to consider its management, and to define the patients with a high risk of developing conversion disorder. The prognosis is dependent on the circumstances of the onset of the disorder, the premorbid psychologic health of the patient, and how rapidly treatment is prescribed.

Orbital Infarction Syndrome after Surgery for Intracranial Aneurysms

Global orbital infarction results from ischemia of the intraocular and intraorbital structures due to hypoperfusion of the ophthalmic artery and its branches. The authors describe six patients in whom acute proptosis, ophthalmoplegia, and blindness developed immediately after surgery for intracranial aneurysms. All patients underwent standard frontotemporal craniotomies to clip their aneurysms. In all patients, proptosis, ophthalmoplegia, and blindness developed in the immediate postoperative period; fundus abnormalities included retinal edema, retinal arteriolar narrowing and other vascular abnormalities, and pale optic disc swelling. Some patients had facial and corneal anesthesia. Ophthalmoplegia and facial anesthesia improved in most patients, but none regained any vision in the affected eye. Orbital infarction syndrome is a rare complication of neurosurgical procedures. Increased orbital pressure probably reduced ophthalmic artery and collateral arterial perfusion, resulting in ischemia of the intraocular and intraorbital structures. There may be multiple factors that compound the risk for orbital infarction, and patients with subarachnoid hemorrhage, increased intracranial pressure, anomalous arterial or venous circulation, or impaired orbital venous outflow seem particularly vulnerable.

Mental neuropathy as a sign of distant malignancy: Report of cases

Altered sensation along the cutaneous distribution of the mental branch of the trigeminal nerve typically occurs from distinct causes, including fractures, osteotomies, ostectomies, or anesthetic injection injuries. Less often, trigeminal nerve involvement may result from a nontraumatic origin, such as masseteric space infections, benign intraosseous cystic lesions, or locally invasive intraoral malignancies. In each of these clinical conditions it is fairly easy to determine the origin of the sensory loss based on the duration of the facial anesthesia and the clinical and mandibular radiographic examinations. More diagnostically troublesome is the infrequent trigeminal neuropathy that presents as a spontaneous finding without an obvious cause, even after careful clinical and radiographic assessment. Although uncommon, lower lip and chin anesthesia, or isolated mental nerve neuropathy (IMNN) as it has been previously called, ‘J may be a sign of malignancy in more distant organ systems. We present two cases that illustrate the unusual occurrence of this form of lower facial anesthesia.

Trigeminal cisternal injection of glycerol for treatment of chronic intractable cluster headaches

Medical treatment of chronic cluster headaches (cluster headaches that occur frequently without remission) can be very difficult. In many patients, the pain remains severe despite all medication trials. For these patients, previous reports recommend radiofrequency trigeminal rhizotomy, which risks corneal anesthesia and subsequent corneal decompensation. As a safer, yet effective, treatment, retro-Gasserian injections of glycerol were given to eight patients having intractable chronic cluster headaches. Needle penetration into the trigeminal cistern, glycerol amount (0.55 ml), and length of patient elevation after the procedure (80-90 degrees upright for 10 h) were modified for maximal exposure of the V1 division. Three patients required one additional injection, and one patient required two additional injections. Verbal pain scales (means +/- 1 standard error of the mean) were: 9.1 +/- 0.30 (preoperative), 2.6 +/- 1.10 (1 mo postoperative), and 2.1 +/- 0.64 (1 yr postoperative). Daily headache frequency decreased from 6.0 +/- 2.0 (preoperative) to 0.2 +/- 0.09 (i.e., one headache every 5 days) (1 yr postoperative). Three of the eight patients had no headaches after 1 year. There were no instances of corneal or facial anesthesia. One year postoperatively, five patients required no medication, and three remained on low doses of medication for headache treatment. In contrast to previous limited reports of glycerol injections for cluster headaches, results with these patients having chronic cluster headaches support the use of glycerol injections as a viable treatment alternative, with significant pain relief and corneal safety.

Trigeminal Cisternal Injection of Glycerol for Treatment of Chronic Intractable Cluster Headaches

Abstract Medical treatment of chronic cluster headaches (cluster headaches that occur frequently without remission) can be very difficult. In many patients, the pain remains severe despite all medication trials. For these patients, previous reports recommend radiofrequency trigeminal rhizotomy, which risks corneal anesthesia and subsequent corneal decompensation. As a safer, yet effective, treatment, retro-Gasserian injections of glycerol were given to eight patients having intractable chronic cluster headaches. Needle penetration into the trigeminal cistern, glycerol amount (0.55 ml), and length of patient elevation after the procedure (80-90 degrees upright for 10 h) were modified for maximal exposure of the V 1 division. Three patients required one additional injection, and one patient required two additional injections. Verbal pain scales (means ± 1 standard error of the mean) were: 9.1 ± 0.30 (preoperative), 2.6 ± 1.10(1 mo postoperative), and 2.1 ± 0.64 (1 yr postoperative). Daily headache frequency decreased from 6.0 ± 2.0 (preoperative) to 0.2 ± 0.09 (i.e., one headache every 5 days) (1 yr postoperative). Three of the eight patients had no headaches after 1 year. There were no instances of corneal or facial anesthesia. One year postoperatively, five patients required no medication, and three remained on low doses of medication for headache treatment. In contrast to previous limited reports of glycerol injections for cluster headaches, results with these patients having chronic cluster headaches support the use of glycerol injections as a viable treatment alternative, with significant pain relief and corneal safety.

Familial Trigeminal Anesthesia

Familial congenital trigeminal anesthesia as an isolated abnormality is an unusual disorder. To our knowledge, only one family has previously been reported. We report here a family with three affected members demonstrating facial anesthesia, bilateral corneal changes, and nasal septal damage secondary to self-traumatization. Magnetic resonance imaging demonstrated hypoplasia of gasserian ganglia and trigeminal nerves in the affected father of two affected sons. The pathogenesis of this disorder appears to be congenital hypoplasia of the trigeminal nerves and gasserian ganglia that is inherited in a dominant fashion.

Assisted local anaesthesia for cataract surgery (ALACS).

This paper describes an assisted local anaesthetic technique which we have used almost exclusively for extracapsular cataract extraction and posterior chamber intraocular lens implant surgery over the last 12 months. This ALACS technique was developed from a combined neurolept-local anesthetic into an assisted local anaesthetic suitable for day-stay cataract surgery. The technique combines the advantages of purely local (retrobulbar and facial) anaesthesia with the advantages usually inherent in a good general anaesthetic. Thus the patient is in a state of general quiescence and psychic indifference throughout the procedure. ALACS provides excellent and long-lasting akinesia and analgesia, with adequate proptosis of the eye which facilitates surgical access. ALACS is suitable for almost all adult cataract and implant surgery. Our results in 104 cases of ALACS are reviewed in terms of visual results and complications both ocular and anaesthetic; the results appear good and the complications minimal. The results of blood gas estimations done intraoperatively in a small number of patients are also presented, and suggest that the technique is systemically safe.

Trigeminal somatosensory evoked responses in patients with facial anaesthesia dolorosa.

The TSER of six patients with facial anaesthesia dolorosa showed shorter latencies and higher amplitudes of the late waves, which are believed to represent the processing of somatosensory input in the higher subcortical and cortical centres. Shorter latencies and higher amplitudes may reflect abnormal facilitation or decreased inhibition by these centres. The TSER also supplied an objective means of pain measurement, as the stimulating impulse at the affected side had to be reduced from 20 mA (the usual intensity used in patients without evoking pain or an unpleasant sensation) down to 9-12 mA, to avoid unbearable pain.

Trigeminal neuralgia and hemifacial spasm: treatment by microvascular decompression.

On the basis of observation of 26 patients, we consider that the common cause in trigeminal neuralgia and hemifacial spasm is compression of the nerve-root entry zone at the brainstem by a blood vessel, usually an artery. By mobilising the vessel, and securing it away from the nerve, symptoms were relieved in 16 of 17 patients with trigeminal neuralgia and in seven of nine patients with hemifacial spasm for a follow-up period of up to four years. Trigeminal microvascular decompression had few complications, but three patients treated for facial hemispasm had postoperative deafness and one had a probable small brainstem infarct. The major advantage of this surgical approach is that is possible to relieve the symptoms without facial anaesthesia or paralysis.

Current Treatment of Blow-out Fractures

Blow-out fracture repair and its timing have been controversial. Originally all x-ray proven fractures were repaired regardless of size or symptoms. Later a controversial report of a large series of cases indicated repair to be unnecessary. Today, x-ray proven fractures with enophthalmos justify surgery, but double vision alone is insufficient. Observation of improving diplopia for several days is suggested. Evaluation of x-rays, enophthalmos, diplopia with restriction, and facial anesthesia are recommended before surgery. Recognition of diagnostic signs and symptoms, as well as potential severe cosmetic and functional complications, have aided the approach to the decision for or against fracture repair.

Bilateral trigeminal neuralgia

A 56-year-old woman previously treated by a retrogasserian neurectomy for a right tic douloureux was rendered free of pain, but complete anaesthesia of the right half of her face remained. Seven years later, she developed a typical left trigeminal neuralgia. Contralateral rhizotomy was refused because of the patient's concern about having bilateral facial anaesthesia. Through a suboccipital craniectomy, the trigeminal nerve was decompressed from a thickened arachnoid membrane and a large bridging vein near the root entry zone. After eighteen months, the patient was free of pain with intact facial sensations on the left side. Therapeutic considerations in cases of bilateral trigeminal neuralgia are discussed.