Trigeminal Palsy Research Articles

Metastatic Tumors to Craniofacial Skeleton: Analysis of Two Cases and Review of the Literature

Craniofacial skeletal metastasis is a rare presentation of advanced prostate cancer. This is a report of a 69-year-old man who presented with numbness of the right lower lip and recently ill-fitting lower denture. Based on the medical history of benign prostate hyperplasia (BPH) and suspicion of a metastatic tumor, prostate core needle biopsy was performed. Histology of the prostate biopsy confirmed an adenocarcinoma with Gleason Score of 6/10. The diagnosis of metastatic prostate adenocarcinoma was established by incisional biopsy from the mandibular lesion. Androgen deprivation therapy (ADT) was administered along with bilateral orchidectomy and radiotherapy. He had a significant resolution of trigeminal nerve palsy and the other symptoms at subsequent follow-ups, but after 18 months passed away. The second case was a 65-year-old man with a history of prostate cancer since 5 years ago. He complained of painful swelling in the right side of the face. Radiographic evaluation revealed new bone formation in right mandibular ramus and condylar process as well as the left temporoparietal region. Incisional biopsy from mandibular lesion revealed metastatic prostate adenocarcinoma. Palliative radiotherapy for increasing quality of life started for the patient but he died after 9 months. The related literatures were reviewed.

A rare case of bilateral trigeminal palsy presenting as a complication of Sjogren syndrome

Sjogren syndrome is a chronic disorder affecting the exocrine glands of the body, mostly lacrimal and salivary glands, resulting in sicca symptoms. Diagnosis is aided by the presence of anti-Ro and anti-La antibodies and gland biopsy showing lymphocytic infiltration. Bilateral loss of facial sensation in Sjogren syndrome (SS) has not been reported before, although unilateral trigeminal palsy as a presentation of SS has been reported in literature. A 25-year-old lady presented in the neurology clinic with complete facial numbness and vision loss for 1 month. The vision worsened, leading to complete blindness. She had dry mouth and dry eyes for the past 3 months. She was diagnosed with SS using American–European consensus Sjogren criteria. Electrophysiological blink reflex testing confirmed complete trigeminal nerve palsy. SS was treated with prednisolone, 1 mg/kg/day, with a poor response. Symptomatic treatment was given for sicca symptoms, which improved significantly. Corneal transplantation was done for visual loss, but limited improvement was seen.

Risk Assessment and Prevention of Corneal Complications After Lateral Skull Base Surgery.

To analyze the rate of corneal complications after lateral skull base surgery, and the relative risk of each potential contributing factor. Retrospective cohort study. Tertiary care center. Adult patients who had undergone lateral skull base surgery involving an otolaryngologist at our institution from 2007 to 2015. None. Relative risk (RR) for each potential contributing factor to corneal complications. Four hundred sixty nine patients met inclusion criteria. Of those, 35 developed mild exposure keratopathy, 13 developed moderate exposure keratopathy, and 5 developed severe exposure keratopathy. Age, sex, previous eye surgery, tumor side, and pathology were not significant predictors of keratopathy. Tumor size greater than 30 mm (RR 4.75), postoperative trigeminal palsy (RR 3.42), postoperative abducens palsy (RR 9.08), House-Brackman score 5-6 (RR 4.77), lagophthalmos (RR 11.85), ectropion (RR 4.29), and previous eye disease (RR 1.83) were all significantly associated with the development of corneal complications. On multivariate analysis, lagophthalmos, abducens palsy, and tumor size were independent predictors of keratopathy. There are several important risk factors for exposure keratopathy after lateral skull base surgery, and knowledge of these risk factors can help identify high-risk patients in whom early, aggressive preventative therapy is warranted.

Multiple myeloma presenting with unilateral abducens and trigeminal nerve palsies

Petrous apex masses can manifest with neurologic symptoms due to their involvement of various structures, including cranial nerves (CN) V and VI. The differential diagnosis of petrous masses is broad and includes a variety of both non-neoplastic and neoplastic lesions. We report a rare case of multiple myeloma confined to the right petrous apex, presenting with ipsilateral abducens and trigeminal nerve palsies. A 63-year-old woman presented with a 6–8week history of facial numbness and a 2week history of diplopia, with examination showing right-sided facial hypoesthesia in the CN V1–V3 region and right-sided lateral rectus palsy. MRI of the brain showed a solitary 2.0cm lesion confined to the right petrous apex involving the right cavernous internal carotid artery and Meckel’s cave. A transnasal biopsy showed a proliferation of plasmacytoid cells, which showed diffuse immunoreactivity with antibodies to CD138 and kappa, consistent with a plasma cell dyscrasia. A bone scan subsequently revealed multiple lytic bone lesions involving the skull, left humerus, bilateral femurs and possibly the L4 vertebral body. Bone marrow biopsy and serum laboratory results confirmed the diagnosis of kappa-type multiple myeloma. Although rare, multiple myeloma may initially present with petrous involvement and associated cranial nerve deficits.

Repeat Gamma Knife surgery for vestibular schwannomas.

Background:Gamma Knife (GK) surgery is a recognized treatment option for the management of small to medium-sized vestibular schwannoma (VS) associated with high-tumor control and low morbidity. When a radiosurgical treatment fails to stop tumor growth, repeat GK surgery can be proposed in selected cases.Methods:A series of 27 GK retreatments was performed in 25 patients with VS; 2 patients underwent three procedures. The median time interval between GK treatments was 45 months. The median margin dose used for the first, second, and third GK treatments was 12 Gy, 12 Gy, and 14 Gy, respectively. Six patients (4 patients for the second irradiation and 2 patients for the third irradiation) with partial tumor regrowth were treated only on the growing part of the tumor using a median margin dose of 13 Gy. The median tumor volume was 0.9, 2.3, and 0.7 cc for the first, second, and third treatments, respectively. Stereotactic positron emission tomography (PET) guidance was used for dose planning in 6 cases.Results:Mean follow-up duration was 46 months (range 24–110). At the last follow-up, 85% of schwannomas were controlled. The tumor volume decreased, remained unchanged, or increased after retreatment in 15, 8, and 4 cases, respectively. Four patients had PET during follow-up, and all showed a significant metabolic decrease of the tumor. Hearing was not preserved after retreatment in any patients. New facial or trigeminal palsy did not occur after retreatment.Conclusions:Our results support the long-term efficacy and low morbidity of repeat GK treatment for selected patients with tumor growth after initial treatment.

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Journal of Paediatrics and Child HealthVolume 50, Issue 11 p. 935-935 Letter to the EditorFree Access Answers First published: 06 November 2014 https://doi.org/10.1111/jpc.12563_2AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Left hypoglossal nerve (cranial nerve XII) palsy Isolated unilateral tongue weakness, in general, implies damage at the level of the hypoglossal nucleus or hypoglossal nerve, rather than a lesion in the cerebral hemisphere. Weakness of the intrinsic tongue muscles allows the contralateral muscles to ‘push’ the tongue towards the side of the lesion. This also applies to the jaw deviation seen with trigeminal (cranial nerve V) nerve palsy, where the weak side is pushed by the contralateral stronger pterygoids, resulting in deviation ipsilateral to the nerve palsy. This is in contrast to the deviation of the angle of mouth seen in facial (cranial nerve VII) and of the uvula seen in vagal (cranial nerve X) nerve palsies, which both deviate contralateral to the side of the pathology. This is well remembered by a mneumonic – Rule of 17 (12 + 5 = 10 + 7). Magnetic resonance imaging brain Hypoglossal nerve palsy is an ominous sign with about 50% patients having an underlying intra- or extra-cranial malignancy.1 It has also been described with varied aetiologies including gunshot wound to the neck, blunt head trauma, stroke, multiple sclerosis, internal carotid artery aneurysm, and post-infectious and post-vaccination neuropathy.2 Surgical trauma due to branchial cyst removal Magnetic resonance imaging of the brain was done and was unremarkable. Hypoglossal nerve palsy resulting from infected neck cysts or its surgical removal has been reported.3, 4 Malformations arising from the second or third branchial cleft remnants are in anatomic proximity to the hypoglossal nerve, making it prone to surgical trauma. The chances of recovery in these cases are low, although patients may continue to be ‘asymptomatic’ as was our patient. References 1Keane JR. Twelfth-nerve palsy. Analysis of 100 cases. Arch. Neurol. 1996; 53: 561– 566. CrossrefCASPubMedWeb of Science®Google Scholar 2Combarros O, Alvarez de Arcaya A, Berciano J. Isolated unilateral hypoglossal nerve palsy: nine cases. J. Neurol. 1998; 245: 98– 100. CrossrefCASPubMedWeb of Science®Google Scholar 3Gatot A, Tovi F, Fliss DM, Yanai-Inbar I. Branchial cleft cyst manifesting as hypoglossal nerve palsy. Head Neck 1991; 13: 249– 250. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 4Mukherjee SK, Gowshami CB, Salam A, Kuddus R, Farazi MA, Baksh J. A case with unilateral hypoglossal nerve injury in branchial cyst surgery. J. Brachial Plex. Peripher. Nerve Inj. 2012; 7: 2. CrossrefPubMedGoogle Scholar Volume50, Issue11November 2014Pages 935-935 ReferencesRelatedInformation

Adenoid cystic carcinoma in the cavernous sinus diagnosed with endoscopic endonasal approach

A 42-year-old woman presented with right oculomotor, abducens, and trigeminal palsy. Neuroimaging revealed a small lesion in the right cavernous sinus mimicking meningioma. Because the symptoms gradually worsened, the patient underwent an endoscopic endonasal transsphenoidal surgery for tumor biopsy. Histological examination of the surgical specimen revealed adenoid cystic carcinoma (ACC). Before and after the operation, no evidence of other primary lesions could be detected. The patient was treated with stereotactic radiosurgery (SRS). ACC in the cavernous sinus can be difficult to diagnosis before histological confirmation, because it is extremely rare as a primary lesion and resembles a cavernous sinus meningioma on neuroimaging studies. Two years after the first SRS, the tumor recurred along the trigeminal nerve and SRS was performed again. Our study illustrates that in case in which a lesion in the cavernous sinus progresses on neurological and neuroimaging studies, a biopsy should be taken to provide most accurate diagnosis and treatment.

The Coexistence of Tolosa-Hunt Syndrome and Diabetic Cranial Mononeuropathy: A Case Report and a Review of Literature

Tolosa-Hunt syndrome (THS) is described as painful ophtalmoplegia caused by nonspesific inflammation of cavernous sinus or superior orbital fissure, which is response to steroid theraphy. Cranial neuropathies in diabetic patients are extremely rare and occur in older patients with poorly controlled diabetes. A 56-year-old diabetic female patient who developed simultaneous right VI., left III., IV., VI., VII. and maxiller branch of trigeminal nerve palsies with acute periorbital pain applied to our outpatient clinic. Although the coexistence of THS and diabetic cranial neuropathy is an uncommon condition, this should be considered as a possible diagnosis on patients who are admitted with painful ophtalmoplegia and simultaneous multipl cranial neuropathies. We approved to present our diabetic patient with cranial magnetic imaging because of this interesting unity and fasial nerve palsy accompanying to THS.

Unusual natalizumab-associated progressive multifocal leukoencephalopathy starting in the brainstem

we report on a 45-year-old German patient with relapsingremitting (RR) multiple sclerosis (MS) who was started on natalizumab (NAT) therapy in November 2007, because of ongoing disease activity despite interferon therapy. She had never been treated with immunosuppressants before. After she tested positive for anti-JCV (John Cunningham Virus)antibodies for the first time, she decided to discontinue NAT treatment in July 2011 (after 49 NAT infusions). At this time point, as well as during NAT therapy, she was clinically stable (EDSS 3.5). Six weeks later in August 2011, she developed new brainstem symptoms, with left facial and trigeminal nerve palsy, double vision and mild dysphagia. On magnetic resonance imaging (MRI), a large brainstem-midbrain lesion was seen (Fig. 1D). The symptoms were initially interpreted as MS relapse and treated with corticosteroids. After transient improvement, she deteriorated again and was seen for the first time at our hospital. Progressive multifocal leukoencephalopathy (PML) was diagnosed in September 2011 after detection of JCV DNA (31 c/ml in CSF, 5 c/ml in serum; EDSS 7.0). Subsequently, she developed severe immune reconstitution inflammatory syndrome (IRIS), deteriorated clinically (EDSS 9.5), and had to be transferred to the intensive care unit (ICU) for several weeks. Finally, she stabilized after repeated courses of high-dose iv glucocorticosteroids (GC) and iv immunoglobulins (IVIgG, 5 days a 0.4 g/kg body weight), as well as concomitant therapy with mefloquine and mirtazapine. Six months later, she had improved, but still showed severe ataxia and brainstem symptoms (EDSS 6.0). Retrospective analysis of all available MRI scans identified a small new-initially asymptomatic-T2 brainstem lesion as the first MRI manifestation of this patient’s PML in November 2010, which slowly progressed over 41 weeks until clinical PML presentation (Fig. 1A–D). Several aspects in this report are unusual: (1) brainstem PML is rare and has been reported in association with NAT therapy in MS patients only once so far [1]; (2) the longlasting pre-symptomatic phase of 41 weeks and clinical manifestation of PML only 6 weeks after NAT was discontinued; and (3) clinical improvement after combined therapy with GC and IVIgG. In this patient, a new, asymptomatic, non-contrast-enhancing T2 lesion appeared in the brainstem in November 2010 (Fig. 1B). Notably, before the MRI lesion was rated as important, the patient decided to stop NAT therapy in July 2011 due to fear of PML. At this time and during NAT treatment, the lesion was completely asymptomatic. The patient developed new brainstem symptoms only 6 weeks after discontinuation of NAT and showed a large brainstem-midbrain lesion on MRI at that time. Detailed retrospective MRI analysis identified that this large lesion had progressed over time from the small brainstem lesion 41 weeks before. NATassociated PML with a pre-symptomatic course up to 24 weeks has been reported, but not in the brainstem so far [2]. More recently, Yousry and colleagues [3] identified common MRI patterns of NAT-associated PML, which help in the early diagnosis of PML. Except for the unusual initial localization in the brainstem and size (\ 3 cm), all J. Havla (&) R. Hohlfeld T. Kumpfel Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Medical Campus Grosshadern, Marchioninistr. 15, 81377 Munich, Germany e-mail: joachim.havla@med.lmu.de

Guillain-Barre Syndrome Following Dengue Fever in Adult Patient

Guillain-Barre syndrome is a post infectious ascending, usually demyelinationg polyradiculoneuropathy. Dengue fever as an antecedent infection in GBS is uncommon. A 39-year-old female presented with acute flaccid weakness of both upper and lower limbs which developed in ascending and progressive fashion following a febrile illness of three days. During work-up IgM for dengue virus was found positive. Diagnosis of Guillain-Barre syndrome was made based on neurologic manifestations, the typical CSF findings and pattern of electrophysiological study and exclusion of other pathologies. Patient was treated with intravenous immunoglobulins. During the course of illness, she developed lower motor neuron type trigeminal, facial, glossopharyngeal, vagus and hypoglossal nerve palsy and autonomic involvement. She had significant recovery and was able to talk, eat and walk six weeks later. Dengue is endemic in Bangladesh. Post dengue Guillain- Barre syndrome in adult, as shown in previous reports, should now be considered in the part of spectrum of neurological complications of this infection. DOI: http://dx.doi.org/10.3329/jom.v13i2.12772 J Medicine 2012; 13 : 246-249

Clival giant cell tumor presenting with isolated trigeminal nerve involvement

Giant cell tumour (GCT) constitutes about 5 % of all skeletal tumors. They rarely occur in the skull. When involved, they preferentially involve the sphenoid or temporal bones. Skull-base GCTs generally present with multiple cranial nerves involvement, most commonly sixth followed by the third cranial nerve. We describe a case of clival GCT presenting with an isolated trigeminal nerve involvement in a 19-year-old man which was managed by surgery and adjuvant radiation. At 18 months of follow-up, the patient is clinically asymptomatic. Clival GCT should also be considered in the differential diagnosis of any isolated trigeminal nerve palsy. Adjuvant radiation has an important role to play in managing this tumour.

A case of Sjögren's syndrome presenting as trigeminal nerve palsy

We herein report the case of a female with Sjogren's syndrome (SS) complicated with trigeminal nerve palsy. Although her sicca symptoms had been unnoticed, head magnetic resonance imaging (MRI) for detecting brain abnormalities revealed parotid gland changes associated with SS. SS should be considerd as a possible cause of trigeminal nerve disturbances. In addition, parotid gland changes related to SS should be aware in examination of cranial nerve disturbances with MRI.

Isolated trigeminal nerve palsy with motor involvement as a presenting manifestation of multiple sclerosis in an equatorial region – a case report

IntroductionIsolated cranial nerve palsies are considered to be an uncommon presenting feature of multiple sclerosis. Involvement of the trigeminal nerve, particularly its motor component as part of a clinically isolated syndrome of multiple sclerosis has rarely been reported in equatorial regions and no cases have been described in Sri Lanka thus far.Case PresentationWe report a case of isolated right sided trigeminal nerve palsy (Motor and Sensory) in a 34 year old previously well lady from urban Sri Lanka who was found to have characteristic lesions on Magnetic Resonance Imaging highly suggestive of multiple sclerosis.ConclusionsMultiple sclerosis should be considered in the differential diagnosis of patients who present with isolated cranial nerve palsies. Clinicians should have a high index of suspicion when evaluating such patients especially in low prevalence regions close to the equator. Early recognition and treatment of such a “Clinically Isolated Syndrome” may prevent early relapse.

Trigeminal Nerve and Facial Nerve Palsy After Combined Spinal-Epidural Anesthesia for Cesarean Section

A case of emergency cesarean section due to a prolonged second stage of labor in a 29 year-old woman is presented. She had trigeminal nerve and facial nerve palsy after combined spinal-epidural anesthesia for cesarean section.

Giant Cell Arteritis: Clinical Features of Patients Visiting a Headache Clinic in Japan

The first symptom of giant cell arteritis (GCA) is usually a headache. Japan has a low prevalence of GCA, and clinical features of this disorder have not been fully investigated. We conducted a retrospective evaluation of clinical features in patients with giant cell arteritis who visited a headache clinic in Japan. Clinical and demographic data were obtained from clinical examinations, face-to-face interviews, and hospital records. Subjects comprised 19 patients (9 men, 10 women). Mean age at disease onset was 78.1 ± 4.8 years (range, 71-86 years). Seventeen of 19 patients (89.5%) had consulted other medical institutions before consulting our hospital, but only 2 of those patients had been diagnosed with GCA at these medical institutions. Manifestations at disease onset included headache (89.5%), ear pain (5.3%), and jaw pain (5.3%). Ocular manifestations were reported in 2 patients (10.5%). No loss of vision occurred. One patient showed trigeminal nerve palsy involving the third division of the nerve. Jaw claudication was observed in 3 patients (15.8%). Concomitant polymyalgia rheumatica was seen in 3 patients (15.8%). No patient showed upper respiratory tract symptoms, arm claudication, or aortic aneurysms. Although most patients had consulted other medical institutions before consulting our hospital, they were not diagnosed with GCA at these institutions. Infrequent clinical findings of GCA and lack of symptoms other than headache may contribute to the high rate of unrecognized and misdiagnosed cases of GCA.

Successful prolonged conservative treatment of Gradenigo's syndrome in a 4-year-old girl: A case report and literature review

Abstract Gradenigo's syndrome, one of the complications of middle ear infection, is characterised by persistent otorrhoea, pain in the region innervated by the first and second divisions of the trigeminal nerve and ipsilateral abducens nerve palsy. We report the case of a 4-year-old girl with Gradenigo's syndrome. Computed tomography and magnetic resonance imaging provided evidence of infection of the apex of the petrous temporal bone. The patient received an appropriate antibiotic therapy but the recurrence of symptoms responded to the prolongation of a conservative treatment without surgical intervention.

Trigeminal nerve and facial nerve palsy after combined spinal-epidural anesthesia for cesarean section

A case of emergency cesarean section due to a prolonged second stage of labor in a 29 year-old woman is presented. She had trigeminal nerve and facial nerve palsy after combined spinal-epidural anesthesia for cesarean section.

Trigeminal nerve palsy in a patient undergoing an anterior cervical discectomy and fusion

aUniversity of Cincinnati School of Medicine, Cincinnati, Ohio bCollege of Engineering, University of Cincinnati, Cincinnati, Ohio Correspondence to Jeffery L. Stambough, MD, 4600 Smith Road, Suite B, Norwood, OH 45212, USA Tel: +513 221 4848; fax: +513 872 7825; e-mail: [email protected]

Gradenigo's syndrome with lateral venous sinus thrombosis: successful conservative treatment

Gradenigo's syndrome (GS) is a rare disease characterised by the triad otitis media, pain in the region innervated by the first and the second division of trigeminal nerve and abducens nerve palsy. Septic sinus thrombosis is one of the most frequent and relevant complication of GS; it is often due to persistent damage and late diagnosis. Computed tomography (CT) scan and magnetic resonance imaging (MRI) allow the correct diagnosis in most cases. Surgical therapy may be necessary for a better and more rapid resolution of the disease. We report the case of a 4-year-old child that was admitted for facial nerve palsy and abducens nerve palsy subsequent to a 2-week persistent pain in the right ear. MRI showed infective acute process of the right mastoid and partial ipsilateral sinus thrombophlebitis. The child was treated with high-dose intravenous antibiotics and with oral anticoagulants. A complete resolution of symptoms and radiological alterations were observed within 7 weeks. In conclusion, lateral sinus thrombosis and Gradenigo's syndrome are rare but potential fatal complications of otitis media and mastoiditis. High-dose intravenous antibiotics and a low dose of anticoagulant can achieve a complete recovery without surgery.

Trigeminal nerve palsy in nasopharyngeal carcinoma: Correlation between clinical findings and magnetic resonance imaging

Our aim was to document the relationship between clinical and MRI evidence of trigeminal nerve involvement. The MRI and medical records of 924 consecutive patients with newly diagnosed nasopharyngeal carcinoma (NPC) were reviewed retrospectively. A total of 92 divisions of palsied trigeminal nerves were found clinically in 46 patients (5.0%). The involved trigeminal nerve was ophthalmic nerve (V1; n = 21), the maxillary division (V2; n = 41), and the mandibular division (V3; n = 30). Of the 316 patients with MRI-demonstrated trigeminal nerve involvements, the symptoms were lacking in 270 patients (85.4%). Of the 92 clinical palsied trigeminal nerve divisions, 91 nerves (98.9%) showed MRI evidence of 1 or more trigeminal nerve involvements. Of the 91 palsied trigeminal nerve with MRI evidence, 85 divisions (93.4%) were found with intracranial or orbital segment involvement, 6 (6.6%) divisions were found only basicranial evidence, and 83 (91.2%) divisions were found with cavernous sinus invasion. The incidence of MRI-evidenced trigeminal nerve involvement is high and often asymptomatic in NPC. Almost all patients with clinical trigeminal nerve palsies had MRI evidence of trigeminal nerve involvement in intracranial or orbital segment, especially in cavernous sinus.