11/56. Occipital neuralgia and twelfth nerve palsy from a chondromyxoid fibroma. The purpose of this case report is to record the unusual combination of occipital neuralgia and hypoglossal nerve palsy causing dysarthria, dysphagia, and unilateral weakness of tongue protrusion, with no other neurological findings. The cause was a discrete tumor in the clivus and the right occipital condyle. Following surgical resection of the tumor, dysarthria and dysphagia persisted. These improved with therapy by a speech therapist, but deviation of the tongue persisted on protrusion. No similar case reports were found in the literature. In addition, the tumor was an unusual one, a chondromyxoid fibroma (CMF); these tumors uncommonly involve the skull base. ( info) |
| OBJECTIVE: The authors report a case of spontaneous and gustatory facial pain and sweating. methods: The patient had frequent episodes of pain, sweating, and flushing bilaterally in the hairless skin of the ophthalmic and maxillary distributions of the trigeminal nerve. Gustatory stimuli (e.g., orange juice, pickled onions) reliably evoked episodes, but episodes also frequently came on spontaneously. The problem had begun during adolescence, about the time of topical treatment and then electrocauteries for facial warts. The patient reported benefit from tricyclic antidepressants, guanethidine, and trospium chloride (an anti-cholinergic quaternary amine used in europe for urinary urgency). There was no pain or excessive sweating in other body areas, nor pain with exercise. RESULTS: Administration of edrophonium IV evoked pain and sweating, and ganglion blockade by IV trimethaphan eliminated pain and sweating and markedly attenuated responses to edrophonium. Trospium chloride also prevented edrophonium-induced pain and sweating. Bicycle exercise produced the same increment in forehead humidity as in a spontaneous episode but did not evoke pain. tyramine infusion did not bring on pain or sweating, whereas iontophoretic acetylcholine administration to one cheek evoked pain and sweating bilaterally. Topical glycopyrrolate cream eliminated spontaneous, gustatory, and edrophonium-induced episodes. CONCLUSIONS: The findings indicate that facial pain and sweating can result from occupation of muscarinic cholinergic receptors after acetylcholine release from local nerves. The authors propose that after destruction of cutaneous nerves, aberrant regenerant sprouting innervates sweat glands, producing gustatory sweating as in auriculotemporal syndrome (Frey syndrome), and innervates nociceptors, producing pain. ( info) |
| It has been long recognized in the otolaryngic community that despite great effort dedicated to the physiology and pathology of the ear, nose, throat/head and neck, there are a number of symptoms, including pain in various locations about the head and neck, which cannot be explained by traditional otolaryngic principles. The tenets of myofascial dysfunction, however, as elucidated by Dr. Janet Travell, explain most of these previously unexplained symptoms; furthermore, treatment based on Dr. Travell's teachings is effective in relieving these symptoms. ( info) |
14/56. Complex regional pain syndrome involving the lower extremity: a report of 2 cases of sphenopalatine block as a treatment option. We report 2 cases of complex regional pain syndrome (CRPS) involving the lower extremity; in both, a sphenopalatine ganglion (SPG) block was performed as part of a pain management program. In the first case, a woman in her late twenties presented with CRPS in the left lower extremity that was inadequately controlled with typical oral medications. Sympathetic block of the extremity did not provide significant pain relief. However, a noninvasive sphenopalatine block with 4% tetracaine resulted in a 50% reduction in pain level. The patient was shown how to self-administer the sphenopalatine block and was provided with exercises and therapy to help improve her functional status. The second case involved a woman in her mid forties with CRPS in the right lower extremity that was partially controlled with oral medications. The patient experienced a 50% reduction in pain level when SPG block with 4% tetracaine was given. Further study is needed to determine the effects of SPG blocks on symptoms related to chronic regional pain syndrome. ( info) |
| BACKGROUND: Herpes zoster (HZ) infection of the trigeminal nerve is associated with complications such as postherpetic neuralgia, facial scarring, loss of hearing ability and conjunctivitis. Until 2005, postherpetic alveolar necrosis and spontaneous tooth exfoliation have been described in 20 cases unrelated to hiv infection. OBJECTIVE: The aim of this study was to describe hiv infection in patients (two women, two men, average age 30 years) who suffered from HZ attacks to their trigeminal nerves. MAIN OUTCOME MEASURES: None of the patients had received antiherpetic medications or antiretroviral therapy. hiv infection was only diagnosed after the development of HZ. Facial scarring with depigmentation and hyperesthesia (postherpetic neuralgia) was diagnosed in all four patients. Oral findings consisted of spontaneous loss of both maxillary or mandibular teeth. osteonecrosis of varying extent was also found. Treatment consisted of extractions of teeth and administration of antibiotics and analgesics. Healing of alveolar wounds was unremarkable. CONCLUSION: Complications affecting the alveolar bone and teeth seem to be rare in hiv-infected patients. ( info) |
16/56. Occipital neuralgia evoked by facial herpes zoster infection. Occipital neuralgia is a pain syndrome which may usually be induced by spasms of the cervical muscles or trauma to the greater or lesser occipital nerves. We report a patient with occipital neuralgia followed by facial herpes lesion. A 74-year-old male experienced sudden-onset severe headache in the occipital area. The pain was localized to the distribution of the right side of the greater occipital nerve, and palpation of the right greater occipital nerve reproduces the pain. He was diagnosed with occipital neuralgia according to ICHD-II criteria. A few days later, the occipital pain was followed by reddening of the skin and the appearance, of varying size, of vesicles on the right side of his face (the maxillary nerve and the mandibular nerve region). This was diagnosed as herpes zoster. This case represents a combination of facial herpes lesions and pain in the C2 and C3 regions. The pain syndromes can be confusing, and the classic herpes zoster infection should be considered even when no skin lesions are established. ( info) |
17/56. Necrotizing retinopathy with herpes zoster ophthalmicus: a light and electron microscopical study. A necrotizing retinopathy following a vesicular cutaneous eruption in the distribution of the right trigeminal nerve developed in a patient who had been receiving systemic corticosteroid therapy one week prior to the onset of herpes zoster ophthalmicus. Seven weeks after the herpetic symptoms began, the patient died of pneumonia following an intracerebral hematoma. At postmortem examination, unexpected multiple focal and confluent lesions, which corresponded to areas of extensive retinal necrosis, were observed in the fundus of the right eye. Intranuclear inclusions with a perinuclear halo were identified within the affected sensory retina. Electron microscopy of the retinal lesions disclosed round to oval enveloped viral particles that were characteristic of the herpes viruses. A mild lymphocytic infiltrate was evident in a demyelinated right Gasserian ganglion. Demyelination and necrosis of the right trigeminal sensory tract and adjacent areas were evident within the brain stem. ( info) |
18/56. Occult tumors of the infratemporal fossa: report of seven cases appearing as preauricular facial pain. Seven patients had occult malignant neoplasms either originating in or extending to the infratemporal fossa. Common symptoms were facial pain centered over the temporomandibular joint and facial numbness. These symptoms were sometimes associated with middle ear effusion and trismus. Multiple biopsies are often necessary to establish the diagnosis. The average delay in diagnosis from first symptom was 14 months. Infratemporal fossa neoplasia belongs in the differential diagnosis of facial pain. ( info) |
19/56. Retrolabyrinthine approach: technique and newer indications. Excellent exposure of the cerebellopontine angle is obtained by an approach through the mastoid posterior to the labyrinth. Since the major portion of the dissection is extradural, this approach is associated with a very low morbidity. The retrolabyrinthine approach has been used for several years for selective partial section of the posterior root of the trigeminal nerve in cases of trigeminal neuralgia. Complete relief of pain has been accomplished in 25 of 28 cases, and the other 3 patients had partial relief of pain. The only complications in these patients were partial hearing impairment in 2, and 1 partial abducens nerve paralysis which subsequently recovered completely. Two patients required secondary closure of cerebrospinal fluid leaks. This approach has also been used for exploration and biopsy of cerebellopontine angle tumors and for treatment of other cranial nerve problems. We conclude that the retrolabyrinthine approach is the preferred route to the cerebellopontine angle in a variety of clinical conditions. ( info) |
20/56. Post-traumatic external nasal neuralgia--an often missed cause of facial pain? Pain about the bridge of the nose is often a diagnostic dilemma. There is an important recognizable subgroup who may, as a consequence of involvement of the external nasal nerve in nasal injury, exhibit neuralgic pain after a latent interval. Temporary relief by anaesthesia can be achieved and cure is possible by division of the anterior ethmoidal nerve. This rare cause of facial pain is presented using two illustrative cases. ( info) |