Transient right phrenic nerve palsy associated with central venous catheterization

An 85-yr-old woman with advanced sigmoid colon cancer developedright phrenic nerve palsy following central venous catheterizationfor preoperative nutritional and fluid balance improvement.The central venous catheter was successfully placed via theleft subclavian vein at the first attempt. Blood returned freelythrough the catheter. The chest x-ray film taken immediatelyafter the catheterization showed the proper placement of thecatheter, but it revealed a significant right hemidiaphragmaticelevation indicating phrenic nerve palsy. A chest computed tomographyscan and bronchoscopy were normal. As the patient did not complainof dyspnoea and vital signs were normal, tumour resection wasperformed. The operative and postoperative course was uneventful.The chest x-ray film after the surgery still showed the elevationof the right hemidiaphragm. It resolved completely within 3days of withdrawing the central venous catheter by 3 cm on thefourth postoperative day. We concluded the likely cause of thephrenic nerve palsy was that the catheter tip impinged uponthe thin venous wall and compressed the phrenic nerve runningalongside the superior vena cava. Br J Anaesth 2001; 87: 510–11     

Herpes zoster in the ulnar nerve distribution

Varicella zoster is a ubiquitous virus which usually affects school-aged children as Chicken Pox. While the initial disease is self-limiting and seldom severe, the virus remains in the body. It lies dormant in the dorsal root ganglia and reactivation may occur years later with variable presentations as Herpes Zoster, or Shingles. While Shingles is common, it rarely presents exclusively in the upper extremity. It is important that hand surgeons recognize the possibility of zoster infection, with or without a rash, when evaluating the onset of neuralgia in a dermatomal distribution in the upper limb. Early diagnosis allows rapid and appropriate treatment, with a lower risk of complications. We report on a case of Herpes Zoster isolated to the ulnar nerve distribution in a young woman.     

Herpes zoster of the trigeminal nerve following microvascular decompression

A patient developed herpes zoster of the maxillary division of the trigeminal nerve after microvascular decompression. Varicella zoster virus lies dormant in the Gasserian ganglion until reactivation and can cause herpes zoster ophthalmicus. This can result in serious ocular complications including blindness. Antiviral agents are effective if commenced promptly.     

Bilateral vidian nerve schwannomas associated with facial palsy. Case report and review of the literature

Intracranial schwannomas are relatively common benign tumors arising from Schwann cells. Among the cranial nerves, the vestibular division of the vestibulocochlear nerve is the site most commonly affected by these lesions, followed by the trigeminal nerve. The authors report a case of bilateral schwannomas arising from both of the pterygoid canals. A 13-year-old girl presented with intermittent headaches and left-sided facial palsy. Preoperative computerized tomography scans and magnetic resonance images revealed nonenhancing round masses within the bilateral vidian canals, bone erosion, and sclerosis. The transnasal transseptal transsphenoidal approach was used to remove the masses. Postoperatively, the patient recovered uneventfully. On histopathological examination, the masses were confirmed as schwannomas. The clinical presentation and probable histogenesis of schwannomas arising in this location are discussed together with a review of the literature.     

Pain associated with craniofacial and cervical herpes zoster

Ophthalmological and cervical involvement of herpes zoster virus ranks second and third, respectively, in terms of localization frequency. Involvement of the cranial nerves is a particular sign of complications, notably ocular complications, possibly compromising the visual or facial prognosis through involvement of the VIIth nerve, which is responsible for facial paralysis. These types of involvement should be rapidly diagnosed and treated so as to limit these complications. The pain associated with herpes zoster remains frequent and difficult to treat, even if today the criteria for defining postzoster pain is increasingly refined. Antalgic and antiviral treatment should be initiated early, from the very first signs, to attempt to reduce the incidence of this postzoster pain. The risk factors, associated with the development of postzoster pain are age over 50 years, the severity of the skin rash and the intensity of the acute pain, and the existence of a prodromic pain phase before onset. The European Federation of Neurological Societies has recently published guidelines on the pharmacological treatments for postzoster pain. Nerve block treatments remain at a limited evidence level. Patients with postzoster pain should be managed by teams specializing in pain management as soon as conventional treatments fail.     

Evaluation of facial nerve palsy with electrogustometry and stapedial reflex

BACKGROUND: To clarify the prognosis of facial nerve palsy, electroneuronal tests, including electrogustometry and stapedial reflex, have been utilized. But, the relationship among these tests and patients' prognosis is not clear. METHODS: Sixty five patients with peripheral facial nerve palsy were investigated. Electrogustometry (EG), stapedial reflex (SR) and blink reflex (BR) were performed at the first visit on the consult of facial nerve palsy. The palsy scale (full score is 100 points) was evaluated 8 weeks after the onset, and we defined cure cases if score became over 90 points. The cure ratio was examined on each group of EG positive or negative, SR positive or negative and BR R1 wave positive or negative, respectively. The relationship among these three examinations was also investigated. RESULTS: There were no significant differences between the cure ratio of EG positive and negative groups. However, the cure ratio of SR positive group was significantly larger than that of SR negative group. The cure ratio of BR positive group was 100%, regardless of the result of other two tests. CONCLUSIONS: The present study suggests that SR is a more useful parameter than EG for the evaluation of the prognosis of patients with facial nerve palsy, and the pathological meaning of these 2 tests is different from that of BR.     

Evaluation of peripheral facial nerve palsy with R 2 wave latency in blink reflex]

Electrically elicited blink reflexes were investigated in 60 patients with peripheral facial nerve palsy. The purpose of this study was to evaluate the utility of analysis of R 2 wave in blink reflex as a prognostic indicator for the patients with facial palsy. The patients treated by stellate ganglion block were classified into three groups: Group I scored more than 90 points (full score is 100 points) within 2 weeks, Group II scored more than 90 points over 2 weeks, and Group III scored less than 90 points. The examinations were performed at the first visit, and 2, 4, 6 weeks after the onset of facial palsy. Latencies of ipsilateral and contralateral R 2 wave were measured by electrical stimulation on both side. There were significant differences of R 2 latency between ipsilateral and contralateral side in each of the three groups at the first visit. In Group II, contralateral R 2 latency obtained by stimulation of the paralytic side was prolonged significantly. In Group III, the ipsilateral R 2 wave was not observed. The results of this study indicate that measurement of the R 2 latency of blink reflex is useful in judging the severity of the peripheral facial nerve palsy. The R 2 latencies obtained by stimulation of ipsilateral and contralateral side should be used as one of the parameters for evaluation of the prognosis of patients with peripheral facial nerve palsy.     

Nonoperative management of traumatic facial nerve palsy

Forty-five patients with facial nerve palsy resulting from head injury were treated nonoperatively between 1975 and 1981. Of 31 patients who had polytomography, temporal bone fractures were demonstrated in 29. In 44 of 45 injuries, satisfactory clinical improvement in motor function was noted, including 65% (overall) who showed complete recovery. Fracture direction on polytomography, results of electromyography (performed in ten cases), and time of onset of paralysis were not correlated with outcome. The present findings suggest a limited role for early surgery in closed traumatic facial nerve palsy.     

Scaphocapitate fracture associated with median nerve palsy

BackgroundTransposition osteotomy of the acetabulum (TOA) was the first periacetabular osteotomy in which the acetabulum was transposed with articular cartilage. TOA improves coverage of the femoral head and joint congruity. The purpose of this study was to investigate whether TOA is an appropriate option for treating osteoarthritis of the hips at the advanced stage by comparing it with matched control hips at the early stage.MethodsBetween 1998 and 2001, TOA was performed in 104 hips of 98 patients. Altogether, 16 of 17 hips (94%) with osteoarthritis at the advanced stage were examined and compared with 37 matched control hips at the early stage. The mean age at the operation was 48 years (38-56 years), and the mean follow-up period was 88 months (65-107 months).ResultsTOA corrected the acetabular dysplasia and significantly improved containment of the femoral head. Clinical scores were also significantly improved in both groups. In the advanced osteoarthritis cases, there was a tendency for abduction congruity before transposition osteotomy of the acetabulum to reflect the clinical outcome.ConclusionsTOA is a promising treatment option for advanced osteoarthritis of the hips as well as for patients at an early stage when preoperative radiographs show good con-gruity or containment of the joint.     

Third nerve palsy associated with preeclampsia and HELLP syndrome

Preeclampsia can cause myriad organ dysfunction, including cranial nerve palsies that pose diagnostic and management dilemmas. We present an unusual case of third nerve palsy, (presenting as diplopia, ptosis) with hypertension, hyperreflexia, proteinuria, easy bruising in a parturient at 34 + 6/52 weeks of twins gestation. She was treated as for severe preeclampsia and HELLP syndrome; intravenous magnesium sulphate and labetalol commenced and emergent cesarean delivery performed under general anesthesia due to concerns of low platelets and for airway protection should her glascow coma scale (GCS) deteriorate. Postoperatively, stroke, aneurysm and intra-cerebral causes of third nerve palsy were excluded, with subsequent recovery of symptoms upon blood pressure normalization. The eye signs are postulated to be due to two preeclamptic mechanisms involving disordered cerebral autoregulation: (1) hyperperfusion and breakdown of the blood–brain barrier that occurs with rising hypertension, causing fluid/blood product extravasation into brain parenchyma, or (2) focal reactive vasoconstriction and local hypoperfusion, contributed to by endothelial dysfunction.