[Case of Fisher syndrome with impairment of taste]

A 38-year-old man developed dysesthesia, diplopia, and an unsteady gait following an upper respiratory infection. IgG anti-GQ1b antibody was detected in his serum and he was diagnosed as Fisher syndrome. The patient also complained of loss of taste sensation, and it resolved along with improvement of other neurological manifestations. In Guillain-Barré syndrome, cranial nerve involvement is very common, though taste disturbance is a rare complaint. Impairment of taste has been reported in association with severe facial nerve involvement, but taste disturbance developed without facial nerve palsy in the present case and taste sensation was diminished in the area of all four nerves involved in taste sensation. These findings suggest that the impaired taste sensation in the present patient was not a complication of facial nerve palsy as in previous cases, but rather due to taste sensory specific involvement.

Extracranial internal carotid artery aneurysm presenting as symptomatic hypoglossal and glossopharyngeal nerve paralysis

Aneurysms of the extracranial portion of the internal carotid artery are rare, particularly in young patients. They usually develop following trauma, or secondary to infection involving the parapharyngeal space that extends to the vessel wall. This is a case of an internal carotid artery aneurysm presenting acutely following chiropractic neck manipulation with hypoglossal and glossopharyngeal nerve palsy. The imaging findings and subsequent operative management are described.

Basicranium Malformation With Anterior Dislocation of Right Styloid Process Causing Stylalgia

Differential diagnosis of stylalgia is broad, and many causes should be taken into account, such as temporomandibular joint disorders, carotidynia, compression of nerve fibers by neoplasms, cranial nerve neuralgias, chronic pharyngotonsillitis, pharyngeal or base of tongue tumors and elongation of styloid process, or Eagle syndrome. Basicranium malformation can determine a rare form of stylalgia that is caused by dislocation of styloid process. This can produce a reduction of maxillo-vertebropharyngeal space and irritation of nerve fibers together with stylopharyngeal muscular chronic contraction. This case report illustrates the diagnostic dilemma and surgical strategy experienced in a rare case of stylalgia caused by a dislocation of styloid process produced by a basicranium malformation. Basicranium malformation should be considered in the pathogenesis of stylalgia when a styloid process with normal dimension is encountered.

[Jugular foramen schwannomas: a review of 17 cases]

OBJECTIVE

To analysis the clinical presentation, radiological findings, surgical techniques and outcomes of jugular foramen (JF) schwannomas.

METHODS

We reviewed our 10-year experience in the surgical treatment of 17 patients suffered from JF schwannomas in Hua Shan Hospital, Shanghai. A total of 8 males and 9 females with a mean age of 42 years underwent surgical procedures. A relative long period of 53-month symptomatic history was shown before surgery. The main clinical presentation are vertigo and hearing difficulty in 10 cases, atrophy of unilateral muscles of tongue in 9 cases, involvement of lower cranial nerve in 8 cases. The classification of tumors was type A (at cerebellopontine angle with minimal enlargement of the JF) in five cases, type B (JF with intracranial extension) in 3 cases, type C (extracranial tumors with JF extension) in 2 cases and type D (dumbbell-shaped with both intra-and extracranial components) in 7 cases.

RESULTS

Far lateral approaches were used in 10 cases, retrosigmoid suboccipital approaches were used in 5 cases. Submandibular approaches were selected in other 2 cases. Gross total removal was achieved in 12 cases, and subtotal removal in 5 cases. Follow-up revealed marked improvement from preoperative symptoms in 9 cases and no additional deficits in 3 cases. 5 cases suffered from additional neurological deficits. There were two cases of temporary hoarseness and gradually improved within follow-up. Two patients suffered from swallowing problems as a new deficit. One patient had facial palsy.

CONCLUSIONS

JF schwannomas can be surgically treated with relative good outcomes. Surgical approaches should be tailored according to the tumor extension.

A case of Collet-Sicard syndrome associated with traumatic atlas fractures and congenital basilar invagination

An 18 year old man with congenital basilar invagination developed multiple lower cranial nerve (CN) palsies including CN IX to XII after a traffic accident. Computed tomography of his skull base revealed a two part atlas Jefferson fracture. Normally, lower cranial nerves (CN IX-XII) pass through a space between the styloid process and the atlas transverse process. Atlas burst fractures rarely cause neurological deficits because of a greater transverse and sagittal diameter of the spinal canal at the atlas, and a tendency of the lateral masses to slide away from the cord after injury. However, when associated with a rare condition-congenital basilar invagination-atlas fractures can compromise the space and make CN IX-XII more vulnerable to compression injury. This report discusses the correlation between the anatomical lesions and clinical features of this patient.

[Peculiarities of the investigation, clinics and treatment of stylohyoid syndrome and glossopharyngeal neuropathy]

The aim of the study was to investigate the causes and the clinics of stylohyoid syndrome and its tendency to convert into glossopharyngeal nerve neuropathy; to investigate clinical peculiarities of glossopharyngeal neuropathy; to estimate differential diagnosis criteria for the glossopharyngeal neuropathy and stylohyoid syndrome; as well as to propose optimal treatment of the neuropathy.

MATERIAL AND METHODS

Sixty-five patients with stylohyoid syndrome and 53 patients with glossopharyngeal neuropathy have been treated on. The diagnosis was estimated according to the data of clinical and X-ray investigation. For the localization of affected zone we performed modified facial straight plain radiograms of the patients in open bite position, facial oblique contact radiograms, orthopantomograms and cervical spondylograms.

RESULTS

The majority of the patients were females; they comprised 61.5% of patients with stylohyoid syndrome and 56.6% of glossopharyngeal neuropathy sufferers. Older persons had neuropathy, younger--stylohyoid syndrome. The mean age of neuropathy patients was 63.8 years, and of stylohyoid syndrome--57.1 years. Seven years and longer duration of disease was observed in 73.3% of glossopharyngeal neuropathy patients, while duration of 7 and more years was observed in only 3.1% of stylohyoid syndrome patients. The mean duration of glossopharyngeal neuropathy was 10.9 years, and of stylohyoid syndrome--2.6 years. The analysis of etiological factors showed they are the same for both diseases.

CONCLUSIONS

The core of the glossopharyngeal neuropathy pathogenesis is destruction at the glossopharyngeal nerve or at the perivascular plexus of carotid artery, because of elongation or dislocation of styloid processus in case of neck osteochondrosis and compression by ossified styloid ligament. In case of stylohyoid syndrome, inflammatory processes occur at the above-mentioned nervous elements.

[Glossopharyngeal neuralgia]

BACKGROUND

Glossopharyngeal neuralgia is a rare but nevertheless important condition as it can be very incapacitating and as effective treatment is available.

MATERIAL AND METHODS

We provide a review of the epidemiology, aetiology, differential diagnosis and treatment of this condition based on a Medline search.

RESULTS AND INTERPRETATION

Glossopharyngeal neuralgia is characterised by severe unilateral pain in the posterior pharynx, tonsillar fossa, and base of the tongue. It is commonly provoked by swallowing, talking and coughing. In most cases the condition is caused by compression of the nerve by an artery, usually the postero inferior cerebellar artery. Medical treatment with carbamazepin or gabapentin is considered first choice. In patients not responding to medical treatment, surgery should be considered; microvascular decompression is considered the first choice of surgical treatment.

Transient Foix-Chavany-Marie syndrome after surgical resection of a right insulo-opercular low-grade glioma: case report

OBJECTIVE AND IMPORTANCE

We describe an atypical case of transient Foix-Chavany-Marie syndrome, or faciopharyngoglossomasticatory diplegia with automatic voluntary dissociation, occurring after surgical resection of a right insulo-opercular glioma.

CLINICAL PRESENTATION

A 26-year-old right-handed man experienced partial seizures that were poorly controlled by antiepileptic drugs during a 2-year period as a result of a right insulo-opercular low-grade glioma, leading to the proposal of surgical resection. In addition, 1 year before the operation, the patient experienced a severe brain injury that resulted in a coma. A computed tomographic scan revealed left opercular contusion. The patient recovered completely within 6 months.

INTERVENTION

Intraoperative corticosubcortical electrical functional mapping was performed along the resection, allowing the identification and preservation of the facial and upper limb motor structures. A subtotal removal of the glioma was achieved. The patient had postoperative anarthria, with loss of voluntary muscular functions of the face and tongue, and he had trouble chewing and swallowing. All of these symptoms resolved within 3 months.

CONCLUSION

These findings provide insight into the use of surgery to treat a right insulo-opercular tumor. First, surgeons must be particularly cautious in cases with a potential contralateral lesion (e.g., history of head injury), even if such a lesion is not visible on magnetic resonance imaging scans; preoperative metabolic imaging and electrophysiological investigations should be considered before an operative decision is made. Second, surgeons must perform intraoperative functional mapping to identify and to attempt to preserve the corticosubcortical facial motor structures. A procedure performed while the patient is awake should be discussed to detect the structures involved in chewing and swallowing in cases of suspected bilateral lesions. Third, the patient must be informed of this particular risk before surgery is performed.

Schwannomatosis in a child--or early neurofibromatosis type 2

A case of multiple cervical schwannomas in a five-year-old boy, without other evidence of neurofibromatosis type 2, is described. Schwannomatosis is a disorder characterized by the presence of multiple schwannomas in the absence of neurofibromatosis type 2 that has only been recognized in the last 15 years. The clinical and genetic features of neurofibromatosis types 1 and 2 and schwannomatosis are compared and contrasted. This patient with possible schwannomatosis is presented to illustrate the potential pitfalls of making this diagnosis in the paediatric age group and to increase awareness of the debate on whether this is a distinct entity or a form fruste of neurofibromatosis type 2.

Glossopharyngeal schwannoma : a case report and review of literature

We report a rare case of glossopharyngeal schwannoma whose clinical presentation and the radiological work up suggested an acoustic schwannoma. The diagnosis was made at surgery, once attachment to ninth cranial nerve was seen. The clinical presentation, radiological features and surgical findings of the glossopharyngeal schwannoma are presented along with the review of literature.

Eagle syndrome produced by a granular cell tumor

Eagle syndrome includes elicitation of pain on swallowing, turning the head, or extending the tongue. The syndrome is thought to be caused by irritation of the glossopharyngeal nerve, most commonly caused by its impingement against an elongated styloid process. We present a rare case of a granular cell tumor presenting as Eagle syndrome. Granular cell tumors orignate from Schwann cells and are most common in the subcutaneous tissue of the head, neck, and oral cavity, especially the tongue. A granular cell tumor is typically benign and solitary, rarely malignant. The differential diagnosis, diagnostic algorithm, and treatment are presented.

[Assessment of tasting disorder in alcoholics]

To clarify the influence of chronic and excessive alcohol consumption on gustatory function, we examined taste functions of 20 male alcoholics by total oral gustometry using salty, sweet, sour, bitter and glutamate solutions. As results, all patients showed markedly impaired taste in all kinds of solutions comparing with age and sex matched healthy persons, nevertheless none of them recognized their impaired taste. Serum zinc levels of all patients were within reference range, but the most of them were within lower part of reference level. Although average serum zinc level increased significantly after 5 weeks of admission, serum zinc level showed no significant correlation with taste function. From these findings, we concluded that alcoholics had impaired taste functions probably due to impaired peripheral nervous system.

Sensory neuropathy of the trigeminal, glossopharyngeal, and vagal nerves in Sjögren's syndrome

Isolated cranial nerve involvement in primary Sjögren's syndrome (primary SS) has rarely been described. We report the case of a patient with sensory neuropathy of the trigeminal and also the glossopharyngeal and vagal nerves, which has not been identified previously. The electrophysiological findings in our patient with primary SS confirmed trigeminal sensory neuropathy with abnormal blink reflexes and abnormal cutaneous masseter inhibitory reflexes.

Surgical treatment of glossopharyngeal neuralgia as vascular compression syndrome via transcondylar fossa (supracondylar transjugular tubercle) approach

OBJECTIVE

These are the first reported cases in whom the transcondylar fossa approach was applied for the treatment of glossopharyngeal neuralgia (GPN) as a vascular compression syndrome.

CASES PRESENTATION

All three cases presented with severe paroxysmal pharyngeal pain which could not be controlled by medical treatment. The patients all underwent microvascular decompression surgery (MVD) via transcondylar fossa approach. The posterior inferior cerebellar artery or the anterior inferior cerebellar artery was clearly verified to be compressing the glossopharyngeal nerve and then was safely and completely moved and fixed to the dura mater by the sling retraction technique to effect decompression. No patient has since experienced any further pain or permanent neurological deficit after surgery. TECHNICAL ADVANTAGE: The transcondylar fossa approach is one of the lateral approaches which is different from the transcondylar approach. In this approach, the posterior part of the jugular tubercle is extradurally removed without injuring the atlanto-occipital joint. The entire course of the cisternal portion of the glossopharyngeal nerve can be sufficiently seen with gentle retraction of the cerebellar hemisphere, when using this approach.

CONCLUSION

This approach makes the MVD for GPN both effective and safe.

Jacobson's nerve schwannoma presenting as middle ear mass

Schwannoma is one of the common benign middle ear space tumors. Middle ear space schwannomas may originate from the nerves of the tympanic cavity or by extensions from outside the middle ear space. In the English-language literature, the facial nerve and chorda tympani nerve, but not yet the tympanic branch of glossopharyngeal nerve (Jacobson's nerve), have been reported as the origins of intrinsic middle ear space schwannomas. We present the clinical and radiologic features of a middle-space schwannoma originating from Jacobson's nerve, and suggest that such a tumor be included in the differential diagnosis of middle ear tumors.

Tonsillar pain mimicking glossopharyngeal neuralgia as a complication of vagus nerve stimulation: case report

An adolescent girl presented with severe, lancinating tonsillar pain exacerbated by swallowing 6 weeks after initiation of left vagus nerve stimulation for intractable epilepsy. Her symptoms mimicked those seen in glossopharyngeal neuralgia and were relieved by temporary cessation of stimulation. Gradual reinstitution of therapy with alteration in stimulus parameters resulted in improved seizure control as well as cessation of pain symptoms. Direct stimulation of the vagus nerve may result in vagoglossopharyngeal neuralgia, which, in this case, was amenable to stimulus modification.

Imaging findings in schwannomas of the jugular foramen

BACKGROUND AND PURPOSE

Tumors of the cranial nerve sheath constitute 5% to 10% of all intracranial neoplasms, yet few articles have described their CT and MR characteristics. We report the imaging findings in a relatively large series of schwannomas of the jugular foramen, contrasting them with other disease entities, especially vestibular schwannomas and tumors of the glomus jugulare.

METHODS

CT and/or MR studies of eight patients who underwent surgery for histologically proved schwannomas were reviewed retrospectively. One additional patient with an assumed schwannoma of the jugular foramen, who did not have surgery, was also included.

RESULTS

Surgical findings showed schwannomas of the glossopharyngeal nerve in seven patients and tumor involvement of both the glossopharyngeal and vagal nerves in one patient. All tumors were partially located within the jugular foramen. Growth extending within the temporal bone was typical. Tumor extended into the posterior cranial fossa in all nine patients and produced mass effect on the brain stem and/or cerebellum in seven patients; in five patients, tumor extended below the skull base. On unenhanced CT scans, tumors were isodense with brain in six patients and hypodense in two. In seven patients, CT scans with bone algorithm showed an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. On MR images, T1 signal from tumor was low and T2 signal was high relative to white matter in all patients. Contrast enhancement on CT and/or MR studies was strong in eight patients and moderate in one.

CONCLUSION

Schwannoma of the jugular foramen is characteristically a sharply demarcated, contrast-enhancing tumor, typically centered on or based in an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. Intraosseous extension may be marked.