Numb chin syndrome as an initial symptom of acute lymphocytic leukemia: report of three cases

Numb chin syndrome: What all oral health care professionals should know

BACKGROUND

Numb chin syndrome (NCS) is a rare sensory neuropathy involving the mental nerve. Symptoms of NCS are often overlooked because of their apparent innocent nature; however, owing to the frequent association of NCS with malignancies, the opposite should be the rule. Oral health care professionals may be the first to encounter patients with NCS and should be aware of its clinical characteristics in an effort to decrease patient morbidity and mortality.

TYPES OF STUDIES REVIEWED

A search in PubMed (MEDLINE) and the Cochrane Library was performed using the terms numb chin syndrome, numb chin, mental neuropathy, mental nerve neuropathy, and malignant mental nerve neuropathy, yielding 2,374 studies. After inclusion and exclusion criteria were applied, 102 studies remained. Descriptive statistics were performed, analyzing the etiology responsible for NCS, characteristics of NCS including associated symptoms, unilateral or bilateral nature, and information on professionals visited and examinations requested to make a diagnosis.

RESULTS

NCS was associated with malignancy in 29% through 53% of the published cases. Twenty-eight percent of patients initially consulted an oral health care professional with the symptom of a numb chin. Patients more likely to have NCS were those from the ages of 61 through 70 years; 74% were unilateral; and the most common symptoms reported were numbness (100%), paresthesia (18%), and pain (17%). Forty-seven percent of the NCS cases were associated with a recurrent malignancy, and the most prevalent associated diagnoses were breast cancer (32%) and lymphoma and leukemia (24%).

CONCLUSIONS

Oral health care professionals should be aware of the characteristics of NCS as they may be the first health care providers consulted for these symptoms.

PRACTICAL IMPLICATIONS

A thorough medical and dental history as well as a complete cranial nerve screening should be performed on all patients, especially those with numbness, as this may prevent misdiagnosis and allow a timely referral and a substantial improvement of treatment course and prognosis.

Numb chin syndrome as a presentation for acute myeloid leukemia relapse post-hematopoietic cell transplant: Case report and review of literature

NCS is defined as reduced or absent sensation in the chin and lower lip within the distribution of the mental or inferior alveolar nerves. Although commonly associated with local trauma, NCS can indicate an underlying malignancy or can be the presenting symptom of cancer recurrence. We describe a 6-year-old female patient with AML and t(8,21) who underwent allogeneic HCT. Five months post-HCT, the patient presented with right-sided facial pain and numbness in her chin and lower lip consistent with NCS. Two weeks later, the patient had bone marrow relapse indicating AML recurrence. Although NCS remains a rare diagnosis especially in children, in the context of leukemia, it usually indicates an advanced disease or could be a sign of recurrence, and is commonly associated with grim prognosis. Further research is needed to study the link between NCS and specific cytogenetic abnormalities.

Orofacial Manifestations of Leukemic Children on Treatment: A Descriptive Study

Aim

To study the prevalence of orofacial manifestations in leukemic children undergoing treatment and to correlate these manifestations with various stages of chemotherapy.

Materials and methods

A prospective noninvasive study comprising 43 acute lymphocytic leukemic pediatric patients at various stages of therapy. They were examined on day of their each blood examination, and lesions were recorded on a self-designed pro forma. A total of 133 observations were recorded by a single observer. The treatment was divided into the phase of induction, consolidation, maintenance, and relapse.

Results

The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 10.1. There were 24 males and 19 females in this study, aged between 3 and 13 years. The common oral lesions seen were dental caries, lymphadenopathy (86.04%), pallor (65.11%), ulcers (13.95%), mucositis (16.27%), gingival enlargement, hemorrhages (20.93%), candidiasis, herpes simplex virus (HSV) infection, xerostomia (44.18%), paresthesia, and tooth mobility. Herpes simplex virus infection was seen only during induction and consolidation phases. Ulcers were seen during all phases of therapy.

Clinical significance

Orofacial manifestations may be seen as the first sign of leukemia and a dentist may play a significant role in the diagnosis of the disease per se. This study highlights not only about commonly occurring lesions but also their variation during various phases of therapy. To the best of our knowledge, no study has such an extensive reporting of orofacial manifestations of acute lymphocytic leukemia (ALL) patients under treatment.

How to cite this article: Aggarwal A, Pai KM. Orofacial Manifestations of Leukemic Children on Treatment: A Descriptive Study. Int J Clin Pediatr Dent 2018;11(3):193-198.

Numb chin with mandibular pain or masticatory weakness as indicator for systemic malignancy - A case series study

BACKGROUND/PURPOSE

Numb chin syndrome (NCS) is a critical sign of systemic malignancy; however it remains largely unknown by clinicians and dentists. The aim of this study was to investigate NCS that is more often associated with metastatic cancers than with benign diseases.

METHODS

Sixteen patients with NCS were diagnosed and treated. The oral and radiographic manifestations were assessed.

RESULTS

Four (25%) of 16 patients with NCS were affected by nonmalignant diseases (19% by medication-related osteonecrosis of the jaw and 6% by osteopetrosis); yet 12 (75%) patient conditions were caused by malignant metastasis, either in the mandible (62%) or intracranial invasion (13%). NCS was unilateral in 13 cases and bilateral in three cases. Mandibular pain and masticatory weakness often dominate the clinical features in NCS associated with cancer metastasis. In two patients, NCS preceded the discovery of unknown malignancy (breast cancer and leukemia). In nine others, NCS heralded malignancy relapse and progression. Metastatic breast cancer in four (36%) cases accounted for the most common malignancy. Other metastatic diseases included two multiple myelomas, and one each of leukemia, prostate cancer, colon cancer, lung cancer, maxillary sinus adenoid cystic carcinoma and adrenal gland neuroblastoma. Radiographic examinations showed obvious mandibular metastasis with compression of the inferior alveolar nerve or mental nerve in nine patients, and leptomeningeal seeding or intracranial metastasis to the trigeminal nerve root at the skull base in two patients.

CONCLUSION

NCS without obvious odontogenic causes or trauma often signals systemic malignancy. It may be the first clue of occult malignancy.

Numb Chin Syndrome

"Numb chin syndrome" (NCS) refers to new-onset numbness of the lower lip and chin within the distribution of the mental or inferior alveolar nerves. While this focal numbness may be downplayed or even overlooked by patients and clinicians, in the right clinical scenario this may be the presenting symptom of an underlying malignancy. In the absence of any obvious, temporally related dental cause, there are certain conditions that clinicians should consider including orofacial and systemic malignancies as well as several inflammatory disorders. Thorough diagnostic evaluation should always be performed when no clear cause is evident. This paper will discuss the differential, recommended evaluations, and the prognosis, for a patient presenting with NCS.

Mental nerve neuropathy: case report and review

Mental nerve neuropathy (MNN) or “numb chin syndrome” is a rare neurologic symptom most often associated with malignancy. Patients typically develop paresthesia or numbness localized to the chin and lower lip and will often seek care at their local emergency department. Pain and expansion of the lower jaw may also be present. We report a case of MNN associated with a metastatic lesion in the mandible. The purpose of this article is to highlight the importance of recognizing MNN, a potentially life-threatening symptom of metastatic carcinoma, and enable clinicians to properly diagnose MNN, which may mimic other conditions that affect the mandible.

Numb chin syndrome: a case series of a clinical syndrome associated with malignancy

INTRODUCTION

Information regarding the appropriate work-up and outcomes in patients receiving palliative treatment for numb chin syndrome (NCS) in the setting of malignancy is sparse. This study aims to describe NCS in malignancy and evaluate the disease trajectory, significance of diagnostic modalities and outcomes with palliative treatment.

METHODS

A retrospective study was performed on patients presenting with NCS between March 2007 and October 2013 at the Capital Region Cancer Service, Canberra.

RESULTS

Thirteen patients were identified who presented with numbness of the chin between March 2007 and October 2013. Seven patients had breast cancer, two had prostate cancer, two had multiple myeloma, one had medulloblastoma and one had an adenoid cystic salivary gland tumour. The mean interval from initial cancer diagnosis to development of the syndrome was 4.32 years. Twelve out of 13 patients had had prior chemotherapy with two or more lines of treatment (with a median of two lines), indicating this condition tended to present late in the course of disease in our patients. Four patients developed bilateral symptoms, and in two of these cases the metastatic lesion was in the base of the skull. Eleven out of 13 patients had positive signs on imaging. Nine out of 13 patients received palliative radiotherapy, with clinical response in eight patients.

CONCLUSION

Patients with malignancy presented with NCS late in the disease trajectory, often after multiple lines of treatment. In our cohort of patients, 84% had positive imaging signs to aid diagnosis, and 77% had resolution of numbness with palliative treatment.

Malignant cell infiltration in the peripheral nervous system

The peripheral nervous system can be affected by malignancies involving different mechanisms. Neoplastic nerve lesion by compression, invasion, and infiltration is rare and occurs in particular in leukemia (neuroleukemiosis) and lymphoma (neurolymphomatosis). Its occurrence is much rarer in cancer, and even less so in sarcoma. The neoplastic infiltration of peripheral nerves by solid tumors is characterized by specific topographical sites such as the base of the skull, the ear, nose and throat region, and the cervico-brachial plexus as well as the lumbar and sacral plexus. Rarely malignant invasion affects the cranial nerves of the face where it can spread centripetally. Autonomic nerves and ganglia can also be affected. The retrograde spread of cancer in nerves is a bad prognostic sign. The clinical diagnosis is determined by tumor type, the pattern of involvement, and often pain.

Neuromuscular complications

Although direct neoplastic involvement of muscle tis-sue is surprisingly rare, considering the large amount of body mass that is represented by muscle tissue, the most important and unresolved muscle effect is muscle cachexia.Other associations, such as inflammatory, paraneo-plastic, toxic, and several extremely rare associations,have been described. Drug-induced toxicity and radiation recall syndrome need to be taken into consideration when muscle symptoms appear in patients with cancer.

Numb chin syndrome with concomitant painful ophthalmoplegia leading to a diagnosis of diffuse large B cell lymphoma

Painful ophthalmoplegia (PO) and concomitant numb chin syndrome (NCS) is a very rare event. There are a few reports in the literature about PO and concomitant NCS that have preceded the diagnosis of a malignancy. In this report, we describe a patient with diffuse large B cell lymphoma who presented with PO and concomitant NCS as the initial symptom of the disease.

Acute lymphoblastic leukaemia: an unusual radiological presentation

A 14-year-old female patient attended Bristol Dental Hospital for an oral screening prior to undergoing a bone marrow transplant as treatment for her acute lymphoblastic leukaemia. Maxillofacial radiographs revealed multiple, well-defined, non-corticated radiolucent lesions throughout the vault of her skull and mandible. These radiological features (coupled with the patient's age) would have correlated with a diagnosis of Langerhans cell histiocytosis. However, a previous bone marrow biopsy confirmed that the patient did indeed have acute lymphoblastic leukaemia. The lytic lesions were present throughout her entire skeletal frame and had previously led to episodes of leg and abdominal pain. We feel that this radiological presentation of leukaemia needs to be reported as these features could easily have been confused with other haematological or even malignant conditions.

Numb chin syndrome as initial manifestation in a child with acute lymphoblastic leukemia

Numb chin syndrome (NCS) describes the affection of the inferior alveolar nerve and is a purely sensory neuropathy. Its symptoms include numbness of the skin of the chin, the lip and the gingival mucosa. Mostly seen in adults, it has rarely been described in children. We report on an 11-year-old male who presented with NCS as initial manifestation of acute lymphoblastic leukemia of B-cell type.

Mental neuropathy as a manifestation associated with malignant processes: its significance in relation to patient survival

PURPOSE

Mental neuropathy (MN) is characterized by the presence of a sensory defect in the form of paresthesias or dysesthesias in the territory innervated by the mental nerve. MN may be the first manifestation of systemic cancer, a symptom of spread of an established tumor, or a sign of infiltration in an intraoral lesion. In any of these cases, the symptom is indicative of a very poor patient prognosis.

MATERIALS AND METHODS

A total of 22 cancer patients with chin paresthesia were studied. Group 1 comprised patients with chin paresthesia who had a primary tumor in some other region at a distance from the oral cavity or maxillofacial zone. Group 2 in turn comprised patients with primary malignancies of the oral and/or maxillofacial territory and who likewise presented with chin paresthesia. Data were collected relating to patient age, gender, primary intraoral lesion (location, size, histologic diagnosis), primary systemic tumor, and mean patient survival.

RESULTS

Group 1 consisted of 11 patients (8 men and 3 women), aged between 36 and 81 years (mean, 58.09 +/- 14.99 years), with different systemic cancers. The mean survival after the diagnosis of chin paresthesia was 14.8 +/- 16.5 months, and only 1 patient was still alive after 9 months. Group 2 consisted of 11 patients (8 men and 3 women), aged between 33 and 72 years (mean, 56.18 +/- 15.69 years). All presented with oral squamous cell carcinoma, with the single exception of 1 case of fibrosarcoma. In this group the mean survival of the 8 patients who died was 28.2 +/- 29.6 months. Three patients survived for a mean of 17 months.

CONCLUSIONS

Chin paresthesia is a very important prognostic symptom determining the degree of infiltration of intraoral lesions, and in some cases it may be indicative of the existence of a primary tumor (identified or otherwise), with poor short-term survival--given that 81.9% of the patients studied (18 cases) had died before a mean of 20 months. Although mean survival was shorter (14.8 months) among the patients in group 1 than in group 2 (28.2 months), the difference was not statistically significant.

Numb chin syndrome: a nonmetastatic neurological manifestation of malignancy

Numb chin syndrome, sometimes called numb lip syndrome, is an uncommon but well-recognized symptom in medical oncology. It may be a nonmetastatic neurological manifestation of malignancy, often with no clinically visible pathology. We report a case of a 79-year-old woman with widespread metastatic disease secondary to breast carcinoma who presented with a left-sided numb lip and chin. The patient had no clinical or radiographic pathology within the head and neck region. Numb chin syndrome is almost unknown within the dental and oral and maxillofacial community, despite being well reported in the medical literature. We urge all general dentists, oral medicine specialists, and oral and maxillofacial surgeons to consider metastatic cancer in patients with unexplained facial hypoesthesia.

Numb chin syndrome--a reflection of systemic malignancy

Background

Numb chin is an uncommon underappreciated though well documented neurological manifestation of metastatic malignancy.

Case presentation

A 50-year-old patient presented with right numb chin for few days. No dental cause was found. He later developed generalized vague symptoms. In few weeks his liver and renal functions deteriorated. Blood picture showed leucoerythroblastic picture. CT scan and bone marrow biopsy done at this stage revealed underlying high grade lymphoblastic lymphoma. He went into multiorgan failure, requiring ventilatory support and death within a short period.

Conclusion

Numb Chin is a syndrome which initially presents with unilateral numbness or orofacial pain in the distribution of the inferior alveolar nerve and its branches with an underlying systemic malignancy. We emphasise that physicians and dentists should consider metastatic cancer in any patient who presents with chin or jaw numbness where no other obvious cause for their complaint is found.

Severe alveolar bone loss and gingival hyperplasia as initial manifestation of Burkitt cell type acute lymphoblastic leukemia

BACKGROUND

The purpose of this case report is to present severe alveolar bone destruction and gingival enlargement as initial manifestation of Burkitt cell type acute lymphoblastic leukemia (ALL-L3) in a 14-year-old boy.

METHODS

The patient was referred to the periodontology department with a 4-week history of gingival enlargement and loosening of teeth. The clinical examination revealed gingival enlargement and expansion of alveolar mucosa particularly in molar regions of both jaws. Almost all teeth had deep periodontal pockets and severe mobility. While the radiographs showed severe alveolar bone loss which extended to apical thirds of many teeth, the microbiologic analysis revealed that the patient did not harbor major periodontopathogenic bacteria species. The results of blood tests and bone marrow aspiration were compatible with ALL-L3.

RESULTS

Remission-induction treatment with BFM-90 ALL chemotherapy protocol was started; however, the patient died 4 weeks after the diagnosis due to neutropenic sepsis.

CONCLUSIONS

Although no biopsy was performed, it is possible that the severe periodontal destruction and gingival enlargement in this case may have been due to the infiltration of leukemic cells in gingiva, periodontal ligament, and alveolar bone. The similarities of these findings with numb chin syndrome (NCS) and Burkitt's lymphoma (BL) are discussed in this report.

Numb chin syndrome in Ewing sarcoma

The numb chin syndrome consists of unilateral hypesthesia of the chin and lower lip. In adults, it is often associated with metastatic disease to the mandible, base of the skull, or leptomeninges. In children, it has been associated with infiltration of the inferior alveolar nerve by leukemic cells. We describe two cases of numb chin syndrome in children with Ewing sarcoma. In a child with a solid tumor, this symptom seems to have an ominous meaning and should lead to the investigation of progressive skeletal involvement.

Mental neuropathy: report of five cases and review of the literature

Mental nerve neuropathy, also referred to as numb chin syndrome, is a rare, seemingly harmless symptom. It is more often associated with cancer, either as first symptom or during the outcome, than with benign diseases. In this review, we will focus on the numb chin syndrome presenting as an isolated neurological symptom. We report five patients with mental nerve neuropathy associated with metastatic disease (small cell lung cancer, prostatic cancer and breast cancer). In one patient, numb chin syndrome preceded the discovery of the disease, while, in the four others, it occurred as a sign of relapse or progression. Isolated mental nerve neuropathy, frequently associated with breast cancer and lymphoproliferative diseases, is generally thought to be the consequence of bone metastases or leptomeningeal seeding, but may also present without an obvious cause, most often secondary to the involvement of the mental nerve itself. Although various therapies may lead to the resolution of this symptom, median survival after diagnosis is generally less than 1 year. The appearance of a mental nerve neuropathy should never be considered as a 'banal' symptom and investigations to detect a possible cancer should be mandatory.

Longstanding trigeminal sensory neuropathy of nontraumatic cause

OBJECTIVE

Trigeminal sensory neuropathy is an uncommon but often significant orofacial symptom. There are few detailed descriptions of the problem in the dental literature. The aim of this study was to evaluate the clinical presentation and management of a cohort of patients presenting with anesthesia/paresthesia affecting one or more divisions of the trigeminal nerve unrelated to any identifiable traumatic cause.

STUDY DESIGN

Nine patients with trigeminal neuropathy were examined. Each patient underwent a standard protocol of examination and hematologic, serologic, radiologic, and histopathologic investigations, as appropriate.

RESULTS

Trigeminal neuropathy was found to be secondary to distant malignancy in 4 patients and to connective tissue disease in 2 patients. In each of 3 other patients, there was no obvious cause for the neuropathy. Patients with malignancy as the cause of their neuropathy tended to have involvement of more than one division of the trigeminal nerve and/or other neurologic features.

CONCLUSIONS

Trigeminal sensory neuropathy may herald underlying distant malignancy or connective tissue disease. Anesthesia and paresthesia of the orofacial region are therefore serious clinical symptoms that must be carefully investigated before a diagnosis of idiopathic disease is made.