Botulinum toxin type A improves pain in numb chin syndrome

Numb chin syndrome is a rare pain disorder characterized by decreased sensation and paresthesia in the territory of the mental nerve. Neuropathic pain is sometimes described in this setting, and the most common treatments include oral analgesics, gabapentinoids, and carbamazepine; however, botulinum toxin type A has never been used in this setting. We describe a case of bilateral numb chin syndrome, secondary to Burkitt lymphoma, associated with refractory and persistent burning neuropathic pain, effectively treated twelve times with subcutaneous Botulinum toxin type A (BoNT/A) injections. The procedure was well tolerated, but the patient reported incomplete mouth closure of minimal entity. BoNT/A could be a safe and effective therapy for neuropathic pain associated with numb chin syndrome.

Orofacial symptoms suggestive of malignant lesions and the role of imaging: literature review and case presentation

Among the patients seeking dental treatment, some may present with symptoms that cannot be resolved by dental treatment alone. Patients with orofacial symptoms associated with malignant diseases, which require medical treatment, often visit dental clinics for their initial consultation. Delays in making a definitive diagnosis worsen the patient's prognosis. Therefore, dental clinicians should also be aware of the signs and symptoms associated with malignant diseases. The chief complaints of these patients include numb chin syndrome (NCS), painless swelling of the palate and neck, trismus and temporomandibular disorders, and an enlarged tongue. This article aimed to review these orofacial symptoms and related diseases and describe representative cases of these diseases to obtain a definitive diagnosis via imaging. Panoramic radiograph is widely used in general dentistry, and this article reaffirmed the importance of panoramic radiograph anatomical landmarks in diagnosing the cases presented in this paper.

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.

Occult prostate carcinoma with metastasis to the mandible presenting as numb chin syndrome

Prostate cancer is one of the leading causes of death due to malignancy in men. Occult malignancy presenting with no primary symptoms could be a challenge to the diagnostician. Metastasis of prostate carcinoma to the mandible is rare and usually presents with non-specific symptoms. Only 1% of oral cancers account for lesions which present as metastasis of other primary malignancies. We report a rare case of prostate carcinoma being diagnosed as metastasis to the mandible with the patient presenting with numb chin syndrome.

The "numb chin syndrome": A case report

INTRODUCTION

Neuroendocrine tumours comprise 0.5-2% of all malignancies in adulthood, and very rarely metastasize to the oral cavity. When they do metastasize to the oral cavity, the mandible is the most common site. This can lead to symptoms such as a numb chin and lip, which in the absence of any odontogenic cause may be an important sign indicating malignant disease. We present a rare case of metastatic neuroendocrine carcinoma to the mandible, resulting in the so-called "numb chin syndrome".

PRESENTATION OF CASE

An elderly lady presented with numbness to the right chin and lip, as well as hypoglossal nerve palsy. She had significant back pain and gave a history of repeat chest infections. Intra-oral clinical examination was normal, but upon further special investigations, the right mental region was suspicious of multiple lytic lesion. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) demonstrated marrow changes in the mandible suspicious of malignant disease. Further findings included multiple pathological fractures of the spine and a mass in the left lung base. A trephine biopsy gave a diagnosis of metastatic neuroendocrine carcinoma, with the left lung mass considered to be the primary site.

DISCUSSION

We discuss the rarity of metastatic disease to the oral cavity, and the importance of "numb chin syndrome" in indicating malignancy.

CONCLUSIONS

This case promotes the importance of considering sinister pathology when presented with sudden, altered sensation to the chin and lips. The "numb chin syndrome" should always raise the suspicion of primary or metastatic disease to the mandible.

Numb Chin Syndrome as the Initial Manifestation of Breast Carcinoma

Numb chin syndrome may be the manifestation of a local dental pathology or secondary to a systemic disease. A systematic physical examination with diagnostic workup is of utmost importance in patients presenting with numb chin syndrome. We report the case of a 58-year-old woman who presented with numb chin syndrome. An orthopantogram and computed tomography of the head revealed osteolytic lesion in the left molar region. Histopathological and immunohistochemical examination confirmed the lesion to be metastatic breast carcinoma. Breast ultrasound scan demonstrated a 1.5 × 1.5-cm lesion in the left breast and fine needle aspiration cytology from the lesion confirmed the diagnosis of breast carcinoma. Bone scan showed multiple bone metastases. She was diagnosed to have numb chin syndrome secondary to bone metastases from breast carcinoma. In view of her disseminated disease status, she was started on palliative hormone therapy (Letrozole) with zoledronic acid. We present this case to highlight the importance of careful evaluation of patients presenting with numb chin syndrome because this may be the only manifestation of a systemic malignancy.

Complete progressive ophthalmoplegia and numb chin syndrome, the first clinical manifestations of a lethal abdominal Burkitt lymphoma

A 57-year-old patient was admitted to the Neurology Clinic for hypoesthesia, intense pain in the right chin and double vision. During the hospitalization, the patient developed progressive complete bilateral ophthalmoplegia and numbness of both sides of the chin. Brain CT and MRI scans with gadolinium were normal. Standard laboratory tests on admission were normal. The cerebral spinal fluid examination and the infectious and autoimmune workup were also normal. A thoracic-abdominal and pelvic CT scan revealed two hypodense lesions in the liver, irregular thickening of the gastric and ileal wall, and multiple abdominal adenopathies. Meanwhile, the patient developed marked fatigue, fever, sweats, nausea, vomiting and abdominal pain. An exploratory laparotomy was performed that showed multiple tumours of the small intestinal wall, stomach wall, multiple liver masses in both lobes and appendicular tumour. Histopathological findings of the liver biopsy and appendicular walls revealed Burkitt lymphoma. The patient died two days after surgery by cardiopulmonary arrest. This case underscores the importance of keeping BL in the differential diagnosis of patients with rapidly progressive ophthalmoplegia and numb chin syndrome, with normal brain MRI and CSF examinations.

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.

Prostate adenocarcinoma mandibular metastasis associated with numb chin syndrome: a case report

The purpose of this study is to report a rare case of mandibular adenocarcinoma that was diagnosed due to metastasis from the prostate. Numb chin syndrome (NCS), which was associated with this case, is also discussed. Computed tomography (CT) and an intraoral incisional biopsy of the left mandibular area were performed. Urology consultation, hormone therapy, chemotherapy and follow-up radiographic images were administered. Histological examination of the incised specimen revealed moderately differentiated adenocarcinoma. The Gleason score was 8 (primary 4/secondary 4). Immunohistochemical features and radiographic results confirmed the diagnosis of metastasis from prostate adenocarcinoma, moderately differentiated. The patient's prostate-specific antigen (PSA) level was very high. After hormone treatment, the patient's PSA levels dropped gradually. Seventeen months later, in May 2015, the PSA level was elevated. The 18-month follow-up CT image indicated that the patient's condition was aggravated. Docetaxel chemotherapy was started in June 2015 (18 months later), and the sixth cycle of the therapy is in progress. Oral metastases that originate from prostate adenocarcinoma are rare and can induce various periosteal reactions. Hormone therapy, chemotherapy and close follow-up could be additional, appropriate treatment, and were applied in this case. Finally, NCS is a valuable indicator of metastatic disease in the mandible.

Numb chin syndrome as a manifestation of jaw metastasis diagnosed in a bone scan

In many cases, numb chin syndrome (NCS) may represent a banal pathology. However, as it can be associated with malignant processes, its presence should alert the clinician of a possible occult disease. In patients already diagnosed with cancer, it often represents an ominous sign that indicates poor prognosis, due to the rapid progress of the disease. The case is presented of a 62-year-old man diagnosed with synchronous lung and bladder cancer, who suddenly complained of numbness in the chin. The bone scan confirmed the suspicion of metastastic bone disease, and the patient died two months after the appearance of this sign.

Intractable Facial Pain and Numb Chin due to Metastatic Esophageal Adenocarcinoma

The etiologies of facial pain are innumerable, thus facial pain misdiagnosis and resultant mismanagement is common. Numb chin syndrome presents with hypoesthesia and/or anesthesia in the dermatomal distribution of the inferior alveolar or the mental nerve. In this case report, we will discuss a case of intractable facial pain in a 57-year-old male with a history of esophageal adenocarcinoma who was initially misdiagnosed and treated as trigeminal neuralgia. During clinical examination, the loss of sensation in the inferior alveolar nerve distribution was identified and led to the diagnosis of mandibular metastasis. The details of the clinical presentation will be discussed in the context of accurate identification and diagnosis. Focal radiation to the metastatic location along with sphenopalatine ganglion radiofrequency ablation and medication management provided significant pain relief. This case report provides additional information to the current medical knowledge and it enhances the clinical vigilance of the clinicians when they encounter similar cases. We concluded that patients with a history of neoplasms who present with atypical symptoms of facial pain should undergo further investigation with advanced imaging. Targeted treatment based on an accurate diagnosis is the foundation of pain management.

Early relapse of Burkitt lymphoma heralded by a bone marrow necrosis and numb chin syndrome successfully treated with allogeneic stem cell transplantation

The optimal salvage therapy for patients with relapsed Burkitt lymphoma is unknown. Bone marrow necrosis is an underreported (<1% of bone marrow failures). Numb chin syndrome is another rare syndrome associated with aggressive malignancies. Survival of these syndromes is dictated by the underlying disease and is usually dismal. Our 35-year-old patient experienced an early relapse of Burkitt lymphoma accompanied by syndromes, achieved second complete remission and underwent allogeneic stem cell transplantation. He remains alive and well >2 years after the transplant. To our knowledge, this is the longest reported survival of the two syndromes in the setting of BL relapse.

[Numb chin syndrome as a sign of tumour recurrence]

Numb chin syndrome is characterized by anaesthesia or paraesthesia in the areas supplied by the chin nerve. It is a rare symptom which tends to be underestimated. Far from being insignificant, it should be taken as an indication of hidden malignant disease. In patients previously diagnosed with neoplasia, it is frequently associated with ominous diagnosis indicating rapid progression of the disease. This paper reports the case of a patient diagnosed with breast cancer 20 years earlier who presents chin numbness. Further tests confirm the suspicion of metastatic disease (meningeal carcinomatosis and multiple bone and pulmonary metastases) leading to death two months after the initial consultation.

Unusual presentation of 'numb chin syndrome' as the manifestation of metastatic adenocarcinoma of the lung

INTRODUCTION

Numb chin syndrome (NCS) is the presence of hypoaesthesia or paraethesia of the lip and chin over the distribution of the mental nerve. It is often caused by the presence of a metastatic tumour in the mandible or the base of skull and represents advanced malignancy.

PRESENTATION OF CASE

This paper presents an unusual case of NCS associated with metastatic adenocarcinoma of the lung, for which no obvious lesion was found in the mandible or base of the skull.

DISCUSSION

NCS can oftentimes present itself in the absence of mandibular or base of skull metastatic lesions.

CONCLUSION

NCS can be a sign of underlying advanced metastatic malignancy and therefore cannot be ignored and must be investigated fully.

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.