Ocular motility abnormalities in orbitofacial neurofibromatosis type 1

PURPOSE

To evaluate the causes of ocular motility disturbances in a group of patients with orbitofacial neurofibromatosis (OFNF) with neurofibromas on the lid, brow, face, or in the orbit from infancy or early childhood.

METHODS

The medical records of patients with OFNF from one institution were retrospectively reviewed; selected patients were reexamined.

RESULTS

A total of 45 patients with unilateral OFNF and 4 with bilateral OFNF were included. Of these, 14 had no strabismus and relatively good vision, with no ductional abnormalities on either side despite large globes, sphenoid dysplasia, and neurofibromas in the orbit and/or cavernous sinus in many. The 8 patients with comitant strabismus also had no ductional abnormalities with a similar constellation of anatomic abnormalities, but these patients all had poor vision in at least one eye. The 27 patients with incomitant strabismus all had downward displacement of the globe and limited ductions.

CONCLUSIONS

The pathologic anatomic changes associated with OFNF do not always cause ocular motility abnormalities: strabismus generally was not present when ocular motility was full and visual acuity was good. Comitant strabismus occurred in the setting of full ocular motility with reduced vision in at least one eye. Incomitant strabismus was always accompanied by reduced vision and a ductional abnormality in one or both eyes due to anatomic abnormalities of the orbit and skull.

A painless neck swelling and von Recklinghausen

BACKGROUND

Von Recklinghausen's disease, an autosomal dominant genetic disorder, may occasionally present with unusual localizations of neurofibromas.

CLINICAL CASE

A 46-year old woman, known with Von Recklinghausen's disease, reported a swelling and a feeling of pressure and globus sensation. Clinical examination revealed multiple large nodi on the right side of the neck. Laboratory testing including thyroid-stimulating hormone (TSH) was normal. An MRI showed a 1 x 3 x 10 centimeter sausage-like structure compressing the right jugular vein. At surgical exploration a string-like tumour firmly attached to the right vagal and recurrent laryngeal nerve was found. The tumor and both nerves were macroscopically curative resected. Histopathological examination demonstrated a plexiform cervical vagus nerve neurofibroma without malignancy.

CONCLUSION

Patients with Von Recklinghausen's disease presenting with painless neck swellings may harbour cranial nerve neurofibromas.

A rare case of a solitary intraocular neurofibroma

BACKGROUND

Solitary neurofibroma in the absence of neurofibromatosis is of rare occurrence and very few cases have been reported till date.

OBJECTIVE

To report a case of a solitary intra-ocular neurofibroma.

CASE

A 65-year-old man presented to us with a large swelling appearing to arise from right pthisical eye for the past one and a half years. After knowing the extent and origin of mass lesion, right eyeball was enucleated and subjected to histopathological examination which revealed intraocular neurofibroma in the absence of neurofibromatosis which is of very rare occurrence.

CONCLUSION

The isolated neurofibroma of intraocular origin can present as an isolated orbital mass without systemic features.

[Lacosamide as an alternative in the treatment of post-surgery neuropathic pain in an allergic patient]

INTRODUCTION

Neuropathic pain is a condition that is still not well understood, although it affects a significantly high percentage of the population. The main problem lies in the fact that it can become a fairly disabling pathology. The most frequent treatment is based essentially on two drugs: gabapentin and pregabalin. Other pharmaceuticals, such as antidepressants, opioids or N-methyl-D-aspartate receptor antagonists can also be employed in combination with the primary drugs. All the same, treatment remains unsatisfactory. Furthermore, it must be borne in mind that there may be patients who are allergic to the two main drugs.

CASE REPORT

We report the case of a 36-year-old female with neuropathic pain secondary to surgery to correct a neurinoma in the brachial plexus, who could not be treated with gabapentin or pregabalin because of a personal history of allergy to these substances. Treatment with another drug (lacosamide), however, was very effective and displayed a very good response.

CONCLUSIONS

Lacosamide is a third-generation antiepileptic drug that has been proven to be effective, safe and with few side effects. It has been considered a good therapeutic option for the treatment of neuropathic pain in patients who are allergic to pregabalin.

Intrascrotal extratesticular neurofibroma as a possible cause of failed descent in ipsilateral testis

Intrascrotal extratesticular neurofibromas (IEN) often originate from genitofemoral nerve (GFN) and present as a paratesticular mass. Synchronous presence of IEN and undescended testis has not been reported previously. A 12-year-old boy with neurocutaneous syndrome and congenital giant melanocytic nevi along with IEN and ipsilateral undescended testis is presented, to discuss the underlying pathophysiology of failed testicular descent in the presence of IEN.

A case of neurofibroma of the appendix in von Recklinghausen disease

A 67-year-old man with von Recklinghausen disease (VRD) was found to have an ill-defined large mass in the ileocecal area on abdominal computed tomography when he was examined for abdominal pain in the right lower quadrant. Because of high serum C-reactive protein level and leukocytosis appendiceal tumor complicated by appendicitis was diagnosed. Due to the possibility of malignancy, standard cancer surgery was carried out to remove the mass, i.e., ileocecal resection together with dissection of the regional lymph nodes. The cecum was displaced by a remarkably enlarged appendix with a firm and thickened wall. The distal portion of the appendix was cystically dilated, forming an abscess. The pathological diagnosis was neurofibromatosis with mucus hyperplasia and abscess formation in the appendix. Neurofibroma of the appendix is very rare, even in patients with VRD. Although it is benign, prompt resection is recommended because of a high risk of appendicitis and malignant transformation.

Neurofibroma of the sciatic nerve with neurofibromatosis type 1

A 28-year-old man with neurofibromatosis type 1(NF1) presented with a tumor in the sciatic nerve and femoral nerve. The differential diagnosis of malignant peripheral nerve sheath tumor was based on clinical, radiological, and histological evidence. The tumor apparently originated in sciatic nerve at the posterior aspect of the left thigh. The lesion was resected totally without neural damage to the sciatic nerve. The tumor did not recur after 2 years.

Orbital inflammation after use of zoledronic acid for metastasized prostate carcinoma

Report of a case of orbital inflammation after the use of zoledronic acid for metastasized prostate cancer.

Solitary neurofibroma of the palate. A case report

The neurofibroma is a benign tumor of neuronal origin not frequently located in the oral cavity. The possible association of this neoplasia with systemic pathologies, such as Von Recklinghausen's disease and multiple endocrine neoplasia, makes its diagnosis fundamental. The diagnosis is, in most cases, quite complex, because of the neurofibroma's strong similarities with a great number of benign neoformations of the connective tissue, of the epithelium, and of the bone. The histology represents, therefore, the fundamental diagnostic criterion, in particular, through the use of appropriate immunohistochemical analysis. This articles presents the case of a solitary neurofibroma, subtype I (common Schwann cell type), detected on the left-hand side of the posterior region of the palate in a 56-year-old woman, which presented itself as an otherwise non-symptomatic ulcerated mass. After a careful anamnesis, an incisional biopsy was performed in order to establish the histological nature of the neoformation. The immunohistochemical test, which resulted positive for S-100 and negative for the epithelial membrane antigen and keratin, allowed the diagnosis of a presumably benign lesion deriving from a neural differentiation. The surgical excision of the entire mass was accompanied by the extraction of the upper left-hand second molar, which was attached to the mass through its palatal root.

Posterior midline approach for large anterior/anterolateral foramen magnum tumours

The standard surgical approaches described for excision of anterior or anterolaterally placed foramen magnum (FM) tumours are the far lateral approach, the extreme lateral approach and the transoral approach. In general the posterior midline approach is considered not suitable for these lesions. We have operated on 27 patients with benign anterior/anterolaterally placed FM tumours in the last 8 years. Thirteen of these were operated via the posterior midline approach. All these 13 patients had large or giant tumours displacing the cervicomedullary region posteriorly and laterally. This allowed adequate access through this approach with minimal handling of neural tissue. For small lesions, the far lateral approach was used. Most of the patients improved significantly neurologically. We recommend the standard midline posterior approach for large/giant FM tumours as the tumour size itself provides enough working space for the surgeon. For small lesions, the far lateral approach is preferred.

Treatment of orbital schwannomas and neurofibromas

We present an overview of the treatment and clinical outcome of five orbital peripheral nerve tumours, carried out in our centre from 1999 to 2003. The surgical approach was determined by the location and extension of the lesion. Supraorbital orbitotomy was performed in two superiorly located lesions, a transconjunctival approach in one medial, basal, extraconal lesion. A pterional extradural approach was used in two cases with involvement of the apex, superior orbital fissure and cavernous sinus. Three patients were diagnosed as having schwannoma, one as neurofibroma, and one as cystic mixed neurofibroma and schwannoma. One patient suffered from multiple schwannomas [bilateral acoustic schwannomas, cervical schwannomas (NF2)]. One patient showed bilateral orbital neurofibromas, plexiform cutaneous neurofibroma (NF1) and glaucoma due to a coexisting Marfan's syndrome. Local recurrences were not seen after complete resection in all patients. Surgery is the therapeutic goal.

Localized hypertrichosis in a pediatric patient--what is the mechanism for excess hair growth?

Localized hypertrichosis is an uncommon complaint among pediatric dermatology patients. We highlight an instance of localized hypertrichosis due to an underlying diffuse neurofibroma in a patient with known neurofibromatosis 1. The classification and possible underlying pathogenic mechanisms of localized hypertrichosis in pediatric patients is discussed.

Neurofibroma of the pinna

Neurofibromas are relatively common lesions of the nervous system, but only a few cases involving the pinna have been reported. The emphasis in most of these reports was on the cosmetic deformity; functional impairment in the form of hearing loss has been mentioned in only a few reports. We report a case of pinnal neurofibroma in which the primary complaint was otitis externa; hearing loss and cosmetic deformity were also present. Surgical excision resulted in an excellent functional and cosmetic outcome. This case demonstrates that neurofibroma of the pinna in the area of the external meatus can produce functional as well as cosmetic impairment, and surgery can produce a very satisfactory result.

Transoral approach to a huge neurofibroma of the parapharyngeal space: a case report

Neurofibroma of the parapharyngeal space accounts for less than 2% of all parapharyngeal space neoplasms. A 38-year-old man presented with complaints of snoring and left-sided nasal obstruction. Medical history also revealed numerous huge skin neurofibromas and multiple café au lait spots all over the body. Pharyngeal endoscopic examination disclosed a firm, nonpulsatile submucosal mass, pushing the left pharyngeal region approximately 5 cm medially, and extending to the inferior part of the epiglottis. The tumor was removed by transoral excision without any subsequent complications. Histological and immunohistochemical examinations revealed a neurofibroma.

Absence of gene mutations in a case of concomitant presence of carcinoid of the ampulla of vater pheochromocytoma and Von Recklinghausen disease

The rare association between Von Recklin-ghausen's disease (VRD) and tumours other than in central nervous system is well recognized. However, the concomitance of VRD, a carcinoid of the ampulla of Vater, and a pheochromocytoma has been described very rarely in literature. Furthermore, the possible role of the genes usually involved in multiple endocrine neoplasia (MEN) syndromes, in this association, is unclear. We report the case of a patient affected by VRD and extra-adrenal pheochromocytoma, operated on in the past for a carcinoid of the ampulla of Vater. To determine if genes involved in MEN syndromes might play a role in this particular triad, we investigated the presence of somatic or germline mutations in the RET proto-oncogene and menin gene by non isotopic polymerase chain reaction single stranded conformation polymorphism (PCR-SSCP) and heteroduplex gel electro-phoresis. The results demonstrated that no somatic or germline mutations in the MEN-1 and MEN-2 genes were involved in the pathogenesis of these tumours.

A peripheral nerve sheath tumour as a cause of nasal obstruction

Neurogenic tumours form a very small percentage of all neoplastic lesions of the head and neck region. However, the head and neck region is by far the most common location for benign peripheral nerve tumours. Several cases involving the nose have been sporadically documented throughout the medical literature. We present a rare case of a solitary neurofibroma arising from the lateral nasal wall of a 68-year-old woman. En bloc surgical resection of the mass was achieved by the lateral rhinotomy approach. The clinical significance of this case report is due to its rare site. In recent medical literature, there has been only one report concerning a solitary neurofibroma arising from the inferior turbinate. This case also highlights the importance of considering this clinical entity in the differential diagnosis when encountering a unilateral soft tissue mass in the nasal cavity.

Unusual association of adrenal pheochromocytoma and para-aortic neurofibroma in pregnancy

The association of pheochromocytoma (PHEO) and pregnancy is uncommon and life threatening for both the fetus and the mother. Early diagnosis and treatment is essential to decrease maternal and fetal mortality and to differentiate the disease from the more common pre-eclampsia. While medical treatment should be started immediately after diagnosis, the timing of surgical treatment is still debated. We describe the case of a 27-yr-old woman in the 18th week of pregnancy who showed a biochemical pattern typical of PHEO and, by imaging studies, 2 tumors with the same characteristics: the first localized on the right adrenal gland, the second at the right renal hilum. The patient underwent surgery because of suspicion of malignant PHEO with local metastasis, while histology revealed a rare association of a solitary PHEO and para-aortic neurofibroma, both tumors embryologically deriving from a common cell precursor.

Intraarticular Neurofibroma of the Hip

The magnetic resonance imaging findings in 2 cases of pathologically proven hepatocellular carcinoma that mimicked focal nodular hyperplasia are presented. Both cases were found in patients with cirrhosis, a condition in which focal nodular hyperplasia is unlikely to occur. Recognition that hepatocellular carcinoma may mimic focal nodular hyperplasia in patients with cirrhosis may prevent misdiagnosis and allow for earlier intervention.

Palatal Neurofibroma Associated With Localized Periodontitis

BACKGROUND

Neurofibromatosis type 1 (NF1) is the most common form of neurofibromatosis. While typically considered a dermatologic disorder, intraoral signs of neurofibromatosis occur quite commonly. This clinical entity can be confused with periodontitis because of the presence of periodontal pockets. In this report, we present the case of a palatal neurofibroma with radiographic involvement in a patient with NF1.

METHODS

A 40-year-old female patient was referred from her general dentist to evaluate advanced periodontitis in the maxillary left quadrant. The patient's medical history was significant for a soft tissue lesion excised from her back 11 years previously and diagnosed as a neurofibroma. Subsequent medical examination at that time confirmed a systemic diagnosis of NF1. A comprehensive periodontal evaluation was performed, and panoramic and periapical radiographs were taken. Teeth were tested for vitality. An incisional biopsy was completed for histopathologic examination.

RESULTS

The periodontal evaluation revealed the presence of 6 to 9 mm probing depths adjacent to teeth #14 and #15. Panoramic and periapical radiographs showed a circumscribed 0.8x0.9-cm unilocular radiolucency superimposed over the root of tooth #13 and extensive horizontal bone loss on the distal side of #15. Incisional biopsy confirmed the presence of a neurofibroma, and because of the extent of the lesion, the patient was referred to the Oral and Maxillofacial Surgery service for complete excision.

CONCLUSIONS

Neurofibromas can cause extensive destruction of alveolar bone, mimicking periodontitis. Due to the potential systemic and genetic implications, the diagnosis of neurofibroma requires appropriate medical referral.

Melanocytic nevi are associated with neurofibromas in neurofibromatosis, type I, but not sporadic neurofibromas: a study of 226 cases

BACKGROUND

Neurofibromatosis, type 1, is associated with cutaneous melanin pigmentation, but an association with ordinary melanocytic nevi has not been described.

METHODS

This retrospective case-control study was designed to see if neurofibromas in patients with neurofibromatosis, type 1 (NF-1) differ from sporadic neurofibromas (SN) in their incidence of associated melanocytic nevi and other histologic features. Slides from 114 NF-1 were compared with 112 SN and 300 intradermal melanocytic nevi (IDN).

RESULTS

Small lentiginous melanocytic nevi were identified over 13 NF-1 (11%) but no SN (P=0.0002). Compared with other NF-1, NF-1 with nevi were more frequently associated with melanocytic hyperplasia, giant melanosomes and diffuse neurofibroma (P<0.03). Compared with SN, NF-1 were also more frequently associated with melanocytic hyperplasia, lentigo simplex-like changes, diffuse neurofibroma and plexiform neurofibroma (P<0.001). Sebaceous hyperplasia (14%), dermal elastosis (9%), lipomatous change (8%), epithelial cysts (4%) and keratin granulomas or folliculitis (3%) were not significantly different in prevalence between NF-1, SN and the control group of IDN.

CONCLUSIONS

This study suggests that there is a difference in the potential for melanocytic proliferation in NF-1 compared with SN. NF-1, SN and IDN are associated with a similar range of incidental histologic changes. Ball NJ, Kho GT. Melanocytic nevi are associated with neurofibromas in neurofibromatosis, type 1, but not sporadic neurofibromas. A study of 226 cases.