Recurrent lateral rectus palsy in childhood

Five patients with recurrent, lateral rectus palsy in childhood, examined at the University of Iowa Hospitals over a period of 22 years, are reported. During the same period, 131 abducens nerve palsy patients, younger than 18 years of age, were evaluated. Eighteen similar patients, most single case reports, are reviewed from the literature. All reported patients, including our own, shared the following features: spontaneous recovery within 6 months in the majority of patients, ipsilateral recurrence, and painless palsy. There is female and left-sided preponderance. Etiology is undetermined. Hypotheses include viral etiology, neurovascular compression by aberrant artery, and migraine.

Characteristics of cranial nerve palsies in diabetic patients

The incidence of palsy in the third, sixth and seventh cranial nerves was studied with regard to central nervous system involvement in diabetic patients. Among 1961 diabetic patients, 19 (0.97%) demonstrated cranial nerve palsies. Nine out of these 19 patients showed facial palsy; 6 palsy of the oculomotor nerve; 2 palsy of the abducent nerve; and 3 both oculomotor and abducent nerve palsies. In contrast, only 5 out of 3841 non-diabetic patients (0.13%) had any cranial nerve palsies; all 5 were cases of facial palsy. The incidence of cranial palsies in diabetic patients was significantly higher than that in non-diabetic patients (P less than 0.01). Concerning age, sex, the state of glycemic control, diabetic complications and method of treatment, there were no differences disclosed in the diabetic patients with cranial nerve palsy. The incidences of diabetic complications were compared between the patients with facial palsy and those with ophthalmoplegia. Only one out of 9 patients with facial palsy (11%) had diabetic complications, whereas 7 out of 10 patients with ophthalmoplegia (70%) demonstrated diabetic complications and the difference was significant. Thus ophthalmoplegia appears to be more closely related to diabetic metabolism while facial palsy is less strongly correlated with diabetes.

[A case of Cogan's syndrome associated with multiple cranial neuropathy]

A 52-year-old woman was admitted to our hospital because of disturbance of right visual acuity and double vision. At 38-year-old she became deaf bilaterally and experienced many vertigo attacks. She was diagnosed as Ménière disease. At 45-year-old vertigo attacks disappeared. At 47-year-old right peripheral facial nerve palsy developed transiently with interstitial keratitis and episcleritis of the both eyes. Oral adrenocorticosteroid therapy produced an improvement of interstitial keratitis and episcleritis. On admission, ophthalmological examination revealed bilateral interstitial keratitis and episcleritis, right retrobulbar optic neuritis and she was proven to have bilateral sensorineural deafness by otologist. Neurological examination revealed right abducens nerve paresis. Laboratory examinations revealed slightly increased erythrocyte sedimentation rate. CRP was positive. Serological tests for syphilis were negative. CSF showed mildly elevated protein level. Orbital CT scans revealed the swelling of right optic nerve. Cerebral MRI showed multiple high spotty areas in left thalamus, bilateral basal ganglia and deep white matter in T2 weighted images. After treatment with adrenocorticosteroid, right optic neuritis and abducens nerve paresis improved together with bilateral interstitial keratitis and episcleritis. Multiple cranial neuropathy may develop with Cogan's syndrome.

[Bilateral abducens nerve palsy in nasopharyngeal carcinoma]

We report a case of bilateral abducens palsy as initial finding in nasopharyngeal carcinoma. Possible mode of involvement is discussed. Only one case has been reported in the past.

[Benign paralysis of the 6th cranial nerve in children]

Acquired sixth nerve palsies in infants and children that occur without fever primarily suggest a tumor or intracranial hypertension. In a few instances, the cause is benign and spontaneous recovery occurs although relapses are occasionally seen. We report seven episodes of benign sixth nerve palsy in four children aged 5 1/2 months to 8 1/2 years. An ENT infection was the precipitating factor in four of these seven episodes. Recovery consistently occurred within 4 days to 6 weeks. None of the children had residual oculomotor impairment. The various etiologic hypotheses put forward in the literature are discussed. No study provides a pathophysiologic explanation for these transient palsies.

Benign recurrent unilateral abducens nerve palsy

The recurrence of an isolated unilateral left abducens nerve palsy on five occasions over five years is described in an adult. No evidence of any systemic or intracranial disorder has been identified. The aetiology remains uncertain and the clinical course is benign. The diagnosis of 'benign' abducens nerve palsy is one of exclusion and is made retrospectively after an adequate period of serial evaluations.

Fusiform superior cerebellar artery aneurysm presenting with contralateral abducens nerve paresis--case report

A 25-year-old female suddenly developed headache and diplopia. On admission, neurological examination revealed neck stiffness and left abducens nerve paresis. A computed tomographic scan suggested subarachnoid hemorrhage. Left vertebral angiogram showed an aneurysm on the anterior pontine segment of the right superior cerebellar artery (SCA) and marked flexion and meandering of the basilar artery to the left. At surgery, an atherosclerotic, fusiform aneurysm was found through the right subtemporal transtentorial approach, and the right SCA was clipped just proximal to the aneurysm. Thirteen cases of SCA aneurysm have been described in the literature, but none was a fusiform aneurysm.

Persistent primitive trigeminal artery: a possible cause of trigeminal and abducens nerve palsy

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[VIth nerve palsy associated with ipsilateral Horner's pupil]

A rare syndrome which includes VIth nerve palsy associated with ipsilateral Horner's pupil was foreseen by Parkinson and Johnston in the mid-seventies. They anticipated the occurrence of this syndrome on the basis of the unique anatomical relationships discovered by them in the cavernous sinus. The main finding consisted of very close proximity between the VIth nerve and a branch emerging from the carotid sympathetic plexus. Recently, several reports of this syndrome caused by a variety of pathologic processes in the cavernous sinus, proved that Parkinson and Johnston were correct. Since it is quite difficult to identify lesions in the cavernous sinus by X-ray or CT scan, the neuroradiologist should utilize special techniques. It is expected that the number of cases of this syndrome will soon increase, due to increasing familiarity with the syndrome and to improved imaging techniques.

Q fever meningoencephalitis associated with bilateral abducens nerve paralysis, bilateral optic neuritis and abnormal cerebrospinal fluid findings

Q fever is an zoonosis caused by Coxiella burnetti, the clinical features of which are often nonspecific and self-limited. Involvement of the central nervous system is rare and is usually seen as a complication of endocarditis caused by this rickettsial organism in the chronic disease. Specific neurological manifestations in the course of the acute illness aseptic meningitis, encephalitis, toxic confusional states, extrapyramidal signs, dementia and behavioral disturbances. We describe a patient who developed reversible bilateral abducens nerve paralysis and bilateral optic neuritis in the course of acute Q fever meningoencephalitis.

Leiomyosarcoma of a lower limb presenting with multiple cranial nerve palsies

Leiomyosarcoma is a relatively uncommon soft tissue sarcoma usually presenting as a mass at the primary site. It arises in the retroperitoneal region, in the cutaneous or subcutaneous tissue of the extremities or, less commonly, from a large vein. A case is described where a patient presented with unilateral third, fourth, and sixth cranial, and ophthalmic division of trigeminal nerve palsies in whom biopsy of a longstanding lower limb mass demonstrated leiomyosarcoma. The presentation of this type of pathology has not been described previously.

Möbius and Möbius-like syndromes (TTV-OFM, OMLH)

There exists a spectrum of syndromes characterized by cranial nerve palsies, limb anomalies, and craniofacial malformations. Criteria based on type and severity of limb anomaly or presence or absence of cranial nerve palsy may alter the syndrome nomenclature due to a selection bias but do not appear to benefit syndrome delineation to any extent. Patients with seventh nerve palsy and abduction weakness are usually diagnosed as having Möbius syndrome by ophthalmologists. The observed ocular motility findings range from primarily abduction deficiencies to patients who have a Duane or gaze palsy pattern of horizontal movements. Some cases previously described as "sixth nerve and partial third" may better fall into one of the latter groups, since an isolated adduction deficit as a manifestation of third nerve involvement is rare. The presence of clinical appearance of Duane syndrome in these Möbius-type patients raises the possibility of abnormal innervation of the lateral rectus as an explanation of some patterns of motility observed.

Management of strabismus with botulinum A toxin

Three hundred eight patients with strabismus were treated with botulinum A toxin (Oculinum) chemodenervation; 153 were followed by the authors for at least 6 months. In this study group, 97 received botulinum A toxin injections as the primary method of treatment of their ocular deviation. Fifty-six received injections after traditional extraocular muscle surgery. Botulinum A toxin was useful for management of patients with recent surgical overcorrections and for management of some patients with sixth cranial nerve palsy. Chemodenervation of an extraocular muscle was not as successful as traditional strabismus surgery for treatment of infantile esotropia and other comitant deviations. Botulinum A toxin injection was ineffective in patients who had restrictive strabismus. This drug has limited application in the management of patients with strabismus.

The role of botulinum toxin in the management of sixth nerve palsy

Fifty-five patients with sixth nerve palsy have been treated with Botulinum toxin injection to the antagonist medial rectus, either in isolation or in combination with rectus muscle surgery. Forty of these patients (72 per cent) obtained significant benefit from injection at some stage in their management. Botulinum toxin has a major role in conjunction with transposition muscle surgery for the treatment of complete unrecovered sixth nerve palsy. In less severe paresis, a functional cure may be obtained in a significant number of cases with the use of Botulinum toxin alone, 37 per cent in this series. No serious complications were observed. In view of the safety of this procedure it is reasonable to consider an injection of Botulinum toxin in any adult patient with a persisting sixth nerve palsy.

High-dose intravenous penicillin G does not prevent further progression in early neurological manifestation of Lyme borreliosis

We report two cases of Lyme borreliosis (LB) with erythema migrans (EM) and simultaneous meningopolyneuritis with radicular pain and lymphocytic pleocytosis in the cerebrospinal fluid (CSF). EM and pain disappeared completely under high-dose penicillin G therapy within few a days. Pathological findings in CSF improved. Nevertheless, during and after therapy, neurological signs of LB developed: cranial nerve palsies as well as paresis of extremity muscles with radicular distribution.

Vertical rectus muscle transposition and botulinum toxin (Oculinum) to medial rectus for abducens palsy

Ten adult patients developed sixth-nerve palsy after trauma or a cerebral tumor. No clinical evidence of recovery of function was noted by at least 8 months after onset. All patients underwent total transposition of the superior and inferior rectus muscle insertions to the area of the lateral rectus insertion, accompanied by botulinum toxin (Oculinum) injection of the ipsilateral medial rectus. These patients developed a mean diplopia-free field of 51 degrees, with a diplopia-free field in the abducted field of 20 degrees. This procedure involved surgery on only two rectus muscles, but the results compared favorably with surgical strategies involving three rectus muscles. Thus, the risk of developing anterior segment ischemia was greatly reduced.

Sixth nerve palsies, temporal artery biopsy, and necrotizing vasculitis

A 79-year-old man with diplopia and weakness was found to have necrotizing vasculitis consistent with polyarteritis nodosa on temporal artery biopsy. Although he had no evidence of visceral involvement from vasculitis, he responded well to corticosteroid therapy. This case illustrates a nosological problem that can occur when dealing with a disease that has diverse clinical manifestations and nonspecific laboratory findings. Moreover, this case demonstrates the value of including a branch artery segment when biopsying the temporal artery.

Sixth nerve palsy after lumbar anesthesia

A middle aged man was referred from orthopedics with the complaint of diplopia, which developed 3 weeks after a lumbar puncture for spinal anesthesia. The practitioner should be aware of this rare effect among other common and not so common causes of 6th nerve paresis/paralysis.

Long-term results: botulinum for sixth nerve palsy

Eight patients with intracranial malignancies or vascular lesions and sixth nerve palsies were treated with botulinum toxin chemodenervation of the antagonist medial rectus muscle. Primary deviation ranged from 20 to 75 prism diopters (pd) of esotropia. Six were treated acutely (within 3 months of onset) and two, which demonstrated partial recovery of lateral rectus function but with residual esotropia and diplopia, were treated after 6 months. After a mean follow-up of 20.6 months, seven were diplopia-free with excellent rotations. Five had complete resolution of the esotropia and diplopia, with near complete recovery of abduction. One had 6 pd residual esotropia, while another, whose sixth nerve had been resected, required a modified Jensen procedure, resulting in full rotations. The single case of bilateral sixth nerve palsy had a functional improvement but was lost to follow-up. One patient had a vertical strabismus induced with the injection and had a gradual return of the esotropia.

[Value of the Carlson-Jampolsky operation in total paralysis of the 6th nerve. Apropos of 10 cases]

We used the Carlson-Jampolsky operation in 10 total paralysis of lateral rectus. Post-operatively 8 had no horizontal deviation in the primary position and had 20 to 25 degrees of abduction. There was limitation of adduction caused by the large medial rectus recession. In 2 cases a very moderate vertical deviation was present in the primary position.

[Use of nerve division in oculomotor paralysis]

Sectors have a double interest in an extraocular muscle palsy: to avoid the diplopia and to aid the reeducation of palsied muscles. Patient can alternatively wear the two types of glasses with sectors. Authors decrease sector's size when motility improves. They are stopped if regression, and in other cases, patients can wait surgical time with maximum comfort. Clinical examples are presented: VI, III and IV cranial nerve palsies and generalized diplopia.

[Benign isolated 6th nerve paralysis in children. Developmental aspects apropos of 9 new cases]

Benign isolated VI nerve palsy in children is a rare but now well-established clinical entity. The diagnosis is essentially an exclusion one. We report nine additional cases. The evolution is discussed, with reference to the literature.

[Otitis media, petrositis and Gradenigo's syndrome]

Complications arising from otitis media are rare. However, it is still important to be aware of the potential complications of the infection. Two patients with petrositis who developed Gradenigo's triad (otitis, abducens paralysis and pain) are presented.

[Surgery of 6th nerve paralysis. 74 cases]

85% of abducens palsies recover spontaneously; then their surgical treatment has not to be hastened. However many non regressive cases are frequently observed. Whatever they may be, partial or complete, uni or bilateral, always they give a great functional handicap which warrants a surgical care. The analysis of 74 successive cases allows to reveal some rules concerning the operative plan. In that respect the electro-oculographic recording often provides many essential informations. The recovery of a normal oculo-motor balance is usual in monolateral paresis. In bilateral complete palsies, in spite of muscle transposition procedures, we can only expect to reduce torticollis and to restore the ocular alignment in primary position, but abduction remains always impaired or fully impeded.

[The treatment of total and consolidated 6th nerve paralysis by transplantation using the Hummelsheim technic]

Surgical cure of total and definitive lateral recti paralysis by muscular transplantation technique according to Hummelsheim seems unjustly accused to be responsible for anterior segment ischemia. Eighteen operations of this kin have been performed without any complications and with results that can be considered as satisfactory. Transplantation itself must not exceed 1/4 or at the most 1/3 of the vertical muscles and must imperatively be associated to a weakening of the 2 medial recti.

[Surgical results in traumatic 6th nerve paralysis]

Authors distinguish complete sixth nerve palsies needing a supply procedure and incomplete palsies needing a classic procedure. Results in the second group are satisfactory. In case of complete palsies, the objective consists in obtaining primary gaze rectitude.

[Surgical treatment of sequelae of oculomotor paralysis of the 4th, 6th, and 3d cranial nerves]

The writers analyse the operative results of 43 cases of oculo-motor paralysis aftermaths of the 4th, 6th and 3rd cranial pairs treated since 1985. The applying of muscular puckering, associated with a controlled or kept tenotomy, of muscular transplant, of "Fadenoperation" and of oblique surgery, allowed to obtain good results with suppression of diplopia, at least in the facing and in the lower glance, attenuation of ocular torticollis, disappearing of the ocular deviation, and restitution of a fusion area in primary position, within a more or less extended zone of space.

Chronic isolated sixth nerve palsies

Twenty-seven cases of chronic isolated abduction deficit, seen in 25 years of neuro-ophthalmology consultation, were reviewed. "Isolated" was defined as the lack of any other neurologic or ophthalmologic findings for at least six months. Cases were further subdivided into the categories of true and pseudo-abducens paresis. The origin, diagnosis, and management of long-standing abducens palsies were determined. Cases of pontine glioma, chordoma, chondrosarcoma, and meningioma that presented as an isolated abducens palsy and remained undiagnosed for at least six months were reviewed.

Clinical evaluation of vidian neurectomy for nasal allergy

For the clinical evaluation of vidian neurectomy, questionnaires were sent to 250 cases operated on from 1971 to 1982, with answers obtained from 171. For sneezing, 56.8% of cases were evaluated markedly effective, 36.7% effective, 4.3% unchanged, and 2.2% aggravated. For rhinorrhea, markedly effective was 54.7%; effective, 39.4%; unchanged, 3.7%; aggravated, 2.2%. For nasal obstruction, markedly effective was 67.5%; effective, 27.4%; unchanged, 5.1%; and aggravated, 0%. On the other hand, 20% of cases complained of relapse of nasal allergic symptoms. Concerning the side effects, 28.7% of cases complained of cheek, upper lip, or palate numbness. Decrease of lacrimation was noted in 9.4% of cases. Several kinds of disturbances in the eye movement were observed in 4% of cases. Among them, 16 cases showed complete recovery within 24 h. In 3 cases, abducens paralysis continued for several months. Postoperative arterial bleeding occurred in one case. My recent strategy for the treatment of allergic rhinitis is conservative treatment at first, secondary nasal surgery such as septoplasty or turbinotomy, and at last vidian neurectomy if the patient agrees to be operated on after understanding the side effects.

Strabismus in infancy

In order to prospectively study the development of strabismus in infancy, the ocular alignment of a large population of normal neonates was studied and follow-up examinations were obtained in a subset of these infants. The characteristic findings of congenital esotropia subsequently developed in three infants who were either orthotropic or exotropic at birth. Pathologic exotropia developed in two infants; both were exotropic at birth, but no more so than most normal neonates. In infants with congenital esotropia or pathologic exotropia, the characteristic deviation appears to develop between 2 and 4 months of age, a period during which normal infants are becoming increasingly orthotropic.

Treatment of sixth nerve palsy in adults with combined botulinum toxin chemodenervation and surgery

This study reports the results of treating unrecovered sixth nerve palsy in adults with a combination of botulinum toxin and surgery. Twenty-two adults, 11 with unilateral and 11 with bilateral unrecovered sixth nerve palsy, were treated with injections of botulinum toxin to the contracted medial rectus followed by transposition surgery to the vertical rectus muscles. This management technique produced a satisfactory reduction in esotropia, averaging 46 prism diopters (PD), comparable with that achieved by conventional surgery in other series. The advantages of this form of treatment are discussed.

[Differential diagnosis of superior orbital fissure syndrome]

Paresis of cranial nerves III, IV, VI and the ophthalmic nerve is termed fissura-orbitalis-superior syndrome. It is caused by affections of the surrounding bones, vascular lesions in the region of the cavernous sinus, tumours of sella and sphenoid bones and diseases of the orbital cavity. Cranial computed tomography (with and without contrast enhancement) is a reliable diagnostic method which may be supported by angiography of NMR in individual cases.

[A case of crushing head injury showing bilateral abducens, facial and acoustic nerve palsies]

Most head injuries are due to two basic mechanisms, contact or acceleration. On the other hand, static loading force makes another type of head injury, so called "crushing head injury". In this report, we discussed the mechanism of the crushing head injury and cranial nerve damage of our case. A 35-year-old male was admitted to our hospital suffering from a crushing head injury. In this accident, his head had been crushed between 1000-kg printing machine and truck bed on both temporal regions slowly. He remained fully conscious. On admission 25 minutes after the injury, he showed bilateral sixth-nerve, seventh-nerve palsies, bilateral hearing loss and obvious bleeding from nares and both ears. Gross motor examination was intact. Skull films demonstrated left temporal linear fracture. CT scan showed remarkable pneumocephalus in the basal cistern but no other intracranial lesions. At discharge, two weeks after the trauma, the patient was alert and remained bilateral sixth-nerve, seventh-nerve palsies, and bilateral hearing loss. At the time of 6 months after the initial injury, bilateral abducens nerve palsies and left facial nerve palsy were improved completely. But he demonstrated right slight facial nerve palsy and bilateral moderate hearing loss continuously. In this rare type of injury, the head of the patients had been crushed slowly by the huge power on both temporal regions. This force makes the avulsion of the petrous bone from the foramen lacerun to the outer side of the bone (Russell WR and Schiller F, 1949). This must tend to stretch the sixth nerve and produce abducens nerve injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated sixth nerve palsy due to intracavernous carotid aneurysm in a young woman

A large intracavernous carotid aneurysm was angiographically demonstrated in a 29 years old woman suffering from a persistent isolated abducens nerve palsy. CT brain scan failed to reveal the lesion. The usefulness of performing angiography in the cases of isolated abducens palsy of undetermined nature, is stressed.

Complicated strabismus and adjustable sutures

Clinical experience in performing over 500 adjustable strabismus operations is mentioned in this paper particularly as it relates to complicated strabismus. A maximum hang-loose recession of a rectus muscle has a limited effect, which is tabulated and the implications discussed. Aids in finding the lost medial rectus muscle are mentioned. Adjustable sutures are then exploited in managing the found "lost" medial rectus. Adjustable recession of both vertical recti in the affected eye were used in some cases of blow-out fracture to manage limitations of upward and downward gaze. Adjustable recession of both yoke medial recti are used in some unilateral superior oblique palsies where the main sequela is hypertropia in downward gaze only. A previously paralysed lateral rectus muscle, which has completely recovered function but has left the patient with a concomitant esotropia with full ductions and normal versions, responds excessively to resection. This should be taken into consideration when planning adjustable strabismus surgery in such a case.

Anterior segment ischemia after three rectus muscle surgery

Nine patients underwent simultaneous or staged detachment of the vertical and medial rectus muscles in the treatment of sixth nerve palsy or Duane's retraction syndrome. In five adult patients (34, 35, 41, 45, and 65 years of age), clinically significant anterior segment ischemia developed postoperatively. Known medical risk factors were present in only one case. With the exception of corectopia, there were no apparent sequelae and all involved eyes returned to preoperative visual acuity within 9 weeks of surgery. Anterior segment ischemia may be a frequent complication of strabismus surgery in adult patients when the superior, inferior, and medial rectus muscles are detached from the globe.

Botulinum toxin treatment of acute sixth and third nerve palsy

Thirty-four patients with acute sixth nerve palsy and nine patients with acute third nerve palsy were treated with botulinum toxin injection to the antagonist, nonparalytic horizontal rectus muscle. In a control group of 52 patients with acute sixth nerve palsy not treated with botulinum in the acute stage, only 16 (31%) recovered spontaneously and did not require surgery. Twenty-two of the 31 surviving patients who could be followed with acute sixth nerve palsy had lateral rectus recovery and surgery was avoided. Four required prisms in their glasses to obtain fusion. Nine patients developed chronic sixth nerve palsy and required surgery. In this group of acute sixth nerve palsy patients, eleven were bilateral. Seven of these eleven developed chronic sixth nerve paralysis, and required strabismus surgery. This suggests the prognosis for recovery following botulinum treatment in cases of acute bilateral sixth nerve palsy is not as good as in the unilateral cases. Botulinum toxin treatment does not appear to be effective in chronic sixth nerve palsy, as judged by results of treatment in one patient known to have a chronic palsy. Nine of nine patients with acute third nerve palsy had medial rectus recovery with fusion horizontally in primary gaze. None have required surgery. Only four of nine showed improvement in vertical rotations. The remaining five patients avoid vertical diplopia by a compensatory chin position. Botulinum toxin treatment of patients with acute sixth and third nerve palsy appears beneficial. However, since some in this group of patients may recover spontaneously, a randomized, double-blind study may be necessary to more definitively determine the effectiveness of this therapy.

Gradenigo's syndrome: a rare complication of otitis media

A 58-year-old woman developed Gradenigo's syndrome. The clinical signs and symptoms of the otitis were rather atypical and there was a considerable delay before the correct diagnosis was made. The pathophysiology, therapy and differential diagnosis of this syndrome, which has become rare since the introduction of antibiotics, are discussed.

Cavernous sinus infection manifested by Horner's syndrome and ipsilateral sixth nerve palsy

A 20-year-old man presented with a left sixth nerve paresis associated with ipsilateral Horner's syndrome several days after surgical drainage of a facial abscess. This unusual association between sixth nerve palsy and Horner's syndrome is presented and its neuroanatomic correlation is discussed.

Petrous apex and subarcuate fossa maturation

During the first year of life, the bone of the petrous apex grows rapidly. At birth, only 5 mm of bone separates the cochlea from Dorello's canal as compared to 2 cm in the adult. More than half this growth occurs during the first year of life. The subarcuate fossa is a cavity within the superior semicircular canal which reaches from the posterior fossa to the future mastoid in fetuses and nearly to the mastoid antrum in newborns. During the second year of left it is nearly obliterated to form a shallow depression or slit on the posterior aspect of the temporal bone and the variable petromastoid canal which contains the subarcuate artery and vein. Clinical petrositis of infants less that 1 year of age is rare, and provides a challenge for surgery. A case is reported and discussed.

Metastasis within a pituitary adenoma presenting with bilateral abducens palsies: case report and review of the literature

A 56-year-old woman with metastatic breast carcinoma presented on her terminal hospital admission with diplopia secondary to bilateral abducens nerve palsies. Postmortem examination revealed a sellar mass composed of an unsuspected pituitary adenoma infiltrated by metastatic carcinoma. Review of the literature revealed only seven patients with this rare neoplasm-to-neoplasm metastasis, none of whom were reported to have had abducens palsies.