Iatrogenic Horner's Syndrome

Purpose

To report two cases of Horner's syndrome. One presented after the ablation of a schwannoma of the cervical sympathetic chain, the second after upper thorascopic sympathectomy for primary palmar hyperhidrosis.

Methods

A 42-year-old man underwent excision of a left neck mass found during routine physical examination. A 20-year-old girl with axillary and palmar hyperhidrosis was treated with cervical sympathectomy.

Results

In the early postoperative days, miosis, ptosis, anhidrosis, and enophthalmos were observed.

Conclusions

In the ablation of a schwannoma, postoperative Horner's syndrome is associated with the relationship between nerves and the tumor mass, which makes it impossible to separate them surgically in most cases. In thorascopic sympathectomy, patients should be warned of this complication.

Botulinum toxin type A versus phenol. A clinical and neurophysiological study in the treatment of ankle clonus

AIM

To reduce ankle clonus in patients with spastic paresis either phenol nerve block of the tibialis posterior nerve or botulinum toxin type A (BTA) injection in triceps surae muscles can be used. This study aims to compare the efficacy over time of phenol nerve block and BTA injection in the inhibition of ankle clonus.

METHODS

Twenty-two patients with spastic paresis presenting with ankle clonus were randomly treated with phenol nerve block of the tibialis posterior nerve or BTA injection in triceps surae muscles. Ankle passive dorsiflexion, clonus, M and H responses and H/M ratio were measured in all patients prior to treatment and 15 days afterwards, as well as one, three and six months later in 12 patients. Patient satisfaction was also recorded.

RESULTS

Both patient groups showed significant clonus reduction over time with the effect of phenol being greater than that of BTA. In one month, the degree of passive dorsiflexion significantly increased in both groups without any significant difference between them. H/M ratio reduced after phenol treatment and remained almost constant during the following six months, whereas it remained at baseline level after BTA treatment.

CONCLUSION

While both treatments led to reduction in ankle clonus, phenol showed greater clinical efficacy. The difference in the neurophysiological results suggests that the two drugs have different action mechanisms with a more prevalent reduction of alpha motoneuron excitability in phenol-treated patients.

Sagittal plane kinematic analysis of the six-minute walk test: a classification of hemiplegic gait

AIM

The aim of this study was to propose a kinematic classification of gait according to six minute walk test performance.

METHODS

Thirty-four hemiplegic subjects were enrolled. Six-minute walk test (SMWT), gait analysis and Walking Handicap Scale score (WHS) were measured. A k-means cluster analysis was used to classify the sample into three sub-groups which were homogeneous in spatio-temporal parameters, kinematic variables, and which reflected three meaningful levels of walking competency.

RESULTS

Three clusters were identified: low-functioning walkers (Cluster 1) walked for 88-172 m; intermediate-functioning walkers (Cluster 2) walked for 180-302 m and high-functioning walkers (Cluster 3) were able to cover 349-430 m. The authors found homogeneous gait profiles in these subgroups. Between-group differences on kinematic data and WHS scores were also underlined.

CONCLUSIONS

Cluster analysis was able to identify consistent gait characteristics of spatio-temporal, walking endurance and sagittal plane kinematic profiles in hemiplegic subjects and is useful for categorizing the levels of walking competency in these subjects.

Congenital dacryocystocele: diagnosis and treatment

Five children were diagnosed with congenital dacryocystocele; in all cases, the cystic lesion was unilateral; age ranged from 7 to 60 days (mean 29 days). The mean ultrasonography diameter of the cyst, at the time of the diagnosis, was 11.51 mm. Topical and systemic antibiotics and massage were prescribed. One patient had no recurrence of the dacryocystocele but 4 showed no improvement with medical treatment; they were submitted to successful probing in the first months of life under general anaesthesia. Nasal endoscopy revealed a nasolacrimal cyst in one patient. True dacryocystocele is relatively rare: ultrasound is a simple, non-invasive method that can reliably distinguish dacryocystocele from other pathological conditions. Several reports have described a variable natural course of these lesions but there are controversial opinions regarding their management. Initially, we treated this congenital anomaly with digital massage, and topical and systemic antibiotics. Probing under general anaesthesia was performed in the event of dacryocystitis or lack of resolution after a short trial period with digital massage. Particular attention was paid to nasal bilateral endoscopy to exclude a nasal obstruction caused by cystic swelling of the nasolacrimal duct. When performed, the probing procedure was successful in all patients.

Two anomalous localizations of mucocele: clinical presentation and retrospective review

Two Caucasian males (57 and 70 years old) were referred to our attention with parasinus mucoceles, maxillary and frontal mucocele, respectively, that had eroded the orbital rim and caused swelling of the eyelids and brow. Invasion of the orbital space caused several ophthalmic symptoms such as diplopia, proptosis, ptosis, and the formation of a palpable mass. Ophthalmic involvement was the first sign of the mucocele. The mucoceles were completely excised through a skin incision and the diseased mucosa of the sinuses was removed: endonasal fibre optic surgery and the Caldwell-Luc procedure were used in the patient with maxillary mucocele. The cases are described with retrospective review.

Schwannoma of cervical sympathetic chain: assessment and management

Schwannoma arising from the cervical sympathetic chain is an uncommon benign nerve tumour. This tumour most often presents as an asymptomatic solitary neck mass, with slow-growing and rare malignant degeneration. Definitive pre-operative diagnosis may be difficult and investigations are not usually helpful. The carotid artery and internal jugular vein may be displaced anterior-laterally. Diagnosis relies on clinical suspicion and confirmation is often obtained by means of surgical pathology. Surgical excision is the treatment of choice for this tumour, with recurrence being rare. Homer's syndrome is a common post-operative neurological consequence, but does not appear to cause problems to the patient. The case is described of a 42-year-old male who presented an asymptomatic left neck mass. Diagnostic studies included computed tomography, magnetic resonance imaging, and ultrasound which confirmed a circumscribed mass in the upper left portion of the neck next to the thyroid gland. The mass was excised through a transverse left cervical skin incision. Post-operatively the patient showed clinical findings of Horner's syndrome. The pathologic and radiological evaluations, treatment and postoperative complications of this neoplasm are discussed.

The upper limb in cerebral palsy: surgical management of shoulder and elbow deformities

The authors report a simple chart that offers a comprehensive picture of spasticity of the upper limb and provides a more objective method of recording data. Distinction is made between fixed postures and the residual active range of motion at the shoulder and elbow. The presence and function of the muscles can be identified easily on dynamic EMG studies, which are essential for understanding the degree of spasticity and dyssynergy related to a single muscle. When spasticity of the upper arm is managed with a global approach and objectives are defined clearly in advance with the patient and caregivers, treatment of shoulder and elbow deformities can achieve important results for personal hygiene or functional targets.

H reflex excitability following voluntary muscle contraction of different duration

The importance of the duration of contraction on the excitability of the motoneuronal pool was evaluated by measuring the H reflex from soleus muscle after short and long contractions at constant effort equal to 60% maximal voluntary contraction (MVC); the difference between the amplitude of H reflex at rest and after contraction of different duration was evaluated in 10 normal subjects and in one hemiparetic patient. The authors found a significant inhibition of H reflex after contraction of 10 seconds and after 40 seconds and a longer duration of the inhibition after 40 seconds. In the hemiparetic patient the H reflex did not show inhibition which suggests a possible reduction of the presynaptic inhibition, and a lack of modulation of the motoneuronal pool after contraction.