Skull Base Osteomyelitis: A Rare Cause of Multiple Cranial Nerve Palsies—A Case Report from Ghana

Introduction: Skull Base Osteomyelitis (SBO) is an infectious inflammation of the skull bones that is often caused by malignant otitis externa (MOE) and affects the temporal bone. This condition commonly affects immunocompromised individuals and the elderly, particularly those with a history of diabetes mellitus. Diagnosis is challenging because of non-specific symptoms that lead to late detection and complications. This report discusses a case of SBO with multiple bilateral cranial nerve abnormalities and highlights the diagnostic and management challenges in high-risk individuals with subtle clinical signs. Case presentation: This report describes a 63-year-old patient with hypertension and diabetes who underwent surgical debridement of the left ear due to malignant otitis externa 4 months prior to presentation. The patient presented with significant dysarthria, dysphagia, ptosis of the left eye with double vision, and hearing impairment in the left ear. Examination revealed bilateral CN VI palsy, right CN VII palsy, left CN VIII palsy, and a right CN XII deficit. Initial tests were unremarkable, but a high Fungitell assay and a second review of the CT scan and MRI revealed a pathological process in the base of the skull involving bony structures and cranial nerves bilaterally, which helped diagnose SBO. The patient was subsequently discharged with oral voriconazole and continued his usual medications. The patient requested further management abroad, because he did not notice resolution of his symptoms. Surgical treatment was employed abroad to relieve his symptoms, as he recovered slowly. Conclusion: This case report underscores the importance of a multidisciplinary approach to address SBO. Collaboration between specialists in infectious diseases, otolaryngology, radiology, and neurology plays a pivotal role in achieving an accurate diagnosis and developing a tailored treatment plan. Although SBO may be infrequent, this case report highlights the need to maintain heightened clinical suspicion in high-risk individuals.

Current landscape in motoneuron regeneration and reconstruction for motor cranial nerve injuries

The intricate anatomy and physiology of cranial nerves have inspired clinicians and scientists to study their roles in the nervous system. Damage to motor cranial nerves may result from a variety of organic or iatrogenic insults and causes devastating functional impairment and disfigurement. Surgical innovations directed towards restoring function to injured motor cranial nerves and their associated organs have evolved to include nerve repair, grafting, substitution, and muscle transposition. In parallel with this progress, research on tissue-engineered constructs, development of bioelectrical interfaces, and modulation of the regenerative milieu through cellular, immunomodulatory, or neurotrophic mechanisms has proliferated to enhance the available repertoire of clinically applicable reconstructive options. Despite these advances, patients continue to suffer from functional limitations relating to inadequate cranial nerve regeneration, aberrant reinnervation, or incomplete recovery of neuromuscular function. These shortfalls have profound quality of life ramifications and provide an impetus to further elucidate mechanisms underlying cranial nerve denervation and to improve repair. In this review, we summarize the literature on reconstruction and regeneration of motor cranial nerves following various injury patterns. We focus on seven cranial nerves with predominantly efferent functions and highlight shared patterns of injuries and clinical manifestations. We also present an overview of the existing reconstructive approaches, from facial reanimation, laryngeal reinnervation, to variations of interposition nerve grafts for reconstruction. We discuss ongoing endeavors to promote nerve regeneration and to suppress aberrant reinnervation and the development of synkinesis. Insights from these studies will shed light on recent progress and new horizons in understanding the biomechanics of peripheral nerve neurobiology, with emphasis on promising strategies for optimizing neural regeneration and identifying future directions in the field of motor cranial neuron research.

Clinical Application of Quantitative Nursing for Lower Cranial Nerves Injury after Cerebellopontine Angle Tumors

Objective: To retrospectively analyze the clinical utility of quantitative nursing measures of 10 cases of lower cranial nerves injury after cerebellopontine angle tumors surgery to provide the experience for improving the recovery rate and living quality of these patients. Methods: The clinical data of 10 cases of lower cranial nerves injury after cerebellopontine angle tumors surgery was analyzed. For problems such as dysphagia and dyspnea of these patients, the nursing care focused on strict monitoring, timely oxygen inhalation nursing, posture nursing, ventilator nursing, swallowing function training, etc. Results: After received quantitative care, 10 patients with lower cranial nerves injury after cerebellopontine angle tumors surgery were recovered well, and their symptoms such as dysphagia and dyspnea were gradually improved and safely discharged. Conclusion: Lower cranial nerves injury is one of the serious complications after removal of cerebellopontine angle tumors, which impacts the life and health of patients. Caregivers should accurately understand and analyze the symptoms, and quantitative and targeted nursing measures for posterior cranial nerves injury are helpful in the postoperative rehabilitation of patients and improve their living quality.

THE RELATIONSHIP BETWEEN THE INVASION OF PARAPHARYNGEAL SPACES AND THE INVOLVEMENT OF CERVICAL NODES AND POSTERIOR GROUP CRANIAL NERVES IN NASOPHARYNGEAL CARCINOMA

Two hundred cates of nasopharyngeal carcinoma (NPC) admitted to this department from Feb. 1985 to May. 1988 were analysed according to the CT scanning and clinical findings of the primary lesions prior to radiotherapy. The results showed that involvement of parapharyngeal space was very common in NPC, about 80% (160/200 cases) ; particularly unilateral or bilateral retro-styloid spaces, about 69.5% (139/200 cases). It was proposed that patients with NPC had a high Incidence of ipsilateral cervical node metastasis. Contralateral cervical node metastasis was rare. The development of cervical node metastasto in NPC has two modes: one Is direct Infiltration of the retro-stylold space by the lesion; the other Is along the nasopharyngeal lymphatic rete. The data also showed that patients with NPC who presented symptoms of Ⅸ- Ⅲ cranial nerve paralyses always had ipsilateral or bilateral retro- styloid space Infiltrations.

Hepatocellular carcinoma metastasizing to the skull base involving multiple cranial nerves

We describe a rare case of HCV-related recurrent multiple hepatocellular carcinoma (HCC) metastasizing to the skull base involving multiple cranial nerves in a 50-year- old woman. The patient presented with symptoms of ptosis, fixation of the right eyeball, and left abducens palsy, indicating disturbances of the right oculomotor and trochlear nerves and bilateral abducens nerves. Brain contrast-enhanced computed tomography (CT) revealed an ill-defined mass with abnormal enhancement around the sella turcica. Brain magnetic resonance imaging (MRI) disclosed that the mass involved the clivus, cavernous sinus, and petrous apex. On contrast-enhanced MRI with gadolinium-chelated contrast medium, the mass showed inhomogeneous intermediate enhancement. The diagnosis of metastatic HCC to the skull base was made on the basis of neurological findings and imaging studies including CT and MRI, without histological examinations. Further studies may provide insights into various methods for diagnosing HCC metastasizing to the craniospinal area.

Cranial Nerve Decompression Gasket

A series of cranial nerve decompression gaskets were prepared with fibers of different fineness and high crimp which were obtained in knit-de-knit texturing process by using different specification general polyethylene terepthalate( PET) multifilament bought from market. The physical properties of the gasket were evaluated comprehensively and biocompatibility was analyzed with MTT assay.

Sellar Chordoma Presenting as Pseudo-macroprolactinoma with Unilateral Third Cranial Nerve Palsy

We described a 61-year-old female with a sellar chordoma, which presented as pseudo-macroprolactinoma with unilateral third cranial nerve palsy. Physical examination revealed that her right upper lid could not be raised by itself, right eyeball movement limited to the abduction direction, right pupil dilated to 4.5 mm with negative reaction to light, and hemianopsia in bitemporal sides. CT scanning showed a hyperdense lesion at sellar region without bone destruction. Magnetic resonance imaging （MRI） revealed the tumor was 2.3 cmx2.8 cmx2.6 cm, with iso-intensity on TlWl, hyper-intensity on T2WI and heterogeneous enhancement on contrast imaging. Endocrine examination showed her serum prolactin level increased to 2,032.49 mlU/ml. The tumor was sub-totally resected via pterional craniotomy under microscope and was histologically proven to be a chordoma. Postoperatively, she recovered uneventfully but ptosis and hemianopsia remained at the 6th month.

Complete III Cranial Nerve Palsy in a Leather Worker: An Unusual Case Report

This case report describes features and surgical management in one patient that developed a worsening total III cranial nerve palsy in his right eye. Our 45 year-old male patient worked for about 25 years in leather tanning industry. He underwent medical history, routine blood test, eye exams that included visual acuity measurement, slit-lamp examination, dilated retinal biomicroscopy and indirect ophthalmoscopy, fundus photography, tonometry, corneal pachymetry, Krimsky test, oculomotor examination and eye deviation surgery. On examination of the fellow eye wasn’t found any disease. Stroke, aneurysm and intracerebral causes of third nerve palsy were excluded, and medical history was negative for diabetes, cardiovascular disease, trauma, neurological disease unless two previous polyneuropathies episodes and one herpetic keratitis episode. Result of any neuroimaging studies were recorded (Our patients performed in hospital CT, MRI and MRI angiography and all the testes were normal). To our knowledge third cranial nerve palsy has never been observed in literature in leather workers. In conclusion, it is important for ophthalmologists to evaluate carefully work history and lifestyle persons and plan the surgical approach focusing the different characteristics of these patients.

Multiple cranial nerve palsies with small angle exotropia following COVID-19 mRNA vaccination in an adolescent:A case report

BACKGROUND Several vaccines against the severe acute respiratory syndrome coronavirus 2 have been approved and widely distributed,raising public concerns regarding the side effects of immunization,as the incidence of ease.Although many adverse events following the coronavirus disease 2019(COVID-19)vaccine have been reported,neurological complications are relatively uncommon.Herein,we report a rare case of multiple cranial palsies following COVID-19 vaccination in an adolescent patient.CASE SUMMARY A previously healthy,14-year-old Asian girl with facial palsy presented to the emergency department with inability to close the right eye or wrinkle right side of the forehead,and pain in the right cheek.She had received second dose of the COVID-19 mRNA vaccine(Pfizer-BioNTech)18 days before onset of symptoms.She was diagnosed with Bell’s palsy and prescribed a steroid(1 mg/kg/day methylprednisolone)based on symptoms and magnetic resonance imaging findings.However,the next day,all sense of taste was lost with inability to swallow solid food;the gag reflex was absent.Horizontal diplopia was also present.Due to worsening of her condition,she was given high-dose steroids(1g/day methylprednisolone)for 3 days and then discharged with oral steroids.Improvement in the symptoms was noted 4 days post steroid treatment completion.At the most recent follow-up,her general condition was good with no symptoms except diplopia;ocular motility disturbances were noted.Hence,prism glasses were prescribed for diplopia relief.CONCLUSION Small-angle exotropia was observed in the facial,trigeminal,and glossopharyngeal nerve palsies,in our patient.The etiology of this adverse effect following vaccination was thought to be immunological.

Metaphysical Energy Therapy in the Treatment of Cranial Nerve Palsies with Special Reference to Bell’s Palsy

Neuropathy, or nerve injury, is a severe and common impediment of diabetes. Studies evaluate that 50% of people with diabetes will develop neuropathy. Diabetic nerve injury is impairment of a single solitary nerve (also named mononeuropathy). Com- monly 2 cranial nerves Viz., cranial nerve VII and cranial nerve VI are involved in facial nerve palsies. The former one is called Bell’s palsy and is acute Lower Motor Neuron facial nerve paralysis (>80%) causing an inability to control facial muscles on the affected side. The later one is sixth nerve palsy, (the abducens nerve), which is responsible for triggering contraction of the lateral rectus muscle to abduct (i.e., turn out) the eye resulting in double vision on the affected side. In recent times, we have found to our amazement, rapid restoration of normalcy within a few hours to a few days, of Cranial Nerve palsies in diabetic subjects at our centre. We are presenting a group of cases having Type2DM over different time periods from 6 to 20 years and those who suddenly suffered facial nerve palsy and they came to VHSDRC for treatment. They were started on the new modality called the Dynamic Acupuncture Mediated Meta-physical Energy Therapy (DAMM Therapy), to recover from the facial palsy. The DAMM therapy is a unique novel way of infusing and transferring healing energy from the therapist to the patient. Within 2 - 7 sittings of DAMM therapy patients showed 75% - 100% improvement in their clinical condition.

Neck pain and absence of cranial nerve symptom are clues of cervical myelopathy mimicking stroke:Two case reports

BACKGROUND Cervical myelopathy is a potential stroke imitator,for which intravenous thrombolysis would be catastrophic.CASE SUMMARY We herein present two cases of cervical myelopathy.The first patient presented with acute onset of right hemiparesis and urinary incontinence,and the second patient presented with sudden-onset right leg monoplegia.The initial diagnoses for both of them were ischemic stroke.However,both of them lacked cranial nerve symptom and suffered neck pain at the beginning of onset.Their cervical spinal cord lesions were finally confirmed by cervical computed tomography.A literature review showed that neck pain and absence of cranial nerve symptom are clues of cervical myelopathy.CONCLUSION The current report and the review remind us to pay more attention to these two clues in suspected stroke patients,especially those within the thrombolytic time window.

Multiple Cranial Nerve Palsies in Otolaryngology Consultation: An Atypical Clinical Presentation Revealing Myasthenia Gravis

Introduction: Myasthenia gravis is a chronic autoimmune neuromuscular disease, presents with weakness and fatigability of striated skeletal muscles. It is a rare disease in Cameroon. We report an uncommon case of myasthenia gravis in a patient with feeding difficulties, notion of oronasal reflux and swallowing disorders as first complaints. Observation: We report the case of a 29-year-old woman consulted at our department of Otolaryngology and Cervico-Facial Surgery for dysphagia and swallowing disorders. She also presented with facial diplegia, oculomotor paralysis, nasal voice, and dysarthria which has been evolving for several years now. The clinical examination revealed multiple cranial nerve palsies. The complementary workup showed a decrement of more than 50% in the electroneuromyography and the presence of anti-acetylcholine receptor autoantibodies in the blood workup. A diagnosis of myasthenia confirms clinical presumption. We initially observed a worsening of neuromuscular disorders despite the pyridostigmine treatment and subsequently a clear improvement of the clinical features concerning swallowing and speech disorders, oculomotricity and facial diplegia under a treatment combining prednisone and azathioprine. Conclusion: Myasthenia gravis is a rare and potentially fatal autoimmune neuromuscular disease. We thus highlight the atypical clinical presentation and therapeutic itinerary of our patient and the importance to think about this clinical diagnosis in front of any multiple cranial nerve paralysis in otolaryngology consultation.

Efficacy of intraorbital electroacupuncture for diabetic abducens nerve palsy： study protocol for a prospective single-center randomized controlled trial

Abducens nerve palsy（ANP） is commonly seen in patients with diabetes mellitus. The validity of acupuncture as a traditional Chinese medicine method in peripheral nerve repair is well established. However, its efficacy in randomized controlled trials remains unclear. Herein, we designed a protocol for a prospective, single-center, randomized controlled trial to investigate the effect of intraorbital electroacupuncture on diabetic ANP. We plan to recruit 60 patients with diabetic ANP, and randomly divide them into treatment and control groups. Patients in both groups will continue their glucose-lowering therapy. A neural nutrition drug will be given to both groups for six weeks. The treatment group will also receive intraorbital electroacupuncture therapy. We will assess efficacy of treatment, eyeball movement, diplopia deviation and the levels of fasting blood-glucose and glycosylated hemoglobin before treatment at 2, 4, and 6 weeks after treatment. The efficacy and recurrence will be investigated during follow-up（1 month after intervention）. This protocol was registered at Chinese Clinical Trial Registry on 16 January 2015（Chi CTR-IPR-15005836）. This study was approved by the Ethics Committee of First Affiliated Hospital of Harbin Medical University of China（approval number： 201452）. All protocols will be in accordance with Declaration of Helsinki, formulated by the World Medical Association. Written informed consent will be provided by participants. We envisage that the results of this clinical trial will provide evidence for promoting clinical use of this new therapy for management of ANP.

Facial nerve paralysis in children

Facial nerve palsy is a condition with several implications, particularly when occurring in childhood. It represents a serious clinical problem as it causes significant concerns in doctors because of its etiology, its treatment options and its outcome, as well as in little patients and their parents, because of functional and aesthetic outcomes. There are several described causes of facial nerve paralysis in children, as it can be congenital(due to delivery traumas and genetic or malformative diseases) or acquired(due to infective,inflammatory, neoplastic, traumatic or iatrogenic causes). Nonetheless, in approximately 40%-75% of the cases, the cause of unilateral facial paralysis still remains idiopathic. A careful diagnostic workout and differential diagnosis are particularly recommended in case of pediatric facial nerve palsy, in order to establish the most appropriate treatment, as the therapeutic approach differs in relation to the etiology.

Electrical stimulation promotes regeneration of injured oculomotor nerves in dogs

Functional recovery after oculomotor nerve injury is very poor. Electrical stimulation has been shown to promote regeneration of injured nerves. We hypothesized that electrical stimulation would improve the functional recovery of injured oculomotor nerves. Oculomotor nerve injury models were created by crushing the right oculomotor nerves of adult dogs. Stimulating electrodes were positioned in both proximal and distal locations of the lesion, and non-continuous rectangular, biphasic current pulses （0.7 V, 5 Hz） were administered 1 hour daily for 2 consecutive weeks. Analysis of the results showed that electrophysiological and morphological recovery of the injured oc- ulomotor nerve was enhanced, indicating that electrical stimulation improved neural regeneration. Thus, this therapy has the potential to promote the recovery of oculomotor nerve dysfunction.

A standardized method to create peripheral nerve injury in dogs using an automatic non-serrated forceps

This study describes a method that not only generates an automatic and standardized crush injury in the skull base, but also provides investigators with the option to choose from a range of varying pressure revels. We designed an automatic, non-serrated forceps that exerts a varying force of 0 to 100 g and lasts for a defined period of 0 to 60 seconds. This device was then used to generate a crush injury to the right oculomotor nerve of dogs with a force of 10 g for 15 seconds, resulting in a deficit in the pupil-light reflex and ptosis. Further testing of our model with Toluidine-blue staining demonstrated that, at 2 weeks post-surgery disordered oculomotor nerve fibers, axonal loss, and a thinner than normal myelin sheath were visible. Electrophysiological examination showed occasional spontaneous potentials. Together, these data verified that the model for oculomotor nerve injury was successful, and that the forceps we designed can be used to establish standard mechanical injury models of peripheral nerves.

Management of intratemporal facial nerve schwannomas: The evolution of treatment paradigms from 2000-2015

Intratemporal facial nerve schwannoma(FNS) are rare benign tumors of the skull base. Many of these tumors will be detected during evaluation for symptoms suggestive of vestibular schwannoma. However, there are several signs and symptoms which can suggest the facial nerve as the origin of the tumor. Intratemporal FNS can be multiple, like "beads on a string", or solitary lesions of the internal auditory canal. This variable tumormorphology necessitates multiple treatment options to allow patients the best chance of preservation of facial nerve function. Historically FNS were managed with resection of the nerve with cable grafting. However this leaves the patient with permanent facial weakness and asymmetry. Currently most patients find this outcome unacceptable, especially when they present with good to normal facial nerve function. Facial paralysis has a significantly negative impact on quality life, so treatment regimens that spare facial nerve function have been used in patients who present with moderate to good facial nerve function. Nerve sparing options include tumor debulking, decompression of the bony facial canal, radiosurgery, and observation. The choice of management depends on the degree of facial nerve dysfunction at presentation, hearing status in the affected ear, medical comorbidities and patient preference. Each treatment option will be discussed in detail and suggestions for patient management will be presented.

经皮耳甲迷走神经刺激治疗慢性意识障碍临床观察

目的 观察经皮耳甲迷走神经刺激(taVNS)治疗慢性意识障碍(pDoC)的临床效果。方法选取宝鸡第三医院2020-06—2022-12收治的68例pDoC患者,随机分成对照组与治疗组各34例。对照组接受常规促醒治疗,治疗组在对照组的基础上接受taVNS治疗,2组患者均治疗4周。对比2组患者格拉斯哥昏迷量表(GCS)评分、昏迷恢复量表(CRS-R)评分、全身无反应性量表(FOUR)评分、安全性及临床疗效。结果 治疗后,2组患者的GCS单项评分(睁眼、言语和运动)及总分、CRS-R单项评分(听觉、视觉、运动、言语、交流和唤醒)及总分和FOUR单项评分(眼部、运动、脑干和呼吸)及总分均升高(均P<0.05),且治疗组GCS单项评分(睁眼和言语)及总分、CRS-R单项评分(听觉、视觉、言语、交流和唤醒)及总分和FOUR单项评分(眼部和脑干)及总分优于对照组(均P<0.05),但2组患者的GCS单项评分(运动)、CRS-R单项评分(运动)和FOUR单项评分(运动和呼吸)评分比较不明显(均P>0.05)。2组患者均未发生不良事件。治疗组总有效率(79.41%)显著高于对照组(61.76%)(P<0.05)。结论 taVNS治疗pDoC有一定的疗效,可改善患者意识障碍程度,且安全可靠。

亚低温疗法联合依达拉奉治疗重症颅脑损伤患儿的临床疗效

目的:探讨亚低温疗法联合依达拉奉治疗重症颅脑损伤(Severe craniocerebral injury,SCCI)患儿的临床疗效,及对患儿神经功能、血液流变学、炎性因子、预后的影响.方法:选取南阳市第一人民医院2019年1月至2022年12月收治的98例SCCI患儿为研究对象,随机数字表法将患儿分为常规组和联合组(n=49),分别进行对症抢救及对症+亚低温疗法联合依达拉奉治疗.治疗2 w后,比较两组临床疗效和不良反应,采用美国国立卫生院卒中评分量表(National Institutes of Health stroke scale,NIHSS)评估患者的神经功能,采用格拉斯哥预后量表(Glasgow outcome scale,GOS)评估患者的预后恢复状况,采用全自动血液流变仪检测患者的血液流变学指标(血浆黏度、全血低切黏度、全血高切黏度、血沉),酶联免疫吸附法检测超敏C反应蛋白(Hypersensitive C-reactive protein,hs-CRP)、白细胞介素-6(Interleukin-6,IL-6)、泛素羧基末端水解酶Ll(Ubiquitin C-terminal hydrolase-L1,UCH-L1)、纤维胶凝蛋白3(Ficolin3,FCN3)水平.结果:治疗2 w后,联合组(93.88%)临床总有效率高于常规组(79.59%)(P<0.05);联合组NIHSS评分低于常规组,GOS评分高于常规组(P<0.05);联合组血浆黏度、全血低切黏度、全血高切黏度、血沉、血清hs-CRP、IL-6、UCH-L1水平明显低于常规组,FCN3水平明显高于常规组(P<0.05);两组不良反应发生率比较,无显著差异(P>0.05).结论:亚低温疗法联合依达拉奉治疗SCCI患儿疗效显著,可有效改善血液流变学,减轻神经损伤,抑制炎症反应,安全性较好.

椎动脉与Ⅸ～Ⅻ脑神经毗邻关系的解剖及其临床意义

目的观察椎动脉与Ⅸ~Ⅻ脑神经解剖特点及毗邻关系,探讨颈椎病与高血压的相关性。方法颅颈部标本15具,解剖剥离法,观察椎动脉颅内段、小脑下后动脉与Ⅸ~Ⅻ脑神经的关系;椎动脉颅内段与延髓的关系。并测量其数据。结果 (1)椎动脉自穿经硬脑膜处向前内侧斜行,在延髓侧方走行于Ⅸ~Ⅻ脑神经根丝的前方。左右侧椎动脉与Ⅺ,Ⅻ脑神经接触,与Ⅸ,Ⅹ脑神经不接触者分别为11例(11/15,占73.3%)和7例(7/15,占46.7%);(2)左右侧小脑下后动脉与Ⅸ~Ⅻ脑神经不接触者分别为5例(5/15,占33.3%)和1例;(3)左右侧椎动脉位于延髓腹外侧并与延髓相接触者分别为11例(11/15,占73.3%)和4例(4/15占26.7%),不接触者分别为4例(4/15占26.7%)和11例(11/15,占73.3%);相对于左侧,右侧椎动脉位置偏后。模拟颈部屈曲时椎动脉与延髓腹侧紧密接触,伸直时分离。结论椎动脉与Ⅺ,Ⅻ脑神经接触可能是高血压伴发枕后痛的形态学基础之一;小脑下后动脉走行迂曲,与Ⅸ~Ⅻ对脑神经根丝相互盘绕交叉,高血压搏动更易刺激脑神经根丝,出现相应症状。椎动脉和延髓密切接触极可能既产生颈部症状,又可能造成高血压。控制血压除了常规抗高血压药物,神经营养药物也可以用于治疗高血压。