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Intractable paroxysmal sneezing in an 11 1/2-year-old girl was characterized by sneezing with her eyes open, no sneezing while asleep, and sneezing that was refractory to various medications. Results of physical examination were unremarkable. A review of the literature reveals that the disorder is usually psychogenic and responds to psychotherapy.
Pleural pressure, airflow and tidal volume during experimental cough and sneeze elicited by mechanical stimulation of the tracheobronchial and nasal mucous membranes were investigated in fifty anaesthetized cats (pentobarbital, 40 mg/kg i.p.). Pressure-volume, pressure-flow and flow-volume relations were studied during these expulsive processes. In comparison to quiet breathing there was a decrease in dynamic lung compliance in both respiratory tract reflexes (p less than 0.001), especially in their expiratory phases. As compared to quiet breathing, the total work of breathing was significantly increased (p less than 0.001) in cough (20 times) as well as in sneeze (13 times). The total lung resistance increased markedly (p less than 0.001) in both cough and sneeze compared to quiet breathing. In these expulsive processes there was also a high "cough index" (resistance calculated from the peak flow and instantaneous pressure). The flow-volume curve in cough, in contradistinction to sneeze, indicated a significantly reduced airflow of the end of expiration (at 85% of the expired volume), demonstrating a concomitant bronchoconstriction.
Intractable sneezing is rare; the 12th case is reported here. Various causative factors have been identified in the literature; these include psychologic problems, cervical lymphadenitis, epilepsy, and allergy. The sneeze reflex consists of two phases, nasal and respiratory, which are mediated by cranial nerves V and VII and by brain-stem respiratory centers. Hypotheses that have been proposed to explain the multiple causation of sneezing are the concept of the trigeminal system as a central neuronal pool, optic-trigeminal summation, and parasympathetic generalization.
Sneezing or sternutation is usually the physiologic response to nasal irritation. The reflex follows a very complicated pathway requiring coordinated communication between the trigeminal and nervous terminalis afferent impulses as well as from glottic and inspiratory muscles in the efferent limb. When the reflex pathway is unbalanced, sneezing can increase in frequency and severity to the extent that some patients become disabled. We present the clinical examination, differential diagnosis, and treatment modalities for the case of an adolescent male who experienced debilitating intractable sneezing for more than one year. As for many of the patients described with this elusive diagnosis, our patient appears to have a functional etiology.
The aim of this study was to precise the role of the different trigeminal nerve branches involved in innervation of the nostril in triggering the sneeze reflex. Electrical stimulation of the anterior ethmoidal, posterior nasal and infraorbital nerves was performed in anaesthetized cats. Stimulation of these 3 nerves produced sneezing identical to that induced by mechanical stimulation. Our results emphasize inhibition of the sneeze reflex related to stimulation of the anterior ethmoidal or the posterior nasal nerves by stimulation of the infraorbital nerve.
Extracellular recordings were made in the dorsal respiratory group (DRG) and adjacent reticular formation following single-shock stimulation of the anterior ethmoidal nerve (AEN) and during sneeze evoked by repetitive stimulation of the AEN in nembutal-anaesthetized, curarized and ventilated cats. These neurones were characterised according to (i) their activity during the respiratory cycle (as inspiratory augmenting or decrementing (I Aug or I Dec), expiratory augmenting or decrementing (E Aug or E Dec), silent or tonic), and (ii) their axonal projection (bulbospinal or non-bulbospinal-non-vagal (BS or NBS-NV)). Following single-shock stimulation of the AEN, most of the inspiratory neurones were transiently inhibited, whereas E Aug neurones were activated and E Dec neurones were activated and then inhibited. Silent neurones responded with a multispike or a paucispike pattern. Following repetitive stimulation of the AEN and during the resulting sneeze reflex, I Aug neurones increased their activity in parallel with the phrenic activity, I Dec neurones fired at the onset and at the end of the inspiration, E Dec and some silent neurones fired either during the compressive phase or after the expulsive phase, whereas E Aug and some silent neurones fired during the expulsive phase. We conclude that sneeze involves a reconfiguration of the central respiratory drive which uses, at least partly, the respiratory network to trigger a non-ventilatory defensive motor act.
A literature review of reported cases of intractable sneezing reveals that intractable sneezing typically occurs in children or adolescents and is a manifestation of conversion disorder. Analysis of these cases demonstrates a number of features that are helpful in differentiating psychogenic from organic sneezing. Also discussed are aspects of patient management once a diagnosis of conversion disorder is established.
Limited data support the use of first-generation antihistamines for treatment of the common cold. The purpose of this study was to test the effectiveness of clemastine fumarate, a first-generation antihistamine, for treatment of sneezing and rhinorrhea associated with naturally occurring common colds. Four hundred three subjects (202 clemastine fumarate recipients and 201 placebo recipients) who reported new onset (< 24 hours) of cold symptoms that included rhinorrhea or sneezing were studied. At baseline (day 1), the mean symptom-severity scores +/- SEM for the clemastine fumarate and placebo groups were not significantly different. The mean rhinorrhea-severity score +/- SEM was not different on day 2; however, on day 3, the mean rhinorrhea-severity score +/- SEM was 1.02 +/- 0.07 for the clemastine fumarate group and 1.39 +/- 0.07 for the placebo group (P < .001). This treatment effect persisted on day 4. A significant effect on sneezing was noted on days 2-4. Sedation occurred in 14% of the clemastine fumarate-treated subjects and 1.5% of the placebo-treated subjects (P < .0001).
Orbital emphysema is a rare condition in the absence of trauma or sinus disease. We report two cases of orbital emphysema caused by sneezing. The patients presented with sudden unilateral eyelid swelling after sneezing. Otorhinolaryngologic and ophthalmic examinations were accompanied by computed tomography (CT). Patient examination disclosed crepitant eyelid swelling, ptosis, and mild unilateral exophthalmos. CT demonstrated areas of emphysema in the orbit. One patient had history of past trauma. The other patient had a history of nasal surgery and concurrent chronic sinusitis. Sneezing may cause orbital emphysema in patients with a history of old periorbital trauma or surgery.
Photic induced sneeze is a reflex that occurs in certain individuals after exposure to bright light. Cystinosis is an autosomal recessive inborn error of metabolism in which nonprotein cystine accumulates within lysosomes. The pathognomonic ocular manifestation of cystinosis is corneal crystal deposition. We observed photic induced sneezes during ophthalmoscopic examination in five of 19 patients with nephropathic cystinosis (26%). We report on this observation and discuss possible pathophysiological mechanisms for photic induced sneezing in cystinosis.
Sneezes were induced in anestized cats by repetitive stimulation of the ethmoidal nerve. Activity of bulbar respiratory neurons during sneezing was recorded extracellularly through tungsten microelectrodes. Most expiratory neurons could be locked onto the stimulus pulses so that they responded either throughout inspiration as well as expiration or so that they began responding at some time during inspiration. As inspiration approached termination, multiple spiking occurred, finally to result in high-frequency bursts which just preceded active expiration. A fraction of expiratory neurons were activated only in bursts. Latent expiratory neurons were recruited in sneezing. Inspiratory neurons near nucleus ambiguus and most of those near fasciculus solitarius displayed similar response patterns consisting of silent periods followed by delayed smooth activations. Temporal characteristics of the silent periods, "inhibitory gaps," suggested that they resulted from inhibition whose source was the expiratory neurons which were driven throughout inspriation. Some inspiratory neurons in the area of fasciculus solitarius failed to exhibit inhibitory gaps.
Four consecutive patients with lateral medullary syndrome reported reversible inability to complete a reflex sneeze, despite retaining the urge to do so and the ability to mimic the motor act. This previously undescribed feature of a relatively common syndrome is in keeping with the known location of a "sneeze center" in the lateral medulla of cat. In man, unilateral brainstem lesion is sufficient to abolish the sneeze reflex temporarily.
To investigate the possible inhibitory effect of olopatadine hydrochloride (olopatadine), an antiallergic drug, on the tachykinin-mediated nasal responses, we examined the effect of olopatadine on the sneezing and the nasal rubbing responses induced by intranasal capsaicin challenge in guinea pigs. Olopatadine (10 mg/kg, p.o.) inhibited the sneezing response by 57% without affecting the nasal rubbing one. The antihistamines chlorpheniramine and clemastine did not affect the responses. Morphine caused the inhibition of both responses, which was antagonized by naloxone. These results suggest that olopatadine inhibits the sneezing response by the inhibition of the tachykinin release and not by its antihistaminic action.
A 13-year-old boy sneezed paroxysmally and continuously, day and night, for 18 days. Sneezing limited his daily activities and motivated hospital admission. Pediatric clinical examination and all other immunologic, otorhinolaryngologic, pneumologic, neurologic, radiologic, and psychiatric studies were normal. There was no response to treatment with antihistamines, corticoids, or anti-convulsants, which obscured the diagnosis. Definitively effective treatment and its implications in the pathophysiology of sneezing are discussed.
INTRODUCTION: Sneeze is an ubiquitous phenomenon that happens to everyone. In spite of this, little attention has been paid to it, among medical literature in general, and even less in neurologic texts. A curious entity, called autosomal dominant compelling helio-ophthalmic outburst syndrome, has been scarcely described in the scientific literature. This reflex appears when subjects are exposed suddenly to intense sunlight and it consists of long incoercible sneeze bursts. There are no publications on this subject among the spanish literature.and intensity increase with time. OBJECTIVE: To study the clinical and physiological features of the reflex in Spanish families. PATIENTS AND METHOD: Affected subjects were identified by personal interview and given a questionnaire drawn up for this study. Besides, they were instructed to give the questionnaire to their relatives.and intensity increase with time. RESULTS: All the six families showed a high-penetrance, autosomal dominant inheritance. The reflex had a high consistency, a latency about 3 seconds, an intersneeze interval of 2 seconds and a frequency of 2-3 sneezes/ burst. Refractory period was long.and intensity increase with time. DISCUSSION: Our study suggest a higher consistency, shorter latency and lower age of onset of the reflex in our patients than general population, and that frequency and intensity increase with time.
Because of X-ray examinations during the process of sneezing the report of Weber is confirmed, that the cavity of the mouth is sealed against the nose in the moment of sneezing. So sneezing can only be done through the mouth. At the same time a spcial middle phase of the velum is described, i.e. its lifting by an active contraction before the actuel exspirational thrust as an essential difference to the coughing reflex. While coughing the movement of the velum is purely passive because of the exspirational thrust. The seal between the nose and cavity of the mouth is often not complete.
In 22 premature newborns the oesophageal pressure, airflow and tidal volume were recorded and the values of various parameters of breathing mechanics were calculated during sneezing and crying. The deep initial inspiration during sneezing occurred in only 20% of the newborns. In the expulsive phase of sneezing, the oesophageal pressure reached the mean value 7.0 +/- 0.3 kPa. The peak expiratory airflow was 0.126 +/- 0.005 1Xs-1 on average: 6.6 times higher than the flow during quiet breathing. The dynamic compliance in this phase decreased from 28.9 +/- 0.5 to 19.3 +/- 2.2 ml X kPa-1 (P less than 0.01), and the total pulmonary resistance increased markedly from 7.9 +/- 1.0 to 50.0 +/- 0.7 kPaX1(-1)Xs (P less than 0.001). On crying the respiratory rate decreased and the inspiration/expiration ratio changed from 1:1.46 to 1:5.1 (P less than 0.001). The change in the ratio was due to the shortening of inspiration as well as the prolongation of expiration. The mean values of oesophageal pressure were -2.9 +/- 0.4 kPa in the inspiratory phase of crying, and 3.7 +/- 0.2 kPa in the expiratory phase. The ventilation during crying increased by 255% in comparison to the quiet ventilation. The dynamic compliance decreased to 13.9 +/- 1.8 mlXkPa-1 and the total pulmonary resistance rose to 26.5 +/- 2.4 kPaX1(-1)Xs.
This is the first study to compare the influence of nasal afferent stimulation on inspiratory and expiratory muscle activity during sneezing, in kittens and adult cats. In kittens, we demonstrate that nasal afferent stimulation does not reinforce inspiratory activity prior to the expiratory thrust as it normally does in adult cats. These stimulations evoke an active expiration similar to but weaker than the expiratory thrusts observed under the same conditions during sneezing in adult cats. Sneezing can be elicited from three weeks of life. Among the different hypotheses discussed, the most likely explanation appears to be the immaturity of medullary respiratory connections.