Paralysis agitans of early onset with marked diurnal fluctuation of symptoms.
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Adolescent↗
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The popularity of injections in the Third World: origins and consequences for poliomyelitis.
Paralysis from poliomyelitis may follow injections yet injections are extremely popular in the Third World. Some injections are given by hospital doctors and nurses but the majority are given by traditional healers, pharmacists and paramedical workers who have acquired syringes. Many injections may be given to a sick child. I suggest that the early use of vaccines did not persuade people of the mystic of injections and that the mystic predated the use of penicillin. The earliest mystical result would have been the injection of quinine for malaria and antrypal for sleeping sickness. The words brilliant, spectacular and dramatic were first used to describe the mass campaigns against yaws and kala-azar in the 1920s and 1930s. A single injection healed the ugly lesions in a week: cause and effect were visible. In the 1950s penicillin was used in mass eradication campaigns. The countries where injections are so popular correspond roughly with the areas of mass eradication programmes. Many or perhaps most of the injections are not sterile and present a great risk of attendant paralysis. Proof that injections are causal may be impossible. Meanwhile we need to know why injections are so popular and how they can be less so.
Attitude to Health↗
Progressive supranuclear palsy: report of two cases (author's transl).
Two cases of progressive supranuclear palsy (PSP) are reported in two men (49 and 75years old) who for one and four years respectively had sudden falling while walking. Rigidity of the neck was an carly feature that prgressed to involve the upper trunk while "subcortical dementia", dysarthria and dysphagia appeared. They had a complete paralysis of vertical eye movements and slow horizontal voluntary eye movements. Oculocephalic reflexes were intact. On caloric stimulation vestibulo-ocular responses were present but only slow saccadic eye movements were observed. With surface electrodes eye movements were studied during the REM phase of sleep. Our patients had both vertical and horizontal eye movements during paradoxal sleep. This findings is in keeping with a supranuclear ophtalmoplegia, and may help in antemorten diagnosis of PSP.
Aged↗
Pharyngeal patency in response to advancement of the mandible in obese anesthetized persons.
BACKGROUND: During anesthesia in humans, anterior displacement of the mandible is often helpful to relieve airway obstruction. However, it appears to be less useful in obese patients. The authors tested the possibility that obesity limits the effectiveness of the maneuver. METHODS: Total muscle paralysis was induced under general anesthesia in a group of obese persons (n = 9; body mass index, 32 +/- 3 kg[-2]) and in a group of nonobese persons (n = 9; body mas index, 21 +/- 2 kg[-2]). Nocturnal oximetry confirmed that none of them had sleep-disordered breathing. The cross-sectional area of the pharynx was measured endoscopically at different static airway pressures. A static pressure-area plot allowed assessment of the mechanical properties of the pharynx. The influence of mandibular advancement on airway patency was assessed by comparing the static pressure-area relation with and without the maneuver in obese and nonobese persons. RESULTS: Mandibular advancement increased the retroglossal area at a given pharyngeal pressure, and mandibular advancement increased the retropalatal area in nonobese but not in obese persons at a given pharyngeal pressure. CONCLUSION: Mandibular advancement did not improve the retropalatal airway in obese persons.
Adult↗
Subjective psychological status of severely ill patients discharged from mechanical ventilation.
OBJECTIVE: To evaluate psychological status in consecutive survivors of ICU who needed mechanical ventilation (MV). DESIGN: Prospective study. SETTING: Twenty-four bed intensive care unit. PATIENTS: Fifty-four mechanically ventilated patients were considered for the study; 43 patients were included, but 11 refused or were unable to fill in the form. INTERVENTIONS: A 32-question form was filled out by the patients 48-96 hours after weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: The mean characteristics of the patients were: age 51.6 years, simplified acute physiologic score (SAPS) 14, organ system failure (OSF) 1.57, OMEGA score 277, length of stay 29 days, length of mechanical ventilation 14 days. Thirty-three required sedation, 30 analgesia, 20 paralysis. The results were as follows: Pain: 13 suffered intolerable pain with a mean intensity of pain during care of 3.5/10. Comfort: 25 felt an inability to communicate, 18 were bothered by noise and 15 by light, while nine feared to be abandoned by staff. Sleep disorders: 28 remember dreaming with a personal judgement about these dreams (0 = pleasant, 10 = nightmare) of 7.6/10; 17 noticed increasing sleep disorders during their stay. Anxiety: 22 felt diffuse anxiety disorder and 16 described intense fear of dying at least once. Mood: 38 felt physical depression and 18 intellectual depression. Delirium or confusion: 33 had delirium or a confused state at the time of weaning and nine suffered hallucinations. Nine correctly appreciated their length of stay and 18 knew the date when they were interviewed. CONCLUSIONS: These results showed that psychological status is poor in ventilated ICU patients, which should be considered in their care.
Adult↗
Photo-evoked eyelid microvibration in newborn infants and children--reflex arc and maturational change.
We studied maturational process of the photo-evoked eyelid microvibration (PEMV) in 166 newborns, 72 children and 10 adults free of any neurologic disorders. The results indicate that the latency of PEMV shortens during growth due to the myelination of the nerve fibers of the involved pathway. Age-related normal values were established. The pathway of PEMV probably consists of retina, optic nerve, pretectum, facial nerve, and orbicularis oculi muscle. We also evaluated the effect on this reflex of retinoblastoma, facial nerve paralysis, holoprosencephaly anomalad, and a muscle relaxant used for artificial respiration in respiratory distress syndrome.
Blinking↗
Advancement of the mandible improves velopharyngeal airway patency.
The velopharynx is the most common site of obstruction in patients with obstructive sleep apnea (OSA). Advancement of the mandible effectively reverses the pharyngeal obstruction. Accordingly, we hypothesized that mandibular advancement increases cross-sectional area of several segments of the upper airway, including the velopharynx and the oropharynx. We examined the pressure-area properties of the pharyngeal airway in 13 patients with OSA. Under general anesthesia and total muscle paralysis, the pharynx was visualized with an endoscope connected to a video-recording system. During an experimentally induced apnea, we manipulated the nasal pressure from 20 cmH2O to the point of total closure at the velopharynx. The procedure was repeated after maximal forward displacement of the mandible. Measurements of the cross-sectional area at different levels of nasal pressure allowed construction of a static pressure-area relationship of the "passive pharynx," where active neuromuscular factors are suppressed. In 12 of 13 patients with OSA, advancement of the mandible stabilized the airway by reducing the closing pressure and increasing the area at any airway pressure. Thus the maneuver shifted the static pressure-area curve of the velopharynx and the oropharynx upward in these patients. We conclude that anterior movement of the mandible widens the retropalatal airway as well as that at the base of the tongue in the passive pharynx of OSA patients.
Adult↗
[Surgical and conservative treatment of lagophthalmus (facial paralysis). II].
Thirty patients with irreversible facial palsy were treated with gold implants from 0.5 to 1.8 g. For the immediate treatment of postoperative facial palsies and reversible kinds of lagophthalmos, lead weights of 1.2 to 1.8 g ("lid dynamic eye dressing") are preferred to hourglass dressings. Insufficient orbicularis muscle function is compensated by the weight. The observation time for gold implants is more than 2 years; the fixation time of the adhesive lead weights is 1 to 10 days. Tolerance is excellent to both treatments. The principle is gravity dependent and is limited to the vertical and oblique head position. For sleeping at night, ointment application and pressure on the upper lid by a pillow are advisable; an additional hourglass dressing is possible. No serious keratopathies were seen in any cases. All patients found the return of lid motility from the restored levator muscle function to be a functional and cosmetic advantage. After weighing the advantages and disadvantages, especially the operative/technical expense in relation to the effective results, it would appear that simple lid-loading is so far the best method of treating lagophthalmos.
Adolescent↗
Long-term comparison of a newly designed gold implant with the conventional implant in facial nerve paralysis.
Patients with complete facial nerve palsy are at risk for eye complications resulting from exposure of the cornea and loss of the blinking reflex. Failure of protection predisposes the patient to exposure keratitis, corneal abrasion and, in rare cases, blindness. The mainstays of non-surgical therapy are cumbersome, obscure vision, and are mostly helpful in patients with acute facial paralysis in whom recovery of orbicularis oculi function is expected. Methods of lid-loading using metal implants and gold eyelid weights have been reported in the literature. Between October of 1988 and March of 1995, 32 patients with lagophthalmos due to facial nerve palsy underwent a total of 34 procedures for the insertion of a gold eyelid weight. Each patient had a gold weight inserted into a small pocket between the orbicularis oculi and the tarsal plate of the upper eyelid. The gold implant is curved to fit the curvature of the eye and contains holes for fixation to the tarsus with sutures. Ingrowth of fibrous tissue through the holes may also help fix the weight in position. Between 1988 and 1991, 10 patients received 10 commercially available rectangular gold implants with 2 holes; these implants resulted in adverse effects, such as infection and exposure in up to 30 percent of the cases. Because of the high complication rate with the rectangular gold implant, the authors began using a new, elliptical gold implant with 3 holes, which is longer, thinner, wider in the center, and narrower in the peripheral portion. This new elliptical implant was used on 22 patients (24 implants) from December of 1991 through March of 1995. The mean follow-up time for the 32 patients in the study was 41.3 months (range, 6 to 63 months), 49.8 months for patients with rectangular implants and 32.8 months for patients with elliptical implants. The elliptical gold implant resulted in dynamic closure of the eyelid and in excellent protection and cosmesis. Lagophthalmos and exposure keratitis resolved, visual acuity significantly improved without complications, and most patients could dispense with eyedrops and salves. A lower eyelid supporting procedure (conchal cartilage graft) should be performed simultaneously in patients with lagophthalmos of a moderate or severe degree to achieve complete closure of the eyelid. Use of a tall pillow decreased the incidence of eyelid opening during sleep. Double eyelid fold operations'were performed on the contralateral eyelid after 6 months, resulting in a symmetrical and beautiful eyelid.
Adolescent↗
Continuous intracisternal and high cervical intrathecal bupivacaine analgesia in refractory head and neck pain.
BACKGROUND: The upper cervical component of the spinomesencephalic tract and cranial nerves V, VII (nervus intermedius), IX, and X are involved in mechanisms of acute and chronic pain from head and neck structures. To date there is no reliable method for relief of refractory pain (i.e., pain that cannot be relieved by conventional pharmacologic therapies) from these structures. Therefore, we explored continuous intracisternal infusion of bupivacaine for the treatment of refractory pain of the head and neck. METHODS: Intracisternal catheters were inserted in 13 adults with refractory nonmalignant (n = 4) and malignant (n = 9) pain from the head, face, mouth, neck, and upper extremities; 0.5% plain bupivacaine was infused continuously at rates of 1-7 (median 1.5) mg/h with optional bolus doses of 0.5-2.0 mg 4-2 times/h. The efficacy was assessed from pain relief (daily VAS(max), VAS(min), and VAS(mean) scores 0-10), daily doses of intracisternal bupivacaine and total opioid (expressed as mg parenteral morphine-eq), amount of nocturnal sleep, and rates of adverse effects. RESULTS: The 13 patients were treated for 3-182 days (median 37, total 712 days), 3 patients being treated at home for 10-112 days (median 88, total 210 days). In one patient, the efficacy of the treatment could not be estimated because of advanced senility. Eleven of the remaining 12 patients obtained acceptable pain relief with daily doses of intracisternal bupivacaine ranging from 20 to 118 mg (median 37 mg): VAS(mean) scores decreased from 7 to 2, mean pain relief increased for 30% to 80%, total opioid daily dose decreased from 53 to 36 mg parenteral morphine-eq, and nocturnal sleep increased from 2 to >6h (all figures are median values). Speech, eating, walking, and natural functions were generally not affected. Side effects such as tiredness and malaise, somnolence and sleep, feeling of coldness in the neck and skull base, transient post-spinal puncture headache, paresthesias, hoarseness, dysphagia, transient paresis of the upper/lower extremities, episodic miosis and conjunctival hyperemia, and transient orthostatic arterial hypotension were each observed in one or two patients. No patient presented clinical evidence of phrenic nerve paralysis. There was no nausea or vomiting. No persistent neurologic deficit or death could be attributed to the intracisternal pain treatment. CONCLUSIONS: Continuous intracisternal infusion of bupivacaine may be a useful method in exceptional, well selected patients with refractory pain from the head and neck structures. Further studies are necessary to establish the indications and the safety of the method.
Adult↗
[Endoscopic CO2 laser arytenoidectomy in the treatment of bilateral vocal cord paralysis].
OBJECTIVE: To evaluate endoscopic CO2 laser arytenoidectomy(ECO2LA) for the treatment of bilateral vocal cord paralysis (BVCP). METHODS: Eight cases have been operated upon and observed for 6 to 40 months. Three of them were extralaryngeal approach artenoidectomy failures. All of them had tracheostomy before. The technique was to modification of Ossoff ECO2LA model. A small part of ventricular fold and posterior part of vocal cord was vaporized by laser. The mucoperichondrium overlying the arytenoid was reserved and sutured. After 3 months the opposite arytenoid was treated similarly. RESULTS: There were no aspiration and no granulation at the surgical site postoperatively. All cases kept satisfactory voice. Five of 8 patients were decannulated. Two patients still had laryngeal stridor during sleep and they had to plug the tracheotomy tube only on daytime. One patient had cannula retained for waiting operation on the opposite side. CONCLUSION: ECO2LA is currently a most reliable and efficient technique for treatment of patients with BVCP.
Adolescent↗
Acute systemic blood pressure elevation in obstructive and nonobstructive breath hold in primates.
Phasic blood pressure (BP) response during obstructive apnea (OA) in human sleep has been previously described as consisting of a slow incremental increase in BP to the point of apnea termination followed by a rapid rise and then fall in BP at the resumption of respiration. This rise in BP has been attributed to postapneic augmentation of cardiac output resulting after release of the marked negative intrathoracic pressure (NIP) of obstructed inspiration. Via an endotracheal tube, we created obstructed and nonobstructed breath hold (apnea) in chloralose-anesthesized baboons consisting of fixed-duration (30, 45, and 60 s) single OAs (mechanical obstruction) and nonobstructive (paralysis, ventilator cessation) apneas of matched duration and arterial desaturation. Systemic BP was measured before apnea (T0), during the last 5 s of apnea (T1), and during the first 5 s after resumption of respiration (T2). Despite wide fluctuations in NIP and BP during the T0 to T1 phase of OA, BP elevation in OA and nonobstructive apnea at T0, T1, or T2 did not differ for any duration apnea. At the release of obstruction, when resolution of NIP changes could theoretically increase cardiac output and accentuate BP, there was no difference in T1 and T2 pressures between the two conditions. We conclude that in this anesthesized animal model, mechanical (NIP) changes do not play a major role in overall maximum BP response to OA. Because of physiological differences between natural sleep in humans and the anesthetized state in animals, care must be taken in extrapolating these results to human sleep apnea.
Airway Obstruction↗
The origin of "Saturday night palsy"?
THE TERM Saturday night palsy has become synonymous with radial nerve compression in the arm resulting from direct pressure against a firm object. It typically follows deep sleep on the arm, often after alcohol intoxication. The commonly accepted origin of the phrase is the association of Saturday night with carousing. We offer an alternate explanation: we think that the term Saturday night palsy was introduced mistakenly as a simplification of saturnine palsy (much like the way the word palsy was shortened from paralysis). Saturnine palsy, which is a relatively common complication of lead poisoning, has the same clinical presentation of radial nerve compression, and Saturday night palsy even sounds like saturnine palsy. Moreover, Saturday, lead, carousing, and alcohol are associated with each other through their connection to Saturn, the Roman god of agriculture, which encourages the association of the two syndromes with one another.
Alcoholic Intoxication↗
Laryngeal pressure receptors.
We studied the response characteristics of laryngeal pressure receptors in anesthetized dogs, breathing through a tracheal cannula, by recording single unit action potentials from the peripheral cut end of the internal branch of the superior laryngeal nerve. The larynx, with the rest of the upper airway, was isolated and cannulated separately for the application of distending and collapsing pressures. We identified receptors responding to either negative or positive pressure and a few responding to both. All these receptors showed a marked dynamic sensitivity and had the characteristics of slowly adapting mechanoreceptors. The majority of pressure receptors were active at zero transmural pressure and the gain of their response to pressure was higher at lower values, suggesting a role for these receptors in eupnea. Reflex alterations in breathing pattern and upper airway muscle activity during upper airway pressure changes, previously reported, are presumably mediated by the receptors described here. Moreover, these receptors may play a role in certain pathological states, such as obstructive sleep apnea, in which the upper airway is transiently subjected to large collapsing pressure.
Action Potentials↗
Vocal cord abductor paralysis (VCAP) in Parkinson's disease: difference from VCAP in multiple system atrophy.
Vocal cord abductor paralysis (VCAP) is rare in Parkinson's disease (PD), while it is frequent in multiple system atrophy (MSA). Although VCAP is a life-threatening complication it has not yet been clarified whether there is any difference in the mechanism of VCAP between PD and MSA. Examining 3 autopsy-proven PD patients who developed severe VCAP requiring tracheostomy, we found the following differences in the mechanism of VCAP between MSA and PD: (1) clinical and laryngofiberscopic examination showed that VCAP in PD was not exacerbated during sleep, unlike in MSA; (2) On histological examination of the intrinsic laryngeal muscles, the posterior cricoarytenoid muscle demonstrated no abnormalities in PD, while the muscle showed characteristic neurogenic atrophy in MSA. There seemed to be two types of VCAP, namely the nonparalytic type observed in PD, and the paralytic type observed in MSA. Severe dysphagia requiring tube-feeding was common among PD patients who presented with VCAP. Although the relationship between VCAP and dysphagia is unknown, one should be aware of the possibility of fatal VCAP in PD patients with severe dysphagia.
Aged↗
[Akinesia and associated motor involvement in Parkinson's disease and basal ganglia lesions].
The paralysis due to lesions of the cortico-spinal tract disturb movements in their different modes while dissociated paralysis result from cortical and particular biopercular lesions. Movements cannot be executed on command whereas they are accomplished in their total complexity when they accompanied certain emotional states or when they are part of an automatic activity. Such a dissociation suggest that the motor program which does not respond to voluntary command will eventually be applied thanks to emotional or affective stimuli. Basal ganglia lesions induce other symptoms. The first to be observed concern the movements and postures implied in automatic series after learning. Akinesias which results from these lesions can be partially controlled by a voluntary command, particularly when helped by sensori stimuli. Such symptoms are observed sometimes from its beginning in the Parkinson's disease. Emotion and sleep are also able to improve these akinesias: therefore they appear either on a deficitary form implying a sensitive reinforcement or on a hyperactive form, which is alleviated by hypotonia and sleep. The localized lesions of striatum or of pallidum provoke identical symptoms but at the interruption of akinesia, a distortion of movement appears, contrary to what is observed in Parkinson's disease. Mechanisms of anticipation and adjustment of postural reaction are disturbed concerning not only the body axis but also the different segments of the limbs. This disturbance provokes unsteadiness and sometimes falls. At the level of the limbs the anomaly of postural reactions slows down the movement and disturbs specially the repetitive gestures.(ABSTRACT TRUNCATED AT 250 WORDS)
Basal Ganglia Diseases↗
[Neurosarcoidosis. Comments on 2 cases].
Sarcoidosis can involve any tissue in the body and, consequently, the disease presents to clinicians of many different disciplines. We report two cases of sarcoidosis involvement of the nervous system: one male patient with right facial nerve palsy and a cutaneous involvement (supraorbital subcutaneous nodule) associated with bilateral hilar adenopathy; and a female patient presenting a hypothalamus involvement with diabetes insipidus, obesity, lethargy, sleep disturbances and amenorrhoea. In the later case an upper respiratory tract involvement was also present with nasal and tonsils sarcoidosis. A review of the clinical manifestations of neurosarcoidosis and the criteria for establishing the diagnosis is presented.
Adult↗
Nontraumatic atlantoaxial subluxation (Grisel syndrome): a rare complication of otolaryngological procedures.
OBJECTIVE: At the conclusion of the report, the readers should be able to recognize the rare complication of adenotonsillectomy of Grisel syndrome, discuss its pathogenesis, and provide early, effective treatment. STUDY DESIGN: Analysis of the clinical presentation, plain radiographs, computed tomography scans, and magnetic resonance imaging scans of a child with Grisel syndrome after adenotonsillectomy. METHODS: Retrospective study of the case record and a review of the literature regarding the pathogenesis, treatment modalities, outcome, and prognosis after early and delayed treatment of Grisel syndrome. RESULTS: Pathophysiology of atlantoaxial subluxation revolves around the periodontoid vascular plexus that drains the posterosuperior pharyngeal region. Infectious and inflammatory emboli cause synovial engorgement, weakening paraspinal ligaments. Radiological studies play an important role in diagnosis. Treatment consists of cervical immobilization, muscle relaxants, analgesics, and antibiotics. Full resolution is expected with early conservative management. Failure to recognize the syndrome can lead to catastrophic results. CONCLUSIONS: Recognition of Grisel syndrome in addition to other rare complications of adenotonsillectomy requires a high index of suspicion. Early intervention is the critical factor for a positive outcome. However, delayed diagnosis is common and can result in catastrophic consequences, including neurological deficits, cosmetic deformity and, in rare instances, paralysis and death in the short term.
Adenoidectomy↗