PARESTHESIA

Spinal cord stimulation is currently used to treat a variety of chronic intractable painful conditions. We report a case of severe Raynaud's phenomenon in the hands refractory to conservative treatment and responsive to diagnostic stellate ganglion block that was effectively treated with a spinal cord stimulator placed in the cervical epidural space. After capturing the affected areas with paresthesias, blood flow in the left hand and fingers significantly improved as evidenced by an increase in skin temperature, a change from cyanotic to pink appearance and concomitant reduction in pain. Moreover, the patient reported that limb ischemia and pain could be managed overnight with stimulation intensities that were below sensory perception thresholds. Thus it seems, at least in the overnight period, paresthesias were not required to maintain pain relief. This case presents a potential divergence between a requirement for paresthesias and pain relief in spinal cord stimulation therap...

Objective: The aim of this retrospective study was to evaluate the effectiveness of laser therapy for acceleration and recovery of nerve sensitivity after orthognathic or minor oral surgeries, by analysis of clinical records of patients treated at the Special Laboratory of Lasers in Dentistry (LELO, School of Dentistry, University of São Paulo), throughout the period 2007-2013. Background data: Nerve tissue lesions may occur during various dental and routine surgical procedures, resulting in paresthesia. Laser therapy has been shown to be able to accelerate and enhance the regeneration of the affected nerve tissue; however, there are few studies in the literature that evaluate the effects of treatment with low-power laser on neural changes after orthognathic or minor oral surgeries. Methods: A total of 125 clinical records were included, and the data on gender, age, origin of the lesion, nerve, interval between surgery and onset of laser therapy, frequency of laser irradiation (one or two times per week), final evolution, and if there was a need to change the irradiation protocol, were all recorded. These data were related to the recovery of sensitivity in the affected nerve area. Descriptive analyses and modeling for analysis of categorical data (a = 5%) were performed. Results: The results from both analyses showed that the recovery of sensitivity was correlated with patient age ( p = 0.015) and interval between surgery and onset of laser therapy ( p = 0.002). Conclusions: Within the limits of this retrospective study, it was found that low-power laser therapy with beam emission band in the infrared spectrum (808 nm) can positively affect the recovery of sensitivity after orthognathic or minor oral surgeries.

Resumo Parestesia é um distúrbio neurossensitivo causado por lesão no tecido nervoso. É caracte-rizada por sensação de queimação, pontada ou perda parcial da sensibilidade local. Quando relacionada à Endodontia pode decorrer de tratamentos nos quais houve extravasamento de material obturador ou de medicação intracanal, como consequência e cirurgia endodôntica ou de infecções perirradiculares. O presente trabalho teve por objetivo a realização de uma revisão de literatura acerca dos aspectos relacionados à parestesia pós-tratamento endodôn-tico, de forma a elucidar os nervos mais comumente afetados, o diagnóstico e as condutas de tratamento mais acertadas. De acordo com a literatura consultada, pode-se concluir que os nervos mais acometidos são os que percorrem a mandíbula, como o nervo alveolar inferior, mentual e o lingual. Para o diagnóstico há a necessidade de anamnese precisa, testes me-canoceptivos e nociceptivos, bem como de exames de diagnóstico por imagem. Em relação à conduta, a literatura aponta que ainda não há um padrão para parestesia relacionada a procedimentos endodônticos, uma vez que várias são as causas relacionadas. Nesse sentido, é imperativa a anamnese criteriosa e diagnóstico preciso para minimizar a injúria ao tecido nervoso e restabelecer o bem-estar do paciente. Abstract Paresthesia is a neuro-sensitive disorder caused by a damage to nervous tissue. It is characterized by a burning, tickling sensation or partial loss of local sensitivity. When related to Endodontics, it may result from treatments in which there has been overflow of filling material or intracanal medication as a result of the paraendodontic surgery or periradicular infections. This study aimed at performing a literature review on the aspects related to post-endodontic treatment paresthesia, in order to identify the most commonly affected nerves, the diagnosis, as well as the proper treatment procedures. According to the consulted literature, it can be concluded that the most affected nerves is that runs through the jawbone, such as the inferior alveolar nerve, the mentual nerve, and the lingual nerve. For the diagnosis, accurate medical history, mecanoception and nociception tests, as well as diagnostic imaging exams are required. As regards the clinical conduct, the literature indicates that there is still no standard for paresthesia related to endodontic procedures, since the related causes are diverse. In this sense, careful medical history and accurate diagnosis are fundamental to proper treatment in order to minimize injury to the nervous tissue and to restore the wellness of the patient.

Purpose: Endoscopic carpal tunnel release using Menon's technique has been shown to reduce recovery time, although previous studies have shown that there is still a considerable risk of nerve complications. The purpose of this study was to evaluate data from 227 hands of 191 patients who underwent releases with Menon's technique. Type of Study: Prospective study. Methods: Endoscopic releases were performed as an outpatient intervention by one surgeon. Follow-up evaluations included were analysis of satisfaction, quantitative measurements of grip strength, return to work time, and complications. After the surgery on the first 50 hands in 41 consecutive cases, the technique was modified. Prospectively, changes in the technique are due to difficulties maintaining the knife within the center of the cannula's slot and a relatively high complication rate. In the modified technique, a 2.7-mm 25°endoscope and a triangular diamond-tipped knife were used to allow for more room for the instruments and a more safe procedure. Results: During the first month after the surgery, 91% of the patients had better subjective satisfaction scores and by 12 weeks, 81% obtained 75% to 100% or greater grip strength. Within 3 weeks, 70% of the patients had returned to work. Twelve of 50 hands operated on using the original technique had nerve disturbance diagnosed at follow-up. Three of these 12 patients developed reflex sympathetic dystrophy. One patient had partial median nerve injury that was repaired at the time of the index operation. There was no serious complication observed in 177 hands of 150 cases operated on using the modified Menon's technique, except one postoperative hypoesthesia along the long and ring fingers that improved with time.

Resident's case problem. The role of premanipulative testing of the cervical spine is an area of controversy, and there are very few data to inform and guide practitioners on the use of ligamentous stability tests when assessing the upper cervical spine. A 23-year-old female was referred to physical therapy by a neurologist for the management of intractable headaches of possible musculoskeletal origin. Her Neck Disability Index score was 54% and she rated her headache pain from 3/10 to 9/10 on a Numerical Pain Rating Scale. She reported a 2-year history of intermittent lower extremity paresthesias without a known mechanism or current symptoms. She was treated in physical therapy for 11 visits with improvements in cervical range of motion, strength, and intensity of her headaches, but noted no change in the frequency of headaches. She was subsequently referred to the primary author for a second opinion and potential manual therapy interventions. Initial neurological screening examination for upper and lower motor neuron lesions was unremarkable. Assessment of the transverse ligament, using the anterior shear test in supine, brought on paresthesias in both feet and her toes. The paresthesias continued after the cessation of the test. The Sharp-Purser test performed in sitting, immediately after the transverse ligament test, abolished the paresthesias. She was then referred back to her primary care physician for further evaluation. Subsequent radiographs and magnetic resonance imaging revealed that the patient had a C2-C3 Klippel-Feil congenital fusion and os odontoideum. The patient was examined by a neurosurgeon who concluded that she was not a surgical candidate. Her neurological symptoms completely resolved, but she continued to have headaches. Os odontoideum is a clinically important condition, given that the mobile dens may render the transverse ligament incompetent, leading to atlantoaxial instability. Both the role and sequencing of upper cervical ligamentous testing is controversial. The results of this case report suggest that physical therapists should be cognizant of this condition and consider screening the upper cervical ligaments prior to manual or mechanical interventions to this region. Differential diagnosis, level 4.

Objective. This study evaluated the results of the use of curettage followed by liquid nitrogen spray cryosurgery in a number of solid or multicystic ameloblastomas of the jaws and the postoperative complications related to this treatment modality.

Problem creases of the face such as frontal lines and frown lines, crow's feet, deep nasolabial and perioral folds, and cervical bands may be caused by the aging process, excessive exposure to the sun, disease, or genetic disposition. The condition may become aggravated by habitual hyperkinesia of certain mimetic muscles like the frontalis, corrugators, orbicularis oculi, levatores labii superioris, zygomatici, and the platysma. The diagnosis is established clinically by electromyography and selective muscle and nerve blocks. In these cases we advocate regulation of the mimetic hyperkinesia through selective myotomy, myectomy, and neurotomy of the responsible mimetic muscles (mimetic modulation). These procedures may be performed exclusively or in combination with a blepharoplasty, rhytidectomy, or other procedure. Our experience with 60 patients over the past five years (medium = 3.5 years) is presented. Problems and complications such as paresthesia and hypesthesia, partial paresis and asymmetry, incomplete correction, and recurrences are discussed. We believe that mimetic modulation is a valuable concept in treating problem creases and thereby improves the results of the aesthetic surgery of the face.

Objective In order to assess their late benefits we present the long-term results of a comparison of treating cubital tunnel syndrome with anterior submuscular transposition or simple decompression. Methods Of 40 patients initially recruited to this study 33 were available for long term follow-up. Sixteen patients underwent anterior submuscular transposition (group A); simple decompression was performed in 17 of the patients (group B). The indications for inclusion were a typical clinical presentation confirmed by abnormal nerve conduction studies. The mean duration of the symptoms before operation was 13 months (range 2 to 84 months) in group A and 8.4 months (range 1.5 to 36 months) in group B. All patients were seen 2 months after surgery and at least 3 years later. The mean duration of follow-up was 63.1 month in the first group and 52 months in the second group. Results No complications were seen in either group. In the group treated by anterior transposition, ten of 16 patients were completely free of signs and symptoms; slight residual hypesthesia or paresthesia was observed in two patients. Paresis and atrophy was observed in only one person. In the simple decompression group, 11 of 17 patients were completely free of signs and symptoms. In five patients slight residual symptoms were observed; no paresis or atrophy was reported in any of this group. Conclusion These long-term results show that both surgical techniques have a good outcome. Thus, the less invasive simple decompression should be preferred.

Chondrosarcoma of the skull base is a rare tumour with a good prognosis following surgical resection. We describe a patient with low-grade chondrosarcoma of the skull base with intradural extramedullary spinal metastases. A 31-year-old female with grade 1 chondrosarcoma involving the cavernous sinus, sphenoid wing and clivus presented at age 19. The tumour was subtotally excised at initial surgery and over the following 4 years, 3 subsequent resections were undertaken for tumour progression followed by proton beam radiotherapy to the residual tumour. The patient re-presented with cervical radiculopathy 7 years later. MRI showed multiple, intradural extramedullary spinal drop metastases. Following surgical excision of the symptomatic lesion, histological diagnosis was confirmed as a mixed hyaline/myxoid grade 1 chondrosarcoma. Patients with skull base chondrosarcoma with intradural extension should have whole spine imaging as part of long-term monitoring to exclude drop metastases, particularly after intradural surgery.

This prospective study compared the sensitivities of a scored questionnaire and electrophysiological examination in the diagnosis of carpal tunnel syndrome. Patients were assessed by a hand surgeon using a scored questionnaire, and then underwent an electrophysiological assessment by an experienced neurophysiologist (blinded to the questionnaire results). Patients diagnosed as having carpal tunnel syndrome by either the questionnaire, the electrophysiological examination or both underwent decompression. Symptom relief was taken as the ''gold standard'' for true carpal tunnel syndrome.

Isolated paresthesia, or paresthesia not accompanied by sensory and/or motor deficits, is an extremely rare manifestation of a cerebrovascular accident. Lacunar pure sensory stroke (PSS) confined to thalamus is characterized by persistent or transient numbness, tingling, pain, burning, or another unpleasant sensation on one side of the body. However, in this condition a sensory loss to all primary modalities in the contralateral face and body is very often encountered. Also previous reported cases of PSS due to lacunar stroke in regions other than thalamus are characterized by the presence of sensory loss together with positive sensory symptoms, none of them reporting isolated paresthesia as the only clinical feature of PSS. We present a case of isolated paresthesia as only clinical manifestation of a lacunar PSS involving both trigeminal and medial lemniscus in dorsal paramedian pontine region. A PSS manifesting with isolated paresthesias may be secondary not only to a thalamic lacunar stroke, but also to a small ischemic lesion confined to both trigeminal and medial lemniscus in dorsal paramedian pontine region.

Neurological involvement occurs in approximately 20% of patients with primary Sjögren's syndrome. Although neurological symptoms can affect the peripheral nervous system and the central nervous system, the most frequent symptom is polyneuropathy. Small fiber neuropathy (SFN) is a form of painful peripheral polyneuropathy that is common in patients with diabetic neuropathy, but may also occur in toxic, infectious, or immune-mediated neuropathy. We show here a patient with Sjögren's syndrome who developed SFN and was treated with intravenous immunoglobulin (IVIG) therapy, which was immediately and extremely effective. Because of the efficacy of IVIG therapy, we propose that direct immunemediated mechanisms may be involved in the pathogenesis of SFN complicated by Sjögren's syndrome.

front-line chemotherapy, the patient received high-dose chemotherapy with granulocyte colony-stimulating factor (G-CSF) stimulated autologous peripheral blood stem cell We describe seven patients who developed symptoms including severe headache, circumoral paresthesia, and (PBSC) transplantation. The conditioning regimen consisted of: cyclophosphamide 2 g/m 2 in 5% dextrose injec-facial flushing during high-dose carmustine (BCNU) infusion as part of the preparative regimen for autolog-tion USP (D5W) 500 cc i.v. over 2 h on days −6 to −4, thiotepa 240 mg/m 2 in 0.9% sodium chloride USP 250 cc ous peripheral blood stem cell (PBSC) transplantation for metastatic breast cancer. Five patients responded to i.v. over 4 h on days −6 to −4, and BCNU 150 mg/m 2 in D5W 500 cc i.v. over 2 h on days −6 to −4. Day 0 rep-pain medications, including partial and complete opiate receptor agonists. Premedication of subsequent doses of resented the day of transplantation. During the infusion of BCNU, the patient developed a unilateral frontal crushing BCNU with corticosteroids, pain medications, or benzodiazepines lessened, but did not prevent the same symp-headache, circumoral paresthesia, photophobia, and facial flushing. The patient was treated with propoxyphene 130 toms from recurring. The incidence and mechanism of this toxicity are unknown, but this adverse syndrome mg p.o. and hydromorphone 1 mg i.v. which relieved the pain. Laboratory values were within normal limits. Sub-should be considered when administering high-dose BCNU infusions. sequent doses of BCNU were pre-medicated with hydromorphone 0.5 mg i.v. and hydrocortisone 50 mg i.v. The

Sensory disturbances such as paresthesia, anesthesia, hypoesthesia, and hyperesthesia may be present in the oral cavity. Paresthesia is defined as a burning or prickling sensation or partial numbness caused by neural injury. Paresthesia in dentistry can be caused by local or systemic factors. Local factors include traumatic injuries such as mandibular fractures, expanding compressive lesions (benign or malignant neoplasia and cysts), impacted teeth, local infections (osteomyelitis, periapical, and peri-implant infections), iatrogenic lesions after tooth extractions, anesthetic injection, endodontic therapy (overfilling and apical surgery), implantology, orthodontic surgery, and preprosthetic surgery. The main purpose of this case report is to present the treatment and resolution of a mental nerve paresthesia stemming from apical pathosis of a mandibular canine tooth and the follow-up of 3 years. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e28-e31)

Tarlov or perineurial cysts are pathological formations located in the space between the peri-and endoneurium of the spinal posterior nerve root sheath at the DRG. These lesions have been estimated to affect between 4.6 and 9% of the adult population. Although originally believed by Tarlov 39 to be asymptomatic lesions, these cysts, when present in the sacral neural canal and foramina, have since been found to cause a variety of symptoms, including radicular pain, paresthesias, and urinary or bowel dysfunction. The development of CT myelography has led to an improvement in our ability to diagnose "Tarlov cysts" as a cause of sacral radiculopathy. Although the term Tarlov cyst has often been erroneously applied to other cystic spinal lesions, the distinctive feature of the Tarlov perineurial cyst is the presence of spinal nerve root fibers within the cyst wall, or the cyst cavity itself. [37] Despite advancements in diagnosis, there remains a great deal of controversy regarding the optimal treatment of symptomatic Tarlov cysts. Nonsurgical therapies include lumbar CSF drainage 2,4 and CT scanning-guided cyst aspiration, 23,24 neither of which prevents symptomatic cyst recurrence. Neurosurgical techniques for symptomatic perineurial cysts include simple decompressive laminectomy, 33 cyst and/or nerve root excision, 37, and microsurgical cyst fenestration and imbrication. Although no consensus exists on the definitive treatment of symptomatic Tarlov cysts, we believe surgical methods have yielded the best long-term results to date. We describe the case of one patient with a symptomatic Tarlov cyst to illustrate the surgical treatment involving cyst fenestration, partial resection of the cyst wall, and myofascial-cutaneous flap closure reinforcement. We also review the literature, summarizing various theories on the origin and pathogenesis of Tarlov cysts, and assess current treatment options.

Neuropathy in rheumatoid arthritis (RA) may result secondary to entrapment, vasculitis, and drug toxicity. We aimed to study clinical and electrophysiological neuropathy and pathological changes in sural nerve in patients with RA. One hundred eight patients of RA, fulfilling American College of Rheumatology 1987 criteria (mean age, 45.83 years; M/F 1:3, 80.3% seropositive) were examined clinically and electrophysiologically for evidence of peripheral neuropathy. Sural nerve biopsies were performed in the involved cases. In all RA patient medications, disease activity, results of blood tests, and X-rays of affected joints were recorded. Twenty-three patients complained of paresthesias in the extremities. Vibration sensations were decreased in 9, and tendon reflexes were decreased or absent in 28 patients. Sixty-two (57.4%) patients had electrophysiologic evidence of neuropathy. Of these 53 (85.5%) patients had pure sensory or sensory motor axonal neuropathy (mononeuritis multiplex, n = 7), while 9 (14.5%) had demyelinating neuropathy (chronic inflammatory demyelinating polyneuropathy, n = 1). Carpal tunnel syndrome was seen in 11 (10.1%) patients (associated with neuropathy in 6). Of 23 sural nerve biopsies available, perineurial thickening (n = 5, amyloid deposits n = 4), perivascular lymphomononuclear cell infiltrate (n = 4), loss of myelin fibers (n = 2), and necrotizing vasculitis (n = 1) were found. Clinically, however, seven patients had evidence of cutaneous vasculitis. Comparing the clinical characteristics of the patients with or without electrophysiological neuropathy, absence of deep tendon jerks (p < 0.005) and presence of extra articular manifestations (p < 0.01) were conspicuous in the neuropathic group. There was no relation of neuropathy with the duration of RA, seropositivity, joint erosions, joint deformities, prior disease-modifying anti-rheumatic drugs or glucocorticoid intake, and 28-joint disease activity score. Neuropathy in RA was mostly subclinical and predominantly axonal. Pathologically, neuropathy secondary to amyloid infiltration was second only to vasculitic neuropathy. Absence of deep tendon jerks and presence of vasculitis were more commonly observed in patients with neuropathy.

and Stony Brook, NY Purpose: Endovenous laser treatment is a minimally invasive technique for ablation of the incompetent great (GSV) and small saphenous vein (SSV). Compared with the GSV, fewer data are available on SSV laser ablation and are not validated. This multicenter prospective study evaluated the feasibility, safety, and efficacy of endovenous laser ablation to treat SSVs. patients (229 limbs) with CVD and incompetent SSVs (evaluated by the CEAP classification) who were eligible for surgery underwent consecutive laser ablation procedures. Many required additional treatment for varicose tributaries and perforator veins with phlebectomy and foam sclerotherapy, Energy was delivered to the vein wall by a 600-m optical fiber using 810-nm or 980-nm diode laser. Ablations were performed with duplex ultrasound (DU) guidance and tumescent anesthesia. Follow-up was with clinical examination and DU imaging. Results: DU imaging showed immediate occlusion of the SSV with no thrombosis in the proximal veins. No complications occurred intraoperatively. All patients had postoperative ecchymosis, but it was minimal. Three patients had distal thrombotic complications. Superficial phlebitis after complementary surgery occurred in three cases. Complete occlusion with absence of flow <2 months of follow-up was detected in 226 SSV (98.7%). It occurred 22 in patients with large SSV diameter. Recanalization was found in one patient at 12 months and in two patients at 24 months. Seven limbs had reflux in previously treated areas, treated segments, and segments in continuity with them. Three underwent an intervention to correct symptomatic reflux. The other four had no symptoms. After 1 year, eight limbs developed reflux in new locations and four underwent treatment. Symptoms resolved in most patients soon after the operation. The mean follow-up was 16 months (range, 2-39 months). After 8 to 12 months postprocedurally, the laser-treated veins were fibrotic and almost indistinguishable on DU imaging from the surrounding tissues. In five patients (2.25%) postoperative paresthesia occurred >2 to 3 days postoperatively and persisted in the follow-up. No paresthesia occurred in our last series whenever a larger amount of tumescent cold saline was infused around the vein. Conclusion: Endovenous laser ablation of the SSV has excellent early and midterm results. The prevalence of thrombosis and paresthesia is very low. Symptom relief is very good. ( J Vasc Surg 2009;49:973-9.) From the Istituto Flebologico Italiano, Ferrara Day Surgery, Ferrara a

Most clinicians dread seeing the patient presenting with a primary complaint of a burning pain on one or more oral mucosal surfaces. Unlike most other clinical conditions presenting in a dental office, burning mouth syndrome is poorly understood with few evidence based remedies. More recently, advances have been made towards clarifying the possible etiology of the disorder and testing the possible therapeutic modalities available. This article attempts to summarize the "state of the art" today.

Currently popular transsphenoidal approaches to the pituitary include sublabial, external rhinoplasty, alotomy, and transnasal techniques. The conventional sublabial approach remains the workhorse method despite postoperative lip edema, potential difficulty for denture wearers, and troublesome persistent upper lip and incisor teeth numbness. We traced the courses of the nasopalatine, infraorbital, and anterior superior alveolar nerves in 41 cadaveric half-head dissections to determine the exact contribution to upper lip and incisor teeth innervation. We then conducted a retrospective patient survey of 25 sublabial, 28 external rhinoplasty, 23 alotomy, and 12 transnasal approaches to the hypophysis to assess the incidence of upper lip and incisor teeth paresthesias lasting longer than I month. We conclude that rhinoplastic techniques are superior to the sublabial approach in limiting upper lip and incisor teeth numbness without compromising neurosurgical exposure for hypophysectomy. (Otolaryngol Head Neck Surg 1997;116:656-61 .) The pioneering efforts of Harvey Cushing and his impressive series of transseptal, transsphenoidal approaches to hypophyseal and sphenoidal lesions remain legendary neurosurgical advances of the twentieth century. 1 Since Cushing's first case report in 19092 of pituitary tumor removal in an acromegalic patient, the extracranial approach has been the preferred means of access to the hypophysis. Though Hirsch 3 and Dott and Bailey 4 were faithful adherents to this approach and reported large series of their own, Cushing eventually abandoned the technique because of technical limitations. Yet his keen insight predicted a return to this approach with appropriate scientific advances.

Objective. Earlier reports, including a preliminary study within our unit, have shown that the surgeon's experience is one of the most influential factors in determining the likelihood of both permanent inferior alveolar nerve (IAN) and lingual nerve (LN) paresthesia, following third molar surgery. The effect of this and other factors influencing such prevalence are assessed in this study. Study design. This prospective study involved 3236 patients who underwent surgical removal of impacted third molars. Patients' demographics and radiological parameters were recorded along with the grade of the treating surgeon. The prevalence of inferior alveolar and lingual nerves paresthesia at 1 month, 6 months, and 18 to 24 months postoperatively were also traced. Results. At 1 month postoperatively, the incidence of IAN paresthesia was 1.5% and the LN was 1.8%. These figures decreased over time and 18 to 24 months postoperatively, the incidence of permanent dysfunction of the IAN was 0.6% and LN was 1.1%. With regard to inferior alveolar nerve paresthesia, risk factors included the patient's age (26-30 years), horizontally impacted teeth, close radiographic proximity to the inferior alveolar canal (IAC), and treatment by trainee surgeons. With regard to the lingual nerve, risk factors included male patients, distoangular impactions, close radiographic proximity to the IAC, and treatment by trainee surgeons. Conclusion. One of the main risk factors of developing permanent sensory dysfunction in the distribution of these nerves is related to the surgical skills/experience of the operator. Other factors are associated with the type of

Various anatomic structures including bone, muscle, or fibrous bands may entrap and potentially compress branches of the mandibular nerve (MN). The infratemporal fossa is a common location for MN compression and one of the most difficult regions of the skull to access surgically. Other potential sites for entrapment of the MN and its branches include, a totally or partially ossified pterygospinous or pterygoalar ligament, a large lamina of the lateral plate of the pterygoid process, the medial fibers of the lower belly of the lateral pterygoid muscle and the inner fibers of the medial pterygoid muscle. The clinical consequences of MN entrapment are dependent upon which branches are compressed. Compression of the MN motor branches can lead to paresis or weakness in the innervated muscles, whereas compression of the sensory branches can provoke neuralgia or paresthesia. Compression of one of the major branches of the MN, the lingual nerve (LN), is associated with numbness, hypoesthesia, or even anesthesia of the tongue, loss of taste in the anterior two thirds of the tongue, anesthesia of the lingual gums, pain, and speech articulation disorders. The aim of this article is to review, the anatomy of the MN and its major branches with relation to their vulnerability to entrapment. Because the LN expresses an increased vulnerability to entrapment neuropathies as a result of its anatomical location, frequent variations, as well as from irregular osseous, fibrous, or muscular irregularities in the region of the infratemporal fossa, particular emphasis is placed on the LN. Clin. Anat. 24:143-150, 2011. V V C 2010 Wiley-Liss, Inc.

The combination of rapid, diffuse alopecia, and neuroiogic and gastrointestinal disturbance is pathognomonic for thailium toxicity. The hair mount, showing a tapered or t>ayortet anagen hair with black pigmentation at the base, may be highly diagnostic t>efore the onset of alopecia. We saw a 10-year-old boy who suffered from thallium poisoning.

Brow ptosis is a common aesthetic concern in aging patients, contributing to the perception of an angry, sad, or tired face. 1,2 A surgical browlift addresses the drooping brow and rejuvenates the upper face. The goal is to produce a long-lasting and aesthetically pleasing browlift with minimal complications.

Fibrolipomatous hamartoma is a rare benign neoplasm that in some cases is associated with macrodactylia. We describe a 31-years-old man who had a tissue enlargement in the wrist, second and third fingers of the left hand since infancy. At 23-years-old he began with continuous, progressive and high intensity pain that occurred more frequently at night, localized in the left hand. It was associated with paraesthesias and hypostesias predominantly at the fingers described above. Investigation with X-ray, ultrasonography, electrodiagnosis, magnetic resonance image of the left wrist and hand showed carpal tunnel syndrome with macrodactylia by fibrolipomatous hamartoma of the median nerve. The patient did not a have good response to clinical therapy, so he was submitted to a surgical decompression of the left carpal tunnel, and after three months of follow up is asymptomatic.

Palmar-plantar erythrodysesthesia (PPE) or hand-foot syndrome (HFS) is a relatively common side effect of cytotoxic chemotherapy. Many cytotoxic drugs have been reported to cause the condition but it is more frequently associated with 5 fluorouracil (5FU), liposomal doxorubicin and cytarabine. The oral 5FU precursor, capecitabine is frequently associated with PPE and with the recent extension of its use to adjuvant treatment, the incidence of PPE is likely to increase. The initial symptoms are dysesthesia and tingling in the palms, fingers and soles of feet and erythema, which may progress to burning pain with dryness, cracking, desquamation, ulceration and oedema. Palms of the hands are more frequently affected than soles of the feet. This condition is painful and distressing to patients and in some incidences it results in patients not being able to work or perform normal daily activities. It can also result in treatment interruptions which impact on the efficacy of the treatment regimen. Effective and appropriate patient education from a specialist nurse prior to treatment is an essential part of patient management which will facilitate early identification of the symptoms and therefore prevent treatment delays and PPE progression. This article reviews current knowledge of the condition, including classification, and discussion of the findings of a clinical audit in a cancer centre. It includes the incidence, grading, management and impact of PPE on normal daily activities.

Objective: To investigate the role of skin biopsy in nitrofurantoin peripheral neuropathy. Design: We describe the clinical features and skin biopsies of 2 cases of non-length-dependent smallfiber neuropathy/ganglionopathy attributable to nitrofurantoin.

Envenomation by the North American coral snake is an uncommon entity in the United States. In most cases fang marks will be present, although they may be quite small and difficult to see. The case of a young man who demonstrated evidence of envenomation following the bite of a Texas coral snake (Aficrurus fulvius fenere), despite the absence of any apparent fang marks on close examination, is reported. The problems associated with coral snake envenomation in terms of diagnosis and management are reviewed. (Am J Emerg Med 1989;7:402-405. 0 1989 by W.8. Saunders Company.)