Chvostek's and Trousseau's Signs

A 38-year-old man presented to the emergency department with facial paresthesias and upper-extremity muscle cramping. His symptoms were progressive, beginning as mild paresthesias on postoperative day 1 by the time he presented, they had been getting worse for about 24 hours. His medical history was noteworthy only for papillary thyroid carcinoma, for which he had undergone a total thyroidectomy 2 days earlier. Physical examination revealed apparent Chvostek's sign (Figure 1A and Video 1) and Trousseau's sign (Figure 1B and Video 2), a result of postsurgical acquired hypoparathyroidism. His total calcium level was 5.8 mg per deciliter (normal range, 8.4 to 10.3) (1.45 mmol per liter [2.1 to 2.6]), his free calcium level was 1.68 mEq per liter (normal range, 2.24 to 2.64) (0.84 mmol per liter [1.12 to 1.32]), and his serum phosphate level was 6.6 mg per deciliter (normal range, 2.7 to 4.5) (2.13 mmol per liter [0.87 to 1.45]). The parathyroid hormone level was 7 pg per milliliter (normal range, 15 to 65).

Gradenigo syndrome

A 28-year-old woman presented with fever, double vision, and facial pain. Neurologic examination showed neck stiffness, pain in the distribution of the right trigeminal nerve, and right abducens palsy (figure 1). Tympanic membranes were normal. MRI revealed sphenoid sinusitis, basilar pachymeningitis, and clivus osteomyelitis (figure 2). CSF analysis showed pleocytosis, increased protein contents, decreased glucose levels, and positive cultures for Staphylococcus aureus. The triad of suppurative otitis media, pain in the distribution of the trigeminal nerve, and abducens palsy is called Gradenigo syndrome.¹ While it most often affects children, it may occur in adults and may rarely present without otitis media.² While bone compromise is usually confined to the petrous apex, it may extend to sphenoid sinuses, clivus, and basal meninges.

Figure 1

Photograph of the patient shows isolated right abducens palsy

Figure 2 Head MRI

Contrast-enhanced T1-weighted MRI of the head shows mucosal thickening of sphenoid sinuses (arrowheads), basilar and right middle fossa pachymeningitis (small arrows), and osteomyelitis of the clivus (large arrow). While the right abducens nerve is not well visualized, it could be inferred in the axial sections (upper row) that it is entrapped throughout the Dorello channel and the cavernous sinus.

 

Acute Adie syndrome

Parasympathetic denervation of the iris sphincter muscle in Adie syndrome results in an enlarged tonic right pupil reacting poorly to light (A, B). Near response was also impaired (C). It is supersensitive to cholinergic agents (pilocarpine 0.1%) (D). Paralysis of the iris results in characteristic segmental vermiform movements. These are visible superolaterally acutely and inferomedially 6 months later

Clinical assessment of pain

Successfully treating chronic pain is challenging, as patients respond heterogeneously to analgesic treatments. Such variation in response can be attributed to differing underlying pain-generating mechanisms. A novel clinical bedside test that identifies distinct pain phenotypes might help deliver more-effective mechanism-based treatment strategies.

Bilateral facial nerve palsy

Foix-Chavany-Marie (bi-opercular) syndromeIn 1926, Foix, Chavany, and Marie described an acquired syndrome of faciopharyngoglossomasticatory diplegia, caused by bilateral infarction of the anterior operculum (eg, anterior choroidal artery infarction). Clinical features included: facial diplegia, dysarthria, pseudobulbar palsy, cognitive deficits, and seizures. Foix-Chavany-Marie syndrome is also known as the biopercular syndrome (descriptively based on the typical associated lesions affecting the anterior operculum bilaterally) or faciopharyngoglossomasticatory diplegia with automatic voluntary association (descriptively based on the clinical features). Essentially this is a cortico-subcortical type of suprabulbar palsy.

Visually-evoked rooting

The group of reflexes collectively known as "primitive reflexes", reviewed by Schott and Rossor,2 include the grasp, snout, palmomental, and rooting reflexes. They are usually associated with neurodegenerative diseases causing dementia and, as the authors point out, loosely linked to frontal lobe pathology, but their exact physiological and anatomical substrates are poorly understood.
The well known tactile-evoked rooting reflex is the movement of both lips towards the examiner’s finger when stroking the lateral side of the upper lip. However, there has been very little written about the related phenomenon of visually-evoked rooting.

Examine eye movements

As with all aspects of the neurological examination, important clues come from a thorough and appropriate history. In relation to eye movement disorders the patients may be complaining of double vision, in which case they should be asked whether it is constant or intermittent; does it occur, or is it maximal, in certain directions of gaze; what is the relationship of one image with the other; and have they tried covering one eye and did that relieve the symptom? A less frequently reported symptom is oscillopsia, an illusion of movement of stationary objects, when enquiries need to be made whether the movement is horizontal or vertical, and does it become maximally apparent in certain positions of gaze, as for example in downbeat nystagmus when the oscillopsia is maximal on down gaze.