Facial Nerve Schwannoma Extending to Jugular Foramen: A Case Report

Facial nerve schwannoma (FNS) is a benign, slow-growing schwannoma that originates from Schwann cells. Facial nerve schwannoma is the most common tumor of the facial nerve but rare and only accounts for 0.15% to 0.8% of intracranial neurinomas. It may be manifested as asymmetric hearing loss, facial palsy, and hemifacial spasm. A 56-year-old woman was transferred to our department, because of pain behind the right ear and spasm of the right lateral muscle for more than 2 years and pulsatile tinnitus for half a year. Based on the preoperative medical history, physical signs, and auxiliary examination, it was diagnosed with jugular foramen (JF) space-occupying lesion. We removed the tumor through the infratemporal fossa type A approach and found that the tumor originated from the facial nerve. After the tumor resection, sural nerve transplantation was performed. The patient demonstrated postoperative facial palsy (House-Brackman grade VI) and was smoothly discharged after good recovery. Facial nerve schwannoma rarely invades the JF, and the most common tumor in the JF is the glomus jugular tumor, followed by the posterior cranial schwannoma. They have common symptoms, making it difficult to obtain a correct diagnosis. Clinical data, medical history, and auxiliary examinations should be carefully analyzed to avoid misdiagnosis or mistreatment. Infratemporal fossa type A approach is an effective method for treating FNS of JF.

The effect on the electroactivity of the abdominal muscles of the level of connective tissue dysplasia and the method of combined hernioplasty of the inguinal hernia

Introduction. Combined methods of hernioplasty appear to be a promising surgical treatment of inguinal hernias, allowing reducing suture tension due to the contraction and stretching of the abdominal muscles optimized during the operation. This protects the inguinal region from relapse in severe connective tissue dysplasia.The aim of research was to study the influence of the level of connective tissue dysplasia and methods of combined hernioplasty of inguinal hernias on the electroactivity of the abdominal muscles.Methods. The study included 151 patients with inguinal hernias. The electroactivity of the abdominal muscles and the level of severity of connective tissue dysplasia were studied in these patients before and after combined methods of hernioplasty according to Milkovskaya Dmitrova diagnostic scheme; this also includes tension-reducing mechanism.Results. In the preoperative period, the decrease in the parameters of electromyograms compared to the healthy side in the inguinal region was 67.2%, compared to the region over the group of lateral muscles - 55% and compared to the region over the rectus abdominis muscles - 23.6%. The increase in the electrical activity of the rectus muscles against the background of a decrease in the severity of connective tissue dysplasia to the middle and light levels obtained 43.5% and 77.9%, respectively.The average frequency parameters of electromyograms of the abdominal muscles after combined tension-reducing hernioplasty of inguinal hernias seemed to be most significant: in the inguinal regions on the side of the hernia they amounted to 91.95 7.1 vibrations per second, in the region over the group of lateral muscles - 94.61 4.6/s and in the region over the rectus abdominis muscles - 93.7 2.9/s. Moreover, approximately similar rehabilitation of the rectus and lateral abdominal muscles was reported, which allowed balancing oppositely directed tension forces in the abdominal wall.Conclusion. Thus, in patients with inguinal hernias before surgery, the decrease in the electroactivity of the lateral muscle group was more pronounced than the decrease in the electroactivity of the rectus abdominis. The combined tension-reducing hernioplasty of inguinal hernias contributed to the most significant electromyographic rehabilitation of the abdominal muscles.

Elusive Diagnosis of Superficial Peroneal Nerve Entrapment (Case Report)

Isolated neuropathy of the superficial peroneal nerve (SPN) is a relatively rare type of peripheral neuropathy. It is linked to the mechanical entrapment of the SPN in predisposed locations of its anatomical pathway. Associated clinical findings are insufficient lifting of the latero-dorsal part of the foot, stepping on the lateral border of the foot, and commonly, a strong pain localized in the nerve dermatome.Case report. We describe a case of a 14-year-old female patient with right leg pain lasting 24 months. Repeated neurological examinations with negative findings on electromyography (EMG) were performed. The patient underwent a Steindler surgery for a suspected diagnosis of a heel spur, without any improvement. Despite complex pharmacotherapy, chronic pain developed. The patient was unable to walk, being bound to a wheelchair. Amputation of her lower limb under the knee was also considered. SPN entrapment was diagnosed at a physical examination at EuroPainClinics. Decompression of the SPN under local anaesthesia was performed at the clinic.Results. The symptoms improved immediately after the procedure, and following 2 months of rehabilitation, the patient was completely symptom-free. Her clinical state remains unchanged until this day.Conclusions. SPN entrapment is not a common diagnosis in the group of pain syndromes. Regarding the lower limb, it is imperative to include it on the list of differential diagnoses in cases of pain and functional disorders of the lateral muscle groups of the calf and leg. In the case of SPN entrapment, EMG findings may be negative.

INFLUENCE OF KINESITHERAPY ON PATIENTS WITH GONARTHROSIS

Degenerative changes in articular cartilage occur as a result of loss of mechanical resistance to it, resulting in a disruption of the degeneration and regeneration processes of the articular cartilage and are characterized by pain and impaired joint function. It begins as a degenerative alteration of the cartilage that subsequently reflects changes in the bone structures of the joints. In the acute period, joint immobilization is applied, isometric exercises of certain muscle groups are performed. Active and passive flexion and extension exercises are used to increase knee range of motion. Isotonic exercises are used to increase muscle strength and auxiliaries are used until muscle strength returns. Primary and secondary prophylaxis is applied, which includes weight regulation, prevention of articular cartilage and strengthening of knee stabilizer muscles, mainly of the medial and lateral muscle groups. The aim is to study the efficacy of CT based techniques of rehabilitation to improve the functional status of patients with GA. Material and methods: The study included 24 patients (18 women and 6 men) with gonarthrosis who were treated for one month approach. Patients were selected according to several criteria in order to have homogeneity of the study: to be between 45 and 65 years of age; have diagnosed gonarthrosis (unilateral and / or bilateral); not have severe cardiovascular and respiratory insufficiency as well as severe cognitive impairment; have stable hemodynamics, and arterial pressure is below 140/90; to move without auxiliary means. For the purposes of the study, a complex set of diagnostic methods is applied, and the results from which are evaluated on day 1, day 10, and month 1 of treatment are shown in a worksheet. Motor and balance options are assessed by: one-leg standing balance test, manual muscle test (MMT) of m.quadriceps femoris, circumcision centimeter 10cm above knee, knee mobility test - ° (°). A kinesiotherapy method is used in the study group. It is based on the basic principles of modern rehabilitation Results and Discussion: The presented results provide an opportunity to analyze the effect of applied kinesiotherapy. The specialized kinesiology method stabilizes permanently functional motor revascularization and equilibrium opportunities in patients with GA. Conclusion: The presence of positive change in all parameters was observed after the administration of specialized kinesiotherapy in all subjects. A thorough and in-depth analysis of the results provides us with the basis for claiming that kinesiotherapy has both a wounded and a late therapeutic effect associated with the continuity of application, the structure of administration and the appropriateness of the kinesis involved.

8. Myositis as an idiosyncratic drug reaction to leflunomide

Introduction Myositis is a broad diagnosis with a number of potential causes. There are numerous drugs that can lead to myotoxicity. We discuss a case of a patient with known rheumatoid arthritis who developed myositis with no evidence of an additional autoimmune condition and where the most likely cause seems to be leflunomide. Case description A 46-year-old Asian lady with a background of seropositive rheumatoid arthritis and overactive bladder developed increasing muscle weakness. Disease activity was well-controlled on leflunomide which had been started four years ago after an initial trial of methotrexate proved ineffective. Other regular medications include tolterodine and rigevidon (combined oral contraceptive pill), paracetamol and co-codamol. She presented to her GP in February with generalised muscle weakness, fatigue, dry mouth, hair loss and occasional shortness of breath on exertion. Blood tests showed elevated CK at 1132 u/l, ALT 57 u/l (AST normal), LDH 302 u/L, CRP 4 mg/l and ESR 25mm/h. Further tests were subsequently arranged following rheumatology review including ANA and ENA (both negative), an extended myositis panel and HMGCoAR antibodies (also negative). MRI of her lower limbs showed bilateral oedema within the anterior and lateral muscle compartments of her thighs, worse on the left, and in keeping with myositis. Given the possibility of leflunomide being the cause of her symptoms it was stopped. Her CK one month after stopping leflunomide had decreased to 819 u/l and then 389 u/l after four months. The patient reported improvement in her muscle weakness, CK is currently being monitored, and she is awaiting an EMG. A muscle biopsy has been discussed with her previously and although she had refused initially, in view of persistent mild elevation in CK, the biopsy and leflunomide washout will be discussed again with her again. As she is clinically asymptomatic and not keen to try new medications, further immunosuppression has not been started. Discussion Myositis is seen in a wide range of conditions with numerous possible causes. It can be drug-induced, secondary to viral infections or caused by autoimmune conditions including overlap conditions and idiopathic inflammatory myopathies. Drug-induced myositis is most commonly associated with statins, but has been seen with many different medications. Leflunomide is a disease-modifying anti rheumatic drug used particularly in the treatment of inflammatory arthritis but has also been used in treatment resistant dermatomyositis. It inhibits the mitochondrial enzyme, dihydroorotate dehydrogenase to reduce the reproduction of rapidly dividing cells. A rise in CK is considered a common side effect. We have only found one other case report where leflunomide was suspected to have induced polymyositis, also in a patient with rheumatoid arthritis. Both biochemical and clinical improvement following cessation of leflunomide, with no other inventions raises the likelihood of this being a leflunomide-induced myositis. Key learning points When faced with a patient with rheumatoid arthritis presenting with symptoms suggestive of myositis, whilst an overlap autoimmune condition is a possibility, it is important to consider potential drug causes. Numerous drugs have been implicated through both direct myotoxicity and immunologically mediated myotoxicity. Importantly for rheumatologists these can include glucocorticoids, antimalarial drugs, colchicine and tumour necrosis factor inhibitors. According to the summary of product characteristics a rise in CK is commonly seen with leflunomide but clinical myositis has only been reported rarely. Conflicts of interest The authors have declared no conflicts of interest.

Structural and physical-functional deficits in lower limbs with fractures and treated surgically

Introduction: A fracture is a traumatic bone injury that can occur from a variety of causes. Although the repercussions of fractures on the musculoskeletal system are documented, studies with more comprehensive outcomes and later stages of injury are still scarce. Objective: To evaluate the structural and physical-functional adaptations in individuals who suffered unilateral lower limb fractures treated surgically. Methods: Thirty-two patients of both genders, aged between 18 and 59 years, with a diagnosis of unilateral fracture of the lower limb and hospital discharge of at least one year, participated in the study. The affected lower limb was compared to the healthy lower limb of all participants using the outcome measures: vastus lateral muscle thickness (ultrasonography), knee extension and flexion strength (isokinetic dynamometer), ankle dorsiflexion range of motion of the distance from the foot to the wall) and functional fitness of the lower limb (single and triple horizontal jump test). Results: Statistically significant differences were found between the limbs affected and not affected in the measurements of muscle thickness (p = 0.0001), knee extension force (p = 0.0094), dorsiflexion amplitude (p = 0.0004) and functional performance (p = 0.0094, single jump and = 0.0114, triple jump). In all significant outcomes, the values of the affected limb were smaller than that of the non-affected limb. The peak torque of the knee flexor muscles did not show a statistically significant difference between limbs (p = 0.0624). Conclusion: Individuals who have undergone a surgically treated unilateral fracture of the lower limb present important structural and physical-functional late changes in relation to the non-affected limb.