Post-parotidectomy facial nerve rehabilitation outcomes: Comparison between benign and malignant neoplasms.

BACKGROUND: Facial nerve dysfunction can be a devastating trouble for post-parotidectomy patients. OBJECTIVE: To assess rehabilitation outcomes concerning patients with post-parotidectomy facial nerve dysfunction, comparing benign versus malignant neoplasms. METHODS: Prospective study enrolling adults who underwent parotidectomy with facial nerve sparing between 2016 and 2020. The Modified Sunnybrook System (mS-FGS) was used for facial assessments. Physiotherapy began on the first post-operative day with a tailored program of facial exercises based on Neuromuscular Retraining, to be performed at home 3 times/day. From the first outpatient consultation, Proprioceptive Neuromuscular Facilitation was added to the treatment of cases with moderate or severe facial dysfunctions. RESULTS: Benign and malignant groups had a statistically significant improvement in mS-FGS (p < 0.001 and p = 0.005, respectively). There was no significant difference between groups regarding treatment duration or number of physiotherapy sessions performed. The history of previous parotidectomy resulted in more severe initial dysfunctions and worse outcome. Age over 60 years and initially more severe dysfunctions impacted the outcome. CONCLUSION: Patients with benign and malignant parotid neoplasms had significant and equivalent improvement in postoperative facial dysfunction following an early tailored physiotherapy program, with no significant difference in the final facial score, treatment duration, or number of sessions required.

Functional ataxia in a specialized ataxia center.

BACKGROUND: Functional gait is a disorder of ambulation and balance internally inconsistent and incongruent with the phenotypic spectrum of neurological gait disorders. OBJECTIVES: This paper aims to clinically characterize patients with functional ataxia. METHODS: Patients with functional ataxia were analyzed out of 1350 patients in Ataxia Unit of the Federal University of São Paulo circa 2008 to 2022. RESULTS: Thirteen patients (1 %) presented with functional ataxia; all female, with a median age of 34.8 years. Six (46.2 %) had psychiatric comorbidities and 7 (53.8 %) endorsed a trigger. Diagnostic features included variable base and stride (100 %), "huffing and puffing" (30.7 %), knee-buckling (30.7 %), uneconomic posturing (38.5 %), tightrope walking (23 %), and trembling gait (15.4 %). Remarkably, no falls were reported in any case. 53.8 % recovered fully or partially, despite no treatment. CONCLUSIONS: Variability of base and stride are universal features of functional ataxia, yet falls are inconspicuous. Functional Ataxia is rare even in a specialized ataxia center.

Post-parotidectomy facial nerve function: comparison between original and modified Sunnybrook Facial Grading Systems.

BACKGROUND: Facial nerve dysfunction is the principal postoperative complication related to parotidectomy. OBJECTIVE: To test the hypothesis that the modified Sunnybrook Facial Grading System (mS-FGS) is superior to the original S-FGS in the assessment of facial nerve function following parotidectomy. METHODS: Prospective, longitudinal study evaluating patients with primary or metastatic parotid neoplasms undergoing parotidectomy with facial nerve-sparing between 2016 and 2020. The subjects were assessed twice, on the first postoperative day and at the first outpatient evaluation, 20-30 days post-surgery. Facial assessments were performed using the original and modified (plus showing the lower teeth) versions of the Sunnybrook System and documented by pictures and video recordings. Intra- and inter-rater agreements regarding the assessment of the new expression were analyzed. RESULTS: 101 patients were enrolled. In both steps, the results from the mS-FGS were significantly lower (p < 0.001). Subjects with a history of previous parotidectomy and those who underwent neck dissection had more severe facial nerve impairment. The mandibular marginal branch was the most frequently injured, affecting 68.3% of the patients on the first postoperative day and 52.5% on the first outpatient evaluation. Twenty patients (19.8%) presented an exclusive marginal mandibular branch lesion. The inter-rater agreement of the new expression assessment ranged from substantial to almost perfect. The intra-rater agreement was almost perfect (wk = 0.951). CONCLUSION: The adoption of the Modified Sunnybrook System, which includes evaluation of the mandibular marginal branch, increases the accuracy of post-parotidectomy facial nerve dysfunction appraisal.

ANTECEDENTES: A disfunção do nervo facial é a principal complicação pós-operatória relacionada à parotidectomia. OBJETIVO: Testar a hipótese de que o sistema Sunnybrook de graduação facial modificado (mS-FGS) é superior ao S-FGS original na avaliação da função do nervo facial após parotidectomia. MéTODOS:: Estudo longitudinal prospectivo avaliando o pós-operatório de pacientes com neoplasias parotídeas primárias ou metastáticas, submetidos à parotidectomia com preservação do nervo facial, entre 2016 e 2020. Os indivíduos foram avaliados duas vezes, no primeiro dia de pós-operatório e na primeira avaliação ambulatorial, 20-30 dias após a cirurgia. As avaliações faciais foram realizadas usando as versões original e modificada (que incluem mostrar os dentes inferiores) do sistema Sunnybrook e documentadas por fotos e vídeos. Foram adicionalmente analisadas as concordâncias intra e interexaminadoras da avaliação da nova expressão. RESULTADOS: Cento e um pacientes foram incluídos. Em ambas as etapas, os resultados do mS-FGS foram significativamente menores (p < 0,001). Indivíduos com história de parotidectomia prévia e aqueles submetidos ao esvaziamento cervical apresentaram comprometimento mais grave do nervo facial. O ramo marginal mandibular foi o mais afetado, acometendo 68,3% dos pacientes no primeiro dia de pós-operatório e 52,5% na primeira avaliação ambulatorial. Vinte pacientes (19,8%) apresentaram lesão exclusiva do ramo marginal mandibular. A concordância interexaminadores da avaliação da nova expressão variou de substancial a quase perfeita. A concordância intraexaminador foi quase perfeita (wk = 0,951). CONCLUSãO:: A adoção do sistema Sunnybrook modificado, que inclui a análise do ramo marginal mandibular, aumenta a precisão da avaliação da disfunção do nervo facial pós-parotidectomia.

Prosper Menière: the man who located vertigo in the inner ear.

Since the Greek Aellus Galenum (129 AD - c.200/c.216), vertigo was considered a problem attributed to a cerebral disorder, diagnosed as the manifestation of apoplectiform cerebral congestion. In the mid-19th century, the Frenchman Prosper Menière changed this concept by placing the origin of this symptom in the inner ear. The main objective of this historical note is to highlight who Menière was, his work, and some aspects of the disease that bears his name.

Professor Faustino Esposel: Neurology, football and spiritualism.

Faustino Monteiro Esposel was a renowned neurologist from Rio de Janeiro, born on October 24, 1888. Together with his mentor, Professor Antônio Austregésilo Rodrigues Lima - the founder of modern Brazilian Neurology -, Professor Esposel described one of the rival signs of the Babinski sign, known as the Austregésilo-Esposel sign, in a study published in the renowned journal L'Encéphale in 1912. This article aims to summarize the life story of this illustrious neurologist as well as to highlight his achievements "beyond medicine".

Can clinical tests detect early signs of monohemispheric brain tumors?

BACKGROUND AND PURPOSE: Prior to modern neuroimaging, neurological treatment decisions were based on findings obtained from patient history and clinical examination. Despite the availability of sophisticated neuroimaging methods, to identify intracranial tumors the clinical recognition of associated subtle motor deficits is important for practice. Precise clinical tests are particularly advantageous, as some tumors may remain unnoticed for many. The purpose of this study was to determine the sensitivity and specificity of 13 clinical tests for detection of subtle motor deficits in patients with unilateral brain tumors. METHODS: Sixty patients with unilateral brain tumors without obvious focal signs and 30 controls with normal magnetic resonance imaging were examined. Thirteen clinical maneuvers described to detect motor deficits were performed and their sensitivity, specificity, and positive and negative predictive values were estimated. RESULTS: The test with greatest sensitivity and specificity (with 95% confidence interval) was the Digit Quinti Sign: 0.51 (0.41-0.61) and 0.70 (0.61-0.79), respectively. The agreement measurement among the 3 most sensitive signs (Digit Quinti Sign, Pronator Drifting Test, and Finger Rolling Test) was 21%. The Kappa index for these 3 tests indicated no significant concordance. CONCLUSIONS: The Digit Quinti Sign, the Pronator Drifting Test, and the Finger Rolling Test are simple yet very useful maneuvers that clinicians can perform at bedside. Even without apparent motor deficits, when present, these signs suggest that comprehensive investigation for intracranial neoplams should be undertaken.

Who was Pierre Marie?

In this manuscript we pay a tribute to Pierre Marie (1853-1940), highlighting his great contribution to medicine and neurology describing several diseases and syndromes. We mainly emphasize aspects of his personal life and personality traits. Considered one of the three greatest neurologists of the late nineteenth and early twentieth centuries, his brilliant career began at La Salpêtrière, followed by the development of a neurological school at Hospice Bicêtre. Pierre Marie had numerous disciples around the world, including Brazil, and published on various neurological and endocrinological themes. Back to La Salpêtrière, he concluded his professional life as a Neurology leader. However, after retirement, his demise was sad and lonely.

Professor Aristides Leão. Much more than spreading depression.

Professor Leão described cortical spreading depression (CSD) in 1944 and changed the way migraine pathophysiology is scientifically conceived. This Brazilian professor and researcher developed his career in Rio de Janeiro. Because of him, the city once became the CSD world capital, attracting scientists from many laboratories around the globe. Aristides Leão was first and foremost a naturalist, a man genuinely interested in birds, fishes, plants, shells, and neuroscience. He could easily fascinate whoever would come for a chat, leaving no question without answers. He was born in 1914 and died in 1993. This report focuses on his life, family, habits, and hobbies, describing a little of Leão apart from CSD and the year of 1944.

Robert Bárány, a scientist with many interests.

OBJECTIVE: Austrian-born Robert Bárány was a scientist with many interests. This article highlights some of these interests and also some personal traits. He enrolled as a surgeon in World War I, was captured by the Russians in 1915 and, while still in the prison camp, was awarded the 1914 Nobel Prize in Physiology or Medicine for his work in otology. In 1916, he accepted an offer from Uppsala University, Sweden, and worked there for almost 20 years. He died shortly before his 60th birthday, in 1936.

Guillaume-Benjamin Duchenne: a miserable life dedicated to science.

Duchenne de Boulogne is known mainly by the disease eponymously named "Duchenne muscular dystrophy", or pseudohypertrophic muscular dystrophy, although some experts consider that the original description of this disease does not belong to him. Less well known are the facts related to the tragic death of his beloved wife shortly after the birth of his only child, the unjustifiable distance he was forced to keep from this son for more than 30 years, and of being humiliated and professionally despised by his peers. These events made the life of this physician, physiologist, researcher and inventor extremely arduous. We emphasize some aspects of the history of this man, his work and his life, a true genius of few friends.

Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System.

OBJECTIVE: Facial nerve injury, affecting mainly the marginal mandibular branch, is the most frequent neurologic complication from parotidectomy. To test a modified Sunnybrook Facial Grading System as a new tool to assess the facial nerve function following parotidectomy, emphasizing the marginal mandibular branch. METHODS: We reviewed the medical records of 73 post-parotidectomy patients (40 female, 18-84 years old, mean age 53.2 years) with facial nerve sparing, referred to the Department of Physical Therapy. All patients had parotid neoplasms or advanced skin cancer, and were followed by the principal author between 2006 and 2014. RESULTS: The muscles innervated by the marginal mandibular branch were the most frequently affected (72.6%), particularly in patients undergoing neck dissection (p = 0.023). The voluntary movement scores obtained with the modified system were significantly lower compared with the original version (p < 0.001). The best and worst scores were observed in patients with benign parotid tumors and skin cancer, respectively. Patients requiring neck dissection (p = 0.031) and resection of other structures (p = 0.021) had the lowest scores, evidenced only with the modified version. Patients with malignant tumors had significantly worse ratings, regardless of the Sunnybrook system version. The post-physiotherapy analysis involved 50 patients. The worst facial rehabilitation outcomes were related to the marginal mandibular branch function. CONCLUSION: The modified Sunnybrook Facial Grading System improved the marginal mandibular branch assessment, preserving the evaluation of other facial nerve branches.

Intracranial meningiomas in children: ten-year experience.

Meningiomas are central nervous system neoplasms derived from arachnoid cap cells. They are the second most common brain tumors after gliomas, but are rare in children. Furthermore, meningiomas exhibit different behavior in this age group. From 1997-2007, 7 children with brain meningiomas were treated at the Department of Neurosurgery, Brazilian National Cancer Institute, Rio de Janeiro, Brazil. They represented 2.7% of all brain meningiomas, and 2.1% of all brain tumors, in children followed during this period at our institution. There were 4 boys, and the mean age at diagnosis was 7.3 years. Headaches, seizures, and motor deficits were the most frequent signs at presentation. All patients underwent surgery, and total resection was achieved in 6 of 7 patients. Most lesions were World Health Organization class I meningiomas. There were no deaths, and patients were asymptomatic or demonstrated mild motor or sensory signs at follow-up. In conclusion, meningiomas are rare in the pediatric population. Most of the lesions are low-grade, and the prognosis in this setting is good.

Lazarevic-Lasègue sign.

Charles Lasègue is reputed to have described the test/sign bearing his name, but he never wrote about it and misinterpreted its mechanism. The purpose of this note is to highlight the work of the Serbian, Laza Lazarevic, who was first to present the original report of this seminal sign in sciatica and provide its appropriate pathophysiological interpretation.

Babinski's hand sign: many have tried .

Recognizing the semiologic importance of the second, and most famous, sign described by Joseph Babinski - the extension of the hallux after stimulation of the plantar region in order to differentiate organic from pithiatic paralysis- several authors have tried to find a comparable signal in the hand. After 122 years, no one has succeeded.

Tumarkin-like phenomenon as a sign of therapeutic success in benign paroxysmal positional vertigo.

OBJECTIVES: To describe an unusual patient reaction to maneuvers used in the treatment of posterior canal benign paroxysmal positional vertigo (PC-BPPV) that we termed the "Tumarkin-like phenomenon". METHODS: At a private practice, 221 outpatients were diagnosed and treated for PC-BPPV. The treatment consisted of performing the Epley or Semont maneuvers. At the end of these maneuvers, when assuming the sitting position, the patients' reactions were recorded. RESULTS: Thirty-three patients showed a Tumarkin-like phenomenon described by a self-reported sensation of suddenly being thrown to the ground. In the follow-up, this group of patients remained without PC-BPPV symptoms up to at least 72 hours after the maneuvers. CONCLUSION: The occurrence of a Tumarkin-like phenomenon at the end of Epley and Semont maneuvers for PC-BPPV may be linked with treatment success.

Margaret Dix, Charles Hallpike and the 'Lagerungs' Manoeuvre.

The main objective of this manuscript is to describe some personal and professional aspects of two outstanding researchers and pioneers in neuro-otology. Among other achievements, Margaret Ruth Dix, and Charles Skinner Hallpike, designed the most-used provocative test for positional nystagmus for the diagnosis of lithiasis in the vestibular posterior semicircular canal.

Post-parotidectomy facial nerve function: comparison between original and modified Sunnybrook Facial Grading Systems / Função do nervo facial pós-parotidectomia: comparação entre os Sistemas Sunnybrook de Graduação Facial original e modificado

Abstract Background: Facial nerve dysfunction is the principal postoperative complication related to parotidectomy. Objective: To test the hypothesis that the modified Sunnybrook Facial Grading System (mS-FGS) is superior to the original S-FGS in the assessment of facial nerve function following parotidectomy. Methods: Prospective, longitudinal study evaluating patients with primary or metastatic parotid neoplasms undergoing parotidectomy with facial nerve-sparing between 2016 and 2020. The subjects were assessed twice, on the first postoperative day and at the first outpatient evaluation, 20-30 days post-surgery. Facial assessments were performed using the original and modified (plus showing the lower teeth) versions of the Sunnybrook System and documented by pictures and video recordings. Intra- and inter-rater agreements regarding the assessment of the new expression were analyzed. Results: 101 patients were enrolled. In both steps, the results from the mS-FGS were significantly lower (p < 0.001). Subjects with a history of previous parotidectomy and those who underwent neck dissection had more severe facial nerve impairment. The mandibular marginal branch was the most frequently injured, affecting 68.3% of the patients on the first postoperative day and 52.5% on the first outpatient evaluation. Twenty patients (19.8%) presented an exclusive marginal mandibular branch lesion. The inter-rater agreement of the new expression assessment ranged from substantial to almost perfect. The intra-rater agreement was almost perfect (wk = 0.951). Conclusion: The adoption of the Modified Sunnybrook System, which includes evaluation of the mandibular marginal branch, increases the accuracy of post-parotidectomy facial nerve dysfunction appraisal.

Resumo Antecedentes: A disfunção do nervo facial é a principal complicação pós-operatória relacionada à parotidectomia. Objetivo: Testar a hipótese de que o sistema Sunnybrook de graduação facial modificado (mS-FGS) é superior ao S-FGS original na avaliação da função do nervo facial após parotidectomia. Métodos: Estudo longitudinal prospectivo avaliando o pós-operatório de pacientes com neoplasias parotídeas primárias ou metastáticas, submetidos à parotidectomia com preservação do nervo facial, entre 2016 e 2020. Os indivíduos foram avaliados duas vezes, no primeiro dia de pós-operatório e na primeira avaliação ambulatorial, 20-30 dias após a cirurgia. As avaliações faciais foram realizadas usando as versões original e modificada (que incluem mostrar os dentes inferiores) do sistema Sunnybrook e documentadas por fotos e vídeos. Foram adicionalmente analisadas as concordâncias intra e interexaminadoras da avaliação da nova expressão. Resultados: Cento e um pacientes foram incluídos. Em ambas as etapas, os resultados do mS-FGS foram significativamente menores (p < 0,001). Indivíduos com história de parotidectomia prévia e aqueles submetidos ao esvaziamento cervical apresentaram comprometimento mais grave do nervo facial. O ramo marginal mandibular foi o mais afetado, acometendo 68,3% dos pacientes no primeiro dia de pós-operatório e 52,5% na primeira avaliação ambulatorial. Vinte pacientes (19,8%) apresentaram lesão exclusiva do ramo marginal mandibular. A concordância interexaminadores da avaliação da nova expressão variou de substancial a quase perfeita. A concordância intraexaminador foi quase perfeita (wk = 0,951). Conclusão: A adoção do sistema Sunnybrook modificado, que inclui a análise do ramo marginal mandibular, aumenta a precisão da avaliação da disfunção do nervo facial pós-parotidectomia.

Jean-Martin Charcot: the polymath / Jean-Martin Charcot: o polímata

Abstract Jean-Martin Charcot, widely regarded as a leading founder of modern neurology, made substantial contributions to the understanding and characterization of numerous medical conditions. His initial focus was on internal medicine, later expanding to include neuropathology, general neurology, and eventually emerging fields such as neuropsychology and neuropsychiatry. Furthermore, Charcot's intellectual pursuits extended beyond medicine, encompassing research in art history, medical iconography, sociology, religious studies, and the arts, solidifying his status as a polymath.

Resumo Jean-Martin Charcot, amplamente considerado como um proeminente fundador da neurologia moderna, fez contribuições substanciais para a compreensão e a caracterização de várias condições médicas. Seu foco inicial era a medicina interna, expandindo-se posteriormente para incluir a neuropatologia, a neurologia geral e, por fim, campos emergentes como a neuropsicologia e a neuropsiquiatria. Além disso, as buscas intelectuais de Charcot foram além da medicina, abrangendo pesquisas em história da arte, iconografia médica, sociologia, estudos religiosos e artes, solidificando seu status de polímata.

Dom João VI's death: convulsions and coma.

Dom João VI's death occurred in adverse political conditions that led to the regicide hypothesis. The main aim of this paper is to mention life style and conditions of the death of the king by means of narrative review based on primary and secondary sources. Dom João VI died in the way of convulsions and gastrointestinal symptoms. This could be the result of the pathological chain of genetic determination, accentuated by the inappropriate life style, obesity and sedentary habits, and/or poisoning. The finding of arsenic in high doses in his viscera favors the last hypothesis as the basic cause of death, but one can not discard the atherosclerosis predisposing risk factors for a final stroke.

Evaluation of the "spasticity of conjugate gaze phenomenon" in unilateral cerebral lesions.

The spasticity of conjugate gaze phenomenon (SCG) is a subtle motor ocular sign that usually indicates unilateral acute cerebral lesion. We analyzed the sensitivity of this sign in a prospective blinded study using 57 patients. All patients had monohemispheric brain lesions without resting deviation of the eyes and no motor complaints. Fourteen individuals without cerebral lesions were included as controls. Patients and controls were submitted to a brain magnetic resonance image. We observed SCG in just 1/57 (sensitivity of 1.7%), while all controls had a normal Bell's phenomenon. We speculate that SCG may disappear over time and is not useful to diagnose a long-lasting unilateral brain lesion.