Radiation-induced cranial neuropathies manifesting as baroreflex failure and progressive bulbar impairment.

INTRODUCTION: Baroreflex failure and bulbar palsy have been rarely reported as potential complications of radiotherapy for head and neck tumors. However, the occurrence of both disorders in the same patient has not been well described. We present a unique patient with radiation-induced cranial neuropathies, resulting in bulbar palsy and baroreflex failure. CASE REPORT: A 67-year-old man underwent surgical resection of tonsillar squamous cell carcinoma and postoperative radiation therapy. Six years later, he developed severe orthostatic hypotension with syncope, followed later by progressive bulbar impairment. EMG showed myokymic discharges in the tongue, and marked orthostatic hypotension was noted on tilt-table testing. CONCLUSION: Progressive bulbar impairment and baroreflex failure can occur following radiotherapy for head and neck cancers. Furthermore, these manifestations of radiation injury can occur in the same patient.

Spinal accessory neuropathy associated with deep tissue massage: a case report.

Spinal accessory neuropathy (SAN) causes impaired arm mobility and pain. The spinal accessory nerve is often injured during surgical procedures such as neck dissection for tumor resection or cervical lymph node biopsy. Other traumatic injuries may also occur. SAN causes weakness of the trapezius muscle and, less frequently, of the sternocleidomastoid muscle. The clinical consequence of trapezius muscle weakness includes impaired stability of the scapula leading to upper limb dysfunction and pain. We present a rare and illustrative case of SAN associated with deep tissue massage leading to scapular winging and droopy shoulder as a result of weakness of the trapezius muscle.

Adjunctive haloperidol prophylaxis reduces postoperative delirium severity and duration in at-risk elderly patients.

BACKGROUND: Delirium is a potentially life-threatening syndrome that is particularly common in elderly hospitalized patients, especially those with preexisting neurologic disorders. Nonpharmacological tactics can reduce the incidence and severity of delirium in acute care settings and antipsychotic drugs are widely used to treat established delirium. More effective preventive strategies could notably impact morbidity, mortality, and health care costs. OBJECTIVE: To determine whether antipsychotic drug prophylaxis reduces the incidence and severity of postoperative delirium in at-risk elderly patients. METHODS: We addressed the objective through development of a structured critically appraised topic that included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of cognitive disorders. RESULTS: One randomized controlled trial addressed the question. In at-risk patients aged >70 years, oral haloperidol 0.5 mg TID, administered from up to 72 hours preoperatively until the third postoperative day, did not alter the incidence of postoperative delirium (15.1%) compared with placebo (16.5%; relative risk 0.91; 95% confidence interval 0.59-1.44). However, the study was underpowered for this primary outcome, possibly because both groups received nonpharmacological delirium prevention strategies. Haloperidol significantly reduced delirium severity ratings, delirium duration (from a mean of 11.8 to 5.4 days), and length of hospital stay in affected participants (from 22.6 to 17.1 day). CONCLUSION: Adjunctive low-dose haloperidol prophylaxis reduces delirium severity, duration, and subsequent hospitalization length in elderly at-risk patients. Further study is needed to determine the optimal pharmacological approach, combination with nonpharmacological strategies, and generalizability to other settings.