Botulinum toxin A in the early treatment of sixth nerve palsy in type 2 diabetes

Purpose: Our study aims at evaluating the efficacy and safety of botulinum toxin A in the early treatment of sixth nerve palsy in type 2 diabetic patients. Methods: This study is a prospective and interventional clinical case series of patients presenting with acute onset of sixth cranial nerve palsy, who received injection botulinum toxin A. Results: Thirty-one cases were included in the study. 58% of the study subjects had incomplete palsy at presentation (abduction deficit -1 to -3) and 42% had complete palsy (-4 and -5). The median dosage of injection was 5 U (range 3--6 U). The median follow-up period is 2 months. The P value shows that there is statistically significant improvement in head turn, ocular deviation in primary position, and improvement in abduction between baseline and 1 week (P-value <0.001), 1 month (P-value <0.001) and 2 month (P-value <0.001) postinjection follow-up visits. 90.3% of patients had full resolution of symptoms in the last follow-up visit. 83.9% of patients were successfully treated. Conclusion: Early injection of botulinum toxin A in select patients with acquired sixth nerve palsy due to diabetes is a safe and efficient treatment option in alleviating symptoms, restoring function and quality of life and reducing need for surgical interventions in future.

Paresia recurrente de sexto nervio craneano asociado a hipoplasia de sexto nervio / Recurrent paresis of sixth cranial nerve associated with sixth nerve hypoplasia

La paresia de sexto nervio craneano recurrente es una entidad ampliamente conocida en la población pediátrica que ha sido asociado a múltiples etiologías, siendo las más frecuentes las infecciones virales o postinmunizaciones. A continuación, exponemos el caso de una niña de 5 años que presenta 2 episodios de déficit de abducción del ojo izquierdo debido a paresia de sexto nervio craneano, que se resolvieron espontáneamente. El estudio con resonancia magnética reveló hipoplasia del sexto nervio craneano izquierdo.(AU)

Recurrent sixth nerve palsy is a well-known entity in pediatric population associated to multiple causes, most frequently viral infection or immunization. We report a case of a 5 years old girl who presents two episodes of left abduction deficit due to sixth nerve palsy that partially resolved spontaneously. A magnetic resonance imaging study revealed a hypoplastic left sixth nerve.(AU)

A Case of Epstein-Barr Virus-associated Brainstem Encephalitis Presenting with Sixth Cranial Nerve Palsy in a Child / 대한소아신경학회지

Brainstem encephalitis caused by Epstein-Barr virus (EBV) is rare in childhood. We describe a 14-month-old-boy who presented with limitation of eye movements with sixth cranial nerve palsy. Brainstem encephalitis caused by EBV was diagnosed, based on the neuroimaging and cerebrospinal fluid (CSF), serological examination for EBV infection. Brain magnetic resonance imaging (MRI) showed high signal intensity in T2 and low signal intensity in T1 in both pons and medulla. The result of EBV polymerase chain reaction (PCR) of the CSF was positive, and a serological test showed a convalescent phase of primary infection: positive for viral capsid antigen (VCA)-IgM, VCA-IgG and EBV nuclear antigen (EBNA)-IgG, negative for heterophil antibody. We suggest that EBV infection should be considered a differential diagnosis cause of pediatric brainstem encephalitis and emphasizes the need for immediate diagnosis and initiation of symptomatic and specific therapy.

Multiple Myeloma Manifesting as a Fluctuating Sixth Nerve Palsy

We report a case of multiple myeloma that presented as a fluctuating sixth cranial nerve palsy in the absence of widespread signs of systemic disease. A 63-year-old woman presented with horizontal diplopia of two weeks duration that subjectively changed over time. Ocular examination showed a fluctuating sixth nerve palsy. A computed tomography (CT) scan of the brain showed multiple, enhancing, soft tissue, mass-like lesions involving the left cavernous sinus and the apex of both petrous bones. Based on bone marrow biopsy and hematologic findings, she was diagnosed with multiple myeloma. Multiple myeloma may be included in the differential diagnosis of a fluctuating sixth nerve palsy, and although ophthalmic signs are rare and generally occur late in the course of multiple myeloma, they can still be its first signs.

Botulinum toxin treatment of sixth cranial nerve palsy.

Twelve patients with sixth cranial nerve palsy were treated with botulinum toxin injections to the antagonist medial rectus muscle at Siriraj Hospital between October 1995 and June 1996, The angle of esotropia, the extent of abduction and stereopsis were measured in all patients before and after the injections. After the treatment, seven patients (58.3 per cent) who exhibited a short duration of palsy, small angle of esotropia and incomplete paresis of the lateral rectus muscle recovered to achieve orthotropia and re-established fusion in the primary position. Of those seven patients, five demonstrated complete recovery of ocular motility. Botulinum toxin treatment can not only be a safe and effective alternative to conventional surgery but can also restore single binocular vision in primary gaze.