Post‐apopletic trigeminal trophic syndrome

Abstract

Trigeminal trophic syndrome is an uncommon clinical entity in which cutaneous trophic ulceration develops with continuous manipulation of trigeminal dermatomes. Patients spontaneously refer picking, rubbing and/or scratching at the affected areas because of hypo-anaesthesia, paraesthesia and/or pain following damage of the sensory trigeminal fibres or nuclei. We herein describe a patient who developed the syndrome as a sequela of brain stem infarction. Diagnosis by scrape cytology in ruling-out basal cell carcinoma and other ulcerative skin diseases is discussed and the importance of neurological examination in disclosing hemi-anaesthesia of trigeminal dermatome(s) is emphasized.

Trigeminal trophic syndrome

“…Spillane et al 8 Ala nasi (2), septum Ulcer and erosion Walton et al 39 Ala nasi (4), septum (2), upper lip Ulcer Owen et al 40 Ala nasi, septum Ulcer Weintraub et al 6 Ala nasi, upper lip, cheek One continuous lesion of a shallow well circumscribed ulcer with shallow bleeding base and erosion Loveman 3 Ala nasi, temple, forehead, angle of eye Carcinomatous-like ulcer and trophic ulcer Karnosh et al 41 Forehead, temple, lip, cheek, nose Well demarcated erythematous plaque Ala nasi, angle of the mouth, cheek, eyelid, chin Red patches of indurated crusted skin. Angle of the jaw, scalp, skin around the ear Kavanagh et al 13 Ala nasi (2), lip and upper lip, cheek Ulceration, erythema, erosion Westerhoff et al 22 Ala nasi, upper lip, check, forhead Superficial sharply demarcated ulcers Data et al 18 Ala nasi, right cheek Ulcer with erythema Elloumi et al 15 Ala nasi (2), upper lip, eyebrow, forehead Non-healing ulcer, well demarcated edges Bhushan et al 24 Ala nasi and cheek Non-healing ulcer/erosion Dicken et al 16 Ala nasi (5), forehead (3), cheek, scalp (2), bridge of nose, chin, bridge of nose Non-healing ulcer, tissue loss and erosion Ferrara et al 42 Ala nasi, forehead and above eyebrow, cheek, chin below lower lip Well defined ulcers with bizarre outlines Munnoch et al 23 Ala nasi, lower eyelid, chin Erosive trophic ulcer Su et al 26 Ala nasi, cheek, forehead, ear, chin Superficial ulcers and destruction of ala nasi Inoue et al 19 Ala nasi, lateral canthus, lower eyelid, upper lip Deep ulcer Mclean et al 43 Ala nasi and septum Ulcer and erosion Howell RG 44 Ala nasi (3) 14 Ala nasi (3), lateral wall of nose (2) Ulcer, punched out defect Macovei et al 46 All over hemi-face (specified ala nasi and upper lip) Trophic ulceration with superficial erosion Schwertdner et al 25 Upper lip Non-healing ulcer Shea et al 20 Nose, upper lip, cheek Ulcer NOTE: Tables were compiled using refs. The trauma and ulcer development/progression follows a classic pattern of a non-healing wound, provoking further injury.…”

Neuropathic Itch

“…38,39 The complete syndrome is caused by infarction of a wedge of lateral medulla, in most cases from vertebral-artery blockage. Occasional cases are attributed to smaller strokes in this same territory, for instance involving the posterior inferior cerebellar artery (PICA), 40,41 or thalamus. 33 The full picture includes signs of abnormality of the vestibular system (vertigo, nystagmus, oscillopsia, vomiting), spinothalamic tract (ipsilateral loss of body pain and temperature), descending sympathetic tract (ipsilateral Horner syndrome) and cranial nerves IX and X (hoarseness and choking), otolithic nucleus (double vision), cerebellar connections (ipsilateral ataxia), as well as the descending tract and nucleus of the trigeminal (V) nerve causing loss of pain and temperature on the ipsilateral face.…”

Das neurotrophische Ulkus des N.�trigeminus

“…So wurde die Ulkusentstehung wenige Wochen bis über 20 Jahre nach Schädigung der sensiblen Trigeminuswurzel bechrieben [1,9,21,23],das mediane Intervall betrug 1 Jahr [23].Die trophischen Störungen scheinen dabei mit dem Ausmaß der Schädigung des N.trigeminus zu korrelieren [5,23]. In bis zu 13% aller einseitigen Trigeminusläsionen sind Ulzera in weiteren Gesichtsregionen außer den bereits beschriebenen Prädilektions-orten beobachtet worden [23], nach bilateraler Trigeminusläsion wurden ausgeprägte Nasendefekte beschrieben [24].…”

“…Die Aufklärung und psychologische Beratung des Patienten sollte immer am Anfang stehen [4]. Eine spontane Abheilung des Defektes ist prinzipiell im Früh-stadium möglich, wenn keine Manipulationen mehr erfolgen [2,3,5,6,7,12,23].…”

“…transkutane Elektrostimulation (TES) führte bei einem Patienten zu einer Verbesserung der lokalen Durchblutung und zum Abheilen der Ulzeration, allerdings nur solange sie regelmäßig angewendet wurde [22].Medikamentöse Versuche zielen v. a. auf die Erhöhung der Wahrnehmungsschwelle. Neben Vitamin B,Diazepam [6],Amitriptylin [5,6] ist Chlorpromazin [10], Pimozid [13] [15,21]. Als beste Methode scheint sich derzeit die plastische Defektdeckung herauszustellen.…”