Recurrent Isolated Sixth Nerve Palsy in Childhood—Review on a Rare Phenomenon

Abstract

Sixth nerve palsy is an ominous sign in pediatric neurology. Due to the long and tortuous course of the sixth (abducens) nerve, it is generally considered a sign of intracranial pathology. Sixth nerve palsy is associated with increased intracranial pressure and neoplasms, among other less frequent causes. In ∼5 to 15% of cases, no cause can be identified. These cases are classified as idiopathic or “benign” and recovery is typically complete. A recurrence of symptoms is very rare. We provide a rare case report of recurrent benign sixth nerve palsy in a 5-year-old child. In addition, we provide an overview of all earlier published cases of recurrent isolated sixth nerve palsy. To date, only 72 pediatric patients with recurrent isolated sixth nerve palsy have been reported. Young females with left-sided sixth nerve palsy and recent immunization are at risk of recurrence. Pathophysiological mechanisms have been discussed, but have yet to be clarified. Recurrent isolated sixth nerve palsy is only rarely associated with severe causes and the need for extensive investigation may be questioned.

Reply: Isolated Sixth Nerve Palsy and COVID-19

“…We agree that the small sample size of 19 cases is a limitation; however, this sample size comports with a number of studies examining cranial nerve 6 (CN6) palsy from a variety of causes. 2–5 Despite this, our statistical analysis revealed significant hypothesis-driven relationships between important clinical features. For example, the likelihood that the relationship between latency to CN6 onset and the time to resolution occurred by chance is 1% ( P = 0.010).…”

Reply: Isolated Sixth Nerve Palsy and COVID-19

“…We agree that the small sample size of 19 cases is a limitation; however, this sample size comports with a number of studies examining cranial nerve 6 (CN6) palsy from a variety of causes. 2–5 Despite this, our statistical analysis revealed significant hypothesis-driven relationships between important clinical features. For example, the likelihood that the relationship between latency to CN6 onset and the time to resolution occurred by chance is 1% ( P = 0.010).…”

Isolated Sixth Nerve Palsy and COVID-19: A Recurrent Case in a 7-Month-Old Child and Analysis of Reported Cases

“…Recurrent CN6 palsy in children is a rare phenomenon; a recently published review included 72 case reports and found that the average age of onset was 3 years and many first episodes were associated with infection or immunization. 5 Most patients, 81%, completely recovered with observation while 11% partially recovered. 5 In our case, 2 recurrences were documented, the first after gastroenteritis and the second after RSV.…”

“…5 Most patients, 81%, completely recovered with observation while 11% partially recovered. 5 In our case, 2 recurrences were documented, the first after gastroenteritis and the second after RSV. How the unknown risk of recurrence with COVID-19 vaccination balances with the unambiguous benefits of promoting immunity should be determined by individual patients and family in discussion with their physicians.…”

Reply: Isolated Sixth Nerve Palsy and COVID-19

“…We agree that the small sample size of 19 cases is a limitation; however, this sample size comports with a number of studies examining cranial nerve 6 (CN6) palsy from a variety of causes. 2–5 Despite this, our statistical analysis revealed significant hypothesis-driven relationships between important clinical features. For example, the likelihood that the relationship between latency to CN6 onset and the time to resolution occurred by chance is 1% ( P = 0.010).…”

Isolated Sixth Nerve Palsy and COVID-19: A Recurrent Case in a 7-Month-Old Child and Analysis of Reported Cases

“…Recurrent CN6 palsy in children is a rare phenomenon; a recently published review included 72 case reports and found that the average age of onset was 3 years and many first episodes were associated with infection or immunization. 5 Most patients, 81%, completely recovered with observation while 11% partially recovered. 5 In our case, 2 recurrences were documented, the first after gastroenteritis and the second after RSV.…”

“…5 Most patients, 81%, completely recovered with observation while 11% partially recovered. 5 In our case, 2 recurrences were documented, the first after gastroenteritis and the second after RSV. How the unknown risk of recurrence with COVID-19 vaccination balances with the unambiguous benefits of promoting immunity should be determined by individual patients and family in discussion with their physicians.…”

Reply: Isolated Sixth Nerve Palsy and COVID-19

“…We agree that the small sample size of 19 cases is a limitation; however, this sample size comports with a number of studies examining cranial nerve 6 (CN6) palsy from a variety of causes. 2–5 Despite this, our statistical analysis revealed significant hypothesis-driven relationships between important clinical features. For example, the likelihood that the relationship between latency to CN6 onset and the time to resolution occurred by chance is 1% ( P = 0.010).…”

Isolated Sixth Nerve Palsy and COVID-19: A Recurrent Case in a 7-Month-Old Child and Analysis of Reported Cases

“…Recurrent CN6 palsy in children is a rare phenomenon; a recently published review included 72 case reports and found that the average age of onset was 3 years and many first episodes were associated with infection or immunization. 5 Most patients, 81%, completely recovered with observation while 11% partially recovered. 5 In our case, 2 recurrences were documented, the first after gastroenteritis and the second after RSV.…”

“…5 Most patients, 81%, completely recovered with observation while 11% partially recovered. 5 In our case, 2 recurrences were documented, the first after gastroenteritis and the second after RSV. How the unknown risk of recurrence with COVID-19 vaccination balances with the unambiguous benefits of promoting immunity should be determined by individual patients and family in discussion with their physicians.…”