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Hemifacial atrophy secondary to poliomyelitis
Copyright 9 Munksgaard]997 Intemational]oumdof
Int. J. Oral Maxillofac. Surg. 1997," 26:215-216 Printed in Denmark. All rights reserved
Oral & MaxillofacialSurgery ISSN 0901-5027
Hemifacial atrophy secondary to poliomyelitis
K. Antoniades, Th. Giannouli, K. Vahtsevanos Department of Oral and Maxillofacial Surgery, "Theagenion" Cancer Hospital of Thessal0niki, Thessaloniki, Greece
K. Antoniades, Th. Giannouli, K. Vahtsevanos: Hemifacial atrophy secondary to poliomyelitis. Int. J. Oral Maxillofac. Surg. 1997; 26: 215-216. 9 Munksgaard, 1997
Abstract. A 25-year-old woman is presented with hemifacial atrophy due to unilateral bulbar poliomyelitis infection. A l t h o u g h bulbar poliomyelitis is not an u n c o m m o n disease, it is rarely a cause of hemifacial asymmetry.
According to COHEN 3, hemiasymmetries are grouped under the following headings: hemihyperplasia, hemihypoplasia, hemiatrophy and miscellaneous hemiasymmetries. Hemihypoplasia may affect bone and/or the soft tissues. In most known syndromes, such as hemifacial microsomia, both elements are affected1,3, 5. The purpose of this paper is to present a case of acquired hemiatrophy of the face due to extensive atrophy and weakness of the masticatory muscles caused by bulbar poliomyelitis. This is referred to by Comsy 3 as a rare etiological cause of hemifacial asymmetry.
Case report A 25-year-old woman was referred to the Oral and Maxillofacial Surgery Clinic for examination and clinical evaluation because of a facial asymmetry first noticed 14 months before. It gradually became apparent during the previous year, while she was on a slimming "diet. Her medical history revealed poiiomyelitis at the age of 8 years; which required a long period of rehabilitation supported by physiotherapy. The patient appeared to be a mentally healthy and socially active person, with no motor dysfunctions. Clinical examination revealed hemiatrophy of the left side, which was especially evident in the lower third of the face and involved the soft tissues, particularly the mass of the masseter muscle (Fig. 1). The texture and structure of the skin appeared normal.
Mobility of the mandible was not impaired a n d there was no deviation of the mandible in mouth-opening. Roentgenographs disclosed normal and symmetrical bone formation and development. A computed tomography scan (CT) of the coronal and axial sections, showed severe atrophy of all the left-side masticatory muscles (Fig. 2). The patient was asked for past photographs which revealed that the hemiasymmetry had existed since the age of 12. The weight loss during the previous year corn-
Key words: hemifacial atrophy; poliomyelitis; muscle weakness - atrophy. Accepted for publication 26 December 1996
bined with a change in hairstyle had made her aware of it. The differential diagnosis included hemifacial microsomia and progressive hemifacial atrophy (Romberg syndrome), but these were disregarded because of the radiographic findings. The neurophysiological investigation disclosed a pathological electromyography (EMG) characterized by automatic muscle activity. It was decided to attribute this masticatory muscle atrophy to a bulbar form of poliomyelitis, which unilaterally affected the motor nucleus of the trigeminal nerve.
Discussion
N
Poliomyelitis is a viral infection. Although the anterior h o r n cells of the
Fig. 2. Axial CT section showing unilateral Fig. 1. Clinical appearance of the patient.
atrophy of masticatory muscles.
216
Antoniades et al.
spinal cord bear the main damage produced by the poliomyelitis virus, involvement of the m o t o r nuclei of the medulla and midbrain is not uncomm o n 2,4. Trigeminal nerve palsies may be unilateral or bilateral in cases of bulbar paralytical poliomyelitis. The incidence of bulbar poliomyelitis differs from one epidemic to another and varies from 6 to 25 percent. The syndromes that subsequently develop depend on the area of the brainstem involved, and result from damage to the medulla, pons, and midbrain 2,6,7. In the case presented, there was facial asymmetry due to unilateral atrophy of the masticatory muscles. N o previous case of unilateral atrophy of the masticatory muscles due to poliomyelitis, without any bone involve-
ment, was traced in the literature. The p u r p o s e of presenting this case is to draw attention to the possibility of this phenomenon.
References 1. ANTONIADES K, LETSIS I, KARAKASIS D. Congenital hemifacial hyperplasia. Br J Oral Maxillofac Surg 1988: 26: 344-8. 2. CANNON S, RITTER FN. Vocal cord paralysis in postpoliomyelitis syndrome. Laryngoscope 1987: 97: 81-3. 3. CO~n~N MM JR. Perspectives in craniafacial asymmetry III and IV. Int J Oral Maxillofac Surg 1995: 24: 127-41. 4. DAHLSTROM L, HARALDSON T. Facial asymmetry and unstable occlusion due to poliomyelitis, report of a case. Swed Dent J 1986: 10: 171-4.
5. GORLIN R J, COHEN MM JR, LEVIN LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press, 1990. 6. MosEs PD, PE~IRA SM, JorrN TJ, STEINHOFF M. Poliovirus infection and Bell's palsy in children. Ann Trap Paediatr 1985: 5: 196-8. 7. NUGENT KM. Vocal cord paresis and glotfic stenosis, a late complication of poliomyelitis. South Med J 1987: 80: 1594-5.
Address: Dr K. Antoniades Department o f Oral and Maxillafacial Surgery Aristotle University of Thessaloniki Thessaloniki 540 06 Greece
Int. J. Oral Maxillofac. Surg. 1997," 26:215-216 Printed in Denmark. All rights reserved
Oral & MaxillofacialSurgery ISSN 0901-5027
Hemifacial atrophy secondary to poliomyelitis
K. Antoniades, Th. Giannouli, K. Vahtsevanos Department of Oral and Maxillofacial Surgery, "Theagenion" Cancer Hospital of Thessal0niki, Thessaloniki, Greece
K. Antoniades, Th. Giannouli, K. Vahtsevanos: Hemifacial atrophy secondary to poliomyelitis. Int. J. Oral Maxillofac. Surg. 1997; 26: 215-216. 9 Munksgaard, 1997
Abstract. A 25-year-old woman is presented with hemifacial atrophy due to unilateral bulbar poliomyelitis infection. A l t h o u g h bulbar poliomyelitis is not an u n c o m m o n disease, it is rarely a cause of hemifacial asymmetry.
According to COHEN 3, hemiasymmetries are grouped under the following headings: hemihyperplasia, hemihypoplasia, hemiatrophy and miscellaneous hemiasymmetries. Hemihypoplasia may affect bone and/or the soft tissues. In most known syndromes, such as hemifacial microsomia, both elements are affected1,3, 5. The purpose of this paper is to present a case of acquired hemiatrophy of the face due to extensive atrophy and weakness of the masticatory muscles caused by bulbar poliomyelitis. This is referred to by Comsy 3 as a rare etiological cause of hemifacial asymmetry.
Case report A 25-year-old woman was referred to the Oral and Maxillofacial Surgery Clinic for examination and clinical evaluation because of a facial asymmetry first noticed 14 months before. It gradually became apparent during the previous year, while she was on a slimming "diet. Her medical history revealed poiiomyelitis at the age of 8 years; which required a long period of rehabilitation supported by physiotherapy. The patient appeared to be a mentally healthy and socially active person, with no motor dysfunctions. Clinical examination revealed hemiatrophy of the left side, which was especially evident in the lower third of the face and involved the soft tissues, particularly the mass of the masseter muscle (Fig. 1). The texture and structure of the skin appeared normal.
Mobility of the mandible was not impaired a n d there was no deviation of the mandible in mouth-opening. Roentgenographs disclosed normal and symmetrical bone formation and development. A computed tomography scan (CT) of the coronal and axial sections, showed severe atrophy of all the left-side masticatory muscles (Fig. 2). The patient was asked for past photographs which revealed that the hemiasymmetry had existed since the age of 12. The weight loss during the previous year corn-
Key words: hemifacial atrophy; poliomyelitis; muscle weakness - atrophy. Accepted for publication 26 December 1996
bined with a change in hairstyle had made her aware of it. The differential diagnosis included hemifacial microsomia and progressive hemifacial atrophy (Romberg syndrome), but these were disregarded because of the radiographic findings. The neurophysiological investigation disclosed a pathological electromyography (EMG) characterized by automatic muscle activity. It was decided to attribute this masticatory muscle atrophy to a bulbar form of poliomyelitis, which unilaterally affected the motor nucleus of the trigeminal nerve.
Discussion
N
Poliomyelitis is a viral infection. Although the anterior h o r n cells of the
Fig. 2. Axial CT section showing unilateral Fig. 1. Clinical appearance of the patient.
atrophy of masticatory muscles.
216
Antoniades et al.
spinal cord bear the main damage produced by the poliomyelitis virus, involvement of the m o t o r nuclei of the medulla and midbrain is not uncomm o n 2,4. Trigeminal nerve palsies may be unilateral or bilateral in cases of bulbar paralytical poliomyelitis. The incidence of bulbar poliomyelitis differs from one epidemic to another and varies from 6 to 25 percent. The syndromes that subsequently develop depend on the area of the brainstem involved, and result from damage to the medulla, pons, and midbrain 2,6,7. In the case presented, there was facial asymmetry due to unilateral atrophy of the masticatory muscles. N o previous case of unilateral atrophy of the masticatory muscles due to poliomyelitis, without any bone involve-
ment, was traced in the literature. The p u r p o s e of presenting this case is to draw attention to the possibility of this phenomenon.
References 1. ANTONIADES K, LETSIS I, KARAKASIS D. Congenital hemifacial hyperplasia. Br J Oral Maxillofac Surg 1988: 26: 344-8. 2. CANNON S, RITTER FN. Vocal cord paralysis in postpoliomyelitis syndrome. Laryngoscope 1987: 97: 81-3. 3. CO~n~N MM JR. Perspectives in craniafacial asymmetry III and IV. Int J Oral Maxillofac Surg 1995: 24: 127-41. 4. DAHLSTROM L, HARALDSON T. Facial asymmetry and unstable occlusion due to poliomyelitis, report of a case. Swed Dent J 1986: 10: 171-4.
5. GORLIN R J, COHEN MM JR, LEVIN LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press, 1990. 6. MosEs PD, PE~IRA SM, JorrN TJ, STEINHOFF M. Poliovirus infection and Bell's palsy in children. Ann Trap Paediatr 1985: 5: 196-8. 7. NUGENT KM. Vocal cord paresis and glotfic stenosis, a late complication of poliomyelitis. South Med J 1987: 80: 1594-5.
Address: Dr K. Antoniades Department o f Oral and Maxillafacial Surgery Aristotle University of Thessaloniki Thessaloniki 540 06 Greece