• No results found

PROGNOSIS OF PALSIES FROM CRANIAL NERVE INVOLVEMENT IN POLIOMYELITIS

N/A
N/A
Protected

Academic year: 2020

Share "PROGNOSIS OF PALSIES FROM CRANIAL NERVE INVOLVEMENT IN POLIOMYELITIS"

Copied!
6
0
0

Loading.... (view fulltext now)

Full text

(1)

PROGNOSIS

OF

PALSIES

FROM

CRANIAL

NERVE

INVOLVEMENT

IN

POLIOMYELITIS

By HANS U. ZELLWEGER, M.D.,* AND E. GABATHULER, M.D.

Zurich, Switzerland

T

HE prognosis of poliomyelitis is modified considerably by involvement of the brainstem and especially the bulbar centers. In the Children’s Hospital, Zurich,

1264 cases have been observed during the years 1932-1948. Of these, 551 were

non-paralytic cases and are not included in the present paper. Seven-hundred thirteen cases

showed spinal paresis and/or encephalitic and/or bulbo-ponto-mesencephalic symptoms.

The distribution of the different symptomatic groups and their early prognosis is shown

in table 1.

TABLE 1

EARLY PROGNOSIS OF P0LI0MYELITIs: CONDITION AT DISCHARGE OF PATIENTS (45-90m DAY OF ILLNESS)

Cases

With Spin al Paralysis With P ure Encephalitic

Symptoms

With

Bulbo-pontomesen-cephalic Symptoms

No. % No. % No.%

Cured 121 26.8 18 82.1 110 45.7

Improved 285 63.2 3 13 63 26.5

Not improved 20 4.4 - - 16 6.6

Died 25 5.6 1 5 5! 21.2

451 100 22 - 240 100

It is well known that the mortality rate in bulbar cases is far higher than in other

forms of poliomyelitis. If patients with bulbar poliomyelitis live, the tendency to heal

seems to be far greater than for those with spinal paralysis. If the fatal cases are taken

out of consideration, it is noted that 58.2% of the patients with

bulbo-pontino-mesen-cephalic Symptoms were completely recovered at discharge whereas in only 28.4% of the

cases had the spinal paralysis disappeared.

The early prognosis of the palsies from the individual cranial nerve involvement is

recorded in table 2. Patients with bilateral palsy from one nerve are recorded as one case.

If a patient had several cranial nerves involved, he is recorded in each of the

corre-sponding columns. The patients were checked between the 45th and 90th day after

onset at the day of discharge from the hospital.

Except the palsies of the soft palate and those from involvement of the sixth nerve,

the palsies from involvement of cranial nerves disappeared within three months in more

than half of the patients. The best early prognosis was seen in swallowing palsy, and in

involvement of the oculomotor (III) and hypoglossal (IV) nerve palsy; whereas the early

From the Children’s Hospital and University Children’s Clinic, Zurich, Switzerland. (Received for publication Feb. 1, 1952.)

* Present address: American University of Beirut, Beirut, Lebanon.

(2)

i28 HANS U. ZELLWEGER AND E. GABATHULER

TABLE 2

EARLY PROGNOSIS OF PALSIES FROM P0LI0MYELITIS OF CRANIAL NERVE:

DETAILS PRESENTED FOR INDiVIDUAL NERVES

Crania I Nerve Involved

Facial Swallowing Soft Abducens Pupillary Hypo- Oculo- Trochlear Motor

Tn-(VII) (X) Palate (VI) Symptoms glossal motor (IV) geminal

(X) (III) (XII) (III) (\‘)

Total no. of patients with uni- or bilateral

palsy 193 74 57 26 23 15 7 2 2

Jabs.

No.ofdeaths,,1 3116 34

45.9 14 24.6 4 15.4 9 36.5 3 20 1

14.5

-

-No. of living patients with uni- or bilateral

palsy 162 40 43 22 14 12 6 2 2

Cured at discharge

(45th-’9Oth day)

No. ofpatients 102 38 18 9 11 10 5 2 1

In%oflivingpatients 63 95 42 41 79 83 83 -

-prognosis of facial palsies is not quite as favorable. Sixty-eight per cent of living patients

with isolated facial palsy and no other paralysis were cured at discharge, whereas only

59% of the patients in whom the facial palsy was combined with other bulbar or encephalitic symptoms and/or spinal paralysis were cured at discharge.

On the other hand the mortality is very high in cases with cranial nerve involvement

because the bulbar centers for respiration and vasomotor control are more often involved

than in spinal cases. The mortality rates recorded in table 2 are so uniformly higher

than the rates for spinal cases in table 1 that the occurrence of involvement of a cranial

nerve seems to be of prognostic value.

LATE PROGNOSIS OF PALSIES IN CRANIAL NERVE INVOLVEMENT

Very few figures are known about the late prognosis of poliomyelitic paralysis. Insofar as spinal cases are concerned, Mustard1 stated that in 40% residual paralyses

are present ; with adequate management and therapy 7 5% of the cases can be made

corn-pletely independent, whereas 25% show residuals of such a degree, that it is necessary

to supply braces and/or surgery.

The late prognosis of palsies from cranial nerve involvement has been studied by

McQuarrie.2 He found that between 14 and 17 months after the onset of definite

paralysis of the palatine, facial or laryngeal muscles, there were significant degrees of

residual impairment of motor function in from 18 to 77% of cases depending upon

which nerve was affected.

Insofar as facial palsy is concerned, Schuhmacher3 found 12 to 18 months after

onset complete recovery in 18 cases, slight evidence of facial palsy in 14 cases, and

marked palsy in one case. In a follow-up examination of 23 cases of facial palsy

per-formed two years after onset, Rascoff found all but one cured.

Considering these few experiences it seemed worth while to follow up the patients

reported here. Since the greatest improvement of poliomyelitis palsies occurs within

the first two years after onset, the authors limited the follow-up studies to those cases

with onset of two years or more previously.

(3)

PALSIES FROM CRANIAL NERVE INVOLVEMENT IN POLIOMYELITIS 129

TABLE 3

FINDINGS ON PATIENTS WITH CRANIAL NERVE INVOLVEMENT 2 vo 18 YEARS AFTER ONSET OF PALSY

Facial (VII) Swallowing (X) Soft Palate (X) Abducens (VI) Pupillary Symptoms (III) Hypo-glossal (XII) Motor Tn-geminal (V)

No. of cases 37 2 19 5 3 2 1

Cured 16 - 3 4 2 2

-Much improved 11 2 7 - - - 1

Slightly or not improved 10 9 1 1 -

-had presented together 107 cranial nerve lesions. Fifty-nine patients with 69 palsies have

been re-examined between 2 and 18 years after onset. Thirty-nine patients with 48

palsies were completely or nearly completely cured ; in 20 patients 21 palsies were still

present ; 10 facial palsies, 9 palsies of the soft palate, one palsy from a lesion of the

sixth nerve and one palsy of the pupillary sphincter of one eye. One of the 10 facial

palsies was still severe with definite deviations of the mouth, whereas in the 9 others

deviations could only be seen if the patients were laughing or crying. The 9 palsies of

the soft palate were slight ; contractions were incomplete and asymmetric, when the

gag reflex was elicited, 4 of them had a rhinolalia, but all could swallow fluids and

solid foods without any trouble. The only palsy from the sixth nerve was severe, but

did not hamper the patient in his work.

Ten patients in whom 38 cranial nerve lesions were involved could not be re-examined;

3 1 of them were even much improved at discharge. Therefore it is possible that the

palsies have disappeared completely ; the seven remaining with palsies were more severe

at discharge ; unfortunately they could not be followed up.

SUMMARY

Seven-hundred thirteen cases of poliomyelitis with spinal paralysis, encephalitic or

bulbar symptoms are reviewed. The mortality rate in bulbar cases was four times that

in spinal cases, whereas early recovery after bulbar symptoms was twice that of spinal

paralysis.

A follow-up study of 59 patients with 69 palsies from cranial nerve injury performed

2 to 18 years after the acute stage showed that 39 patients with 48 palsies were cured;

18 patients had together 19 palsies of minor degree. Two patients, one with involvement

of the sixth and one with involvement of the seventh cranial nerve had more severe

sequelae. None of the palsies affected the life of the patients.

Thus if patients with cranial nerve involvement stay alive the late prognosis is much

better; the majority of the palsies disappear, the remaining ones have no crippling effect

for the patient.

REFERENCES

1. Mustard, H. S., Questions and Answers About Polio, New York, National Foundation for

Infantile Paralysis, Inc., 1949.

2. McQuarrie, I., in Poliomyelitis, Philadelphia, J. B. Lippincott Company, 1949.

3. Schuhmacher, P., Zur Prognose den Fazialisl#{228}hmungbei Poliomyelitis, M#{252}nchenmed. Wschnschr. 87:591, 1940.

(4)

130 HANS U. ZELLWEGER AND E. GABAThULER

SPANISH ABSTRACT

Pron6stico de las Par#{225}lisis de los Nervios Craneanos en la Poliomielitis

Los autores del trabajo revisaron 713 casos de poliomielitis con par#{225}lisis espinal y bulbar. La mortalidad en los casos bulbares fu#{233}4 veces mayor que en los espinales en tanto que Ia recuperaci#{243}n temprana de los smntomas bulbares fu#{233}2 veces mas frecuente que la de las par#{225}lisis espinales.

ExcepciOn hecha de las par#{225}lisisdel velo del paladar blando y del sexto par craneano, las otras variedades de par#{225}lisis craneanas desaparecieron dentro de los 3 primeros meses, en mas de Ia mitad de los enfermos. Las de mejor pronOstico temprano fueron las par#{225}lisisde Ia degluciOn, del nervio

oculomotor e hipogloso en contraste con las par#{225}lisis del facial pues ci 68% de los casos con par#{225}lisis facial exclusivamente estaban curados entre el 45#{176}y 900 dIa, a! salir del hospital, y

sola-mente el 59% de los casos en que aquella coexistia con smntomas bulbares o encefalIticos, combinados

O no con par#{225}lisisespinal.

Con respecto al pronOstico tardlo o lejano de las par#{225}lisiscraneanas encontraron que de 59

pacientes con 69 par#{225}lisis39 de ellos que tenian 48 par#{225}lisis hablan curado entre el 2#{176}y 18#{176}afio

despu#{233}sdel peniOdo agudo. Dc los otros 20 casos restantes 18, que tenlan en total 19 par#{225}lisis las

presentaban aun pero en grado ligero, y solo 2, uno con par#{225}lisisdel sexto par y otro del s#{233}ptimo

las tenIan aun en forma severa. Dc los 18 casos que tenian par#{225}lisisaunque en forma ligera 9 eran

par#{225}lisisdel facial y solo era apreciable cuando ci enfermo rela o lloraba, y los otros 9 eran del velo del paladar manifestandose por su contracciOn incompleta y asim#{233}trica, en 4 de ellos por

rinolalia, pero ninguno tenia dificuitad para tomar iiquidos o deglutir alimentos sOlidos.

En Ia revisiOn de la literatura encuentran que el 40% de los casos espinales quendan con par#{225}lisis

residuales y de ellos, el 75%, con tratamiento adecuado, no requieren de la cirugIa u aparatos. Por

lo que respecta a los casos con par#{225}lisis de los nervios craneanos, de un 18 al 77% de ellos,

de-pendiendo del tipo de par#{225}lisis; palatina, facial o laringea, presentaban un grado significativo de

interferencia motora residual entre ci 15#{176}y 17#{176}meses despu#{233}sdel pnincipio franco de la par#{225}lisis. Con referencia a Ia par#{225}lisis facial en particular, de 33 casos revisados entre 12-18 meses del principio, 18 curaron por completo, 14 la presentaban en grado ligero y en solo 1existIa en forma acentuada. En otro grupo de 23 casos, todos curaron con excepciOn de uno de elios, a los 2 a#{241}osde instalarse.

Los autores concluyen, que si los enfermos con par#{225}iisiscraneanas sobre viven, ci pronOstico

tardio es mucho mejor desapareciendo la mayor parte de las par#{225}lisis y las que permanecen no pro-ducen invalides en ci paciente.

(5)

1952;10;127

Pediatrics

HANS U. ZELLWEGER and E. GABATHULER

POLIOMYELITIS

PROGNOSIS OF PALSIES FROM CRANIAL NERVE INVOLVEMENT IN

Services

Updated Information &

http://pediatrics.aappublications.org/content/10/2/127

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(6)

1952;10;127

Pediatrics

HANS U. ZELLWEGER and E. GABATHULER

POLIOMYELITIS

PROGNOSIS OF PALSIES FROM CRANIAL NERVE INVOLVEMENT IN

http://pediatrics.aappublications.org/content/10/2/127

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

Related documents

Very early on in formulating his conception of calculi, Wittgenstein was acutely aware of difficulties in determining the number of measurement scales to be used

In this work, a 2D hydraulic model has been applied to reproduce rainfall–runoff processes in the small urbanized catchment of the Ravone stream, with the aim of simulating the

Aim: The study aimed at determining the pattern of semen profile and its relationship with semen concentration in male partners of infertile couples.. Frequency percentages

Stage 3 – Policy-making focuses on expected/achieved results and justifies the allocation of resources Evaluation Allocation Réalisations Outputs Ressources Inputs Résultats

There is a gradient of health in which people with lower income, who are unemployed or in precarious or low-paid work, or who face other forms of social inequality and exclusion

The core goal of the case study in heavy process industry was to define how to create an effective and efficient integration in the business operations systems including quality,

Therefore, such groups are more likely to accept working within (and, in a sense, integrating into) established, mainstream political parties as the best strategy