Question for the OMFS Res Re: Loss of Sensation

[capisce?]

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Quick question about something I had never encountered until tonight during my call:

14y/o male with a h/o a of fall onto the carpet and blunt trauma to his chin. MHR-NSF. MOC was not in the room during the fall, details are shady about trauma. No LOC, no vom. [As a sidenote...moc left room to buy coffee...code for going to light up a cig...and i get it out of the kids that they were 'playing' that asphyxiation game]. Trauma happened 4 hours prior to me seeing him. CC is L jaw pain, some fractured teeth.

EOE: chin lac, non-complicated. Limited ROM, probably 25mm. Right TMJ - to palp, L TMJ + to palp but nothing major (3 or 4 w/ pain scale), no dev on opening. As exam went on, pt regained more and more ROM.

IOE: class I ellis fxs on 12, 13, 20, 21.

Clinically it just looked like trauma and some trismus. I ordered a mand series and the pt was cleared, no sub-cond or any other type of fractures.

My question is this: patient c/o loss of sensation in areas of V1 and some V2 distribution. Over the course of the 1.5 hrs or so that he was here, he regained all feeling except in about a circle w/ a 1cm diam. Is this normal aftermath of blunt trauma to the chin? I've seen loss of sensation w/ jaw/facial fractures but never really in a case where there was no evidence of any fracture. I guess since he knocked the crap out of himself it just jars the nervous supply a bit.

I know it will return, but was just curious to see if this is a 'common' thing.

Thanks in advance for any feedback.

Another random thought...do any states out there allow pedos to use ketamine in-office? We aren't allowed by our program but i had the ED sedate a kid today w/ it and it knocked the kidd off his arse. I know the bad rep w/ halluc but i wish it was more widely accepted.

 

[scalpel2008]

No, never seen or heard of supra and/or infraorbital hypoesthesia secondary to blunt chin trauma. In the absence of any orbital trauma or edema, hypoesthesia of V1 and V2 distributions is unlikely. In fact, with chin trauma, you rarely see any hypoesthesias because usually the fractures occur in the symphysis and subcondylar/intracapsular regions, thus avoiding V3 as well. Maybe he was doped up on narcs and couldn't tell which is why he "regained" sensation.

 

[capisce?]

No, never seen or heard of supra and/or infraorbital hypoesthesia secondary to blunt chin trauma. In the absence of any orbital trauma or edema, hypoesthesia of V1 and V2 distributions is unlikely. In fact, with chin trauma, you rarely see any hypoesthesias because usually the fractures occur in the symphysis and subcondylar/intracapsular regions, thus avoiding V3 as well. Maybe he was doped up on narcs and couldn't tell which is why he "regained" sensation.

Thanks dude, i was sorta scratching my head with this one as well.

 

[toofache32]

When in doubt, document on the bad side. In other words, if it's a younger kid and you can't tell if he's really numb or just playing along, then document the numbness. If he's really numb after your treatment, then it's been documented. If he's numb later and you wrote "V3 intact" then you may have some explaining to do.

 

[scalpel2008]

ditto what toofache said. infact, nerve injury (especially lingual) will get you sued more than anything else. Infact, it isn't the injury itself that gets you sued, but rather the lack of good informed consent, f/u, documentation and lack of timely referral for nerve repair (once again, more of an issue with lingual and facial nerve injuries). I strongly recommend documenting with a diagram if there is a persistent distribution of nerve injury. I can't stand it when someone documents V3 hypoesthesia when all they tested was the mental nerve. Furthermore, I can't stand it when someone documents paresthesia when they really mean hypoesthesia. Damn, I have a lot of neuro exam pet peeves. Finally, I hate it when someone calls it "Vee" 3. It isn't "Vee" 3. Theres nothing "Vee" about the trigeminal nerve. It's a damn roman numeral. Ok, I'm getting off my neuro soap box now.

 

[aphistis]

ditto what toofache said. infact, nerve injury (especially lingual) will get you sued more than anything else. Infact, it isn't the injury itself that gets you sued, but rather the lack of good informed consent, f/u, documentation and lack of timely referral for nerve repair (once again, more of an issue with lingual and facial nerve injuries). I strongly recommend documenting with a diagram if there is a persistent distribution of nerve injury. I can't stand it when someone documents V3 hypoesthesia when all they tested was the mental nerve. Furthermore, I can't stand it when someone documents paresthesia when they really mean hypoesthesia. Damn, I have a lot of neuro exam pet peeves. Finally, I hate it when someone calls it "Vee" 3. It isn't "Vee" 3. Theres nothing "Vee" about the trigeminal nerve. It's a damn roman numeral. Ok, I'm getting off my neuro soap box now.

Just to split hairs, can you stand it when people document hypoesthesia when they really mean anesthesia?

 

[scalpel2008]

Just to split hairs, can you stand it when people document hypoesthesia when they really mean anesthesia?

I don't think anesthesia should ever be documented unless you have done a thorough neuro exam including sharp, dull, two point discrimination, directional, temperature. These pet peeves aren't without reason. They influence prognosis and management. For example, if a patient has complete anesthsia, I tell them that sponateous recovery is unlikely (although it can in the case of the IA nerve due to a nice bony conduit after fracture reduction). This is usually due to complete transeciton (neuronotmesis) or severe 3rd degree axonotmesis. On the other hand if they have directional sense, decent two point discriminaiton, and can feel a pin prick, then I can let them know that observation is an option and they will likely regain some sensation. I have a pet peeve for when people have pet peeves for no reason and that don't affect outcome. Damn I need to get back on my meds.

 

[Doggie]

Finally, I hate it when someone calls it "Vee" 3. It isn't "Vee" 3. Theres nothing "Vee" about the trigeminal nerve.

Continuing on with your ranting......I hate the way everyone pronounces AAOMS. There's nothing "aymus" about AAOMS. It should be called "Ayohms" if anything.

 

[toofache32]

I hate it when asparagus makes my pee turn orange.

 

[Doggie]

I hate it when asparagus makes my pee turn orange.

I hate how my upper level has a red neck to match his orange pee.

 

[IcedOMFS]

I hate how my upper level has a red neck to match his orange pee.

I hate everything.

 

[IcedOMFS]

I don't think anesthesia should ever be documented unless you have done a thorough neuro exam including sharp, dull, two point discrimination, directional, temperature. .

Perhaps my understanding is wrong, but I was under the impression directional testing involved a proprioceptive sense of what direction a joint was bent in, as in testing interphalangeal joints in diabetic foot neuropathy...

I have certainly seen clinicians running through excercises with a cotton tip applicator on a patient's chin asking them to tell which direction the cotton swab is moving... I fail to see how it is any more informative than what one garners from sharp/dull touch and two point discrimination... I think it's mostly smoke and mirrors to make the patient feel like you are doing something fancy.

But I agree re: your comments on anaesthesia vs paraesthesia vs hypoaesthesia, and folks who chart 'V3 paraesthesia'...

I prefer the AE-sthesia spelling as opposed to E-sthesia spelling.

 

[scalpel2008]

Perhaps my understanding is wrong, but I was under the impression directional testing involved a proprioceptive sense of what direction a joint was bent in, as in testing interphalangeal joints in diabetic foot neuropathy...

I have certainly seen clinicians running through excercises with a cotton tip applicator on a patient's chin asking them to tell which direction the cotton swab is moving... I fail to see how it is any more informative than what one garners from sharp/dull touch and two point discrimination... I think it's mostly smoke and mirrors to make the patient feel like you are doing something fancy.

But I agree re: your comments on anaesthesia vs paraesthesia vs hypoaesthesia, and folks who chart 'V3 paraesthesia'...

I prefer the AE-sthesia spelling as opposed to E-sthesia spelling.

I see what you are saying. However, testing proprioception (as you described) is different that testing directional sensation. I guess I was trying to say that if you were to conduct a neuro exam by the book (which isn't a bad idea in a known nerve injury pt) I've read that it's typically done @ 3 levels. Now pin prick is level C so if that's intact, it doesn't necessarily mean that level A (2 point discrimination and directional sense) is intact. These are usually injured with crushing injuries. Also, these specifically test myelinated nerves. I agree that all this is pretty much bull**** for the usualy trauma paresthesia, but if someone does have a known nerve injury and needs serial neuro exams over a few months to see degree of impairment/improvement, I think directional testing has it's place, clinically and medicolegally. Once again, I'm no nerve expert, but this is what I've read.

PS. I thought the AE-sthesia applies to AEsthetics vs Esthetics but not to hypo/parEsthesia? Maybe I need spelling 101. do you also prefer pAEdiatric and orthopAEdic? I think you should try my meds too 🙂

 

[rrc]

Perhaps my understanding is wrong, but I was under the impression directional testing involved a proprioceptive sense of what direction a joint was bent in, as in testing interphalangeal joints in diabetic foot neuropathy...

I have certainly seen clinicians running through excercises with a cotton tip applicator on a patient's chin asking them to tell which direction the cotton swab is moving... I fail to see how it is any more informative than what one garners from sharp/dull touch and two point discrimination... I think it's mostly smoke and mirrors to make the patient feel like you are doing something fancy.

But I agree re: your comments on anaesthesia vs paraesthesia vs hypoaesthesia, and folks who chart 'V3 paraesthesia'...

I prefer the AE-sthesia spelling as opposed to E-sthesia spelling.

It seems to be quite common to confuse the two, but proprioception has nothing to do with directional testing. Proprioception is the way the body knows where an appendage is in space. Such that if you close your eyes, you know if your arm is sticking up in the air or straight out at your side. These receptors are in the muscles, joints, etc. Directional testing is a means to test the sensory fibers of the area in question. It tells you what the status of the nerve is over a small area and if you use the end of a cotton tip applicator, it can provide prognosis about the finest of sensations that we can perceive. If a patient can perceive direction sense with a very light touch, that is much better than a patient who can only feel pressure or pain. 2 point discrimination is sort of similar to direction sense but just another means of level A testing.