Lower motor neuron facial palsy in cerebral venous sinus thrombosis
A 30-year-old lady congenitally deaf and mute presented with history of headache since one month and right LMN facial palsy since last 20 days. Using the sign language, she indicated that at the onset headache was predominantly over the anterior part of head and within few days it became diffuse. It was pressing in character, present throughout the day and associated with vomiting on increased severity. Ten days after the onset of headache she noticed difficulty in closing her right eyelid and three days later deviation of angle of mouth to left. There was no history of fever, ear discharge, weakness of limbs, seizures, diplopia, blurring of vision, ataxia, tinnitus or recent worsening of deafness. Physical examination showed presence of pallor, no organomegaly, external ear, mastoid and eardrum were normal. She was conscious, alert and oriented. Her visual acuity was 6/9 on both sides. Examination of the optic fundi revealed presence of bilateral papilledema. Eye movements and pupillary reactions were normal. She had right LMN facial palsy with absent taste and tearing ipsilaterally with bilateral sensory neural deafness as evidenced by tuning fork tests. Rest of the cranial nerves, motor, sensory and cerebellar examinations were normal. Clinically she was diagnosed as a case of raised intracranial pressure (ICP) with right LMN facial palsy with congenital deaf mutism.\nInvestigations revealed hemoglobin of 7.1 gm%, microcytic hypochromic blood picture with normal white blood cells and platelets. Serum biochemistry and electrolytes were normal. Rheumatoid factor and antinuclear antibodies were negative. Serum antiphospholipid antibodies, homocysteine levels, angiotensin converting enzyme levels and chest X-ray were normal. Computerized tomography (CT) scan of the brain showed posterior empty delta sign in the superior sagittal sinus. Temporal bone and middle ear cavity were normal. MRI and MRV [] showed thrombosis of superior and right lateral sinus, with no parenchymal lesions. Lumbar puncture was normal except with raised opening pressure. Audiometry showed bilateral profound sensory neural hearing loss. Brain stem auditory evoked responses were absent bilaterally. She was diagnosed as a case of CVT (superior and right lateral sinus) with ipsilateral LMN facial palsy with congenital deaf-mutism. She was started on parenteral followed by oral anticoagulation (prothrombin time, international normalization ratio maintained at about two), hematinics, anti edema measures. Over the next one month her symptoms of headache and facial palsy improved and at 4 months after her symptom onset, she was asymptomatic.