A case of extensive left-sided facial atrophy of Romberg
A 50-year-old female presented with gradually progressive left-sided facial atrophy for the last 30 years. She also complained of intermittent left-sided headache for the last 8–9 years, which was throbbing, pulsatile with photophobia, phonophobia with history of visual auras. She had continuous tearing and redness of left eye since 3 years. There was no history of extraction of teeth, local trauma, seizures or lancinating pain suggestive of trigeminal neuralgia. The patient denied history of joint pains, rash, dyspnea, double vision and neurologic deficits in the extremities. Family history was non-contributory.\nOn examination, marked left-sided facial atrophy was present []. Oral cavity assessment disclosed left-sided tongue atrophy []. Ocular examination revealed enophthalmos and uveitis in left eye. The skin over left lower face had bluish hue. Rest of neurological examination was unremarkable. The investigations, including hematological parameters, blood sugar, serum creatinine, blood urea and liver function test revealed normal results. The C-reactive protein and erythrocyte sedimentation rate were not raised. The autoimmune markers, comprising antinuclear antibody, anti-double-stranded DNA antibody, anticardiolipin antibody and rheumatoid factor were non-reactive in sera. The viral studies for Epstein Barre virus, cytomegalovirus, dengue virus, herpes simplex virus and Japanese encephalitis virus showed negative results. Electroencephalography was reported to be normal. Magnetic resonance imaging of cranium did not demonstrate any abnormality []. Facial nerve stimulation at anterior ear on both sides revealed minor differences in latency and amplitudes []. Blink reflex on stimulation of supraorbital nerves showed insignificant differences of R2-R1, on left side 27.95 ms, while on right side 24.20 ms []. The clinical description and laboratory evaluation suggested the diagnosis of facial atrophy of Romberg and migraine with aura. The patient was prescribed propranolol 40 mg twice a day, flunarizine 10 mg/day as prophylactics for migraine along with abortive medications for control of acute headache. The patient was not willing for facial reconstructive surgery. On follow up after 6 months, her frequency of headache was significantly decreased.