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• Re: Sneezing: a powerful Valsalva-like manoeuvre affecting the central nervous system
  Paul E Peknikj
  Published on: 13 April 2016
• Response to: Sneezing: a powerful Valsalva-like manoeuvre affecting the central nervous system
  Manuel Seijo-Martinez
  Published on: 13 April 2016
• Sneezing: a powerful Valsalva-like manoeuvre affecting the central nervous system
  Vinod K Gupta
  Published on: 13 April 2016
• Hypercusis in lateral medullary syndrome
  Jacob PC
  Published on: 13 April 2016

• Published on: 13 April 2016

  Re: Sneezing: a powerful Valsalva-like manoeuvre affecting the central nervous system

  • Paul E Peknikj, teacher

  Dear Editor,

  I would be intertesed in how one would calculate the number of newtons in a sneeze as well as the force that is required to break a rib during a sneeze.

  Regards,

  PE Peknik

  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  Response to: Sneezing: a powerful Valsalva-like manoeuvre affecting the central nervous system

  • Manuel Seijo-Martinez, Neurology Service
  • Other Contributors:
    • A. Varela Freijanes, J. Grandes, F. Vazquez

  Dear Editor,

  We thank Dr. Gupta for his interest and comments in relation to our clinical report (1).

  The patient presented an incomplete clinical manifestation of lateral medullary syndrome, with partial Horner´s syndrome, sensitive and cerebellar signs; the right facial palsy was slight, and perhaps may be secondary to the peripheral mechanical shear-stress mechanism that Dr. Gupta mentions. Howeve...

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  Dear Editor,

  We thank Dr. Gupta for his interest and comments in relation to our clinical report (1).

  The patient presented an incomplete clinical manifestation of lateral medullary syndrome, with partial Horner´s syndrome, sensitive and cerebellar signs; the right facial palsy was slight, and perhaps may be secondary to the peripheral mechanical shear-stress mechanism that Dr. Gupta mentions. However, a partial facial palsy may, in some cases, form part of the lateral medullary syndrome (2). The explanation for this is not fully understood, since the facial nerve nucleus is more rostrally located. Some authors mention on the possibility of an aberrant corticobulbar tract innervation of the facial nucleus (3). Also, there may be some variability in the manifestations of the syndrome in relation to a more caudal or rostral location of the ischemic lesion (4)

  In the case that we present, a computed tomography scan of the brain was performed on admission and excluded the presence of a hemorrhage. The first magnetic resonance imaging of the brain was performed a few days after stroke onset and showed a hyperintense T2 lesion in the medulla consistent with an ischemic stroke and excluded hemorrhage.

  Dr. Gupta correctly states that sneezing is not part of the classical Wallenberg´s syndrome. However, neurologists do not usually ask patients with an acute lateral medullary stroke if they present sneezing problems and, to our knowledge, studies of the sneezing reflex in patients with Wallenberg´s syndrome have not been reported. If there are two independent sneezing centers in the human medulla, as we hypothesize, dysfunction in one side may not be noted by the patients, and thus they may not complain of sneezing difficulties. It would be of interest to perform controlled studies of the sneezing reflex in patients with medullary lesions to further understand the reflex. The use of capsaicin challenge test may be the technique of choice to study this reflex; however, it is a painful procedure at standard doses. We used a dilution to 25 µmg/ml, but perhaps a lower concentration or stimulating dose may suffice to provoke sneezing. Interestingly, hiccups, which may share some common pathophysiological mechanisms with sneezing seem to be a common complaint in some patients with the lateral medullary syndrome (5).

  As we indicate on our paper, months after the stroke the patient recovered the ability to sneeze normally but we did not repeat the capsain challenge test. It is possible that a difference in sneezing threshold between both nostrils may have persisted.

  References

  1. Seijo-Martinez M, Varela-Freijanes A, Grandes J, Vazquez F. Sneeze related area in the medulla: localisation of the human sneezing centre? J Neurol Neurosurg Psychiatry. 2006;77:559-61.

  2. Kim JS. Pure lateral medullary infarction: clinical–radiological correlation of 130 acute, consecutive patients. Brain 2003;126:1864-72.

  3. Urban PP, Wicht S, Vucorevic G, et al. The course of corticofacial projections in the human brainstem. Brain 2001;124:1866-76.

  4. Kim JS, Lee JH, Suh DC, Lee MC. Spectrum of lateral medullary syndrome. Correlation between clinical findings and magnetic resonance imaging in 33 subjects. Stroke 1994;25:1405-10.

  5. Park MH, Kim BJ, Koh SB, et al. Lesional location of lateral medullary infarction presenting hiccups (singultus). J Neurol Neurosurg Psychiatry. 2005;76:95-8.

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  Sneezing: a powerful Valsalva-like manoeuvre affecting the central nervous system

  • Vinod K Gupta, Physician

  Dear Editor,

  Seijo-Martý´nez and colleagues report an interesting rare case of possibly sneeze-related lateral medullary infarct with loss of the sneezing reflex (1). These authors believe that the acute bout of sneezing was a direct and initial consequence of the brain stem infarction and suggest ischaemic irritation of the sneeze-reflex related structures in the medulla. Although the lateral medullary syndrome i...

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  Dear Editor,

  Seijo-Martý´nez and colleagues report an interesting rare case of possibly sneeze-related lateral medullary infarct with loss of the sneezing reflex (1). These authors believe that the acute bout of sneezing was a direct and initial consequence of the brain stem infarction and suggest ischaemic irritation of the sneeze-reflex related structures in the medulla. Although the lateral medullary syndrome is well-defined, sneezing is not part of the symptom complex. Ischaemic lesions can manifest positive neurological “seizure-like” phenomena by irritation of neurons either early in the course by accompanying oedema or as a late sequela following gliosis. For brain infarcts to begin with positive 'irritative' symptoms is distinctly unlikely. The MRI scan performed early for this patient did not show any evidence of infarct-related oedema. Also, four-months later the ability to sneeze had normalized, indicating temporary suppression of the sneeze-reflex related neuronal centre in the medulla rather than permanent neurological loss due to infarction. Several features of the “classical” lateral medullary syndrome are missing; miosis without ptosis (partial Horner’s syndrome) and slight right facial palsy with relatively quick and complete recovery also stimulate lateral thinking about the underlying disease mechanisms in this case.

  The sneeze reflex is a powerful physical event that can cause acute aortic dissection (2), orbital emphysema (3), permanent cranial neuropathy or transient alteration of ocular blood flow in certain anatomically predisposed patients (4), subhyaloid hemorrhage (5), or orbital fracture (6). Sneezing raises the intrathoracic pressure and limits cranial venous return, thereby mimicking the cranio-ocular vascular effects of the Valsalva manoeuvre. It is a common experience, as also noted by the authors (1), that sneezing begins with closure of the eyes. I have myself attempted on several occasions to sneeze with a deliberate attempt to maintain the eyes open and have found it to be a very difficult exercise if not impossible. Valsalva-like activities (coughing, sneezing, laughing, straining at stools, and parturition) instantaneously decrease cranial venous return and raise the episcleral venous pressure thereby causing considerable ocular congestion and rise of intraocular pressure (IOP) (7,8,9). Forcible screwing of the lids together can raise IOP by 60-70 mm Hg; stimulation of facial nerve in experimental animals increases the tone of the orbicularis oculi and similarly raises IOP (7,8). IOP itself exerts an important intraocular tamponade function with increasing IOP decreasing the pressure-sensitive ultrafiltration component of aqueous humour formation and ocular blood volume (10). Closure of the eyes in sneezing probably serves an adaptive function designed to protect the eye by limiting sudden ocular congestion. I have encountered two patients with repeated attacks of cluster headache precipitated by bouts of sneezing (unpublished observation); such a development has previously been reported only once (11).

  Similar to ocular venous congestion, sneezing causes brain venous congestion. In addition, sudden head-and-neck movements during sneezing cause a mechanical shear-stress on brain structures. Although sneezing is not reported to be associated with intracranial haemorrhage, the rapid development of neurological loss and the hyperintense lesion on MRI scan seen early in this patient (1) suggests a discrete medullary haemorrhagic lesion. Also, facial nerve/nucleus involvement cannot be explained by a medullary vascular lesion. Importantly, the right facial palsy in this case was slight and recovered rapidly (1). I suggest that the mild facial palsy in this case (1) was caused by neuropraxic torsional shear-stress at the facial nerve-pons junction due to repetitive forceful movements of the head-neck axis during the bout of sneezing.

  References

  1. Seijo-Martý´nez M, Varela-Freijanes A, Grandes J, Va´zquez F. Sneeze related area in the medulla: localisation of the human sneezing centre? J Neurol Neurosurg Psychiatry 2006;77:559–561. doi: 10.1136/jnnp.2005.068601

  2. Baydin A, Nural MS, Güven H, Deniz T, Bildik F, Karaduman A. Acute aortic dissection provoked by sneeze: a case report. Emerg Med J 2005;22:756-757.

  3. Gonzalez F, Cal V, Elhendi W. Orbital emphysema after sneezing. Ophthal Plast Reconstr Surg 2005;21:309-311.

  4. Andreoli CM, Leff GB, Rizzo JF. Sneeze-induced visual and ocular motor dysfunction. Am J Ophthalmol 2002;133:725-727.

  5. Guigon-Souquet B, Salaun N, Macarez R, Bazin S, De La Marnierre E, Mazdou M. Subhyaloid hemorrhage following a Valsalva maneuver. J Fr Ophtalmol 2004; 27:1159-62 (Abstract).

  6. Chiu TW, Chung CK, Chan SH, Ng WM, Lam LK. Sneezing and orbital fracture. Plast Reconstr Surg. 2006; 117:1049-50

  7. Shields MB. Textbook of glaucoma. 2nd ed. Baltimore: Williams & Wilkins; 1987. p. 45-70.

  8. Duke-Elder S. System of Ophthalmology. The physiology of the Eye and of Vision, vol 4, London: Henry Kimpton, 1968, p. 276-7; 280-3.

  9. Barriga FJ, Cuadrado ML, Bueno A, Barón M, Dobato JL, Vela L et al. Cluster headache: orbital hemodynamic changes during Valsalva maneuver. Headache 2006; 46: 298-305.

  10. Gupta VK. Is benign cough headache caused by intraocular haemodynamic aberration? Med Hypotheses 2004;62:45-48.

  11. Ko J, Rozen TD. Valsalva-induced cluster: a new type of cluster headache. Headache 2002;42:301-302.

  E-mail: dr_vkgupta@yahoo.com

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  Hypercusis in lateral medullary syndrome

  • Jacob PC, neurologist

  Dear Editor,

  I report a patient with lateral medullary syndrome,who developed hypercusis. A 55 year old hypertensive patient presented with inco- ordination of the right side,dysarthria and loss of pain and temperature sensation on the left side, as soon as he recovered from an angioplasty procedure for acute myocardial infarction. He also had right Horner's syndrome and hyperacusis, more marked on the right side.N...

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  Dear Editor,

  I report a patient with lateral medullary syndrome,who developed hypercusis. A 55 year old hypertensive patient presented with inco- ordination of the right side,dysarthria and loss of pain and temperature sensation on the left side, as soon as he recovered from an angioplasty procedure for acute myocardial infarction. He also had right Horner's syndrome and hyperacusis, more marked on the right side.Neuroimaging confirmed right lateral medullary and cerebellar infarct. Transcranial Doppler study showed absent flow in the right vertebral artery. This case illustrates that like the centre for sneezing, the centre for the stapedius reflex is also in the lateral medulla and its dysfunction,leads to hyperacusis. Lateral medullary syndrome also produces other symptoms of vestibulocochlear dysfunction such as vertigo, oscillopsia and the ocular tilt reaction.

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  Conflict of Interest:
  None declared.

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