The Journal of Emergency Medicine, Vol. 44, No. 2, pp. e183–e185, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Clinical Communications: Adults ‘‘DE MANDIBULAE DYSARTHRIA’’ – THINKING OUTSIDE THE BOX Julien F. Bally, MD, Pierre Me´gevand, MD, PHD, Anne-Catherine M. Huys, MD, and Roman Sztajzel, MD Department of Neurology and Clinical Neurosciences, Geneva University Hospitals and School of Medicine, Geneva, Switzerland Reprint Address: Julien F. Bally, MD, Department of Neurology, HUG - Geneva University Hospitals, rue Gabrielle-Perret-Gentil 4, 1211 Gene`ve 14, Switzerland
, Abstract—Background: Urgent decisions in the Emergency Department allow for only a short history and physical examination. Objectives: To highlight the risks associated with a strict application of protocols, especially in the emergency setting. Case Report: An unusual case of acute dysarthria is presented. Conclusion: Even in the emergency setting, thorough history-taking and physical examination remain fundamental, and it is necessary to ‘‘think outside the box.’’ Ó 2013 Elsevier Inc.
a low educational background and only spoke Albanian, the history was taken with the help of her husband, who could speak elementary French. The patient presented with an acute neurological deficit within time limits for possible thrombolysis; history-taking was therefore reduced to the minimum. Blood pressure was 174/ 57 mm Hg (2 h later it was 150/72 mm Hg), pulse was 100 beats/min in sinus rhythm; there was no fever. Clinical examination revealed no facial asymmetry, no paresis, no sensory abnormalities, no dysphasia, and a moderate dysarthria. Cerebral computed tomography (CT) scan and angiography showed no lesions or any vascular abnormalities. Given the low score on the National Institutes of Health Stroke Scale (1 point due to moderate dysarthria) and the absence of any intraarterial thrombus, thrombolysis was not carried out. Intravenous acetylsalicylate was given and the patient admitted to the stroke unit. The presumed diagnosis of stroke was explained to the patient and her husband before admission (1). More careful history-taking the next morning revealed that episodes of acute-onset dysarthria had already occurred on several occasions in the past. According to her husband, the patient’s jaw remained ‘‘blocked’’ during these episodes, which always resolved very suddenly. This information further pointed to the hypothesis of a recurrent dislocation of the temporomandibular joint producing dysarthria; moreover, a bilateral dislocation was readily visible on the brain CT scan performed the night before (Figure 1).
, Keywords—dysarthria; stroke; thrombolysis; protocols; emergency
INTRODUCTION In the Emergency Department (ED), it is often necessary to limit the history-taking and physical examination to the minimum to gain time and make goal-directed decisions. However, a presumed diagnosis always must be reconsidered when time is available. CASE REPORT This is the case of a 51-year-old Albanian woman with no cardiovascular risk factors except for untreated arterial hypertension. The patient had recently undergone a total ablation of her teeth, to prepare for a denture. Two weeks later, she was brought to our ED by her husband due to the sudden onset of dysarthria associated with bilateral perioral paresthesia. As the patient had
RECEIVED: 1 July 2011; FINAL SUBMISSION RECEIVED: 20 October 2011; ACCEPTED: 19 February 2012 e183
J. F. Bally et al.
Figure 1. Cerebral computed tomography scan with bone window. (A) Sagittal plane: showing the anterior temporomandibular dislocation on the left; the arrow indicates the normal location of the condylar process. (B) Coronal plane: circles and arrows indicating the normal location of the mandibular condylar processes, confirming the bilateral dislocation. (C) Coronal plane: circles showing the abnormal location of the condylar processes. (D) Coronal plane: patient control; no mandibular dislocation.
The confounding factors in this case were the absence of pain or discomfort and a distortion of the anatomy due to the total teeth ablation, with a corresponding lack of misalignment of the teeth. The dislocated joint was reduced and the patient discharged.
ough physical examination as the basis for further management. In order not to miss the obvious, often simple diagnosis, it is necessary not to limit one’s attention to one system alone when reviewing the clinical and radiological features (3).
As we have learned with this patient, dysarthria is frequently, but not always, neurological in origin, and dislocation is not always painful nor asymmetric (in case of bilateral dislocation); furthermore, due to the previous total teeth ablation, the prognathia that is usually seen in patients with bilateral dislocations was absent in this patient (2). This case highlights the importance of thorough history-taking, including adequate translation, and thor-
It is important to keep one’s mind open, including looking for the less apparently relevant but important elements of a case. ‘‘Thinking outside the box’’ is essential in these days of ever-increasing protocols and demands for a speedy diagnosis. Thus, one should work fast, but work smart. Do not forget the basics, which are fundamental for the correct management of each and every patient: thorough historytaking and physical examination.
De Mandibulae Dysarthria
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e185 2. Chaudhry M, Kulkarni R. Mandible dislocation clinical presentation. Available at: http://emedicine.medscape.com/article/823775clinical. Accessed October 9, 2012. 3. Ahmad A, Teoh HL, Sharma VK. Would you perform thrombolysis in this acute ischemic stroke patient? Arch Neurol 2009;66: 410–1.