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Show Tinnitus in Fourth Nerve Palsy: An Indicator for an Intra-Axial Lesion Seo Young Choi, MD, Jae Jin Song, MD, Jeong Min Hwang, MD, Ji Soo Kim, MD, PhD Abstract: Accompanying neurological symptoms and signs are diagnostic hallmarks of fourth nerve palsy (4NP) from an intra-axial lesion. Due to the proximity of the trochlear nucleus and fascicles to the inferior colliculus (IC), auditory symptoms including tinnitus may occur with an intra-axial 4NP. A 53-year-old man with hyper-tension and diabetes developed right 4NP with a sudden worsening of tinnitus. MRI disclosed an infarction involving the trochlear fascicle and IC in the left dorsal midbrain. Tinnitus may be a symptom indicating an intra-axial lesion causing a 4NP. Journal of Neuro-Ophthalmology 2010;30:325-327 doi: 10.1097/WNO.0b013e3181e4e03e 2010 by North American Neuro-Ophthalmology Society Fourth cranial nerve palsy (4NP) from intra-axial lesions usually is associated with other neurological deficits (1). Since the trochlear nucleus and fascicles are adjacent to the inferior colliculus (IC) (2,3), auditory symptoms including tinnitus may accompany an intra-axial 4NP (4). However, tinnitus has not been described as the only accompaniment of 4NP from a midbrain lesion. We describe a patient with sudden aggravation of mild tinnitus and contralesional 4NP from midbrain infarction. CASE REPORT A 53-year-old man with hypertension and diabetes for 12 years was referred for evaluation of binocular vertical diplopia of 1-month duration. The diplopia developed while driving a car and worsened in leftward and downward gazes. He also reported sudden aggravation of bilateral tinnitus, which had been intermittent and mild as ‘‘chirrups of a cicada'' for several years, becoming louder than ‘‘air-plane sounds'' and persistent with the onset of diplopia. He denied headache, hearing impairment, or history of head trauma.His medications included amlodipine and metformin. Examination revealed a right hypertropia of 5 prism-diopters (PD) in primary position, which increased in leftward (7 PD) and downward (8 PD) gazes and in right head tilt (10 PD). Abnormal torsion of the right eye was not noted on fundus photography. Pure tone audiometry showed a mild high tone sloping in both ears, consistent with presbycusis, and brain stem auditory evoked potentials (BAEP) were normal bilaterally. Four days after onset of symptoms, brainMRI revealed an acute infarction circumscribed to the area of left fourth cranial nerve fascicle and IC (Fig. 1). MRA was normal. Antiplatelet therapy (75 mg/day clopidogrel) was begun, and the tinnitus and diplopia gradually improved over several weeks. DISCUSSION Our patient developed contralesional 4NP from infarction involving the midbrain tectum and aggravation of tinnitus was the only accompanying neurologic deficit. The troch-lear nucleus lies dorsal to the medial longitudinal fasciculus (MLF) and just ventrolateral to the cerebral aqueduct at the level of the IC (2,3). The nerve fascicles course poster-oinferiorly around the aqueduct to decussate in the anterior medullary velum (2,3). Damage to the trochlear nucleus or the proximal fascicles before their decussations gives rise to contralateral palsy (1,5,6). Since the trochlear nucleus and fascicles are adjacent to various structures in the lower midbrain, accompanying Department of Neurology (SYC, JSK), Seoul National University College of Medicine, Seoul National University Bundang Hospital; Eulji University College of Medicine (SYC); and Department of Otorhinolaryngology (JJS) and Ophthalmology (JMH), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea. Supported by grant of the Korea Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea (A080750). Address correspondence to Ji Soo Kim, MD, PhD, Department of Neurology, College of Medicine, Seoul National University, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea E-mail: jisoo-kim@ snu.ac.kr Choi et al: J Neuro-Ophthalmol 2010; 30: 325-327 325 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. neurological symptoms or signs are diagnostic hallmarks of an intra-axial lesion. Internuclear ophthalmoplegia, Horner syndrome, upbeat nystagmus, and sensory disturbances are frequently associated since the trochlear nucleus and fascicles are in close proximity with the ascending trigeminothalamic tract, spinothalamic tract, MLF, descending sympathetic tract, decussating fibers of the superior cerebellar peduncle, and lateral lemniscus (Fig. 2) (1,3-7). However, to the best of our knowledge, tinnitus has not been described as the only accompaniment in 4NP from an intra-axial lesion. Our patient reported sudden worsening of preexisting tinnitus without hearing loss. Even though the mechanism of tinnitus is only partially understood (8-10), cochlear impairment is a frequent cause of tinnitus at the peripheral level (e.g., senile hearing loss) (8,10,11). Accordingly, the preexisting mild tinnitus in our patient may be ascribed to the high tone hearing loss consistent with presbycusis. Tinnitus is also associated with dysfunction of the central auditory pathways (8,10,11). Central auditory neurons are subject to glutaminergic and GABAergic modulation, and inhibitory GABAergic synapses are affected more than ex-citatory glutaminergic ones in generating tinnitus (9,11). In particular, the IC is a relay nucleus for all ascending auditory information. Accordingly, impaired inhibitory processing in the IC could give rise to tinnitus or aggravate preexisting tinnitus. The IC is consisted of 3 parts: central nucleus, FIG. 1. (A) Diffusion-weighted and (B) T2 axial MRI reveal an acute midbrain infarction (arrows) in the area of the left fourth cranial nerve fascicle and inferior colliculus. FIG. 2. Schematic illustration of location of midbrain infarction (gray circle). Original Contribution 326 Choi et al: J Neuro-Ophthalmol 2010; 30: 325-327 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. external nucleus, and dorsal cortex (Fig. 2) (9,12). The central nucleus of IC is connected to the ventral medial geniculate body (MGB) and the primary auditory cortex (9,12). These structures constitute the classical auditory pathway. In contrast, the nonclassical pathway consists of the dorsal cortex and external nucleus of IC, dorsal MGB, and secondary auditory cortex (9,12). This pathway has diffuse and bilateral interconnections with other neural structures and integrates other sensory information (8,9). Both the classical and nonclassical pathways may be responsible for tinnitus (8,9). However, in view of the bilateral tinnitus, and normal hearing and BAEP, our patient most likely had tinnitus from isolated damage to the nonclassical pathway. Differentiation of 4NP from skew deviation is important in lesions involving the brain stem (1,14). Skew deviation is usually contraversive in the upper brain stem lesions, that is, the eye on the involved side is hypertropic (15), while ipsilesional eye was hypotropic in our patient. Skew de-viation is also more likely to accompany contraversive ocular torsion (ocular tilt reaction) (16,17). Furthermore, results of the Parks-Bielschowsky 3-step test in our patient were consistent with a 4NP. In conclusion, tinnitus may accompany 4NP due to an intra-axial lesion. 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