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Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 1  |  Page : 107-109

Intractable yawning caused by foramen magnum meningioma in a patient with neurofibromatosis type 2


1 Department of Neurosurgery, Marmara University Faculty of Medicine, Istanbul, Turkey
2 Department of Neurosurgery, Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
3 Department of Anesthesiology, Marmara University Institute of Neurological Sciences, Istanbul, Turkey

Date of Web Publication4-Mar-2015

Correspondence Address:
Yasar Bayri
Department of Neurosurgery, Marmara University Faculty of Medicine, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.152675

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How to cite this article:
Bayri Y, Tanrikulu B, Bayrakli F, Koç DY, Dagçinar A. Intractable yawning caused by foramen magnum meningioma in a patient with neurofibromatosis type 2. Neurol India 2015;63:107-9

How to cite this URL:
Bayri Y, Tanrikulu B, Bayrakli F, Koç DY, Dagçinar A. Intractable yawning caused by foramen magnum meningioma in a patient with neurofibromatosis type 2. Neurol India [serial online] 2015 [cited 2018 Jun 17];63:107-9. Available from: http://www.neurologyindia.com/text.asp?2015/63/1/107/152675


Sir,

Yawning is a stereotyped event seen in all vertebrates. Neural networks in the brainstem, autonomic nervous system, hypothalamus, and limbic system may be involved in the physiology of yawning. Tumor-related yawning has rarely been reported. [1],[2] We present a rare case of a patient with a meningioma at foramen magnum who presented with intractable yawning. After total removal of the tumor, the recurrent yawning resolved completely.

A 17-year-old girl was admitted with complaints of headache for 2 years. Her neurological examination revealed no abnormality other than hearing deficit in the right ear.

Her magnetic resonance imaging (MRI) of the brain revealed hydrocephalus, bilateral vestibular schwannomas with the right one being 23 × 25 × 22 mm and the left one,14 × 8 × 6 mm, in size. She also had a falcine meningioma, that was 13 × 10 × 11 mm in size. Due to the presence of these bilateral vestibular schwannomas, she fulfilled the diagnostic criteria of neurofibromatosis type 2 (NF2).

The patient underwent a ventriculo-peritoneal shunt and had radiosurgery for the right vestibular schwannoma and the falcine meningioma. The left vestibular schwannoma was left untreated as it was small in size and she had completely preserved hearing on that side.

Fourteen months after the administration of stereotactic radiosurgery, the patient was again admitted to the hospital with the complaint of an involuntarily tilt of her head to the right side. Any attempts to correct the head position precipitated intractable yawning. She denied any sleeping disorder. The patient's Epworth Sleepiness Scale was 2/24. Her cranial MRI, revealed an additional meningioma, 10 × 12 × 15 mm in size located toward the right side of the foramen magnum extending down to the C1 level [Figure 1]. The patient had no additional neurological deficits.
Figure 1: Preoperative axial, coronal and sagittal T1 weighted contrast MRI of the patient showing homogenously enhancing mass lesion at the right side of foramen magnum extending down to C1 level. The lesion has shifted medulla oblongata


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She was operated through a posterior approach using a dorsal midline skin incision between the external occipital protuberance and spinous process of C2. The tumor was dissected meticulously from the surrounding structures, and total excision was performed. It was histopathologically diagnosed as a psammomatous grade 1 meningioma.

The patient had no additional neurological deficits after surgery. A postoperative cranio-vertebral junction MRI confirmed complete tumor removal [Figure 2]. Following surgery, the patient was able to hold her head in the normal anatomical position. The phenomenon of intractable yawning on correction of head position had resolved completely. At follow-up after 9 months, there was no recurrence of the yawning phenomenon.
Figure 2: Postoperative axial, coronal and sagittal T1 weighted contrast MRI of the patient showing complete removal of the lesion


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Yawning involves wide opening of the mouth with concurrent deep inspiration, followed by a slow expiration. This complex and well-coordinated process resembles a classical reflex because once it starts, it is completed without any influence from an external stimuli. [2] However, yawning is not a simple reflex because it has a complex spatio-temporal organization with contributions from facial and respiratory muscles, and other component systems.

It is proposed that the complex neuronal network that regulates yawning may be located in the brainstem reticular formation. This is supported by the observation that yawning also occurs in anencephalic newborns in whom only medulla oblongata exists as a brain structure. [3]

In our patient, the symptom was probably associated with the meningioma that was located at the foramen magnum and C1 level. The involuntarily tilting of her head to the side of the tumor relieved pressure on medulla. This made her involuntarily maintain that position of the head prior to tumor removal. Yawning started with correction of the head position because this maneuver, in all likelihood, stretched the medulla and increased tumor pressure on it. In addition, yawning disappeared immediately after surgery and did not recur.

There are two cases in the literature that report the phenomenon of intractable yawning associated with brain tumors. One is related to a hemangioblastoma of the IVth ventricle, and the other is related to a mature teratoma of supramedial cerebellum. [1],[4] Our unique case reports yawning triggered by an extra-axial lesion at the level of foramen magnum.

 
 » References Top

1.
Saura H, Beppu T, Matsuura H, Asahi S, Uesugi N, Sasaki M, et al. Intractable yawning associated with mature teratoma of the supramedial cerebellum. J Neurosurg 2014;121:387-9.  Back to cited text no. 1
    
2.
Argiolas A, Melis MR. The neuropharmacology of yawning. Eur J Pharmacol 1998;343:1-16.  Back to cited text no. 2
    
3.
Askenasy JJ, Askenasy N. Inhibition of muscle sympathetic nerve activity during yawning. Clin Auton Res 1996;6:237-9.  Back to cited text no. 3
    
4.
Arai K, Kita K, Komiyama A, Hirayama K, Saeki N, Nagao K. Progressive dysautonomia in hemangioblastoma in the region of the fourth ventricle. No To Shinkei 1986;38:195-200.  Back to cited text no. 4
    


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