Cancer isn’t always easy to detect, especially when most signs and symptoms don’t appear until the disease has progressed to a more advanced stage. The mean dose to the neck extensor muscles of the three patients with DHS was 58.5 Gy, 42.3 Gy, and 60.9 Gy, while the dose was <50 Gy in all nine patients in the control group. The onset of DHS was five, six, and 15 months in the three affected patients, respectively, following radiotherapy. These authors suggested that early-onset DHS may be due to the magnitude of the radiation dose to the neck extensor muscles, and they recommended that the radiation dose should be <46 Gy. Of the nine previously reported cases of early-onset DHS after radiation, seven were also treated with chemotherapy (Table 1). Inaba and colleagues compared three patients with DHS after radiotherapy for head and neck cancer to nine patients without DHS. IMRT 7000 cGy (200 cGy per fraction 35 fractions) IMRT 70 Gy and additional 3DCRtT 10 Gy for primary disease (42.3 Gy/40 fractions) IMRT 70 Gy for hypopharyngeal carcinoma 3DCRT 60 Gy for esophageal carcinoma (58.5 Gy/35 fractions)
Hypopharyngeal carcinoma/esophageal carcinoma Radiotherapy mean dose to neck extensor muscles/fractionsħ580 rad at 190 cGy/fraction to primary cancer, 5580 rad at 180 cGy/fraction to regional lymphatics T1 weighted (Figures 1A, 1B) and T2 weighted (Figures 2A, 2B) cervical MRI scans demonstrated extensive fatty degeneration of paraspinal muscles (black arrows) and atrophic paracervical muscles containing white areas of fatty degeneration extending from the skull base to the C7 level in the posterior paraspinous region, suggestive of myositis. Laboratory investigation one day after the initiation of the neck/arm weakness revealed a total creatine kinase (CK) level of 82 U/L (26-192 U/L) which increased to 136 U/L six days later. The patient underwent gastrostomy tube placement due to the dysphagia. She was treated with intravenous methylprednisolone (a single 125 mg injection) while hospitalized followed by an oral prednisone 10 mg taper upon hospital discharge. Dropped head syndrome (DHS) involves severe weakness of the neck extensor muscles causing the mandible to drop to the chest wall. Isolated neck extensor weakness is a rare complication of radiotherapy. This condition may result within a few weeks or months following radiotherapy (early-onset) or several years after radiotherapy (late-onset), with the latter more commonly encountered. Person-in-the-barrel syndrome is marked by bilateral brachial diplegia, intact cranial nerves, and preserved lower extremity strength. We describe the unique clinical profile of a patient with a six-week history of significant neck and bilateral upper extremity weakness who was diagnosed three months prior to the onset of these symptoms with moderately differentiated squamous cell carcinoma within the base of the tongue (Stage III T2N1M0) and metastasis to the cervical lymph nodes. She underwent concurrent chemotherapy with three cycles of cisplatin (197 mg x 197 m 2) and hyperfractionated external beam radiation therapy. The cisplatin was administered since the patient had a 5.0 mm nonspecific noncalcified pulmonary nodule within the right lung apex which may have been infectious, inflammatory, or metastatic by chest CT. The radiation was focused on the base of the tongue (BOT) regimen which involved a volumetric modulated arc therapy (VMAT) modulated beam and 3 arcs intensity-modulated radiation therapy (IMRT) to the base of the tongue and regional lymph nodes. The total dose administered was 7000 cGy in 35 fractions (200 cGy per fraction).Īt the conclusion of chemotherapy and radiation, the patient denied any dysarthria, dysphagia, or weakness of the neck or arms. She reported the rapid onset of neck and bilateral upper extremity weakness six weeks following cisplatin termination and four weeks after the radiation termination. Dysarthria and severe dysphagia developed within the next week. She also complained of symptoms of neuropathy in her hands and feet as well as tinnitus after being treated with cisplatin.
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