Abstract Details

Loss of sternutation due to cerebellar hemorrhage, without extension into the pons or medulla, has not heretofore been described.

Case: A 67 year old right handed male sustained a left cerebellar hemispheric hemorrhage. Since then, he suffers from an instability in gait, clumsiness of his left hand, change in cadence of speech, dysarthria, and chin tremor. Throughout his lifetime, he has sneezed twice a day, but, since then, he has been unable to sneeze. He feels the urge and the buildup to sneeze but without the propulsive component. 

Abnormalities in Neurologic examination: Cranial Nerve (CN): CN lll, lV, Vl: Left lateral first degree end gaze sustained nystagmus. Drift testing: left abductor digiti minimi sign. Gait: wide based unstable with decreased left arm swing. Cerebellar examination: bilateral finger to nose dysmetria, left greater than right. Rapid alternating movements: dysdiadochokinesia in the left lower extremity. Holmes rebound phenomenon: positive on the left. 

Peradventure destruction of the facilitatory cerebellar outflow pathways projecting from superior cerebellar peduncle to the pontomedullary sneeze centers may have lead to the lack of activation in the nuclei involving exsufflation (Provine, 2019). Alternatively, the abnormality may occurred in the afferent pathways through the middle or inferior cerebellar peduncle originating from the ethmoid nerve, inducing the sensation of the need to sneeze. The abnormalities may exist in cerebellar nuclei themselves, most probably due to the medial portion of the fastigial nuclei which then projects to the outflow tracts, aligned with the somatotopic representation of the head region within the vermis of the cerebellum (Brodal, 1981). Alternatively, the sternutation centre in the Pons may have been affected, suggesting this could be a subtle variant of Wallenberg Syndrome with associated absent sternutation. Query as to whether non-traumatic cerebellar disease impacts exsufflation is warranted.