916 - Neurovascular Malformation in a Professional Horn Player Treated by a Multidisciplinary Arts Medicine Team

Case Diagnosis: Neurovascular malformation

Case Description: A musician in a major symphony presented to an arts medicine clinic with worsening right upper lip pain associated with playing his instrument, to the point his job was in jeopardy. On exam, pressure and light touch of the vermilion caused focal pain. Diagnostic block of the infraorbital nerve provided temporary relief. Topical steroids were ineffective. Oral steroids had benefit. Diagnostic ultrasound by outside radiology demonstrated what was interpreted as an arterioveinous (AV) malformation. Our interventional radiologist performed angiography for embolization. No AV malformation was identified, but the right superior labial artery was large, tortuous, and crossed midline. He ultimately underwent vessel resection with retention of the infraorbital nerve.

Discussions: Postoperatively, he was successfully weaned off steroids and began a structured return-to-play program, and care was coordinated with physiatry closer to his home. Within 3 weeks of surgery, he was able to return to playing horn, but symptoms returned.  Further discussion revealed a 10-year history of chronic pain, extraordinary stress at the symphony, and fatigue that limited optimal performance.  Low-dose naltrexone was initiated for fatigue and pain, and pregabalin was added.  Playing technique and positioning were modified in conjunction with manual medicine. Within a few weeks, he returned to playing, and after a few months, resumed playing without pain.

Conclusions: Musicians are highly skilled artists/athletes whose examination, diagnosis, and treatment are often different from that of the general population. Comprehensive, individualized management—including surgical intervention, pharmacologic support, manual medicine, and ergonomic modifications—can enable performing artists with complex histories to return safely to full professional activity.

It is important for performers to be treated by providers who specialize in arts medicine.  It is also important for providers to work as a team within their programs and across other programs with excellent communication in order to provide the best care for this population.