Clinical case presentation Dr. Arunbabu. R Post MCh Senior Resident - - PowerPoint PPT Presentation

Clinical case presentation

• Dr. Arunbabu. R

Post MCh Senior Resident Neurosurgery, NIMHANS.

Chief complaints

58 yrs old gentleman, Rt handed

• Headache- 1year
• Deviation of tongue to the right side- 9months
• Regurgitation of food and hoarseness of voice-

6months

• Right ear hearing loss- 6months
• Deviation of mouth to the left side- 5mnths
• Right sided facial numbness- 4months
• Double vision- 3months

History of present illness

Headache- 1yr

• Insidious onset, dull aching, initially intermittent, but

later became continuous.

• More in the suboccipital region, non radiating
• No diurnal variation/ No aggravating or relieving

factors

• Not associated with vomiting, blurring of vision,

diplopia.

Deviation of tongue to the right side- 9mnths

• Noticed first when he was cleaning tongue after

brushing teeth

• Associated with thinning and twitching of the right

side of the tongue.

• Son noticed slurring of speech and he was not able to

pronounce words starting with ‘ta and la’ phonemes.

• Difficulty in mixing bolus of the food inside the mouth

Nasal regurgitation of food and Hoarseness of voice - 6mnths

• More to liquid food than solid food.
• Prefers solid food with increased time for taking each meal.
• Prefers to take food in small bolus.
• Has cough while having food.
• Voice had become more husky.
• Not able to speak loudly/ Not able to make sound after

speaking for a long time.

• No h/o recurrent respiratory tract infection.

Drooping of the right shoulder- 6mnths

• Son noticed drooped right shoulder when he is

walking

• Associated with neck tilt to the left side
• No neck pain
• No wasting
• No thinning or twitching movements of the muscle.

Decreased hearing in the right side- 5 months

• Insidious onset and gradually progressive.
• First noticed while he was hearing over a phone-

volume of the voice was less in the right side,

• But he was able to understand the speech when it was

spoken loudly.

• Reports that hears better in noisy surroundings.

• Associated with fullness of right ear.
• Continuous hissing sound in the right ear, non

pulsatile.

• No h/o sudden increase in the sound while increasing

volume of the TV.

• No ear discharge. No vertigo.

Deviation of angle of mouth to the left side- 5mnths.

• Associated with drooling of the saliva
• Frequently food getting stuck in the bucco labial fold.
• Difficulty in mixing food bolus in the mouth.
• Son noticed decreased blinking in the right eye.
• Decreased watering of the right eye.
• Decreased taste sensation in the right side of the

tongue.

Decreased sensation in the right side of the face- 4 months.

• First noticed when he was shaving.
• Noticed redness of the right eye while washing face.
• Had irritation only in the left eye while washing face

with the soap.

• Difficulty in chewing.
• Prefers to chew chappathi, chicken and other hard

food in the left side.

• Son noticed right temporal hollowing- 2months

Double vision- 3 months.

• Binocular
• Sharp and blurred images placed side by side with

blurred image always placed to the right side.

• Double vision increased on long sight and while seeing

to the right side.

• Deviation of right eye inwards.
• Drooping of the right eyelid+.
• No double vision on seeing near objects or while

walking downstairs.

Negative history

• No h/s/o Higher mental function impairment like abnormal

behavior, irrelevant talk, urinary incontinence, difficulty in dressing, right left disorientation.

• No h/o anosmia, blurring of vision, field defects.
• No h/o weakness or stiffness of limbs.
• No h/o sensory disturbances over the body.
• No h/s/o cerebellar impairment like swaying while walking,

tremors, etc.,

• No h/o vomiting, seizures, LOC.

• Etiology history-
• No h/o loss of weight or appetite
• No h/o fever
• No h/o TB/contacts with TB/ trauma
• No h/s/o any primary malignancy
• No h/o pigmented patches or subcutaneous swelling
• ver the body

• Treatment history- Has taken ayurvedic medications

for these complaints.

• Personal history- chronic smoker and alcoholic, mixed

diet, K/C/O DM for 15 yrs. No other co-morbidities.

• Family history- No similar problems in family

members, No h/o hearing loss, No h/o subcutaneous swellings.

• Past history- not significant

Analysis

Headache- 1yr

• Headache – d/t dural stretch
• unlikely d/t raised ICP since there is no vomiting,

blurring of vision or diplopia/ no diurnal variation

Deviation of f tongue to the right side- 9mnths

• D/T Right 12th nerve LMN palsy- The normal

genioglossus muscle in the left side pushes the tongue to the right side

• Wasting and fasciculations indicate LMN type of palsy

Nasal regurgitation of f food and Hoarseness of f voice

• 6mnths
• d/t 9th and 10th nerve palsy
• Nasal regurgitation- d/t incompetent soft palate
• Dysphagia- is neurogenic; Mechanical obstruction-

More to the solid fluid

• Cough while swallowing- d/t aspiration
• Voice change – d/t vocal cord palsy

Drooping of the right shoulder- 6mnths

• Substrate involved- 11th nerve
• Drooping of shoulder- Trapezius weakness
• Neck tilt to opposite side- d/t normal SCM in the left

side

Decreased hearing in the right side- 5 months

• D/t Conductive hearing

loss

• SNHL- has
• Poor speech

discrimination

• Specific loss to high

frequency sounds

• Recruitment
• Roll over phenomenon
• Tone decay
• CHL has
• Better speech

discrimination

• Better bone conduction
• Hears better in noisy

surroundings

• Asociated with ear pain,

discharge, fullness, ear mass

Deviation of f angle of f mouth to the le left sid ide- 5mnths.

• D/T right LMN 7th nerve palsy- both upper and lower half of the

face involved.

• Decreased watering- d/t GSPN involvement
• Increased watering- d/t orbicularis oculi weakness and

epiphora.

• Decreased taste sensation- d/t chorda tympani involvement
• Can have decreased sensation in the posterior aspect of EAM-

posterior auricular nerve- a branch of 7th nerve

• Hyperacusis- d/t impaired stapedial reflex

Decreased sensation in in the ri right sid ide of f the face- 4 4 months.

• D/t 5th nerve involvement- all three division
• Redness of right eye- d/t decreased corneal sensation
• Difficulty in chewing – d/t weak muscles of mastication
• Jaw deviation- d/t weak pterigoid muscles
• Temporal hollowing- d/t wasting of temporalis muscle

Double vis ision- 3 months.

• D/T right 6th and 3rd nerve palsy
• Diplopia increasing on seeing to the right side and

deviation of right eye inwards- 6tht nerve palsy

• Drooping of the right eye- d/t right 3rd nerve

involvement

• Substrates involved

Duration (months)

• 12th nerve

9

• 9, 10, 11th nerve

6

• Conductive hearing loss

6

• 7th nerve

5

• 5th nerve

4

• 6th nerve

3

• 3rd nerve

3

• No sensori motor or cerebellar involvement

Localisation- Right side middle and posterior fossa skull base.

Plane of the lesion- Extra axial. Pathological possibilities-

• Tumours- Chordoma, Chondrosarcoma, Spheno

petro clival meningioma, Skull base metastasis, epidermoid, Glomus jugulare.

• Infection- TB meningitis, Fungal granuloma
• Inflammatory conditions- Sarcoidosis, Non specific

inflammation.

• Order of DD:
• 1. Chordoma
• 2. Chondrosarcoma
• 3. Skull base metastasis

Examination

• G/E- moderately built and nourished
• No PICCLE
• No neurocutaneous markers
• Spine and cranium- normal
• Ear- tympanic membrane- pinkish white and bulging- no

anatomical features made out in the right ear, no discharge. No Bruit.

• Nose and throat examination- normal, no mass seen/

palpated

• S/E- normal

CNS examination

• HMF-
• Conscious, oriented,
• Memory- normal
• Language- normal
• Speech- slurring of the speech+, Not able to

pronounce ‘la la’ correctly

• Intelligence insight- normal
• No lobar signs.

Cranial nerves

• I st nerve- normal in both sides when tested with

coffee powder

• II nd nerve-
• VA- 6/6 B/L
• VF- normal by confrontation method.
• Fundus- normal B/L

• IIIrd, IVth, VIth nerves-
• Pupils-

Right Left Size 5mm 3mm Shape Round Round Light reaction Direct Absent Normal Indirect Absent Normal

• Accomodation reflex - impaired
• EOMS-
• Right deviated medially in the primary gaze
• All the EOMS in the right eye is restricted-

maximum for abduction

• Left eye EOMS- normal
• Saccades and pursuit- normal
• No nystagmus.
• S/O Right 3rd, 4th and 6th nerve involvement

• Vth nerve-

Right Left Motor Normal Sensory 75% loss in V1-3 Normal Corneal Reflex Direct Diminished Normal Indirect Normal Diminished Jaw jerk Absent Absent

• Wasting of right

temporalis and masseter

• Deviation of the jaw to the

right on opening mouth

• VIIth nerve-
• Reduced blinking.
• Wide palpebral fissure in the right side – eye closure

adequate.

• Reduced frowning of the forehead in the right side .
• Not able to lift right eyebrow.

• Loss of right nasolabial fold.
• Deviation of the angle of the mouth to the left side.
• Not able to whistle.
• Decreased taste sensation in the right side of the

tongue for salt and sugar

• S/O grade 3 LMN right 7th nerve palsy

• VIIIth nerve- Right

Left

• Whisper test diminished normal
• Rinnes BC>AC

AC>BC

• ABC Normal

Normal

• Weber

Lateralized to the right ear

• S/O Conductive hearing loss.

• IXth, Xth nerves-
• Uvula deviated to the left side
• Palatal arch sagging+ with decreased movement of

the right palate

• Gag reflex- impaired on the right side both sensation

and the movement

• S/O 9th and 10th nerve palsy

• XIth nerve-
• Drooping of right shoulder+
• Winging of right scapula+ on abducting the shoulder
• Mild Neck tilt to the left
• Weakness of right trapezius- not able to shrug the

shoulder

• Trapezius
• Difficulty in bringing occiput to acromian and
• move forward abducted and supinated UL forward
• No difficulty in extending the head against resistance
• SCM-
• Thinning of right SCM,
• difficulty in tilting the neck to the right side
• S/O 11th nerve palsy

• XIIth nerve-
• Right side of the tongue- tone- decreased
• Thinning of the right side of the tongue+.
• Fasciculations of the right side of the tongue.
• Deviation to the right side on protruding.
• S/O 12th nerve palsy

Motor system-

• Tone- normal
• Bulk- normal
• Power- 5/5
• DTR- 2+
• Abdominal and cremastric reflex- present b/l
• Plantars- B/L flexors

Sensory system- normal for touch, pain and temperature- except for facial sensation.

Cerebellar system-

• Finger nose test- normal
• Heel knee ankle test- normal
• No dysdiadokokinesia
• No nystagmus

Gait- normal

• Substrates involved- right 3rd, 4th, 5th, 6th, 7th, 9th, 10th,

11th and 12th cranial nerves and conductive hearing loss.

• No sensori motor or cerebellar involvement
• Localization, Plane- same.
• Pathology-
• 1. Chordoma
• 2. Chondrosarcoma
• 3. Skull base metastasis

Investigations

• Complete hemogram
• LFT, RFT, RBS, Serum Electrolytes
• Chest X-ray
• CT head- plain + contrast- 1mm cuts with bone

window

• MRI Head and neck – Plain + contrast with MRS and

MRA and MRV

Tha Thank you nk you