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
over 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 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 food and Hoarseness of 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 CHL has
loss  Better speech
SNHL- has discrimination
 Poor speech  Better bone conduction
discrimination  Hears better in noisy
 Specific loss to high surroundings
frequency sounds  Asociated with ear pain,
 Recruitment discharge, fullness, ear
 Roll over phenomenon mass
 Tone decay
 Deviation of angle of mouth to the left side-
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 the right side of the face- 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 vision- 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 -Wasting of right Normal
temporalis and masseter
-Deviation of the jaw to the
right on opening mouth
Sensory 75% loss in V1-3 Normal
Corneal Reflex
Direct Diminished Normal
Indirect Normal Diminished
Jaw jerk Absent Absent
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
Thank you