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 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 f tongue to the right side- 9mnths  D/T Right 12 th 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 9 th and 10 th 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- 11 th 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  Better speech loss  SNHL- has discrimination  Poor speech  Better bone conduction  Hears better in noisy discrimination  Specific loss to high surroundings  Asociated with ear pain, frequency sounds  Recruitment discharge, fullness, ear  Roll over phenomenon mass  Tone decay

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 7 th 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 5 th 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 6 th and 3 rd 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 3 rd nerve involvement

• Substrates involved Duration (months) • 12 th nerve 9 • 9, 10, 11 th nerve 6 • Conductive hearing loss 6 • 7 th nerve 5 • 5 th nerve 4 • 6 th nerve 3 • 3 rd 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

• III rd , IV th , VI th 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 3 rd , 4 th and 6 th nerve involvement

 V th nerve- Right Left Motor Normal - Wasting of right 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

 VII th 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.