In this video, you see right sided atrophy, right sided deviation, and fasiculations R>L, indicating a peripheral 12th nerve palsy. He also had some slurred speech. Remainder of neuro exam WNL. Remember: atrophy and fasiculations = LMN process!
42yo with nasopharyngeal CA (in remission) s/p chemo/rad presents with 3 months of progressive posterior head/neck pain, and slurred speech. On PE, you notice the following. What are you seeing? What’s your ddx?
This patient had difficulty with certain sounds and with slurring words. Dysarthria means a difficulty producing speech: cranial nerves VII, IX/X, & XII are vital to producing speech and these can be tested by asking the patient to say different sounds.
CN VII (facial weakness) “mee-mee-mee;” CN IX/X (pharyngeal weakness) w/ guttural sounds “kay-kay-kay” & laryngeal hoarseness; and CNXII (tongue weakness) w/ lingual sounds “la-la-la” & pronounced slurring. Remember the name Mi-kay-la!
MRI brain and C-spine showed bony enhancement of the skull base, the hypoglossal canal, atlantoaxial joint, and C1 body, consistent with osteoradionecrosis +/- osteomyelitis. Recurrent malignancy also possible.
Biopsy was not feasible and he was started on a course of empiric IV ertapenem and hyperbaric oxygen with plans to repeat imaging after treatment.
Dr. Nate Warner - @NateWarnerMD
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