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Vagus nerve paralysis due to skull base fracture
Auris Nasus Larynx 35 (2008) 153–155 www.elsevier.com/locate/anl
Vagus nerve paralysis due to skull base fracture Hsueh-Hsin Huang a, Tuan-Jen Fang b,d,*, Hsueh-Yi Li a, Shy-Chyi Chin c,d a
Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan b Department of Otolaryngology,Keelung, Taiwan c Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan d Chang Gung University, Taoyuan, Taiwan Received 31 May 2006; accepted 9 May 2007 Available online 14 September 2007
Abstract Lower cranial nerve paralysis originating from skull base fracture is rare and isolated vagus nerve paralysis after close head injury is extremely rare. We, in this study, present the case of a 49-year-old man sustained a right vocal cord paralysis and dysphagia in a fighting accident. Initial examination, including flexible laryngoscope, esophagogram and fine-cut neck computed tomography scan, failed to find out the cause of isolated vagus paralysis. Until high resolution computed tomography of skull base revealed the jugular foramen bony disruption. One individual cranial nerve paralysis may be a significant sign for skull base fracture in closed head injury. Considering the serious consequences of the disease, thorough neurologic and radiologic examination are needed to evaluate the condition of skull base, and to develop reliable effective management for the neurologic sequalae, result from it. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Vagus nerve paralysis; Skull base fracture; Closed head injury
1. Case report A 49-year-old man was sent to our emergency room because of a closed head injury resulting from a fight. On admission, he complained of headache, dysphagia, dysphonia, coughing and easily choking. Physical examination revealed multiple ecchymoses and lacerations on his head and neck. Strength, range of motion, reflexes, and pulses were normal and equal. No cerebro-spinal fluid (CSF) rhinorrhea or otorrhea was found. Neurologic examination showed swallow and phonation difficulty. Cervical plain Xray films did not reveal any abnormality. Brain computed tomography (CT) and magnetic resonance imaging (MRI) on the same day revealed a suspected infarction or hemorrhage in the right cerebellar and posterior limb of * Corresponding author at: Department of Otolaryngology, Chang Gung Memorial Hospital, 5 Fu-Shin Street, Gueishan, Taoyuan 333, Taiwan. Tel.: +886 3 3281200x3967; fax: +886 3 3979361. E-mail address: [email protected] (T.-J. Fang).
the right internal capsule. The clinical studies and examinations could not explain the causes of abnormal voice and swallowing ability. Initial evaluation at our department included a flexible laryngoscope, esophagogram and fine-cut neck computed tomography scan. The laryngoscope revealed right vocal cord palsy with saliva pooling in his right piriform sinus, esophagogram showed esophageal paralysis and barium stasis at the pharyngoesophageal junction, and the CT revealed normal study. High resolution CT of skull base was arranged on the 7th day of admission, and revealed bilateral C1-occipital junctions and bilateral jugular foramen disruption; the injuries were more severe on the right side (Fig. 1). These findings were consistent with our suspicion of isolated vagus nerve palsy due to skull base fracture. Over the next 6 months of outpatient follow-up, the patient’s right vocal paralysis and swallowing impairment persisted. In neurologic clinics, a gustatory regional test that assesses sweet, sour, bitter, and salty taste perception within the anterior (cranial nerve VII) and posterior (CN IX) lingual
0385-8146/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2007.05.004
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H.-H. Huang et al. / Auris Nasus Larynx 35 (2008) 153–155
Fig. 1. The black arrows indicate the fracture involving the jugular fossa and fractured bony fragment next to jugular foramen and the arrowhead indicates the fracture in right temporal bone.
Fig. 2. Strobovideoscopy. (A) Pre-OP: Right side complete vocal palsy and insufficient glottic closure. (B) The black arrow indicates mild over-correction of right vocal cord with little overlapping was performed to improve the patient’s choking.
taste bud fields was performed by a neurologist, and the test showed normal taste perception. In order to restore a normal voice and reduce the possibility of aspiration, medialization laryngoplasty was performed. After surgery, his vocalization and swallowing functions returned with only little residual aspiration while drinking (Fig. 2). The patient returned to quite normal life within 8 months follow-up.
2. Discussion Up to 24% of patients with sustaining blunt head injuries have skull base fractures, but many are undiagnosed due to the complex anatomic relationships in the skull base and subclinical manifestations of skull base fracture [1]. Cranial nerve paralysis after closed head injury is very uncommon. Traditionally, the diagnosis of skull base fracture is made on the basis of clinical findings such as cranial nerve (CN) palsies and CSF leakage [2]. It is hard to identify skull base fractures by standard X-ray or regular CT scans [2]. Cranial nerves IX–XI exit the cranial vault through the jugular foramen, whereas CN XII exits from the hypoglossal canal, next to the occipital condyle [3]. It is not difficult to image
how occipital condyle fracture and jugular foramen disruption can produce lower cranial nerve palsies. Cranial nerve palsies related to skull base fracture may result from nerve compression or transaction by displaced bony fragments, arterial ischemia, and nerve stretching or nerve root avulsion [4] Clinically, skull base fracture should be suspected in patients who show immediate symptoms of lower cranial nerves palsies [5], even just one individual vagus nerve paralysis. The skull base fracture may not be detected on initial plain X-ray films or even routine CT scans [2]. Spencer et al. stated high resolution CT with sagittal and coronal reconstructions was a valuable diagnostic procedure because it provided adequate visualization of the skull base and did not require excessive movement of the patient [3]. In our case, because of the absence of CSF leakage, we did not find out hindered skull base fracture in the beginning. Therefore, we suggest a skull base CT should be performed in the case of head injury with cranial nerve paralysis. To our knowledge, this case report is the first to describe isolated vagal nerve paralysis due to skull base fracture after closed head injury. It provides further evidence to support that even an individual CN palsy may be significant enough to suspect a skull base fracture.
H.-H. Huang et al. / Auris Nasus Larynx 35 (2008) 153–155
References [1] Brawley BW, Kelly WA. Treatment of basal skull fractures with and without cerebrospinal fluid fistulae. J Neurosurg 1967;26:57–61. [2] Urculo E, Arrazola M, Arrazola Jr M, Riu I, Moyua A. Delayed glossopharyngeal and vagus nerve paralysis following occipital condyle fracture. J Neurosurg 1996;84:522–5.
155
[3] Bridgman SA, McNab W. Traumatic occipital condyle fracture, multiple cranial nerve palsies and torticollis: a case report and review of the literature. Surg Neurol 1992;38:152–6. [4] Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle. Neurosurgery 1984;15:101–3. [5] Timothy JK, Reza J, Joseph BE, Ronald AM, Daniel RM, Hrayr KS. Craniofacial and skull base trauma. J Trauma 2003;54:1026–34.
Vagus nerve paralysis due to skull base fracture Hsueh-Hsin Huang a, Tuan-Jen Fang b,d,*, Hsueh-Yi Li a, Shy-Chyi Chin c,d a
Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan b Department of Otolaryngology,Keelung, Taiwan c Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan d Chang Gung University, Taoyuan, Taiwan Received 31 May 2006; accepted 9 May 2007 Available online 14 September 2007
Abstract Lower cranial nerve paralysis originating from skull base fracture is rare and isolated vagus nerve paralysis after close head injury is extremely rare. We, in this study, present the case of a 49-year-old man sustained a right vocal cord paralysis and dysphagia in a fighting accident. Initial examination, including flexible laryngoscope, esophagogram and fine-cut neck computed tomography scan, failed to find out the cause of isolated vagus paralysis. Until high resolution computed tomography of skull base revealed the jugular foramen bony disruption. One individual cranial nerve paralysis may be a significant sign for skull base fracture in closed head injury. Considering the serious consequences of the disease, thorough neurologic and radiologic examination are needed to evaluate the condition of skull base, and to develop reliable effective management for the neurologic sequalae, result from it. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Vagus nerve paralysis; Skull base fracture; Closed head injury
1. Case report A 49-year-old man was sent to our emergency room because of a closed head injury resulting from a fight. On admission, he complained of headache, dysphagia, dysphonia, coughing and easily choking. Physical examination revealed multiple ecchymoses and lacerations on his head and neck. Strength, range of motion, reflexes, and pulses were normal and equal. No cerebro-spinal fluid (CSF) rhinorrhea or otorrhea was found. Neurologic examination showed swallow and phonation difficulty. Cervical plain Xray films did not reveal any abnormality. Brain computed tomography (CT) and magnetic resonance imaging (MRI) on the same day revealed a suspected infarction or hemorrhage in the right cerebellar and posterior limb of * Corresponding author at: Department of Otolaryngology, Chang Gung Memorial Hospital, 5 Fu-Shin Street, Gueishan, Taoyuan 333, Taiwan. Tel.: +886 3 3281200x3967; fax: +886 3 3979361. E-mail address: [email protected] (T.-J. Fang).
the right internal capsule. The clinical studies and examinations could not explain the causes of abnormal voice and swallowing ability. Initial evaluation at our department included a flexible laryngoscope, esophagogram and fine-cut neck computed tomography scan. The laryngoscope revealed right vocal cord palsy with saliva pooling in his right piriform sinus, esophagogram showed esophageal paralysis and barium stasis at the pharyngoesophageal junction, and the CT revealed normal study. High resolution CT of skull base was arranged on the 7th day of admission, and revealed bilateral C1-occipital junctions and bilateral jugular foramen disruption; the injuries were more severe on the right side (Fig. 1). These findings were consistent with our suspicion of isolated vagus nerve palsy due to skull base fracture. Over the next 6 months of outpatient follow-up, the patient’s right vocal paralysis and swallowing impairment persisted. In neurologic clinics, a gustatory regional test that assesses sweet, sour, bitter, and salty taste perception within the anterior (cranial nerve VII) and posterior (CN IX) lingual
0385-8146/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2007.05.004
154
H.-H. Huang et al. / Auris Nasus Larynx 35 (2008) 153–155
Fig. 1. The black arrows indicate the fracture involving the jugular fossa and fractured bony fragment next to jugular foramen and the arrowhead indicates the fracture in right temporal bone.
Fig. 2. Strobovideoscopy. (A) Pre-OP: Right side complete vocal palsy and insufficient glottic closure. (B) The black arrow indicates mild over-correction of right vocal cord with little overlapping was performed to improve the patient’s choking.
taste bud fields was performed by a neurologist, and the test showed normal taste perception. In order to restore a normal voice and reduce the possibility of aspiration, medialization laryngoplasty was performed. After surgery, his vocalization and swallowing functions returned with only little residual aspiration while drinking (Fig. 2). The patient returned to quite normal life within 8 months follow-up.
2. Discussion Up to 24% of patients with sustaining blunt head injuries have skull base fractures, but many are undiagnosed due to the complex anatomic relationships in the skull base and subclinical manifestations of skull base fracture [1]. Cranial nerve paralysis after closed head injury is very uncommon. Traditionally, the diagnosis of skull base fracture is made on the basis of clinical findings such as cranial nerve (CN) palsies and CSF leakage [2]. It is hard to identify skull base fractures by standard X-ray or regular CT scans [2]. Cranial nerves IX–XI exit the cranial vault through the jugular foramen, whereas CN XII exits from the hypoglossal canal, next to the occipital condyle [3]. It is not difficult to image
how occipital condyle fracture and jugular foramen disruption can produce lower cranial nerve palsies. Cranial nerve palsies related to skull base fracture may result from nerve compression or transaction by displaced bony fragments, arterial ischemia, and nerve stretching or nerve root avulsion [4] Clinically, skull base fracture should be suspected in patients who show immediate symptoms of lower cranial nerves palsies [5], even just one individual vagus nerve paralysis. The skull base fracture may not be detected on initial plain X-ray films or even routine CT scans [2]. Spencer et al. stated high resolution CT with sagittal and coronal reconstructions was a valuable diagnostic procedure because it provided adequate visualization of the skull base and did not require excessive movement of the patient [3]. In our case, because of the absence of CSF leakage, we did not find out hindered skull base fracture in the beginning. Therefore, we suggest a skull base CT should be performed in the case of head injury with cranial nerve paralysis. To our knowledge, this case report is the first to describe isolated vagal nerve paralysis due to skull base fracture after closed head injury. It provides further evidence to support that even an individual CN palsy may be significant enough to suspect a skull base fracture.
H.-H. Huang et al. / Auris Nasus Larynx 35 (2008) 153–155
References [1] Brawley BW, Kelly WA. Treatment of basal skull fractures with and without cerebrospinal fluid fistulae. J Neurosurg 1967;26:57–61. [2] Urculo E, Arrazola M, Arrazola Jr M, Riu I, Moyua A. Delayed glossopharyngeal and vagus nerve paralysis following occipital condyle fracture. J Neurosurg 1996;84:522–5.
155
[3] Bridgman SA, McNab W. Traumatic occipital condyle fracture, multiple cranial nerve palsies and torticollis: a case report and review of the literature. Surg Neurol 1992;38:152–6. [4] Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle. Neurosurgery 1984;15:101–3. [5] Timothy JK, Reza J, Joseph BE, Ronald AM, Daniel RM, Hrayr KS. Craniofacial and skull base trauma. J Trauma 2003;54:1026–34.