The Hoarse Lady

 

A 45 y.o. real estate broker is referred to your neurology office because of hoarseness by an otolaryngologist. She had originally gone to the otolaryngologist for the hoarseness and he had noted that her vocal cords were paralyzed on the right before referring her to you. She is not sure when or how the hoarseness began, but it has been present for about 6 months. In the beginning she thought it was from the amount of talking that she did in her job, but lately she feels that it has worsened. On review of systems, she reports a frequent headache in the right temporal and right occipital region, worse at night. She had attributed that to stress and found that taking two tylenol relieved it.

 

On examination, the abnormal findings are confined to the cranial nerve exam. She has upper and lower facial weakness on the right, diminished hearing on the right, and there is moderate atrophy of the right half of her tongue. She has diminished tearing in the right eye, loss of taste on the anterior 2/3's of her right tongue, and has noticed that loud sounds are louder in the right ear. A Weber test with a 512 Hz tuning fork lateralizes to the left. On a RinnË test with the same tuning fork, bone conduction is greater than air conduction bilaterally.

Questions:

  1. Diagram the path of the facial nerve from its origin in the brainstem to each of its targets in the head. Which branches are affected in this patient?

  2. Where is the most likely anatomical localization of the lesion producing the signs and symptoms in this patient? What tests would you do to confirm that localization?

  3. Give a differential diagnosis for the lesions producing the patient's symptoms.

  4. What treatment would you recommend if the tests you order confirm your clinical impression?
Last updated by Webmaster on August 18, 2009

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