Case 157

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #157

Date of Consultation: 5-11-2009

HISTORY OF PRESENT ILLNESS:

This 45-year-old right-handed African-American female was referred for neurologic evaluation because of right ear pain and deafness. She is known to have a history of hypertension and diabetes.

Approximately three weeks prior to consultation, the patient woke up in the morning with pain in her right ear and right ear deafness. She was unable to hear anything with her right ear. At that time, she also noted double vision with the objects vertically oriented. The double vision was transient and lasted about one day.

For the next week, the patient had difficulty with walking and unsteadiness, but this symptom resolved over the course of the week. In retrospect, she felt that her unsteadiness was due to vertigo, which worsened when she attempted to walk.

The patient went to her primary care physician because of the right ear pain and deafness. The primary care physician started her on amoxicillin.

Two days prior to admission, the patient again developed diplopia, but this time the objects appeared to be side-by-side. Once again, the diplopia did not last for long and resolved over the next few hours. However, at the same time she noted that her face was asymmetric and that she was unable to close her right eye completely. At this point, her primary care physician admitted her to the hospital for further evaluation.

The patient denied all other neurologic signs or symptoms. She indicated that she did not have a prior history or family history of autoimmune disease, sarcoidosis, multiple sclerosis, or cancer.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: Intact.

Cranial Nerves: Sensation of smell was not tested. Visual acuity, visual field, and funduscopic examinations were normal. Pupils were equal, round, and reactive to light. External ocular movements were full without nystagmus or diplopia. Sensory examination of the Vth cranial nerve revealed decreased appreciation of pinprick and light touch in the ophthalmic and maxillary divisions of the right trigeminal nerve. The muscles of mastication were normal. There was a facial asymmetry with weakness of the entire face involving forehead, eye closure, and lower facial muscles on the right side. Muscles of facial expression were normal on the left. Taste sensation was impaired over the anterior two-thirds of the tongue on the right. Hearing was normal in the left ear. However, the patient was unable to hear anything with the right ear. With the Weber test, there was lateralization to the left ear. With the Rinne test, the patient was unable to perceive sound with the right ear. XIth cranial nerve functions were normal. Tongue and palate were normal.

Motor System: Intact.

Reflexes: Deep tendon reflexes were equal and symmetric, and the plantar reflexes were flexor bilaterally.

Sensory System: Intact.

Cerebellar Function: Intact.

Gait and Stance: Regular and tandem gait were performed normally, and the Romberg test was negative.

Questions

1. Is the weakness of the right side of the face of the upper motor neuron or lower motor neuron type?

2. List all of the possible structures that could be involved by the pathologic process to produce each of the abnormal signs and symptoms experienced by this patient.

a. Deafness, vertigo, and pain, AD

b. Diplopia

c. Right facial weakness, decreased taste on the anterior two-thirds of the tongue on the right

d. Decreased pain and light touch sensation of the right side of the face

3. Is the involvement in this patient likely to be intrinsic to or extrinsic to the central nervous system? Is the pathologic process in this case localized or multifocal?

4. In general, what type of pathologic process do you think is involved in this case?

5. What diagnostic procedure(s) would you undertake at this point?

Answers