An unusual cause of dysphagia and dysphonia

The glossopharyngeal, vagus, and accessory cranial nerves pass through the jugular foramen and may be involved by transforaminal tumors.^1,2 Weakness of the muscles supplied by these cranial nerves may simulate the bulbar variant of ALS or myasthenia gravis. Here we report a 94-year-old woman with a schwannoma of the left jugular foramen (figure, A, B, C, D) who presented with a 4-year history of worsening dysphonia and mild dysphagia. Clinical examination revealed weakness and hypotrophy of the left sternocleidomastoid and trapezius (see figure, E), dysphagia and dysphonia with the left vocal cord in adduction, hypoesthesia of pharyngeal left posterior mucosa, bilateral hearing loss (more severe on the left), and tinnitus. EMG showed total denervation in the upper part of the left trapezius muscle. Stereotactic radiosurgery was planned.

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Figure. (A) Magnetic resonance sagittal spin-echo T1-weighted and (B) axial fluid-attenuated inversion recovery T2-weighted images without contrast. (C) Coronal and (D) axial fast spin-echo T1-weighted images after contrast. A 3-cm tumor, is seen in the enlarged left jugular foramen, involving the extra- and intracranial portions of the IX, X, and XI cranial nerves and the intracranial portion of the VIII nerve. Homogenous signal intensity and contrast enhancement, well-shaped margins, and a smooth enlargement of foramen suggest a diagnosis of schwannoma. (E) Photograph of the patient showing atrophy of the left trapezius.

1. Eldevik OP, Gabrielsen TO, Jacobsen EA. Imaging findings in schwannomas of the jugular foramen. AJNR Am J Neuroradiol 2000;21:1139–1144.OpenUrlAbstract/FREE Full Text

2. Caldemeyer KS, Mathews VP, Azzarelli B, Smith RR. The jugular foramen: a review of anatomy, masses, and imaging characteristics. Radiographics 1997;17:1123–1139.OpenUrlPubMed