Thread by @NateWarnerMD

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? (consent obtained). #PhysicalExam #IDConsults 1/

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! 2/

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. 3/

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! 4/

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. 5/

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. 6/

I hope you enjoyed this #tweetorial! Remember to always #LookAtTheTongue and don’t forget that ATROPHY and FASICULATIONS are signs of lower motor neuron disease. 7/

References:
1. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.
2. Chen, Yu-Guang et al. Isolated Hypoglossal Nerve Paralysis. The Am J of Med, 2014;127(10):926-927.
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