A 67-year-old woman with a known history of lung cancer comes to the office due to hoarseness and difficulty swallowing. She has no disturbances in vision or hearing. On examination, there is loss of the gag reflex on the left side; when the patient is prompted to say "ah," the uvula deviates to the right side. Her left shoulder is drooped and strength is reduced during left shoulder shrug testing. Chest x-ray shows a right lower lobe lung mass and several osteolytic rib lesions. MRI of the head also demonstrates multiple lesions consistent with metastasis. A lesion involving which of the following anatomical structures is most likely responsible for this patient's symptoms?

Question

A 67-year-old woman with a known history of lung cancer comes to the office due to hoarseness and difficulty swallowing.  She has no disturbances in vision or hearing.  On examination, there is loss of the gag reflex on the left side; when the patient is prompted to say "ah," the uvula deviates to the right side.  Her left shoulder is drooped and strength is reduced during left shoulder shrug testing.  Chest x-ray shows a right lower lobe lung mass and several osteolytic rib lesions.  MRI of the head also demonstrates multiple lesions consistent with metastasis.  A lesion involving which of the following anatomical structures is most likely responsible for this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_35a7_9878_9249_214dc30cae2e_MD0001_00 This patient's symptoms are consistent with a lesion involving the jugular foramen , a large aperture located in the base of the skull behind the carotid canal. It is formed by the petrous portion of the temporal bone and the occipital bone. Passing through the jugular foramen are cranial nerves (CN) IX, X, and XI. Lesions of the jugular foramen (eg, due to tumors, trauma, or infection) can result in jugular foramen (Vernet) syndrome, which is characterized by CN IX, X, and XI dysfunction. Symptoms are related to the nerve affected: (Choice A) Lesions at the cerebellopontine angle (eg, vestibular schwannoma) typically cause sensorineural hearing loss and tinnitus due to dysfunction of CN VIII. Educational objective: Lesions of the jugular foramen can result in jugular foramen (Vernet) syndrome, which is characterized by the dysfunction of cranial nerves IX, X, and XI. Symptoms include dysphagia, hoarseness, loss of gag reflex on the ipsilateral side, and deviation of the uvula toward the normal side. __________ References: Jugular foramen syndrome as initial presentation of metastatic lung cancer. (http://www.ncbi.nlm.nih.gov/pubmed/23946920)

A 67-Year-Old Woman with a Known History of Lung Cancer