Neurovascular compression syndrome is known to be an uncommon condition that involves mechanical irritation caused by direct contact of the cranial nerve with blood vessels. Trigeminal neuralgia, hemifacial spasm, vestibulocochlear neuralgia are the most prevalent symptoms to occur, and dysphagia due to CN IX and X invasions have rarely been reported.
The Glossopharyngeal nerve provides taste sensation and sensory information from the posterior one-third of the tongue, while the Vagus nerve is responsible for sensation and motor function of the soft palate, pharynx, larynx, and esophagus. Thus, neuritis of these two nerves can result in dysphagia.
On April 12, 2018, a 75-year-old female patient had head trauma by falling down forwards inside her house and after the incident, dysarthria and dysphagia consecutively occurred. The patient was sent to the emergency room via 119 and was transferred to the neurology department. Enhanced ICA MRI results taken on April 15, 2018, indicated neurovascular compression. The radiograph showed neuritis involving the left cranial nerve complex 9 to 11 with perineural inflammation of left distal vertebral artery appeared to be tortuous and in contact with the exit root zone of the left lower cranial nerve. 25mg of Solondo was initiated and was tapered by 5mg a week and discontinued after 5 weeks.
Due to unsolved dysphagia, the patient was admitted to our Department of Rehabilitation Medicine on July 14, 2018, in a nasogastric feeding state. Cranial nerve exam indicated left uvular deviation and impaired gag reflex. The oral phase showed to be intact on a VFSS performed on 17, July 2018. In the semisolid bolus swallow test, the initial remnant was 40% of the bolus, which was nearly cleared after multiple swallowing and without aspiration. Liquid cup swallows were also successful with no aspiration. Thereafter, nasogastric tubing was successfully removed, and the patient proceeded to dysphagia diet level I with no occurrence of aspiration. To evaluate the presence of vocal cord palsy, we consulted to the otorhinolaryngology department and verified the bilateral vocal cord mobility to be intact, and then continued rehabilitation with rehabilitative balloon swallowing treatment included. At a follow-up VFSS on August 2, 2018, the initial post-swallow remnant of semisolid bolus improved to 5%, which allowed dietary build-up adjustments to dysphagia diet level II and eventual discharge.
The patient was admitted to the hospital with dysphagia after neurovascular compression resulted in neuritis in cranial nerves 9 to 11 due to head trauma. This is known to be a rare condition, which usually demands drug therapy or surgical treatment in severe cases.
However, after active ballooning treatment and removing the nasogastric tube, the patient recovered quickly, and resulted in the pharyngeal remnant from 40 to 5 percent. Therefore, it may be necessary to consider rehabilitation first rather than surgical treatment. |
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Fig. 1. Brain MRI. A : T2 TSE transverse, Lt. Vertebral artery (Black arrow) and Cranial nerve 9-11 complex (White arrow). B : T1 TSE transverse, Lt. Vertebral artery (Black arrow) and Cranial nerve 9-11 complex (White arrow)
Fig. 2. fluoroscopic image of rehabilitative balloon swallowing. A : image just before ballon swallowing, B : image just after balloon swallowing
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