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An Unusual Posttraumatic Dysphagia With Special Reference to Cerebellopontine Angle

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 30s with a medical history of epilepsy and alcohol use disorder who was taking lamotrigine presented with severe head trauma. Her Glasgow Coma Score (GCS) was 11 M5V4E2 on admission, and a computed tomographic (CT) scan showed a right frontal epidural hematoma with a maximum thickness of 19 mm and a volume of 30 cm3 (Figure 1A). The hematoma was evacuated by neurosurgery, and her GCS improved to 14 postoperatively. On postoperative day 2, she developed isolated dysphagia and dysphonia. Laryngoscopic examination revealed right vocal cord paralysis (Figure 1B).

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B. Cerebral vein thrombosis

A CT scan of the patient’s neck with contrast showed venous thrombosis of the right sigmoid-jugular complex (Figure 1, C and D), and she was diagnosed with incomplete posttraumatic Collet-Sicard syndrome (CSS) with compression of the vagus nerve (CN [cranial nerve] X).

The jugular foramen is divided into 2 portions, separated by a temporal intrajugular process that continues with a fibrous intrajugular septum (Figure 2).1 The anteromedial petrous part (historically pars nervosa) contains the glossopharyngeal nerve (CN IX) and the inferior petrosal sinus (IPS). The IPS crosses CN IX inferiorly, then CN X superiorly before flowing into the jugular bulb (JB). The posterolateral sigmoid part (historically pars vascularis) contains CN X and the accessory nerve (CN XI) anteriorly, which are closely connected during their course through the jugular foramen, and the JB posteriorly, which is the junction between the sigmoid sinus and the internal jugular vein (IJV). The CN X and XI pass through a dura-matter duplication attached to the intrajugular process, which defines the intrajugular compartment; the ascending pharyngeal artery provides a posterior meningeal artery, which also passes through this compartment. As it exits the jugular foramen, the CN IX is tethered to the internal carotid artery and the JB by dense connective tissue,2 and thus is vulnerable to vessel injuries. The cranial accessory nerve (cXI) separates from the spinal accessory nerve (sXI) to rejoin the middle ganglion of the vagus nerve, to further become the recurrent laryngeal nerve. Finally, the hypoglossal nerve (CN XII) exits from the hypoglossal canal medially to the jugular foramen, then descends between the IJV and the internal carotid artery (ICA) before crossing the ICA laterally while heading forward. Hence, the last 4 CNs share close relations to neck vessels as they exit the skull base.

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Article Information

Corresponding Author: Nathan Beucler, MD, Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, 83800 Toulon, Cedex 9, France (nathan.beucler@neurochirurgie.fr).

Published Online: October 24, 2019. doi:10.1001/jamaoto.2019.3025

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We also thank David Hibbert, MD, University of California, San Diego Medical Center for proofreading this work. He was not compensated.

References
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2.
Ayeni  SA, Ohata  K, Tanaka  K, Hakuba  A.  The microsurgical anatomy of the jugular foramen.  J Neurosurg. 1995;83(5):903-909. doi:10.3171/jns.1995.83.5.0903PubMedGoogle ScholarCrossref
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Sarrazin  J-L, Toulgoat  F, Benoudiba  F.  The lower cranial nerves: IX, X, XI, XII.  Diagn Interv Imaging. 2013;94(10):1051-1062. doi:10.1016/j.diii.2013.06.013PubMedGoogle ScholarCrossref
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Collet  FJ.  Sur un Nouveau Syndrome Paralytique Pharyngolaryngé par Blessure de Guerre (Hémiplegie Glosso-Laryngo-Scapulo-Pharyngée). Lyon Médical; Paris, France. 124th ed. 925;129.
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Sicard  A.  Syndrome du Carrefour Condylo-Déchiré Posterieur (Type pur de Paralysie des Quatre Derniers Nerfs Crâniens). 53rd ed. Marseille Médical; Marseille, France. 1917:385-397.
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Gutiérrez Ríos  R, Castrillo Sanz  A, Gil Polo  C,  et al.  Collet-Sicard syndrome.  Neurologia. 2015;30(2):130-132. doi:10.1016/j.nrl.2013.04.002PubMedGoogle ScholarCrossref
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Neo  S, Lee  KE.  Collet-Sicard syndrome: a rare but important presentation of internal jugular vein thrombosis.  Pract Neurol. 2017;17(1):63-65. doi:10.1136/practneurol-2015-001268PubMedGoogle ScholarCrossref
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Stam  J.  Thrombosis of the cerebral veins and sinuses.  N Engl J Med. 2005;352(17):1791-1798. doi:10.1056/NEJMra042354PubMedGoogle ScholarCrossref
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