Roberto F. Cordero, DO
Resident Physician
UCF/HCA Florida West Hospital
Pensacola, Florida, United States
Kristina Ledbetter, DO
Resident Physician
UCF/HCA Florida West Hospital
Clearwater, Florida, United States
Caroline Amerson, MD
Resident Physician
UCF/HCA Florida West Hospital
Pensacola, Florida, United States
Joseph Cahill, MD
Attending Physician / Neurologist
UCF/HCA Florida West Hospital
Pensacola, Florida, United States
Susan Belcher, MD
Attending Physician
UCF/HCA Florida West Hospital
Pensacola, Florida, United States
A 74-year-old male was admitted with intermittent neuropathic pain in the left oropharynx, face, and inner ear. His pain worsened with cold liquids, coughing, and swallowing. He also experienced decreased appetite, weight loss, dysphagia, odynophagia, hypophonia, and xerostomia. A videofluoroscopic swallow study revealed moderate-to-severe oropharyngeal dysphagia. An ENT consultation for worsening dysphagia revealed left vocal cord paralysis on laryngoscopy. A dietitian confirmed severe protein-calorie malnutrition. A gastrostomy tube was placed, and he began taking Carbamazepine along with daily tube feedings. Imaging was negative for lesions, infarct, or compressions. CSF analysis revealed lymphocytic pleocytosis, and labs were remarkable for positive anti-ANA, anti-Ro/SSA, RF, and anti-CCP. The patient was started on IVIG and high-dose steroids. Throughout the hospital course, his neuropathic pain and systemic symptoms improved.
Discussions: Glossopharyngeal and vagus neuralgia, rare conditions with various potential causes, were suspected. Imaging was unremarkable, making an autoimmune process higher on the differential. The patient met the EULAR/ACR classification criteria for SLE and RA. Treatment with Carbamazepine, IVIG, and high-dose steroids improved his symptoms. The patient received acute physical, occupational, and speech therapy. He was sent to a long-term acute care hospital (LTACH) with neurology and rheumatology outpatient follow-up.
Conclusions: Damage to cranial nerves 9 and 10 can significantly impact activities of daily living (ADLs) and social functioning. Awareness of symptoms related to glossopharyngeal and vagus neuralgia is crucial, as these conditions can lead to malnutrition. It is important to keep autoimmune disorders on the differential like SLE and RA, as they can present with cranial mononeuritis multiplex. Early nutritional intervention, acute rehab, and access to care can greatly improve recovery outcomes. This case was complicated by his malnutrition and finding the etiology of his neuralgias, which led to further debility.
