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681 - Not Just Shrugging It Off: An Unusual Presentation of Spinal Accessory Nerve Lesion as Shoulder Pain and Scapular Dyskinesia

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

SH

Sharon Y. Hsu, MD

Residet Physician
Rutgers-NJMS/Kessler Institute for Rehabilitation
Roseland, New Jersey, United States

Co-Author(s)

RM

Rex Ma, MD

Clinical Assistant Professor
East Orange VA Medical Center, Veteran's Affairs New Jersey Healthcare/Rutgers-NJMS
East Orange, New Jersey, United States

Case Diagnosis: Spinal accessory nerve lesion due to skull base osteomyelitis from progression of chronic malignant otitis externa

Case Description: 68 year-old male patient with chronic right-sided Pseudomonal malignant otitis externa who presented to outpatient physiatry clinic for 6 month history of right shoulder pain with gross changes of the right scapula and shoulder. Five months prior, patient was hospitalized for predominantly right-sided skull base osteomyelitis demonstrated on advanced imaging. Neurology evaluated patient for neuritis cranialis; however, evaluation of CN XI was not included in documentation. On initial physiatric evaluation, patient was found with atrophy of the right sternocleidomastoid and trapezius with lateral scapular winging at rest, painful active right shoulder abduction and flexion, and right shoulder shrug weakness. Patient was diagnosed with spinal accessory nerve lesion due to right-sided skull base osteomyelitis from progression of ipsilateral chronic Pseudomonal malignant otitis externa despite long-term antibiotic treatment. He was referred for occupational therapy and electrodiagnostic evaluation. Neither were completed due to re-hospitalization soon thereafter.

Discussions: Spinal accessory nerve lesions may present as shoulder pain and/or shoulder shrug weakness; however, they uncommonly occur in the setting of an infectious intracranial process. Malignant otitis externa (MOE) is a rare, aggressive, and potentially fatal infectious inflammatory process usually caused by Pseudomonas aeruginosa in immunocompromised, elderly, and diabetic patients. MOE can rapidly progress as skull base osteomyelitis to cause cranial neuropathy. Spinal accessory nerve lesions have been infrequently previously described as a result of medial skull base osteomyelitis infiltration.

Conclusions: Shoulder pain is a chief complaint commonly encountered in musculoskeletal medicine with a broad differential of potential diagnoses. This case underscores an unusual presentation of spinal accessory nerve lesion causing shoulder pain and scapular dyskinesis. It further highlights the critical role that physiatrists play in performing neuromuscular evaluations in the setting of medically complex clinical care.