Lower cranial nerve palsies.

A 70 year old diabetic male presented with a three weeks history of left temporal pain radiating to the left eye and left side of the neck without any symptoms relating to the ear or nose. Two days later, the patient developed difficulty in swallowing and speaking with nasal regurgitation of fluids. Clinical examination revealed bilateral palatal weakness (more marked on the left side), bilateral weakness of sternocleidomastoids and bilateral weakness of tongue muscles (more marked on the right side). The gag reflex was diminished. There were no pyramidal or cerebellar signs and there was no neck stiffness. MRI of the brain showed bilateral otitis media with involvement of the petrous temporal bone. In addition, the patient had osteomyelitis of the clivus with increased uptake upon gallium scanning. He was treated with intravenous ceftriaxone 4 grams daily for three weeks, moxifloxacin 400 mgm daily and voriconazole 400 mgm daily for three months. The symptoms improved, but the patient was left with tongue weakness, more marked on the right side. Clinical Quiz