Clinical Reasoning: A 37-year-old man with multiple cranial neuropathies.

SECTION 1 A 37-year-old man presented with a 7-month history of vertigo, nausea, dysphagia, right-sided tinnitus, and hearing loss. He denied headache, paresthesias, change in vision, or problems with cognition. He endorsed a history of progressive fatigue, generalized weakness, and poor libido. His symptoms left him functionally impaired and bedridden. His medical history was remarkable for dyslipidemia, obesity hypoventilation syndrome, nephrolithiasis, and an episode of bilateral anterior uveitis 6 years prior. In addition, he had been in a motor vehicle collision that caused a facial degloving injury requiring multiple operations, leaving the patient with vision loss in his left eye. On examination, the patient was morbidly obese with extensive scarring on the left side of his face. There was decreased visual acuity and left exotropia. The right pupil was dilated with a sluggish response to light. The left pupil could not be reliably examined due to the changes from his prior facial degloving injury. There was also lower lid scarring on the left with lagophthalmos, again secondary to his prior injury. The right lid was normal. There was a mild left-sided facial weakness in a lower motor neuron pattern. His speech was dysarthric. Examination of the remaining cranial nerves (CNs) was normal. Strength was 5/5 in the upper extremities bilaterally and 41/5 in the lower extremities bilaterally. Muscle bulk and tone were normal, as were coordination and fine motor movements. Sensation and reflexes were intact. Romberg test was negative. Bilateral sensorineural hearing loss, mild to moderate on the left and moderate to severe on the right, was confirmed objectively with audiometry.