Abstract
Case Histor A 52-year-old Tongan woman, with a background of diabetes and hypertension, presented with a one week history of left-sided head and neck pain, provoked by sitting or standing, and relieved by lying down. At times, the pain was associated with paroxysmal spasm of the left side of the tongue. Neurological examination was normal, other than occasional left sided tongue spasm lasting 1–2 seconds, without definite weakness or deviation of the tongue. An MRI of the head and cervical spine revealed a soft tissue mass on the clivus, with invasion of the left hypoglossal canal, and erosion of the left lateral mass of C1. A staging CT scan revealed other osseous and paravertebral lesions in the thoracic and lumbar spine, multiple pulmonary nodules, and a left thyroid nodule. An ultrasound guided biopsy of one of the paravertebral lesions confirmed the diagnosis of metastatic follicular thyroid carcinoma.
Discussion This case highlights an unusual presentation of skull base metastases. Orthostatic headache and neck pain is typically associated with intracranial hypotension. However, the unilateral nature of the pain would not be consistent with this. Rarer causes of orthostatic head and neck pain include upper cervical nerve root compression, postural orthostatic tachycardia syndrome, type 1 Chiari malformation, cerebellar haemorrhage, and skull base tumor.1 Hemilingual spasm is a rarely reported entity, associated with vascular contact with the hypoglossal nerve, analogous to hemifacial spasm.2 In this case, the symptom was likely caused by early compression of the hypoglossal nerve, resulting in ephaptic transmission.
