Question:

A 67-year-old woman with a known history of lung cancer comes to the office due to hoarseness and difficulty swallowing. She has no disturbances in vision or hearing. On examination, there is loss of the gag reflex on the left side; when the patient is prompted to say "ah," the uvula deviates to the right side. Her left shoulder is drooped and strength is reduced during left shoulder shrug testing. Chest x-ray shows a right lower lobe lung mass and several osteolytic rib lesions. MRI of the head also demonstrates multiple lesions consistent with metastasis. A lesion involving which of the following anatomical structures is most likely responsible for this patient's symptoms?

Cerebellopontine angle

Foramen magnum

Foramen ovale

Foramen rotundum

Hypoglossal canal

Jugular foramen

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	Skull foramen	Traversing structures
Anterior cranial fossa	Cribriform plate	CN I olfactory bundles
Middle cranial fossa	Optic canal	CN II, ophthalmic artery, central retinal vein
	Superior orbital fissure	CN III, IV, V₁, VI, ophthalmic vein, sympathetic fibers
	Foramen rotundum	CN V₂ (maxillary)
	Foramen ovale	CN V₃ (mandibular)
	Foramen spinosum	Middle meningeal artery & vein
Posterior cranial fossa	Internal acoustic meatus	CN VII, VIII
	Jugular foramen	CN IX, X, XI, jugular vein
	Hypoglossal canal	CN XII
	Foramen magnum	Spinal roots of CN XI, brain stem, vertebral arteries
CN = cranial nerve.

This patient's symptoms are consistent with a lesion involving the jugular foramen , a large aperture located in the base of the skull behind the carotid canal. It is formed by the petrous portion of the temporal bone and the occipital bone. Passing through the jugular foramen are cranial nerves (CN) IX, X, and XI. Lesions of the jugular foramen (eg, due to tumors, trauma, or infection) can result in jugular foramen (Vernet) syndrome, which is characterized by CN IX, X, and XI dysfunction. Symptoms are related to the nerve affected:

Loss of taste from the posterior 1/3 of the tongue (CN IX)
Loss of gag reflex (CN IX, X)
Dysphagia (CN IX, X)
Dysphonia/hoarseness (CN X)
Soft palate drop with deviation of the uvula toward the normal side (CN X)
Sternocleidomastoid and trapezius muscle paresis (CN XI)

(Choice A) Lesions at the cerebellopontine angle (eg, vestibular schwannoma) typically cause sensorineural hearing loss and tinnitus due to dysfunction of CN VIII.

Educational objective:
Lesions of the jugular foramen can result in jugular foramen (Vernet) syndrome, which is characterized by the dysfunction of cranial nerves IX, X, and XI. Symptoms include dysphagia, hoarseness, loss of gag reflex on the ipsilateral side, and deviation of the uvula toward the normal side.