Multiple Cranial Nerve Palsies as the First Presentation of Sarcoidosis

Sarcoidosis is a disease process which predominantly affects the lungs but can involve virtually any organ in the human body. Neurosarcoidosis is a rare manifestation which can present in a variety of ways. There is no single diagnostic test for sarcoidosis; hence, the diagnosis is based on combined clinical, laboratorial, and radiological grounds. We describe a rare case where a patient presented with dysphagia, hoarseness, hearing loss, and unsteadiness. 1. Introduction Sarcoidosis is a multisystem granulomatous disorder of unknown cause. Although it can involve virtually any organ system, it shows a predilection for the lungs with up to 90% of cases displaying pulmonary sarcoidosis. This is followed by ocular, skin, lymph node, and salivary gland involvement. Neurosarcoidosis is relatively rare accounting for approximately 5–15% of cases [1, 2]. As the disease can present in a variety of ways and to multiple medical specialities, it can be a challenge to diagnose and treat promptly with the potential for catastrophic complications. Cranial neuropathy appears to be the most frequent presentation of Neurosarcoidosis with the 7th cranial nerve being the most frequently affected nerve followed by the optic nerve [1, 2]. A presentation with multiple cranial nerve palsies is rare, and, hence, we present a case report with the involvement of cranial nerves V, VII, VIII, IX, and X. 2. Case A previously healthy 32-year-old lady presented acutely to the ORL service with a 2-day history of increasing dysphagia, hoarseness of voice, and a blocked sensation in the right ear. She was unable to swallow any solids and experienced choking spells with thin fluids. She also described a recent viral-like illness that lasted for about 2 weeks followed by an episode of left sided facial weakness and asymmetry earlier during the week which seemed to have resolved completely at the time of presentation. On further questioning, she reported vague symptoms of unsteadiness especially while driving her car. On examination, she had a very husky voice associated with difficulty in swallowing her saliva. She had weak palatal muscles and an absent gag reflex. Flexible laryngoscopic examination showed marked hypomobility of the left vocal cord and pooling of secretions in the hypopharynx. Pure tone audiogram showed a mild, high frequency sensorineural hearing loss on the left and a downsloping mild to moderate sensorineural hearing loss on the right side, (as illustrated in Figure 2). She had bilateral supraclavicular lymphadenopathy. Cerebellar and vestibular testing was