ICA dissection with IX/X/XII palsy

Yesterday’s images in clinical medicine in the New England Journal is the base of todays session. We use this wonderful case to recall the examination of the glossopharyngeal nerve; in particular why the Kulissenphänomen is really a Vorhangphänomen and probably is more due to vagal lesions. Also why it makes sense to stimulate various parts of it’s sensory region, the various reflexes (gag, uvula, secretory, carotid sinus) and much more.

Apart from these basic details on physical examination I take home that dissections of the ICA can harm the surrounding nerve and that localization is king (why can’t the problems of the lady in this case not be caused by medullary lesions?). Finally, that the NEJM is not immune to slight mistakes (wrong arrows).