Multilevel surgical management for severe dysphagia due to lower cranial nerve palsy with multimodal functional assessment: a case report

INTRODUCTION: Lower cranial nerve (LCN) palsy may develop following tumor resection in the cerebellopontine angle or jugular foramen, often resulting in dysphagia and dysphonia. Although many patients recover with rehabilitation, some exhibit persistent functional deficits. In such cases, detailed pathophysiologic evaluation may assist in guiding surgical intervention to improve outcomes. CASE PRESENTATION: A 77-year-old woman presented with severe dysphagia and hoarseness after resection of a right cerebellopontine angle meningioma, which caused glossopharyngeal, vagus, and accessory nerve palsies. Despite initial recovery, she developed repeated aspiration pneumonia and malnutrition. Comprehensive reassessment using high-resolution manometry (HRM) and dynamic swallowing computed tomography (CT) revealed right-sided velopharyngeal insufficiency, pharyngeal constrictor dysfunction, vocal fold paralysis with paramedian fixation, and impaired upper esophageal sphincter relaxation. A tailored multi-procedural surgical approach was performed, including right pharyngeal flap, arytenoid adduction, right hypopharyngeal pharyngoplasty with expanded polytetrafluoroethylene mesh reinforcement, right cricopharyngeal myotomy, and tracheostomy. Postoperatively, swallowing and phonation significantly improved. The patient resumed oral intake, and tracheostoma closure was performed on postoperative day (POD) 25. Maximum phonation time improved sevenfold by POD 32. She was discharged on POD 33, and resumed a regular diet with some limitations by 3 months postoperatively. CONCLUSIONS: Intractable dysphagia due to complex LCN dysfunction requires individualized surgical strategies. Multimodal functional assessment, including dynamic swallowing CT and HRM, aids precise evaluation and helps refine surgical planning in selected complex cases, potentially leading to significant improvements in quality of life.