Can a pontomedullary infarct present with weakness of facial muscles and difficulty swallowing?

Pontomedullary Infarct Presentation with Facial Weakness and Dysphagia

Yes, a pontomedullary infarct can definitely present with weakness of facial muscles and difficulty swallowing (dysphagia), as these symptoms reflect damage to cranial nerve pathways in this critical brainstem region. 1

Anatomical Basis

The pontomedullary junction contains critical neural structures that control facial movement and swallowing:

• Facial nerve (CN VII): The facial nerve nucleus is located in the pons, with fibers exiting at the pontomedullary sulcus 2
• Swallowing pathway: Multiple cranial nerves involved in swallowing (IX, X, XII) have nuclei or fiber tracts traversing this region

Clinical Presentation of Pontomedullary Infarcts

Pontomedullary infarcts can present with:

• Facial weakness: May affect both upper and lower facial muscles on the ipsilateral side 1, 3
• Dysphagia: Often severe due to involvement of swallowing pathways 1
• Associated symptoms that help distinguish from Bell's palsy:
  • Contralateral sensory deficits in face and arm
  • Diplopia or gaze abnormalities
  • Vertigo
  • Dysarthria 1, 4

Diagnostic Considerations

Key Differentiating Features from Bell's Palsy

Bell's palsy is the most common cause of facial weakness (72% of facial palsies) 3, but pontomedullary infarcts should be suspected when:

1. Dysphagia is prominent: Difficulty swallowing is a red flag symptom suggesting brainstem involvement 1
2. Acute onset: Sudden development of symptoms rather than gradual 3
3. Additional neurological deficits: Particularly contralateral sensory changes 1
4. Vascular risk factors: Hypertension, diabetes, or other stroke risk factors 3

Imaging Considerations

• MRI is essential: Small pontine infarcts (as small as 4mm) can be easily missed on initial review 3
• Dedicated brainstem sequences: May be needed to visualize small infarcts 2
• CT head alone is inadequate: Not recommended for evaluation of brainstem pathology 2

Management Approach

Acute Management

1. Urgent stroke evaluation: Follow standard acute stroke protocols
2. Swallowing assessment: Immediate dysphagia screening is critical 2
   • Place patient NPO until formal swallowing assessment
   • Look for signs of aspiration risk: abnormal gag reflex, impaired voluntary cough, dysphonia, incomplete oral-labial closure 2

Dysphagia Management

1. Formal swallowing evaluation:

   • Bedside screening followed by instrumental assessment
   • Videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) 2, 5

2. Compensatory strategies:

   • Postural adjustments (chin-tuck position)
   • Dietary modifications (thickened liquids)
   • Swallowing maneuvers 5

3. Nutritional support:

   • IV fluids initially
   • Consider nasogastric tube feeding if dysphagia is severe
   • PEG tube for prolonged feeding needs 2

Prognosis and Monitoring

• Regular reassessment of swallowing function is essential 5
• Monitor for complications:
  • Aspiration pneumonia
  • Malnutrition
  • Dehydration 2, 5

Unusual Presentations

In rare cases, medullary infarction can present with isolated facial paralysis as the only symptom 6, though this is uncommon. More typically, pontomedullary infarcts present with multiple cranial nerve deficits and other brainstem signs 4.

Remember that facial weakness with dysphagia requires urgent neuroimaging to rule out stroke, as this combination strongly suggests a central rather than peripheral etiology.