Vagal Neuropathy From an Ear Foreign Body: A Black Swan Event in Clinical Practice

Abstract

Background: Foreign bodies (FBs) in the external auditory canal (EAC) are common in children but rarely cause cranial neuropathies. We report the first documented case of vagal and glossopharyngeal nerve palsies secondary to a migratory ear FB penetrating the jugular foramen. Case presentation: A 2.5-year-old boy presented with a 50-day history of right otalgia, bloody otorrhea, and new-onset dysphonia with aspiration. Initial workup revealed granulation tissue and methicillin-resistant Staphylococcus aureus (MRSA) infection, refractory to antibiotics. Flexible endoscopy demonstrated right vocal cord paralysis as well as diminished pharyngeal sensation and paralysis, suggesting cranial nerve (CN) IX and X dysfunction. Temporal bone imaging initially overlooked a 22 mm glass fragment embedded in the hypotympanum, extending into the jugular foramen. Multidisciplinary review identified the FB, previously misclassified as an artifact. Surgical extraction, performed through mastoidectomy through a post-auricular incision, led to symptom resolution, and confirmed neuropraxia secondary to FB-induced neuritis. Conclusion: This case highlights a novel mechanism of cranial neuropathy, direct FB migration to the skull base, and underscores the importance of reevaluating imaging in refractory otologic cases. Clinicians should suspect occult FBs in pediatric patients with persistent ear bleeding and cranial nerve deficits, even without a clear history of insertion.