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Hypoglossal Nerve Palsy

Cranial Nerve Palsy XII Hypoglossal

Hypoglossal nerve palsy is an uncommon neurological deficit characterized by unilateral weakness and/or atrophy of the tongue that may arise due to trauma, iatrogenic causes (eg. surgery), infections, vascular malformations, or tumors. The clinical examination is the principal method by which hypoglossal nerve palsy can be detected, but imaging studies, either computed tomography or magnetic resonance imaging, must be used to identify the exact site of the lesion and the underlying cause.


Presentation

The hypoglossal nerve, also known as the XII cranial nerve, arises from the medulla oblongata, carriers only motor fibers and supplies the muscles of the tongue [1] [2]. Its travel, from the point of origin to the tissue it innervates, is quite long and is generally divided into five segments - medullary, cisternal (intracranial), skull base, nasopharyngeal/oropharyngeal and carotid [1] [2]. Many pathologies have been described in the literature when it comes to the damage of the hypoglossal nerve in any of the mentioned segments, and it is estimated that tumors, such as nasopharyngeal carcinomas, gliomas, acoustic neuromas, chordomas, and metastases, are responsible for the majority of cases [2] [3] [4]. Other known causes include trauma [3], surgery-induced (examples being endotracheal intubation, cervical spine surgery, etc.) [5] [6] [7], and vascular changes (ischemia or hemorrhage) [1]. Signs and symptoms of hypoglossal nerve palsy are highly distinctive, the main feature being a unilateral weakness of the tongue [1]. In addition, the tongue may deviate toward the side of the damaged nerve (if the lesion is located inferior to the hypoglossal nerve nucleus) or contralaterally in the case of a supranuclear lesion [1]. Weakness is often accompanied by atrophy of the tongue, as well as fasciculations [1]. Furthermore, a number of patients might suffer from impaired speech (dysarthria) and swallowing difficulties (dysphagia), which may be severely debilitating [1] [3] [5] [6].

Chronic Infection
  • Every possible prophylactic measure should be taken (eg, sedating the patient during oral or dental procedures, aggressive preoperative management of general and local periodontal chronic infections, avoiding prolonged perioperative neck hyperextention[ncbi.nlm.nih.gov]
Streptococcal Infection
  • Anti-streptolysin O titre was increased to 1280 suggesting a preceding streptococcal infection. Magnetic resonance imaging of the brain did not show any intracranial or extracranial abnormality. She had a partial improvement at 3 months.[ncbi.nlm.nih.gov]
Sepsis
  • The authors report a normally fit and well 17-year-old boy who presented with severe sepsis following a 5-day history of a sore throat, myalgia and neck stiffness requiring intensive care admission.[ncbi.nlm.nih.gov]
Cervical Lymphadenopathy
  • The patient's oropharyngeal and laryngeal examination was unremarkable with no cervical lymphadenopathy. He had normal laboratory investigations and cerebrospinal fluid examination.[ncbi.nlm.nih.gov]
Fasciculation of the Tongue
  • […] of the tongue at rest, tongue flaccidity, or the inability to move the tongue rapidly from side to side or vertically.[medigoo.com]
  • Lesions of the hypoglossal nerve Paralysis, atrophy and fasciculations of the tongue on the ipsilateral side (with nuclear or infranuclear lesions) Mild weakness of the tongue on the contralateral side (with supranuclear lesions) The "central" supranuclear[derangedphysiology.com]
  • Nuclear or infranuclear lesions produce paralysis, atrophy, and fasciculations of the tongue on the involved side. Supranuclear lesions produce mild to moderate contralateral weakness that may be transient.[ncbi.nlm.nih.gov]
Hemiatrophy of the Tongue
  • Hemiatrophy of the tongue with fatty displacement was demonstrated by means of T1-weighted magnetic resonance imaging.[ncbi.nlm.nih.gov]
  • Intraoral examination of the patient revealed hemiatrophy of the tongue, on the right side, and the inability to completely deviate the tongue toward the left side of the mouth on protrusion.[anatomybox.com]
Urticaria
  • Neuroradiological examinations and other investigations for etiology of hypoglossal nerve palsy and urticaria were normal. We suggest that all patients with hypoglossal palsy must be carefully evaluated for atypical findings and etiologies.[ncbi.nlm.nih.gov]
Arthritis
  • Isolated hypoglossal nerve (HN) palsy has been reported in a variety of disorders involving the cervical spine and/or skull base, however, unilateral HN palsy caused by rheumatoid arthritis (RA) has rarely been reported.[ncbi.nlm.nih.gov]
  • Rheumatoid arthritis (RA) involvement of the cervical spine is a well-known but perhaps underappreciated phenomenon. Neurologic complications of this involvement include pain, myelopathy, and cranial nerve (CN) palsies.[ncbi.nlm.nih.gov]
  • Register BILATERAL HYPOGLOSSAL NERVE PALSY DUE TO VERTICAL SUBLUXATION OF THE ODONTOID PROCESS IN RHEUMATOID ARTHRITIS - 24 Hours access EUR 36.00 GBP 28.00 USD 45.00 Rental This article is also available for rental through DeepDyve.[academic.oup.com]
  • Rheumatoid arthritis causing hypoglossal nerve palsy in one of our patients has earlier been reported by Aki Konishi et al [ 18 ].[jneuro.com]
  • No patient had a history of rheumatoid arthritis, psoriatic arthritis, gout, or calcium pyrophosphate deposition disease.[ajnr.org]
Tongue Muscle Weakness
  • Distinguishing between extrinsic and intrinsic tongue muscle weakness in unilateral hypoglossal palsy. Neurology. 1984; 34 :1367–68. [ PubMed : 6541310 ] Rubinstein MK. Cranial mononeuropathy as the first sign of intracranial metastases.[ncbi.nlm.nih.gov]
Myalgia
  • The authors report a normally fit and well 17-year-old boy who presented with severe sepsis following a 5-day history of a sore throat, myalgia and neck stiffness requiring intensive care admission.[ncbi.nlm.nih.gov]
Papilledema
  • The neurological examination revealed bilateral papilledema and mild truncal ataxia, although weakness and atrophy of the tongue were not observed.[ncbi.nlm.nih.gov]
  • Very rare examples of IIH with unilateral papilledema and pseudopapilledema, and of patients with headache, papilledema, and normal CSF pressure have been reported [2,3]. Conversely, IIH may occur without papilledema [4].[webmedcentral.com]
Babinski Sign
  • At last, we suggest that hyperreflexia and Babinski's sign may not be indispensable to the diagnosis of Opalski's syndrome and we propose that "hemimedullary infarction with ipsilateral hemiparesis" is intrinsically a variant of lateral medullary infarction[ncbi.nlm.nih.gov]
Hyperreflexia
  • At last, we suggest that hyperreflexia and Babinski's sign may not be indispensable to the diagnosis of Opalski's syndrome and we propose that "hemimedullary infarction with ipsilateral hemiparesis" is intrinsically a variant of lateral medullary infarction[ncbi.nlm.nih.gov]
Cranial Nerve Finding
  • It is of interest that this patient had features of NDPH except that his headache was obviously lateralized from the onset and associated to cranial nerve findings.[webmedcentral.com]

Workup

To make the diagnosis of a hypoglossal nerve palsy, the physician is obliged to perform a detailed physical examination and obtain a thorough patient history that should reveal any preexisting disorders or events that could predispose the patient to this neurological deficit. The unilateral weakness of the tongue can be readily observed during a properly conducted neurological exam and the assessment of cranial nerves. To test the hypoglossal nerve, the patient is asked to protrude his tongue, when the deviation (and possibly atrophy or fasciculations) to one side is apparent [3] [5] [6] [7]. In order to identify the underlying cause, however, a more detailed investigation is warranted, with imaging studies being the cornerstone. Computed tomography (CT) and magnetic resonance imaging (MRI) are both recommended for the evaluation of hypoglossal nerve palsy. CT is able to visualize the skeletal structures in greater detail, while soft-tissues are better defined using MRI, particularly when gadolinium is employed as a contrast [1]. In fact, either CT or MR angiography are of great value in the diagnosis of vascular insults [2].

Mural Thrombus
  • Vessel imaging was taken using angio-MR showing mural thrombus of the RICA. The diagnosis of spontaneous non-traumatic dissection of the carotid arteries is a major challenge for clinicians.[ncbi.nlm.nih.gov]

Treatment

  • Following treatment with intravenous antibiotics for 6 weeks, symptoms resolved.[ncbi.nlm.nih.gov]
  • Dentists who might at times see patients with isolated hypoglossal nerve palsy should be aware of the significance of its oral manifestation, and they should be able to perform differential diagnosis of patients with the condition who appear for treatment[ncbi.nlm.nih.gov]
  • He made a good recovery without treatment. English literature search revealed very few cases of idiopathic, transient, unilateral hypoglossal nerve palsy.[ncbi.nlm.nih.gov]
  • The patient refused treatment and so has been managed conservatively for more than five years, and he remains well.[ncbi.nlm.nih.gov]
  • The authors discuss their experience with the treatment of a 67-year-old woman who presented with an isolated hypoglossal nerve palsy caused by a nonenhancing cystic septated lesion abutting the lateral medulla just medial to the left hypoglossal canal[ncbi.nlm.nih.gov]

Prognosis

  • There was uncertainty around prognosis at onset due to the rarity of this condition.[ncbi.nlm.nih.gov]
  • Although the aetiological importance and ominous prognosis of neoplasia has been emphasized by others, our study suggests that an isolated hypoglossal nerve palsy may be benign and idiopathic.[link.springer.com]
  • Keywords: Hypoglossal nerve ; Paralysis ; Prognosis 1. Combarros O, Alvarez de Arcaya A, Berciano J. Isolated unilateral hypoglossal nerve palsy: Nine cases. J Neurol 1998;245:98–100. 2. Lee SS, Wang SJ, Fuh JL, Liu HC.[synapse.koreamed.org]
  • The prognosis for recovery seems better in secondary nerve palsy than in immediate palsy. It is therefore important to note the chronology of appearance of the deficit as this may have medico-legal consequences.[em-consulte.com]
  • Neurophysiological examinations are commonly employed for prognostication after SCI, but whether neurophysiology could improve the functional prognosis based on clinical predictors remains open.[scinapse.io]

Etiology

  • Neuroradiological examinations and other investigations for etiology of hypoglossal nerve palsy and urticaria were normal. We suggest that all patients with hypoglossal palsy must be carefully evaluated for atypical findings and etiologies.[ncbi.nlm.nih.gov]
  • Results: Major etiologic categories included: postoperative (29.3%), idiopathic (15.1%), primary neoplastic (14.2%), metastatic malignancy (13.0%), inflammatory (7.3%), radiation (6.1%), and traumatic (4.1%).[mayoclinic.pure.elsevier.com]
  • The diagnosis is frequently missed by the anesthesia care team in the recovery room due to the delayed symptomatic onset and often requires neurology and otolaryngology evaluations to exclude serious etiologies.[ncbi.nlm.nih.gov]
  • It also represents a diagnostic challenge in every day clinical practice due to its diverse etiologies.[jneuro.com]
  • Etiology Clinical features Extorsion of the eye : inability to depress and adduct the eyeball simultaneously (the pupil shoots upward during attempted adduction of the eyeball) Diplopia ( double vision ) Mild esotropia Trigeminal nerve lesion (V) Etiology[amboss.com]

Epidemiology

  • Home Online First Current Issue Past Issues Journal Home FIND ISSUES Current Issue ARTICLE & MULTIMEDIA Most Accessed Articles Clinical Epidemiology Workshop Series Supplements Videos FOR AUTHORS Guide for Author Reviewer List BOPA Online Submission ABOUT[hkmj.org]
  • Epidemiology In 2007, the Moebius Syndrome Foundation estimated that there were at the time a total of approximately 2,000 cases of Moebius Syndrome worldwide [6].[physio-pedia.com]
Sex distribution
Age distribution

Pathophysiology

  • The relevant literature is reviewed and different hypotheses concerning the pathophysiological mechanisms of nerve damage are discussed.[ncbi.nlm.nih.gov]
  • We reviewed the pathophysiological causes of hypoglossal nerve injury and discuss the associated clinical and procedural characteristics of affected patients.[ncbi.nlm.nih.gov]

Prevention

  • Currently, there are no specific preventive or therapeutic recommendations. We found 69 cases of HNP after procedural airway management reported in the literature from 1926 to 2013.[ncbi.nlm.nih.gov]
  • […] possible prophylactic measure should be taken (eg, sedating the patient during oral or dental procedures, aggressive preoperative management of general and local periodontal chronic infections, avoiding prolonged perioperative neck hyperextention) to prevent[ncbi.nlm.nih.gov]
  • Treatments focus on maintaining function and prevention of abnormal airway-related swallowing events.[ncbi.nlm.nih.gov]
  • Understanding radiological patterns of tongue denervation is important to prevent misinterpretation. Close evaluation of the skull base is critical as hypoglossal palsies resulting from pathology here are often overlooked.[ncbi.nlm.nih.gov]
  • Therefore, in order to prevent this complication, we must perform mask ventilation and direct laryngoscopy carefully. Head and neck manipulation should be gentle during anesthesia for shoulder surgery.[ncbi.nlm.nih.gov]

References

Article

  1. Thompson EO, Smoker WR. Hypoglossal nerve palsy: a segmental approach. Radiographics. 1994;14(5):939-958.
  2. Boban M, Brinar VV, Habek M, Rados M. Isolated hypoglossal nerve palsy: a diagnostic challenge. Eur Neurol. 2007;58:177-181.
  3. Loro WA, Owens B. Unilateral Hypoglossal Nerve Injury in a Collegiate Wrestler: A Case Report. J Athl Train. 2009;44(5):534-537.
  4. Hui AC, Tsui IW, Chan DP. Hypoglossal nerve palsy. Hong Kong Med J. 2009;15(3):234.
  5. Yasuda T, Togawa D, Hasegawa T, et al. Hypoglossal Nerve Palsy as a Complication of an Anterior Approach for Cervical Spine Surgery. Asian Spine J. 2015;9(2):295-298.
  6. Al-Benna S. Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery. Saudi J Anaesth. 2013;7(3):341-343.
  7. Shah AC, Barnes C, Spiekerman CF, Bollag LA. Hypoglossal Nerve Palsy After Airway Management for General Anesthesia: An Analysis of 69 Patients. Anesth Analg. 2015;120(1):105-120.

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Last updated: 2019-07-11 20:45