Hypoglossal paralysis due to compression by a tortuous internal carotid artery in the neck

Hypoglossal Nerve Neuropathies-Analysis of Causes and Anatomical Background

The hypoglossal nerve is the last, and often neglected, cranial nerve. It is mainly responsible for motor innervation of the tongue and therefore the process of chewing and articulation. However, tumors, aneurysms, dissections, trauma, and various iatrogenic factors such as complications after surgeries, radiotherapy, or airway management can result in dysfunction. Correct differential diagnosis and suitable treatment require a thorough knowledge of the anatomical background of the region. This review presents the broad spectrum of hypoglossal neuropathies, paying particular attention to these with a compressive background. As many of these etiologies are not common and can be easily overlooked without prior preparation, it is important to have a comprehensive understanding of the special relations and characteristic traits of these medical conditions, as well as the most common concomitant disorders and morphological traits, influencing the clinical image. Due to the diverse etiology of hypoglossal neuropathies, specialists from many different medical branches might expect to encounter patients presenting such symptoms.

Spontaneous internal carotid artery dissection with lower cranial nerve palsy

BACKGROUND

Typical presentation of spontaneous internal carotid artery (ICA) dissection is an ipsilateral pain in neck and face with Horner's syndrome and contralateral deficits. Although rare, lower cranial nerve palsy have been reported in association with an ipsilateral spontaneous ICA dissection.

CASE STUDIES

We report three new cases of ICA dissection with lower cranial nerve palsies.

RESULTS

The first symtom to appear was headache in all three patients. Examination disclosed a Horner's syndrome in two cases (1 and 2), an isolated XIIth nerve palsy in two patients (case 1 and 3) and IX, X, and XIIth nerve palsies (case 2) revealing an ipsilateral carotid dissection, confirmed by MRI and angiography. In all cases, prognosis was good after a few weeks.

CONCLUSIONS

These cases, analysed with those in the literature, led us to discuss two possible mechanisms: direct compression of cranial nerves by a subadventitial haematoma in the parapharyngeal space or ischemic palsy by compression of the ascending pharyngeal artery.

Oral manifestations and differential diagnosis of isolated hypoglossal nerve palsy: report of two cases

Isolated hypoglossal nerve palsy is rare, but occasionally it appears as the initial or solitary sign of an intracranial or extracranial space-occupying lesion, a head and neck injury, or a vascular abnormality of the internal carotid artery. Therefore it should be considered in differential diagnosis. We report two cases of isolated unilateral hypoglossal nerve palsy. In Case 1 the cause of the palsy appeared to be hypoglossal nerve neurilemmoma within the hypoglossal canal, whereas in Case 2 the cause could not be identified. Neither patient complained of any disability other than slight dysarthria. The tongue deviated toward the healthy side at rest and toward the affected side on protrusion. Hemiatrophy of the tongue with fatty displacement was demonstrated by means of T1-weighted magnetic resonance imaging. 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.

Traumatic dissection of the internal carotid artery as unusual cause of hypoglossal nerve dysfunction

A dissection of the internal carotid artery (ICA) in a 50-year-old man with hypoglossal nerve dysfunction is reported. This case illustrates how non-invasive imaging techniques, such as computed tomography and magnetic resonance angiography, can demonstrate this unusual etiology.

Multiple cranial neuropathy as a feature of internal carotid artery dissection

The traditional presentation of spontaneous internal carotid artery dissection includes ipsilateral hemicranial headache, oculosympathetic paresis, and contralateral focal cerebral ischemic deficits. However, we describe two cases with multiple cranial nerve involvement ipsilateral to the dissection as the principal feature. The first patient, a 36-year-old man, had involvement of the 9th, 10th, 11th, and 12th cranial nerves. The second case was a 53-year-old man with abnormalities of the 5th, 7th, 9th, 10th, and 12th cranial nerves. In both, magnetic resonance imaging revealed a ring-like area of abnormal signal intensity surrounding the carotid artery at the skull base. Carotid angiography was consistent with the suggestion of dissection on the magnetic resonance studies in both cases. The patients recovered without anticoagulation. Internal carotid artery dissection may thus present with multiple cranial nerve palsies, which could be mistaken for an infiltrating tumor of the skull base. Magnetic resonance imaging is useful in identifying the condition.

Pseudoaneurysm of the cervical internal carotid artery with associated hypoglossal nerve paralysis. Demonstration by CT and angiography

A case of pseudoaneurysm of the cervical internal carotid artery with associated hypoglossal nerve paralysis resulting from trauma is presented. CT and angiographic manifestations of this pseudoaneurysm and the resulting hypoglossal nerve paralysis are discussed. Correlative CT and angiographic findings of this association have not previously been described in the literature.

Hypoglossal nerve palsy after tooth extraction

A rare complication involving hypoglossal nerve paralysis after extraction of third molars is reported. The possible pathophysiology of the condition is discussed. The paralysis was temporary and resolved within one week of surgery.

The tortuous or kinked carotid artery: pathogenesis and clinical considerations. A historical review

The significance and management of cervical carotid artery tortuosity are controversial. One hundred eighteen cases of angulation of the common carotid artery and over 800 cases of elongation of the internal carotid artery have been reported. The etiology, presentation, diagnosis, and treatment of each entity are reviewed. Angulation of the common carotid artery is often managed conservatively. For clarity, elongations of the internal carotid artery should be classified as either tortuosities or kinks. Some patients with kinks of the internal carotid artery will have episodes of cerebrovascular insufficiency related to the position of their heads. Such patients merit thorough diagnostic evaluation. When other etiologic factors have been eliminated, patients in this group may benefit from a surgical procedure directed at the vascular abnormality. Applicable surgical techniques are discussed.

Peripheral hypoglossal nerve palsy caused by lateral position of the external carotid artery and an abnormally high position of bifurcation of the external and internal carotid arteries--a case report

An unusual case of peripheral hypoglossal nerve palsy, caused by lateral position of the external carotid artery and an abnormally high carotid bifurcation is reported. Improvement followed ligation and cutting of the external carotid artery at its origin.

The course and relations of the hypoglossal nerve and the occipital artery

Three main types of variations in the relations of the occipital artery and the hypoglossal nerve found in 42 dissected specimens are described, according to the level at which the nerve crosses the external carotid artery and the point of origin of the occipital artery. In Type I, the hypoglossal nerve crosses the external carotid artery inferior to the origin of the occipital artery; in Type II, the nerve crosses the external carotid artery at the level of origin of the occipital artery; and in Type III, it crosses superior to that level. In Type III the occipital artery makes a loop around the hypoglossal nerve and is in a position to pull and exert pressure on the nerve. This possibility should be taken into consideration in the diagnosis of peripheral paresis or paralysis of the tongue and during surgery in this area.

Spontaneous dissecting aneurysm of cervical cerebral arteries. Report of six cases and review of the literature

Six cases of spontaneous dissecting aneurysm of the internal carotid and vertebral arteries are reported. The angiographic findings and the clinical aspects of the disease are described. The lesion is not as rare as generally assumed.

Megadolicho vascular malformation of the intracranial arteries

A patient is presented suffering a hemiparesis. Megadolicho-vascular malformation of the intracranial part of the internal carotid arteries and some of its branches and of the basilar artery was suggested by CT and confirmed by angiography. The value of CT compared with angiography in relation to intracranial megadolicho vascular malformations is discussed.

Carotid artery aneurysms: an otolaryngologic perspective

Aneurysms of the carotid arteries are relatively rare and can present difficult diagnostic problems. They may occur anywhere along the course of the carotid artery in its cervical route, petrous portion, or intracranial extension. The associated clinical findings may range from a simple neck mass to a variety of neurologic deficits. Symptoms of headache, facial pain, tinnitus, vertigo, epistaxis, hoarseness, and dysphagia may require otolaryngologic evaluation. The high morbidity and mortality associated with the natural history of carotid aneurysms makes their early detection essential. Although these lesions have been a subject of great interest in the neurological and neurosurgical literature, surprisingly little has been written to bring them to the attention of otolaryngologists. A review of the literature and an assessment of 10 cases of extracranial carotid aneurysms treated at the University of Pennsylvania in the past 10 years form the basis of this report. Patients with aneurysms involving various portions of the carotid system are presented to illustrate the numerous head and neck manifestations these lesions produce. Differential diagnosis, etiology, natural history, and current management of carotid aneurysms are discussed.

Aneurysm of the internal carotid artery at the base of the skull: an unusual cause of cranial neuropathies

Aneurysms of the cervical portion of the internal carotid artery are relatively rare and can present difficult diagnostic problems. Signs and symptoms of cerebral ischemia are common, but isolated cranial neuropathies are unusual. A patient with hypoglossal and glossopharyngeal cranial nerve palsies secondary to an extracranial internal carotid artery aneurysm is the subject of this case report and discussion.