Tongue Deviation Research Articles

Teaching Neuro Images : Villaret syndrome

A 3-year-old boy presented with fever and painful swelling of the left side of the neck due to retropharyngeal bacterial infection (figure 1). Neurologic examination showed left-sided ptosis, miosis, paresis of the sternocleidomastoid and trapezius muscle, difficulty swallowing, hoarseness, and left tongue deviation …

A Case of Idiopathic Isolated Hypoglossal Nerve Palsy

－Abstract－Isolated hypoglossal nerve palsy is a rare clinical condition and it causes deviation of the tongue and dysarthria. A 50-year-old female presented with tongue deviation to the left and mild dysarthria. She had no remarkable past medical history except several recent upper respiratory infections. On examination, the other cranial nerves were intact and she had no focal neurological signs. The findings of MRI and MR angiography were normal. Cerebrospinal fluid analysis revealed only mild elevation of protein. We diagnosed her as suffering with idiopathic isolated hypoglossal nerver palsy and we administered steroid therapy. The dysarthria was improved, but the tongue deviation still remained at 50 days after onset. We report here on a rare case of idiopathic isolated hypoglossal nerve palsy.KeyWords:Hypoglossal nerve palsy, Isolated, Idiopathic서 론설하신경마비는 동측 설근의 마비를 초래하기 때문에 혀의 편위와 발음장애를 유발한다. 설하신경의 주행경로에 발생하는 종양에 의한 경우가 가장 많으며 다음으로는 외상에 의한 것이다.

A Case of Hypoglossal Nerve Palsy after Tonsillectomy

Tonsillectomy is a common procedure in the ENT department but unusual complications related to nerve injury might be associated with the surgery. We report a case of permanent hypoglossal nerve palsy following tonsillectomy in a 33-year-old female patient. The findings from the neu-rologic examination were unremarkable except for tongue deviation to the left, hemiatrophy of the tongue and associated dysarthria. Forceful pressure and stretch of hypoglossal nerve during surgery can explain the cause of injury. To avoid nerve compression, intermittent release of the mouth gag and avoidance of neck hyperextension are suggested especially when long operation time would be expected. Although rare, having knowledge of the existence of hypoglossal nerve injury complicating tonsillectomy is important when counseling patients.

2010 ASN Abstracts

1. Vertebral Artery Pseudoaneurysm Presenting as Swishing Noise Jayashree Sundararajan, Manoj Mittal, Saud Khan Kansas University Medical Center, Kansas City, Kansas, United StatesA 48‐year‐old male with history of gun shot wound to the neck 20 years ago presented with chronic daily headaches, left face numbness, left ear “swishing “ noise and intermittent dizziess. Examination revealed tongue deviation to the left and decreased sensation on the left facial on light touch and pinprick. Computer tomographic angiography showed left vertebral artery pseudoaneurysm (measuring 18 mm × 13 mm × 10 mm) which was located between the C1 vertebral body and skull base. Four vessel ateriogram confirms the same findings. MRI brain was not performed due to the presence of the bullet. It is hypothesized that this large pseudoaneurysm caused thromboembolic phenomena.Extracranial vertebral artery injury and pseudoaneurysm formation is most often due to trauma often penetrating in nature (stabbing, gunshot wound, sharpnel) (1). Symptoms secondary to vertebral artery pseudoaneurysm are variable and result from mass effect or arterial insufficiency. Lower cranial nerve dysfunction can be observed if the pseudoaneurysm is large with intraspinal or intracranial extension or secondary to infarction or ischemia from microembolization or thrombosis of vertebral artery or PICA (1). Sometimes the speudoaneurysms can be safely observed; however spontaneous thrombosis or rupture may occur (2).

Asymmetry of protracted tongue: Can it replace the Wada test?

Some asymmetry of body parts (thumbs, cubital crease levels, popliteal crease levels, toes, breasts, gonads and facial structures) is commonly observed. And there is also neurobehavioral asymmetry such as handedness and language lateralization. Since right-handedness is closely associated with left-hemisphere dominance for language, it is known that handedness can be linked with language lateralization. But because cultural and social pressures influence handedness, handedness is able to shift. If so, handedness can't always reflect language lateralization. We can also detect another asymmetry in protracted tongue which is thought to be inherently unchangeable. Some midline deviation of fully protracted tongue is observed in every person. Protractor of the tongue, genioglossus muscle, is solely innervated by contralateral corticobulbar fibers from the inferior part of precentral gyrus. This part is closely related with language expressive area. Therefore, the midline deviation of tongue observed when it is fully protracted could be more related with language lateralization than handedness changeable to external pressures.

Index of Suspicion

Index of Suspicion

Tongue Deviation in a Man with Alcoholism: Diagnosis and Discussion

The patient presented in the case “Tongue Deviation in a Man with Alcoholism” (JW Neurol Jan 20 2009) had a right carotid dissection and a large

Index of Suspicion in the Nursery

A 4-day-old term female infant is being evaluated for fever, with a rectal temperature of 100.9°F (38.2°C), and an episode of oxygen desaturation to 70% while breathing room air. The mother reports that the infant had increasing fussiness. Prenatal care and delivery were within normal parameters. She denies use of illicit drugs and is unsure of her group B Streptococcus status. The infant has eight to nine wet diapers and about 10 bowel movements per day. She consumes 1 to 2 oz of regular infant formula every 3 hours. The only finding of note on physical examination is the fever. Her neck is supple and has no abnormalities. A full sepsis evaluation is performed, including a complete blood count and blood, urine, and cerebrospinal fluid cultures. Respiratory syncytial virus antigen and influenza test results are negative. Radiographs of the chest and lungs appear normal. The infant is admitted and treatment with ampicillin and cefotaxime is begun. Thirteen hours later, the infant develops respiratory distress manifesting with stridor and desaturation while breathing room air. Physical examination at this time reveals a new cystic, moveable mass on the anterior triangle of her neck. Follow-up radiograph of the neck shows displacement of the trachea to the right. An 80% helium/20% oxygen mixture is started in the pediatric intensive care unit. Computed tomography (CT) scan of the neck and chest shows a 4.0×2.5-cm cystic lesion with an air-fluid level located in the anterior triangle of her neck slightly to the left of midline (Fig. 1). Thyroid study results are normal. Surgical removal of the cyst and histologic evaluation lead to the diagnosis. Figure 1. Computed tomography scan showing a cystic lesion with an air-fluid level in the anterior triangle of the neck. ### Hospital Course The patient was taken to the operating room the next day for neck exploration. …

Tongue Deviation in a Man with Alcoholism

Following an altercation in a bar, a 54-year-old alcoholic man developed right-sided facial pain; right-sided headache; and left hemiparesis that

A Case of Multiple Sclerosis with Sick Sinus Syndrome and Postural Orthostatic Tachycardia Syndrome

A 19-year-old girl was admitted to our hospital with nausea, vomiting, hiccups, constipation and syncope. After hiccups or vomiting sinus arrest developed and lasted more than 5-8 seconds. She lost consciousness every one hour. Based on an electrocardiographic diagnosis of sick sinus syndrome (SSS), a temporary pacemaker was implanted. The next day, although her syncope and bradycardia disappeared, she had orthostatic tachycardia of over 120 beats/minute and swelling of the legs, which led to a diagnosis of postural orthostatic tachycardia syndrome (POTS). Neurologically, she showed the right-sided tongue deviation and parasympathetic system disorders revealed by coefficient of variation of R-R interval (CVR-R), the Achner eye-ball pressure test, the valsalva ratio, and the head-up-tilt test. Brain MRI disclosed a small hyperintense lesion on a T2-weighted image with gadolinium enhancement in the right dorsal medulla including the hypoglottis nucleus and the posterior nucleus of vagus. After steroid pulse therapy (methyl prednisolone 1 g/day×3 days, 5 times) was administered, this lesion became smaller and finally disappeared. Before the lesion disappeared, she was able to begin rehabilitation by wearing elastic stockings and treatment with midodrine hydrochloride. The following year, she developed other MRI-proven brain lesions, suggestive of demyelination. Such a spinal and temporal distribution of lesions led to a diagnosis of multiple sclerosis (MS). A case of POTS caused by MS has not been reported previously, however, MS often affects the medullary paraventricular regions associated with autonomic failures. Autonomic failures often prevent patients from experiencing early rehabilitations. We should promptly give symptomatic treatment against autonomic failures, which leads to good patient recovery not only in patient vitality but also functionality.

Intradural Microsurgery and Extradural Gamma Knife Surgery for Hypoglossal Schwannoma: Case Report and Review of the Literature

There have been only 26 cases of hypoglossal schwannomas reported to originate intradurally and extend extradurally into the hypoglossal canal. This 31-year-old mother of two children presented with a 5-day history of progressive headache, nausea, vomiting and vertigo. Her neurological exam was significant for nystagmus and left tongue deviation with marked atrophy. An initial head CT revealed extensive left hypoglossal canal erosion with 4th ventricle compression. T1-weighted MR images with contrast revealed a 4x3 cm left cerebellopontine angle non-homogeneously enhancing mass with an intracranial cystic component and prominent extension into the eroded hypoglossal canal. A left lateral suboccipital craniotomy was performed for subtotal microsurgical resection of the intradural posterior fossa mass. A schwannoma was diagnosed after resection and gamma knife surgery (GKS) was performed three months later for the extradural residual tumor without further deficits. This is a rare report of a hypoglossal schwannoma in a young patient who was treated with a multimodality approach in order to minimize risks. A review of the literature and discussion of the respective benefits of microsurgery versus GKS and long-term follow-up issues are presented.

Glossoplegia in a small cortical infarction

We recently observed a patient with obvious contralateral tongue deviation with minimal lower facial paresis caused by a small cortical infarction confirmed by MRI. The small cortical lesion, causing obvious...

Congenital arhinia

Lateral sinus thrombosis is a well-known complication of otitis media. The classical picture is often modified by previous antibiotic therapy, making the diagnosis and management difficult.A 14-year-old male patient with attico antral type of otitis media presented with fever, headache, deviation of left eye and deviation of tongue to left on protrusion. On investigation patient was found to have lateral sinus thrombosis, petrous apicitis, meningitis and internal jugular vein thrombosis along with cranial nerves palsies. Patient underwent radical mastoidectomy and intravenous antibiotics were given for 2 weeks. Patient recovered well in 1 month.Lateral sinus thrombosis is now a rare intracranial complication of otitis media. The presence of lateral sinus thrombosis mandates further investigation for additional complication.Here a case of lateral sinus thrombosis with internal jugular vein thrombosis, petrous apicitis, abducent and hypoglossal nerves palsies is presented for its rarity.

Lateral sinus thrombosis with cranial nerves palsies

Lateral sinus thrombosis is a well-known complication of otitis media. The classical picture is often modified by previous antibiotic therapy, making the diagnosis and management difficult. A 14-year-old male patient with attico antral type of otitis media presented with fever, headache, deviation of left eye and deviation of tongue to left on protrusion. On investigation patient was found to have lateral sinus thrombosis, petrous apicitis, meningitis and internal jugular vein thrombosis along with cranial nerves palsies. Patient underwent radical mastoidectomy and intravenous antibiotics were given for 2 weeks. Patient recovered well in 1 month. Lateral sinus thrombosis is now a rare intracranial complication of otitis media. The presence of lateral sinus thrombosis mandates further investigation for additional complication. Here a case of lateral sinus thrombosis with internal jugular vein thrombosis, petrous apicitis, abducent and hypoglossal nerves palsies is presented for its rarity.

Malignant external otitis with extensive cranial neuropathy but no facial paralysis

Sirs: Malignant or necrotizing external otitis (MEO) is a lifethreatening Pseudomonas aeruginosa infection of the external auditory canal leading to skull base osteomyelitis and soft tissue inflammation of the infratemporal fossa. Although MEO primarily belongs to the domain of the earsnose-throat specialist, it represents a true neurological emergency if cranial nerves are affected. The disease is characterised by the following triad: (A) An elderly diabetic or otherwise immunocompromised patient presents with (B) persistent headache, otalgia and auditory discharge after water irrigation for cerumen impaction, (C) complicated by multiple cranial nerve palsies. Due to its close proximity to the external acoustic meatus and the stylomastoid foramen, the facial nerve is the first and foremost involved cranial nerve [1]. However, here we report to our knowledge the first case of a patient with MEO suffering from extensive cranial neuropathy without facial paralysis. In November 2005 a 68-year old man with poorly regulated diabetes mellitus and hypertension consulted an otolaryngologist because of left ear deafness. After irrigation for cerumen impaction, hearing returned to normal. A week later he developed constant left-sided headache and painful drainage of a yellowish smelly fluid from the left ear. Otalgia and otorrhoea resolved two weeks later after repeated irrigations and the prescription of topical hydrocortisone cream. However, headache persisted. The pain extended to the left temporo-mandibular joint and mastoid. In December the patient noticed hypestesia on the left side of the face. In January 2006 he was operated for an abscess of the left external auditory canal. In February he developed slurred speech and hoarseness, in March difficulties with swallowing. He lost six kg in three weeks and complained of constant headache. He was now referred by his otolaryngologist to a university neurological department. On admission he was alert and orientated without fever or neck stiffness. Neurological examination revealed a sensory deficit in the maxillary and mandibular nerve distribution, mild conductive hearing impairment, deviation in the Unterberger’s stepping test, a positive curtain sign with elicitation of the gag reflex, dysphagia, hoarseness and tongue deviation. All symptoms were confined to the left side. Of note, there was no facial paresis. A CT and MRI scan of the head revealed bone erosion of the left occipital condyle and mastoid with extensive soft tissue inflammation around the skull base (Figs. 1, 2); however, the facial nerve remained unaffected (Fig. 1). A diagnosis of MEO with involvement of multiple cranial nerves was made and the patient received ciprofloxacin 750 mg twice daily. Two days later the headache had vanished. After three more days dysphagia and hoarseness had resolved. Culture from a mastoid biopsy revealed Pseudomonas aeruginosa. The patient received eight weeks of antibiotic treatment and made an uneventful recovery. Although MEO affects mostly elderly male diabetics, due to increased frequency of immunosuppression MEO is now seen in patients with AIDS or malignancies as well. When left untreated, MEO has a mortality of more than 50% [1], but since the introduction of ciprofloxacin and other oral antipseudomonal agents in the 1990ies, survival rates are much better. Long-term systemic therapy (>6 weeks) is mandatory and excellently tolerated [2]. Local application of aluminium acetate, known as Burow’s solution [3], might be used additionally. Moreover, hyperbaric therapy has been widely advocated [4, 5], but a recent Cochrane Review concluded that there is so far no evidence from randomized controlled trials for such an approach [6]. Due to undifferentiated ciprofloxacin use for simple external otitis, aberrant and recurrent forms of MEO and even quinolone-resistance are increasingly reported. Sinus and jugular vein thrombosis, meningitis, trismus, facial nerve palsy and other cranial neuropathies, ophtalmoplegia and skull base osteomyelitis often necessitate surgical debridement. Even with aggressive surgical and medical treatment mortality of protracted MEO is high [7]. Thus, early diagnosis of MEO is essential. CT, MRI and SPECT bone imaging provide the anatomic D. Kondziella, MD, DMSC (&) I. Skagervik, MD Dept. of Neurology Goteborg University Hospital Sahlgrenska 41345 Goteborg, Sweden Tel.: +46-730791599 Fax: +46-31826227 E-Mail: daniel_kondziella@yahoo.com LETTER TO THE EDITORS J Neurol (2007) DOI 10.1007/s00415-006-0516-1

Transient Hypoglossal Nerve Palsy after Septorhinoplasty - A case report -

Hypoglossal nerve palsy is a rare complication after general anesthesia with orotracheal intubation. It can present with symptoms of tongue deviation, dysarthria and swallowing difficulties. We report 33-year-old female who was scheduled to undergo surgery for a nasal bone fracture under general anesthesia, using orotracheal intubation. After surgery, she complained right side tongue deviation and, dysarthria, and was diagnosed with right hypoglossal nerve palsy. The cause of the hypoglossal nerve palsy was assumed to be a complication of the orotracheal intubation. Fortunately, the patient fully recovered 2 weeks after surgery.

Conversion Disorder

Conversion Disorder

Usefulness of dynamic maneuvers in MR evaluation of oral malignancies

Abstract Objectives: The purpose of this study was to evaluate the usefulness of dynamic maneuvers like "distended cheek" and "tongue deviation" in MR evaluation of oral malignancies. Methods: Ninety nine patients of oral malignancies who reported to this institute for treatment were enrolled in this study. All the patients evaluated with conventional MR imaging and supplemented by additional MR imaging with dynamic maneuvers using T1Weighted and STIR sequences with reduced scan time. Distended cheek imaging was performed in 73 cases of carcinoma cheek, gingiva & RMA (retromolar area) and tongue deviation in 24 cases of carcinoma tongue & floor of mouth. Two cases of carcinoma of lower gingiva performed both maneuvers. In selected cases MR imaging with dynamic maneuvers was also performed following contrast administration. Results: Lesions appearing inseparable from two mucosal surfaces (buccal mucosa and gingiva) on routine MR images were well separated in the distended cheek images in all cases except for two cases who could not perform the maneuvers. Distended cheek images demonstrated involvement of buccogingival sulci in 30 patients of carcinoma of cheek, involvement of cheek in 8 cases of carcinoma gingiva & involvement of gingiva in 6 cases of carcinoma cheek which were not appreciated on routine MR images. Similarly MR imaging with tongue deviation helped in better delineation of tongue lesions in 12 cases and showed involvement of glossogingival sulcus in 5 cases that were not appreciable on routine MR imaging. Conclusion: MR imaging with dynamic maneuvers provide additional information of clinical significance regarding origin and extent of disease in oral malignancies & should supplement the conventional MR imaging in selected cases.

Bipolar radiofrequency induced thermotherapy of the tongue base: its complications, acceptance and effectiveness under local anesthesia

We assessed adverse events and complications of bipolar radiofrequency induced thermotherapy of the tongue base (RFTB) in patients with socially unacceptable snoring (SUS) or obstructive sleep apnea syndrome (OSAS) and determine its acceptance and effectiveness when conducted under local anesthesia. This investigation consisted of (1) a prospective, open-enrollment study of 24 consecutive patients with snoring and OSAS at the tongue base level only (Fujita III), assessed by sleep endoscopy. Polysomnography, questionnaires, and visual analog scales (VAS) were used to assess outcome. (2) In addition, a retrospective review of 83 patients, who underwent RFTB (in 59 cases as part of a multilevel treatment), was performed to evaluate adverse events and complications. Twenty-two of the 24 patients completed postoperative questionnaires and VAS, and ten patients had postoperative polysomnography. Reduction in snoring (P = 0.0003), hypersomnolence (P = 0.002), and globus (P = 0.031) was significant. A positive trend in AHI (P = 0.001, n = 3) is shown in patients with moderate to severe OSAS. Concerning postoperative adverse events and complications, only two patients had a mild and transient tongue deviation directly after the procedure, which resolved within an hour postoperatively (adverse event rate 1.8%). No postoperative complications such as infections, abscesses, hematomas, or ulcerations of the tongue base occurred. This study demonstrates that bipolar RFTB in patients with obstruction at the tongue base only (Fujita type III) as visualized by sleep endoscopy is a safe and simple procedure under local anesthesia and can be effective in patients with SUS. No complications during this study were observed. Its effect on OSAS has been shown by other authors, although long-term effects are not stable. The RFTB can be considered as first choice treatment in case of snoring and mild OSAS in Fujita type III obstruction. In the case of moderate to severe sleep apnea, RFTB can be considered as an additional treatment.

SURGICAL MANAGEMENT OF EXTRACRANIAL INTERNAL CAROTID ANEURYSMS BY CERVICAL APPROACH

Extracranial internal carotid artery aneurysms (EICAA) are rare vascular problems with a great potential for lethal thromboembolic episodes. From 1994 to 2004, nine patients with EICAA, seven men and two women, were surgically treated for 10 aneurysms in our department. Aneurysm led to hemispheric symptoms in six cases (two hemispheric strokes and four hemispheric transient ischaemic attacks). The cause was fibrodysplasia in two cases, atherosclerosis in four cases, trauma in two cases and spontaneous dissection in two cases. All aneurysms were treated surgically by the cervical approach using shunting. Extended cervical approach was necessary in four patients with high-lying aneurysms. Nine aneurysms were totally resected and successful revascularization was carried out. Open aneurysmorrhaphy with vein patch angioplasty was carried out in one case of a saccular aneurysm. There were no perioperative deaths or transient ischaemic attacks or strokes. Four patients developed cranial nerve deficits: one had hoarsness, two had partial facial paralysis (patients with extended cervical approach) and one had tongue deviation. These neurological symptoms were observed in large aneurysms (>4.5 cm) and disappeared within 14 months. No neurological complication was observed in a follow up that ranged from 6 months to 10 years. Surgical repair of EICAA, especially with total resection and arterial reconstruction, is strongly recommended. Extended cervical approach has many technical difficulties but can allow treatment of high-lying aneurysms.