|Year : 2015 | Volume
| Issue : 4 | Page : 200-202
Isolated hypoglossal nerve palsy posttonsillectomy
Amina Lami Okhakhu1, Kingsley Ufuoma Tobi2
1 Department of Ear, Nose, Throat, University of Benin Teaching Hospital, Benin City, Nigeria
2 Department of Anaesthesiology, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication
Amina Lami Okhakhu
Department of Ear, Nose and Throat, University of Benin Teaching Hospital, Benin City
Source of Support: None, Conflict of Interest: None
Hypoglossal nerve palsy posttonsillectomy is a rare complication that can occur following orotracheal intubation for general anaesthesia for surgical procedures. We present a case of hypoglossal nerve palsy occurring in a 38-year-old female medical practitioner. Possible mechanisms of this complication are discussed.
Keywords: Hypoglossal nerve, intubation, isolated, palsy, tonsillectomy
|How to cite this article:
Okhakhu AL, Tobi KU. Isolated hypoglossal nerve palsy posttonsillectomy. Sahel Med J 2015;18:200-2
Tonsillectomy is one of the commonest surgical procedures carried out by the otolaryngologist. It is not without complications with some being more common than others. Hypoglossal nerve palsy posttonsillectomy is a relatively rare complication and as such, does not enjoy much reference in otolaryngology literature. We present a case of isolated right hypoglossal nerve palsy posttonsillectomy highlighting the possible aetiological factors in its development and steps to forestall its occurrence.
| Case Report
M.U. was a 38-year-old female medical practitioner who had tonsillectomy on account of chronic tonsillitis. She is not a known hypertensive or diabetic. Examination was essentially normal except for the anterior faucial pillars which were congested. The tonsils were not enlarged or inflamed but had prominent crypts. The jugulodigastric nodes were palpably enlarged bilaterally but not tender. Preoperative examination revealed no neurologic abnormality. Her full blood count was within normal limits. She was then counselled for tonsillectomy.
Anaesthesia was induced with intravenous (i.v.) propofol 120 mg and orotracheal intubation was facilitated with i.v. suxamethonium 100 mg with size 7.5 mm cuffed endotracheal tube (ETT) after a second attempt. The cuff of the ETT was inflated with 10 ml air and connected to the anaesthetic machine and the lungs were ventilated with a mechanical ventilator with 500 ml tidal volume. Anaesthesia was maintained with isoflurane 1–2% and muscle relaxation was achieved by i.v. atracurium. Neck extension was achieved by means of sandbag under the shoulder with head supported on a head ring. Surgery was performed using traditional cold steel technique for tonsillectomy and tonsillar fossa approached through the oral cavity. The oral cavity was exposed by means of a Boyles–Davis mouth gag frame with tongue blade. Surgery lasted for about 40 min and was uneventful. Anaesthesia was reversed and the ETT was removed after the cuff was deflated. She was then transferred to the recovery room and moved to the ward an hour later with stable vital signs.
Six hours postoperatively, she complained of a heavy sensation on the right side of her throat when she attempted to swallow but there was no pain. The next morning, she complained of heaviness in her tongue and deviation of the tongue to the right side [Figure 1]. There was no pain, no odynophagia or hoarseness. Examination was normal except for the deviation of the tongue to the right and inability to move the tongue to the left. The other cranial nerves examination was essentially normal. Full blood count done was essentially normal and the fasting blood sugar was also normal. A diagnosis of isolated hypoglossal nerve palsy? Cause was made. She was reassured and was scheduled to have computerized tomographic scan (computed tomography scan) of the skull base as magnetic resonance imaging is not available at our centre.
She was seen a week later with persistence of the tongue deviation. By now she was anxious and had pain at the base of her tongue whenever she talked for long periods. She denied any change in the quality of her voice. Examination revealed the deviated tongue. There was no fasciculation or atrophy of the tongue. Her speech appeared slightly slurred. She was again counselled and advised to continue on her antibiotics and analgesics. She called 3 days later, now more anxious and was subsequently commenced on a 2 weeks course of tapering oral steroid. The hypoglossal nerve palsy had resolved before the completion of her 2 weeks course of steroids [Figure 2]. She has remained symptom free 5 months posttonsillectomy.
Tonsillectomy is one of the commonest surgical procedures performed by the otolaryngologist. This procedure is carried out in both children and adults for varying indications. Like every other surgical procedure, it is not devoid of complications. Hypoglossal nerve palsy posttonsillectomy is a relatively rare complication and does not enjoy mention in most otolaryngologic literature. This has far reaching implications when it then occurs in a postsurgical patient who had not been adequately counselled preoperatively about the possibility of it occurrence albeit rare. Our patient was a medical practitioner and was not counselled about the possibility of a hypoglossal nerve palsy hence the heightened anxiety she experienced when it occurred.
Hypoglossal nerve palsy can result from multiple etiological factors with tumours accounting for more than half of the pathology. Surgical trauma accounts for about 5% of hypoglossal nerve injuries and this is common in head and neck procedures., Infections can also result in palsy of the hypoglossal nerve., The hypoglossal nerve is the twelfth cranial nerve and it arises from it nucleus in the medulla and leaves the skull through the hypoglossal canal in the occipital bone. It descends between the internal carotid artery and the internal jugular vein to pass above the hyoid bone and reaches the lower border of the posterior belly of the digastric muscle where it turns forward and medially to lie below the submandibular gland and lingual nerve. At the anterior margin of the hypoglossal muscle, it curves upwards towards the tip of the tongue to innervate all the intrinsic and extrinsic muscles of the tongue except the palatoglossus. The course of the nerve is such that surgical injury is unlikely during tonsillectomy. Surgical injury to the hypoglossal nerve during tonsillectomy is unlikely because the procedure is confined to the tonsillar fossa and as such, we would like to assume that the isolated hypoglossal nerve palsy encountered in our patient may have been as a result of manipulations of the tongue base. This was the 1st time we were encountering such a complication following tonsillectomy. The anaesthetic literature recognises this complication as a possible occurrence if precautions are not taken to avoid excessive stretching of the hypoglossal nerve. Other mechanisms of injury include forceful laryngoscopy, hyperextension of the head, cricoid pressure and tight throat packs.,,,
Anterior displacement of the tongue by the blade of the laryngoscope and excessive extension of the head during intubation can cause substantial strain on the hypoglossal nerve. This nerve injury may result in either a temporary impairment or a permanent impairment. A bilateral affectation of the hypoglossal nerve has also been reported in the literature and the reason adduced for this is the close proximity of the nuclei in the medulla. More than one attempt was made during the process of intubation of our patient. This would have further predisposed her to more manipulation at the base of the tongue. Cricoid pressure was also applied during intubation, coupled with the tongue blade that was applied for the duration of the surgery. Our patient suffered a transient isolated right hypoglossal nerve palsy which resolved within 3 weeks. Transient impairment of the function of the nerve is believed to be due to neuropraxic injury while axonotmesis or neuronotmesis would result in a more permanent impairment of function. The risk of nerve injury is heightened if cricoid pressure is applied during intubation as this manoeuvre immobilizes the hypoglossal nerve. Neuropraxic injuries to the hypoglossal nerve may be as a result of ischaemia or mechanical compression and usually resolves within 6 months. Avoidance of hyperextension of the neck may lower the risk of development of this injury. The use of a shorter laryngoscope blade may eliminate the pressure on the lateral wall of the base of the tongue. Prolonged use of mouth gag is another mechanism of injury that has been proposed.
Hypoglossal nerve is closely related to vagus and lingual nerves and as a result multiple nerve palsies can occur. When hypoglossal nerve palsy occurs in combination with recurrent laryngeal nerve palsy (Tapia's syndrome), the patient presents with features suggestive of vocal fold paralysis., This is believed to be due to pressure neuropathy of both nerves due to inflation of the ETT cuff within the larynx. The lingual nerve can also be similarly affected. Our patient's pathology was isolated hence no change in her voice and laryngeal examination was essentially normal. This complication can be prevented by ensuring close monitoring of cuff pressure and that the cuff is inflated with the least volume that can achieve a seal of the airway and by avoiding excessive traction at the base of the tongue.
Hypoglossal nerve palsy posttonsillectomy is a possible albeit rare complication and there is need to take precautions to forestall its occurrence and proper patient counselling preoperatively about it is necessary.
Leong SC, Karkos PD, Papouliakos SM, Apostolidou MT. Unusual complications of tonsillectomy: A systematic review. Am J Otolaryngol 2007;28:419-22.
Sharp CM, Borg HK, Kishore A, MacKenzie K. Hypoglossal nerve paralysis following tonsillectomy. J Laryngol Otol 2002;116:389-91.
Hong SJ, Lee JY. Isolated unilateral paralysis of the hypoglossal nerve after transoral intubation for general anesthesia. Dysphagia 2009;24:354-6.
Al-Benna S. Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery. Saudi J Anaesth 2013;7:341-3.
Kodiya AM, Ngamdu YB, Sandabe MB, Isa A, Garandawa HI. Isolated right hypoglossal nerve palsy – A case report. Borno Med J 2012;938-40.
Khan M, Ohri N. Unilateral hypoglossal nerve palsy due to infected molar: A rare entity. J Investig Clin Dent 2011;2:293-5.
Lin HC, Barkhaus PE. Cranial nerve XII: The hypoglossal nerve. Semin Neurol 2009;29:45-52.
Hung NK, Lee CH, Chan SM, Yeh CC, Cherng CH, Wong CS, et al
. Transient unilateral hypoglossal nerve palsy after orotracheal intubation for general anesthesia. Acta Anaesthesiol Taiwan 2009;47:48-50.
Evers KA, Eindhoven GB, Wierda JM. Transient nerve damage following intubation for trans-sphenoidal hypophysectomy. Can J Anaesth 1999;46:1143-5.
Rubio-Nazábal E, Marey-Lopez J, Lopez-Facal S, Alvarez-Perez P, Martinez-Figueroa A, Rey del Corral P. Isolated bilateral paralysis of the hypoglossal nerve after transoral intubation for general anesthesia. Anesthesiology 2002;96:245-7.
Nalladaru Z, Wessels A, DuPreez L. Tapia's syndrome – A rare complication following cardiac surgery. Interact Cardiovasc Thorac Surg 2012;14:131-2.
Boisseau N, Rabarijaona H, Grimaud D, Raucoules-Aimé M. Tapia's syndrome following shoulder surgery. Br J Anaesth 2002;88:869-70.
Yavuzer R, Basterzi Y, Ozköse Z, Yücel Demir H, Yilmaz M, Ceylan A. Tapia's syndrome following septorhinoplasty. Aesthetic Plast Surg 2004;28:208-11.
[Figure 1], [Figure 2]