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CASE REPORT
Year : 2013  |  Volume : 7  |  Issue : 3  |  Page : 341-343

Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery


Department of Plastic and Reconstructive Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

Correspondence Address:
Sammy Al-Benna
Department of Plastic and Reconstructive Surgery, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.115331

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Date of Web Publication20-Jul-2013
 

  Abstract 

Aesthetic and functional complications caused by general anesthesia have been rarely described after aesthetic surgery. We report a case of unilateral right hypoglossal nerve paralysis following the use of a cuffed endotracheal airway in a 24-year-old woman undergoing aesthetic breast surgery. Neurological examination and magnetic resonance imaging of the head failed to provide additional insights into the cause of the nerve injury. Postoperatively, the patient was carefully monitored and made a full recovery within 2 weeks without any pharmacological treatment. The transient hypoglossal nerve paralysis seemed to be due to neuropraxia. In this patient, we postulate that the right hypoglossal nerve was compressed between the endotracheal tube cuff and the hyoid bone, which was inflated with 30 cm H 2 O. Patients undergoing aesthetic surgery must be appropriately and adequately informed that postoperative aesthetic and functional deficits can occur due to anesthesia as well as the surgery.

Keywords: Aesthetic surgery, hypoglossal nerve palsy, intubation anesthesia, postoperative complications


How to cite this article:
Al-Benna S. Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery. Saudi J Anaesth 2013;7:341-3

How to cite this URL:
Al-Benna S. Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery. Saudi J Anaesth [serial online] 2013 [cited 2019 Aug 17];7:341-3. Available from: http://www.saudija.org/text.asp?2013/7/3/341/115331


  Introduction Top


Unilateral hypoglossal nerve palsy has been rarely described after endotracheal intubation. Michel and Brusis described unilateral hypoglossal nerve palsy after tonsillectomy. [1] Agnoli and Strauss reported four cases of hypoglossal nerve palsy following intubation and direct laryngoscopy. [2] Kaess described transitory hypoglossal paralysis following bronchoscopy. Konrad and Lakomy described peripheral hypoglossal paralysis after intubation anesthesia for surgery of the aortic isthmus. [3],[4] Further case reports of hypoglossal nerve palsies have been reported by Nagai et al. after laryngeal mask airway, Gatot et al. after infected second branchial arch cleft cysts, and Stankiewicz and Pazevic after tooth extraction. [5],[6],[7]] We describe a patient with isolated unilateral hypoglossal nerve paralysis after uneventful tracheal intubation for aesthetic breast surgery.


  Case Report Top


A 24-year-old female Caucasian patient, 171 cm tall and weighing 60 kg, was to undergo bilateral breast augmentation, exchange of implants, and mammaplasty for bilateral breast ptosis and capsular contracture. Past medical history included bilateral breast augmentation in 2008 and abdominoplasty in 2007 after 90 kg weight loss, lower Cesarean section in 2004, and tonsillectomy as a child. She was otherwise well and did not take any regular medication. The pre-operative physical examination showed good neck extension and mouth opening, and a straightforward endotracheal intubation was anticipated. Two hours before the induction of anesthesia, she received chlorazepam 20 mg orally as premedication. General anesthesia was induced with fentanyl 0.1 mg and 200 mg propofol, and atracurium 25 mg was used to prevent laryngospasm during insertion of the endotracheal tube. At intubation, the Cormack and Lehane grade was described as 1, using a standard size 3 Macintosh blade. A 7.5-mm Magill tube was used. After intubation, proper placement of the endotracheal tube was confirmed by bilateral breath sounds. The endotracheal tube cuff was inflated with air until the cuff pressure was 30 cm H 2 O. During surgery, the patient received intermittent positive pressure ventilation with 67% nitrous oxide in oxygen, 0.8-1.2% isoflurane, supplemented with fentanyl 0.15 mg. The maximum endotracheal tube cuff pressure did not exceed 34 cm H 2 O. The patient was placed in a 30° elevated supine position and the head was supported in position with a donut-type pillow. Surgery was completed uneventfully within 90 min, blood loss was minimal, and fluid replacement was done with 1000 ml of full electrolyte solution Jonosteril (Fresnius, Bad Homburg, Germany) and 500 ml of conventional 6% hetastarch 130/0.4 (Tetraspan, B. Braun, Melsungen, Germany). No significant changes in cardiovascular or respiratory parameters occurred during the operation. When spontaneous respiration and muscle tone were considered to be adequate, the endotracheal tube was carefully removed and transferred to the recovery unit. After 35 min, the patient was discharged to the ward.

The next morning, she complained of slight difficulty in swallowing solid foods but was able to drink water. On clinical examination, her tongue deviated to the right on protrusion and she was unable to move it to the left; there were no further detectable cranial nerve abnormalities. Magnetic resonance imaging of her brain did not demonstrate any evidence of an ischemic event or focal abnormality. A neurologist diagnosed an isolated paralysis of the right hypoglossal nerve. The neurologist recommended supportive treatment and did not prescribe any pharmacological therapy. Two weeks post surgery, the patient attended the neurology out-patient clinic; at this time, she had complete resolution of symptoms and had made a complete recovery.


  Discussion Top


Hypoglossal nerve palsy has been reported as a result of both idiopathic [8] and iatrogenic trauma. [9] It has been reported, both in isolation [10] and in conjunction with neuropraxia of the lingual nerve subsequent to diagnostic and therapeutic surgical procedures such as tonsillectomy, [11],[12],[13] direct laryngoscopy, [2],[14] posterior third of tongue operations, [15] and bronchoscopy. [3],[16] Pertinently, it has also been described subsequent to both laryngeal mask [5],[17],[18] and endotracheal anesthesia. [19] Non-iatrogenic traumatic injury to the hypoglossal nerve has been described in association with fractures of the occipital bone in relation to the hypoglossal foramen, [20] and in neck hyperextension, [21],[22],[23] infection with Epstein Barr virus, [24] vaccination against influenza virus, [25] carotid artery aneurysms, [26] hematomata, [27] intracranial tumors and their treatment by radiotherapy, [28] and in patients suffering from Horner's syndrome. [29] Infection of branchial cleft cysts resulting in compression of the hypoglossal nerve with subsequent nerve weakness has also been previously described. [6] Hypoglossal nerve palsy has been reported subsequent to dental extraction under both local [7] and general anesthesia. [6],[30] Lingual nerve injury, on one occasion in combination with hypoglossal nerve damage, has been reported as a result of compression from the blade of a laryngoscope at the root of the tongue. [31],[32],[33],[34],[35]

Possible mechanisms of injury in this case, therefore, include indirect trauma (from positioning/stretching of the neck) or direct trauma (laryngoscopy, bronchoscopy, or from continuous pressure of laryngeal mask airways). In this case, intubation was uneventful and the head was supported in a neutral position for the length of the operation with a donut-type pillow.

Thus, the injury must have been caused by some other mechanism, the nature of which can only be elucidated by considering the pathway of the hypoglossal nerve. It originates from the hypoglossal nerve nucleus in the medulla, leaves the cranium through the hypoglossal canal, and descends between the internal jugular vein and the internal carotid artery, deep to the posterior belly of digastric. The nerve then continues anterior and superior to the greater cornu of the hyoid bone and enters the floor of the mouth deep to the posterior margin of the myohyoid muscle, supplying motor innervation to both intrinsic and extrinsic lingual muscles. [36]

In this patient, we postulate that the right hypoglossal nerve was compressed between the endotracheal tube cuff and the hyoid bone, which was inflated with 30 cm H 2 O. Thus, extreme care should be taken to prevent nerve injuries and other complications during the use of the endotracheal tube.

Dysarthria and dysphagia as a result of hypoglossal nerve palsy tend to be distressing for the patient. The treatment of hypoglossal nerve palsy is supportive with fluid replacement. [37] In addition, empirical courses of systemic steroids and/or vitamin B12 have been used for treatment. [37] Hypoglossal nerve imaging is recommended, if there is any suspicion of a central cause or base of skull fracture. [38] Damage to the hypoglossal nerve is a rare complication of general anesthesia, which has been reported to be associated with procedures utilizing both laryngeal mask and endotracheal airways. Patients undergoing aesthetic surgery must be appropriately and adequately informed that postoperative aesthetic and functional deficits can occur due to anesthesia as well as surgery. [39],[40],[41],[42],[43]

 
  References Top

1.Michel O, Brusis T. Hypoglossal nerve paralysis following tonsillectomy. Laryngorhinootologie 1990;69:267-70.  Back to cited text no. 1
    
2.Agnoli A, Strauss P. Isolated paresis of hypoglossal nerve and combined paresis of hypoglossal nerve and lingual nerve following intubation and direct laryngoscopy. HNO (Berlin) 1970;18:237-9.  Back to cited text no. 2
    
3.Kaess H. Transitory hypoglossal paralysis following bronchoscopy. HNO (Berlin) 1955;16:115-6.  Back to cited text no. 3
    
4.Konrad RM, Lakomy J. Combined peripheral hypoglossal paralysis after intubation anesthesia. Anaesthesist 1960;9:206-8.  Back to cited text no. 4
    
5.Nagai K, Sakuramoto C, Goto F. Unilateral hypoglossal nerve paralysis following the use of the laryngeal mask airway. Anaesthesia 1994;49:603-4.  Back to cited text no. 5
    
6.Gatot A, Tovi F, Fliss DM, Yanai-Inbar I. Branchial cleft cyst manifesting as hypoglossal nerve palsy. Head Neck 1991;13:249-50.  Back to cited text no. 6
    
7.Stankiewicz JA, Pazevic JP. Hypoglossal nerve palsy after tooth extraction. J Oral Maxillofac Surg 1988;46:148-149.  Back to cited text no. 7
    
8.Sugama S, Matsunaga T, Ito F, Eto Y, Maekawa K. Transient, unilateral, isolated hypoglossal nerve palsy. Brain Dev 1992;14:122-3.  Back to cited text no. 8
    
9.Lee SS, Wang SJ, Fuh JL, Liu HC. Transient unilateral hypoglossal nerve palsy: A case report. Clin Neurol Neurosurg 1994;96:148-51.  Back to cited text no. 9
    
10.Baumgarten V, Jalinski W, Böhm S, Galle E. Hypoglossusparese nach septumkorrektur in intubationsnarkose. Der Anaesth 1997;46:34-7.  Back to cited text no. 10
    
11.Michel O, Brusis T. Hypoglossusparese nach Tonsillektomie. Laryngorhinootologie 1990;69:267-70.  Back to cited text no. 11
    
12.Boenninghaus HG, Denecke U. Hypoglossusparese nach Tonsillektomie? Laryng Rhinol Otol 1982;61:189-92.  Back to cited text no. 12
    
13.Guthrie D. Hypoglossal paralysis following tonsillectomy. J Laryng Otol 1926;41:662-3.  Back to cited text no. 13
    
14.Hinze F, Linke HO. Kombinierte Hypoglossus/Lingualis- Schädigung nach direkter Laryngoskopie. Akt Neurol 1976; 3:233-5.  Back to cited text no. 14
    
15.Condado MA, Mordis D, Santos J, Alonso-Vielba J, Miyar V. Hypoglossal nerve palsy after intubation and direct laryngoscopy. Acta Otorrinolaringol Esp 1994;45:477-9.  Back to cited text no. 15
    
16.Tomasi-Davenas C, Vighetto A, Confavreux C, Aimard G. Causes of paralysis of the hypoglossal nerve: Apropos of 32 cases. Presse Med 1990;19:864-8.  Back to cited text no. 16
    
17.Mullins RC, Drez D Jr, Cooper J. Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation with the patient in the beach-chair position: A case report. J Bone Joint Surg 1992;74:137-9.  Back to cited text no. 17
    
18.King C, Street MK. Twelfth cranial nerve paralysis following use of a laryngeal mask airway. Anaesthesia 1994;49:786-7.  Back to cited text no. 18
    
19.Bachmann G, Streppel M. Hypoglossusparese nach endonasaler Nasennebenhöhlenoperation in Intubationsnarkose. Laryngo- Rhino-Otol 1996;75:623-4.  Back to cited text no. 19
    
20.Castling B, Hicks K. Traumatic isolated unilateral hypoglossal nerve palsy-case report and review of the literature. Br J Oral Maxillofac Surg 1995;33:171-3.  Back to cited text no. 20
    
21.Dukes IK, Bannerjee SK. Hypoglossal nerve palsy following hyperextension neck injury. Injury 1993;24:133-4.  Back to cited text no. 21
    
22.Delamont RS, Boyle RS. Traumatic hypoglossal nerve palsy. Clin Exp Neurol 1989;26:239-41.  Back to cited text no. 22
    
23.Brennan RJ, Shirley JP, Compton JS. Bilateral hypoglossal nerve palsies following head injury. J Emerg Med 1993;11:167-8.  Back to cited text no. 23
    
24.Maddern BR, Werkhaven J, Wessel HB, Yunis E. Infectious mononucleosis with airway obstruction and multiple cranial nerve paresis. Otolaryngol Head and Neck Surg 1991;104: 529-32.  Back to cited text no. 24
    
25.Felix JK, Schwartz RH, Myers GJ. Isolated hypoglossal nerve paralysis following influenza vaccination. Am J Dis Child 1976;13:82-3.  Back to cited text no. 25
    
26.Vighetto A, Lisovoski F, Revol A, Trillet M, Almard G. Internal Carotid Artery dissection and ipsilateral hypoglossal nerve palsy. J Neurol Neurosurg Psychiatry 1990;53:530-1.  Back to cited text no. 26
    
27.Vito KJ, Wannamaker JR, Shields RW. Massive haematoma resulting in bilateral hypoglossal nerve paralysis. Otolaryngol Head Neck Surg 1995;113:491-4.  Back to cited text no. 27
    
28.Berger PS, Bataini SP. Radiation induced cranial nerve palsy. Cancer 1977:40:152-5.  Back to cited text no. 28
    
29.Saito H, Onuma T. Isolated hypoglossal nerve palsy and Horner's Syndrome with benign course. J Neurol Neurosurg Psychiatry 1991:54:282-3.  Back to cited text no. 29
    
30.Dearing J. Transient contralateral hypoglossal nerve palsy following third molar surgery under day-case general anaesthesia: A case report and review of the literature. Br J Oral Maxillofac Surg 1988;36:24-6.  Back to cited text no. 30
    
31.Jones BC. Lingual nerve injury: A complication of intubation. Br J Anaesth 1971;43:730.  Back to cited text no. 31
    
32.Loughman E. Lingual nerve injury following tracheal intubation. Anaesth Intensive Care 1983;11:171.  Back to cited text no. 32
    
33.Brimacombe J. Bilateral lingual nerve injury following tracheal intubation. Anaesth Intensive Care 1993;21:107-8.  Back to cited text no. 33
    
34.Teichner RL. Lingual nerve injury: A complication of orotracheal intubation. Br J Anaesth 1971;43:413-4.  Back to cited text no. 34
    
35.Mullins RC, Drez D Jr, Cooper J. Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation with the patient in the beach-chair position. J Bone Joint Surg Am 1992;74:137-9.  Back to cited text no. 35
    
36.Sinnatamby CS. Last's Anatomy-Regional and Applied. 11 th ed. London: Churchill-Livingstone; 2006.  Back to cited text no. 36
    
37.Rontal E, Rontal M. Lesions of the hypoglossal nerve-diagnosis, treatment and rehabilitation. Laryngoscope 1982;92:927-31.  Back to cited text no. 37
    
38.Thompson EO, Smoker WR. Hypoglossal nerve palsy: A segmental approach. Radiographics 1994;14:939-58.  Back to cited text no. 38
    
39.Al-Benna S, Steinstraesser L, Patani N. Free flap breast reconstruction consent forms should warn against the potential loss of the internal thoracic artery for coronary artery bypass grafting. Plast Reconstr Surg 2012;129:867e-8e.  Back to cited text no. 39
    
40.Al-Benna S, Al-Busaidi SS, Papadimitriou G, Schonauer F, Steinstrasser L. Abdominoplasty consent forms do not caution against the potential loss of a reconstructive option for breast reconstruction. Plast Reconstr Surg 2009;123:208e-9e.  Back to cited text no. 40
    
41.Al-Benna S. Caution in the use of the internal mammary artery in breast reconstruction. Plast Reconstr Surg 2007;120:348.  Back to cited text no. 41
    
42.Al-Benna S, Grob M, Mosahebi A, Dheansa BS, Pereira J. Caution note on the use of the internal mammary artery in breast reconstruction. Plast Reconstr Surg 2006;117:1653-4.  Back to cited text no. 42
    
43.Al-Benna S, Steinstraesser L, Patani N. Free flap breast reconstruction consent forms should warn against the potential loss of the internal thoracic artery for coronary artery bypass grafting. Plast Reconstr Surg 2012;129:867e-8e.  Back to cited text no. 43
    



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