Sir, hypoglossal nerve palsy (HNP) is a rare condition affecting the head and neck region. Patients with HNP present with a wide range of symptoms, including difficulties with speech or swallowing, or changes in the tongue appearance. The clinical appearance of HNP is characteristic including lateral tongue atrophy with fasiculations and deviation of the tongue during protrusion.

We wish to highlight the importance of early recognition of this condition and the need for prompt secondary referral. We present four cases of HNP that were seen within a department of oral and maxillofacial surgery.

Case 1

A 71-year-old female was urgently referred by her dentist. She described a one-month history of difficulty protruding her tongue and manipulating food. On examination, she had an audible lisp, with right-sided tongue deviation and weakness in keeping with a right-sided HNP. Subsequent investigations identified a 3.5 cm mass involving the base of the clivus bone. After multidisciplinary input, histology confirmed a diagnosis of chordoma. The patient subsequently completed a course of radiotherapy.

Case 2

An 81-year-old male was urgently referred by his doctor. He complained of a lump in his neck and a painful tongue which was making swallowing difficult. On examination, a left HNP was present. Subsequent investigations led to a diagnosis of squamous cell carcinoma (SCC) of the left tongue base. The patient was treated with primary chemo-radiotherapy.

Case 3

A 53-year-old male was urgently referred by his doctor. He reported a vague history of difficulty swallowing over a 6-month period. On examination his tongue showed left-sided atrophy and deviation to the left on protrusion. He also had a firm fixed level 2 lymph node. Further investigations identified a moderately differentiated SCC of the tongue base. The patient underwent a left-sided selective neck dissection and primary chemo-radiotherapy to the tongue base.

Case 4

A 55-year-old female was referred by her dentist. She described a one-month history of difficulty moving her tongue and changes in its appearance. On examination her tongue was deviated to the right hand side with obvious atrophy. Subsequent investigations included nasoendoscopy, magnetic resonance imaging (MRI), computed tomography (CT) and PET scanning; results of which were unremarkable. The patient was reviewed periodically for six months and over this time her idiopathic transient HNP resolved.

Conclusion

Although HNP is rare, it should be regarded with suspicion. The majority of these patients initially present to primary care practitioners and hence it is vital that a good understanding of this condition is present. Thorough history and examination followed by urgent referral to a two-week-wait clinic is the expected standard. Literature supports a strong association between nerve palsies and malignancy. This small case series demonstrates the same.

We seek to highlight that awareness of abnormal tongue morphology or mobility is essential, and recognition of symptoms should alert suspicion and prompt rapid referrals to secondary care.