Hypoglossal nerve injury
Introduction
Introduction to sublingual nerve injury The hypoglossal nerve is the last pair of twelve pairs of cranial nerves. The damage is clinically common. It is often combined with the medullary-related lesions and the clinical manifestations of the posterior group of cranial nerves, sometimes in the form of a single lesion. Firearm injuries in the posterior mandibular space, submandibular area, oral or mandibular horizontal branches, fractures and surgical injuries can cause separate damage to the hypoglossal nerve. Contusions around the nerves, bleeding, and nerve sputum caused by local anesthesia are generally temporary, or only leave a slight residue. The rough contusion or rupture of the nerve is manifested as the lingual tendon of the affected side. When the tongue is extended, the tip of the tongue is skewed to the affected side and then shrinks. basic knowledge The proportion of illness: 0.002% Susceptible people: no special people Mode of infection: non-infectious Complications: aspiration pneumonia malnutrition
Cause
Cause of sublingual nerve injury
Sublingual nerve injury is usually divided into two types, namely central hypoglossal nerve injury and peripheral hypoglossal nerve injury, and the causes of the two types of injury are different.
Central sublingual nerve injury
(1) bilateral supraoptic supracondylar and one-sided suprarenal tendon: can be caused by various causes, but most commonly in the sequela of factor or several strokes, amyotrophic lateral sclerosis, diffuse brain Arteriosclerosis, multiple sclerosis, multiple cerebral infarction, syphilitic cerebral arteritis, medullary cavity, poliomyelitis, cerebrovascular disease, cerebral hemorrhage, cerebral embolism, intracranial tumor and craniocerebral injury.
(2) sublingual nuclear lesions: medullary vascular lesions, medullary cavity, progressive bulbar palsy; craniocerebral malformations such as skull base depression, congenital cerebellar tonsillar mandibular deformity; metastatic carcinoma infiltration at the base of the skull (such as nasopharyngeal carcinoma); lesions near the foramen magnum, such as tumors, fractures, meningitis, neck tumors.
2. Peripheral hypoglossal nerve injury
Mainly caused by sublingual nerve peripheral lesions, the most common causes are skull base fractures, aneurysms, tumors, submandibular injuries (gunshot wounds), cervical dislocation, occipital condyle fractures, anterior ostium periostitis and skull base or Unintentional or intentional (such as sublingual nerve and facial nerve anastomosis) injury during neck surgery, as well as primary sublingual nerve tumor, peripheral lingual nerve damage signs except for the lingual tendon is unilateral, The rest is basically similar to the damage of the sublingual nucleus.
Prevention
Sublingual nerve injury prevention
Currently there are no related content description. It is best to eat some light foods, so that patients can attract more vitamins. Take a proper rest and avoid strenuous exercise. But when the condition is stable, pay attention to proper exercise. Increase disease resistance, avoid cold, reduce the chance of infection, in the event of various infections, timely application of strong antibiotics and early control of infection.
Complication
Sublingual nerve injury complications Complications, aspiration pneumonia, malnutrition
Bilateral supraorbital spasm and bilateral hypoglossal nerve injury, often complicated by refractory aspiration pneumonia and eating difficulties, leading to asphyxia, malnutrition and systemic failure.
Symptom
Symptoms of hypoglossal nerves Common symptoms Mouth nausea and lips are often weak and can not be ventilated. Mirrors and tongues are unclear, dysarthria, hoarseness, vocal dysfunction, muscle atrophy, difficulty swallowing
1. Simple peripheral hypoglossal nerve injury unilateral hypoglossal nerve palsy when the disease side of the tendon tendon, when the tongue is extended, the tip of the tongue is biased to the affected side, the diseased side of the tongue muscle is atrophy; both sublingual nerve paralysis is completely paralyzed, tongue It can't be stretched out at the bottom of the mouth, and it has speech and difficulty in swallowing.
2. Sublingual nerve injury (bulbar palsy) with posterior group of cranial nerve injury. The posterior group of cranial nerves (lingual pharyngeal nerve, vagus nerve, accessory nerve, hypoglossal nerve) originate from the medulla oblongata, and the relationship is very close. Nerve, central sublingual nerve injury (nuclear and nuclear) and peripheral sublingual nerve of the skull base combined with posterior sublingual nerve group, often combined with the clinical manifestations of medullary related lesions, and The appearance of medullary paralysis is one of the most common and most important types of hypoglossal nerve injury. It is also an important manifestation of brain diseases after the medulla oblongata. The main classification and clinical manifestations of medullary paralysis are:
(1) Lower motor neuron medullary palsy: also known as medullary paralysis, which is caused by the nucleus of the medulla oblongata or its peripheral nerves. The hypoglossal nerve is combined with the glossopharyngeal nerve, the vagus nerve, and the subnucleus is damaged by nuclear and nuclear. The difference of sexual damage is more difficult. The symptoms and signs of the adjacent structure are also helpful for diagnosis. The ninth, X, and XI are located in the medulla oblongata, and the medulla is small in size, so the lesions are few and only damage the brain. The nucleus or its intracerebral fibers do not affect other structures. Therefore, the nuclear lesions of these cranial nerves are often accompanied by the sensory and dyskinesia of the contralateral limbs (cross-cutting sputum). The bilateral sublingual nucleus is very close, so the tongue The nuclear lesions of the inferior nerve are often bilateral, and the damage of the sublingual nucleus, in addition to the development of the lingual muscle paralysis, can also produce the ipsilateral orbicular palsy muscle paralysis; the sublingual nerve subnucleus lesion does not affect Oral sacral muscle function, because part of the fibers emitted by the lower nucleus participate in the facial nerve, innervation of the orbicularis oculi muscle, and the clinical syndrome of the posterior group with cranial nerve damage and its diagnosis: the clinical manifestation is the medulla Dominant pharynx, larynx, sputum, muscles of the tongue, atrophy, visible dysphagia, food out of the nostrils when eating, hoarse voice, difficult speech, unclear articulation, pharyngeal reflex disappear, nuclear damage fashion can have tongue Myofibrillar fibrillation.
(2) Upper motor neuron medullary palsy: also known as pseudobulbar palsy, which is caused by bilateral cortical brain stem damage. The combined damage of the glossopharyngeal nerve, vagus nerve, accessory nerve and hypoglossal nerve may have suprarenal lesions. The cortical medullary bundle between the cerebral cortex and the medulla is nuclear, and the nucleus is nuclear, the glossopharyngeal nerve, and the vagus nerve are bilateral, on one side. In the case of supranuclear lesions, the glossopharyngeal nerve and vagus nerve palsy are generally not caused, but in some cases, temporary dysarthria may occur in the acute phase, dysphagia, disappearing after a few days, so one side of the pharynx, laryngeal paralysis, lesions The position is definitely nuclear and subnuclear. The sternocleidomastoid muscle and the trapezius muscle of the accessory nerve are innervated by the cortex. Therefore, when the one side of the nucleus is damaged, the sternocleidomastoid and trapezius muscles remain normal. It can still contract without clinical attention. Although the hypoglossal nerve is dominated by the cerebral cortex, although it is basically bilateral, the genioglossus muscle that is responsible for the tongue extension is dominated by the contralateral cerebral cortex. When the lesion is present, the tongue can appear Contralateral to the lesion, and often accompanied by hemiplegia. Therefore, in the case of one side of the supralateral pyramidal lesion, in addition to the contralateral hemiplegia, mainly in the cranial nerve, only the hypoglossal nerve paralysis (the opposite side of the lesion is biased to the side of the lesion) and facial paralysis (the paraplegia of the contralateral side of the lesion) are caused. In the ninth to XII cranial nerve nucleus fibers (cortical medullary bundle) bilateral lesions, causing bilateral pharyngeal, larynx, tongue, facial and chewing movement disorders, this syndrome is called supranuclear medullary paralysis or Pseudobulbar paralysis, clinical manifestations of muscle spasm or incomplete paralysis dominated by the medulla oblongata, soft palate, throat, tongue muscle movement difficulties, swallowing, pronunciation, speech difficulties, due to upper motor neuron spasm, no muscle atrophy, pharyngeal reflex Exist, the mandibular reflex is enhanced, and there is strong crying and strong laughter.
Examine
Examination of hypoglossal nerve injury
1. X-ray and tomograms include tomographic X-rays of the skull, head and neck, cervical X-ray and jugular foramen.
(1) The jugular foramen is divided into two parts: the medial nerve part and the lateral part of the vein. The jugular foramen area expands the inner part of the nerve, while the jugular bulbar enlarges the outer part of the vein. In the skull X-ray, the abnormal enlargement and erosion of the jugular vein and the middle ear cavity of the skull base can be seen. The jugular vein can be enlarged by the X-ray film of the skull. The jugular foramen can be enlarged and the jugular foramen can be enlarged. The difference between 1 and 18 mm and 95% difference is less than 12 mm. The difference between the two sides is more than 20 mm, which means that the diagnosis is meaningful. The jugular vein area tumor can be considered. In order to fully reveal the size of the jugular foramen, a special position photograph is needed. For example, taking a skull base (a top position) or a tomographic film, a large tumor that develops toward the cerebellopontine angle is often difficult to distinguish from an acoustic neuroma, but if the jugular foramen can be seen in the X-ray film, the inner ear can be seen. The road is normal and can be distinguished.
(2) Bone destruction in the jugular foramen of the hypoglossal neuroma can invade the mastoid and inner ear canal along the rock bone.
(3) X-ray film of the skull in the cranial-cervical junction area can be seen in the bone hyperplasia or destruction of the occipital foramen, neck 1 and neck 2 or pedicle bone absorption, widening and intervertebral foramen enlargement.
(4) congenital diaphragmatic malformation: cerebellar tonsil malformation, congenital malformation in the flat skull base, occipital condyle fusion, cervical spine insufficiency and atlantoaxial dislocation can be diagnosed according to ordinary X-ray films, skull base depression Some information is also available on the X-ray film.
The X-ray film of the head and neck can be seen that the edge of the occipital foramen is inverted and the odontoid process of the vertebral body is moved upward. The measurement methods and values are as follows:
1 hard occipital large hole line (Chamberlain line): on the lateral slice of the skull, from the posterior edge of the hard palate to the posterior margin of the occipital foramen, if the odontoid is more than 3mm above the line, it is the skull base depression, if only It is suspicious if it is 3mm higher.
2 hard -occipital line: on the side of the skull, from the trailing edge of the hard palate to the lowest point of the occipital scale, if the odontoid is more than 9mm above the line, it is the skull base depression, if it is 7~9mm higher than this line It is suspicious.
3 hard -ring angle (Bull angle): the angle formed by the plane of the hard palate and the plane of the ring, such as the skull base depression above 13 °.
4 Second abdominal muscle groove line: the line between the two abdominal muscles in the anterior and posterior X-ray films of the skull. The distance from the dentate tip to the line is normally 10mm. If it is less than this value, it is the skull base depression. One method is the connection between the mastoid tips on both sides. If the dentate protrusion is 2 mm above the line, it is a skull base depression.
5 occipital macropores - slope angle: the angle formed between the anterior and posterior edge of the occipital foramen and the occipital slope, the normal angle is 120 ° ~ 136 °, the angle increases when the skull base is depressed.
The fusion of the occipital occipital sac is also called the occipital occipital occipital. The fusion of the atlas and the occipital bone can be all. It can also be limited to the anterior vertebral arch, partial fusion of the posterior vertebral arch or lateral mass, and may be accompanied by partial vertebrae defects. It can be rotated or tilted to one side.
The flat skull base refers to the abnormal enlargement of the skull base formed by the long axis of the sphenoid body and the occipital slope. The measurement of the skull base angle is measured by the central point of the sella (saddle nodule or posterior bed) and the nasal root and occipital bone. The angle formed by the leading edge connection is based on the normal angle of 110° to 145° and the average is about 130°. The method of measuring the skull base angle is to measure the saddle nodule and the nasal root and occipital bone on the lateral radiograph of the skull. The angle between the leading edge of the large hole, the normal value is 110 ° ~ 145 °, the small angle of the skull base has no important clinical significance, the skull base angle of more than 145 ° is a flat skull base.
(5) cervical X-ray films: including orthostatic, lateral, open, overextended and overflexed.
1 can show cervical segmental insufficiency (cervical fusion): the lack of cervical vertebrae and different degrees of fusion of the cervical vertebrae, often combined with skull base depression, neck ribs, spina bifida, scoliosis, congenital pterygopalatine and other malformations.
2 Dislocation of the atlas: On the lateral radiograph of the X-ray (especially the tomogram), the normal distance between the anterior arch of the atlas and the front of the odontoid process is <2.5 mm, and the child is <4.5 mm. Prevertebral dislocation, the distance between the odontoid and the block on both sides of the atlas should be equal and symmetrical, such as the asymmetry of the joints on both sides and the joint of the joint, or the dislocation of the joint on one side. Sometimes you need to take the flexion, the posterior position of the posterior position, you can find the presence or absence of subluxation or dislocation.
2. X-ray angiography
(1) spinal iodine oil angiography: suspected cranial-cervical junction tumor, the use of lumbar puncture injection of iodophenyl ester spinal iodized oil angiography is very helpful for diagnosis, can show the clear filling defect area of the occipital macropore area boundary .
(2) angiography of sublingual neuroma: the cerebral cerebral horn and the jugular foramen mass, transverse sinus, sigmoid sinus were oppressed.
(3) carotid artery and / or vertebral artery angiography: jugular bulbar tumor in the early arterial image, visible tumor abnormal staining and blood supply artery, the tumor is larger fashion can understand the side of the jugular vein blocked and pressure, neck Vertebral angiography of the venous hole area showed that the anterior inferior cerebellar artery elevation and the posterior inferior cerebellar artery were displaced backward and downward, and the tumor staining was also observed in the tumor site, which can be combined with some epithelioid tumors lacking vascular shadow. Or arachnoid cysts can be distinguished from meningioma and jugular bulbar tumors with deep tumor staining.
(4) Cerebellar tonsil malformation cerebral angiography and spinal iodine (oil) angiography: due to its limitations and certain risks, clinical use has been less used.
3.CT and MRI
CT scans of the cranial-cervical junction area, especially MRI, can diagnose the occipital macropore area and the upper cervical spinal cord, and can clearly show the adjacent medulla, cervical spinal cord and vertebral artery, posterior cerebellar artery. Relationship, CT scan of hypoglossal neuroma showed that the cerebellopontine angle occupied and the image was enhanced.
Diagnosis
Diagnosis and diagnosis of hypoglossal nerve injury
Diagnostic criteria
1. Determine whether there is hypoglossal nerve injury based on clinical manifestations, signs and complications can be diagnosed.
(1) Symptoms: Patients with simple hypoglossal nerve injury may have some sputum at the beginning, but there is no difficulty in swallowing. In severe cases, significant speech and dysphagia appear, accompanied by a difference in the simultaneous injury of the posterior cranial nerve. It first occurs in fast meals or drinking water, speaks during meals and drinking water, laughs and causes coughing, and the dysphagia gradually worsens in the future. It is also difficult to eat in a quiet and normal situation. Difficulty in swallowing can make food easy to stay due to facial paralysis. On the cheeks, the lingual paralysis of the tongue causes the food to move to the pharyngeal dysfunction. The lingual paralysis of the tongue makes the pharyngeal entrance not fully closed when swallowing, and the food, especially the liquid, flows back from the nostrils, and the food is transported in the pharynx and esophagus. It is also slower than normal. Finally, it is difficult to chew. The patient is unable to bite hard food. He can only enter soft food and semi-liquid food. Due to difficulty in swallowing, food and a large amount of saliva are often trapped in the mouth, causing frequent cough, but coughing. It is often weak, until the end of the course of the disease shows bilateral performance, mouth opening, saliva in the mouth, can not talk and swallow, must rely on nasal feeding tube Eating, can cause intractable aspiration pneumonia, and eventually die due to aspiration pneumonia, asphyxia and exhaustion. The earliest symptoms of medullary paralysis are often speech disorders, and speech is prone to fatigue, especially when it is necessary to improve the voice and aggravate the tone. Gradually speaking unclear, the first difficulty is the pharyngeal sound, then the tongue sound, and finally the throat sound, and gradually changed from this dysarthic barrier to eating.
(2) physical examination: firstly, unilateral or bilateral dyskinesia is found, followed by lingual muscle atrophy and fasciculation. The lips are often weak and unable to suffocate, that is, the use of fingers to close the nostrils often cannot be drumsticked. When the lips are pressed and closed, the sacral palsy is seen, the sucking reflex disappears, the tongue muscle atrophy is accompanied by or without the lingual muscle fibrillation, and the brain stem reflex is abnormal.
2. Correctly distinguish between medullary palsy and simple peripheral hypoglossal nerve injury, and determine the location and type of sublingual nerve injury.
(1) medullary paralysis: the main difference between true bulbar palsy and pseudobulbar paralysis:
1 no muscle atrophy, fasciculation and electrical displacement reaction, especially with or without atrophy of the tongue muscle, has important clinical significance for differential diagnosis.
2 The muscles of the affected muscles are paralyzed, and the reflex movements that are dominated by the medulla oblongata are present, especially for the facial muscles of the mouth, and the tooth movements of the tooth movements are paralyzed, but there is still strong crying, strong laughing action, still swallowing, still The main manifestation of nausea is dysphonia, which is more obvious than dysphagia. Generally, it is not easy to swallow. If you have difficulty swallowing, you can't move food to the back of the mouth.
3 brain stem reflex hyperthyroidism: Since pseudobulbar paralysis is an upper motor neuron paralysis, various brainstem reflexes (reflection center located in the brainstem) may occur; brain stem reflexes may decrease or disappear in true medullary paralysis. Brain stem reflexes include:
A. Mandibular reflex: This reflex is hyperthyroidism, sometimes even a mandibular fissure or a closed jaw.
B. Oral sacral muscle reflex: When slamming the middle of the upper lip, the upper and lower lips protrude.
C. Looking up at the head: The patient's head is slightly bent forward, slamming its nose or middle part of the upper lip, causing a rapid contraction of the posterior neck muscles, and the head suddenly reclines (the reflex arc also includes the upper cervical spinal cord).
D. Corneal mandibular reflex: Lightly touch one side of the cornea with cotton, no contraction of the orbicularis muscle (cornea reflex), and due to the contraction of the extra-pterygium, the mandible is deflected to the contralateral side (the corneal mandibular reflex), the infiltration of the corneal mandibular reflex and The efferent passage through the trigeminal nerve does not occur at normal time, such as a positive suggestion of double cortical medullary bundle damage.
E. Palmar reflex: Stimulate the skin of the palm of the hand and cause contraction of the ipsilateral frontal muscle. These brainstem reflexes in the bilateral cortical medullary bundle above the pons.
(2) simple peripheral hypoglossal nerve injury: one side of the hypoglossal nerve paralysis, the tongue is biased to the disease side, the affected side of the tongue muscle atrophy, and often accompanied by muscle fiber fibrillation; swallowing and pronunciation generally no difficulty, both sublingual nerves When paralyzed, complete tongue numbness occurs, and the tongue cannot move at the bottom of the mouth, resulting in difficulty in eating and swallowing, dysphonia, especially when the tongue is sounded.
Differential diagnosis
1. Identification of combined cerebral palsy and posterior cranial nerve injury
(1) combined damage of the glossopharyngeal nerve, vagus nerve, accessory nerve and hypoglossal nerve: combined damage of the unilateral posterior group of cranial nerves. When these nerves are far away from the cranial cavity, their directions are more dispersed, if it causes a combined injury and extracranial The lesions have a wide range of lesions. In the clinical group, extracranial tumors are caused by the damage of the posterior group. Generally, malignant tumors are common. At this time, there may be cervical lymphadenopathy, there may be a mass in the back of the throat, and there is sympathetic nerve damage. The performance of the ipsilateral internal carotid artery angiography showed that there was no compression of the internal carotid artery before entering the internal carotid artery hole. In some cases, bone destruction was observed on the cervical spine.
(2) Gloss of the glossopharyngeal nerve, vagus nerve, accessory nerve and hypoglossal nerve: After the cranial nerve of the posterior group is far away from the cranial cavity, their orientation is relatively scattered. Therefore, if there is a lesion, only a single cranial nerve is often affected.
1 pharyngeal nerve paralysis: rare, only causes sensory disturbances in the throat and the back of the tongue, sometimes accompanied by parotid gland dysfunction, but the motor symptoms are often not obvious, because the vagus nerve compensates, this situation can be seen in the throat In malignant tumors, the irritative damage of the glossopharyngeal nerve is characterized by glossopharyngeal neuralgia.
2 vagus nerve paralysis: to affect the recurrent laryngeal nerve, common in thyroid cancer, thyroidectomy surgery, unilateral sputum with ipsilateral vocal cord paralysis, vocal cord position in the right side of the median, sometimes by the side of the vocal cord excessive Adduction, there may be no obvious difficulty in pronunciation, the bilateral recurrent laryngeal nerve injury is the position of the vocal cords in the median position, the throat is narrow, hoarseness, even aphasia, difficulty breathing, and sometimes throat.
3 paralysis: seen in cervical lymph node tuberculosis, neck malignant tumor, but most commonly in the neck lymph node biopsy when accidental injury.
The trapezius muscle of the affected side, the scapularis muscle, the sternocleidomastoid muscle atrophy, the scapulae are displaced downward and forward, the upper limbs of the affected side are lifted, the weightlifting is weak, accompanied by the atrophy of the above muscles, and the bilateral accessory nerves are damaged. The head often leans back, and the para-neural paralysis is also rare. It can be seen after trauma, and it usually occurs in combination with other neurological diseases. It is caused by cervical spinal cord, occipital foramen and jugular foramen. Tendons are seen in the spastic torticollis, caused by central nervous system lesions.
4 hypoglossal nerve paralysis: one side of the hypoglossal nerve paralysis, the tongue is biased to the side of the disease, the affected side of the tongue muscle atrophy, and often accompanied by muscle fiber fibrillation; swallowing and pronunciation are generally more difficult, both sides of the sublingual nerve paralysis, resulting in complete The tongue is paralyzed, the tongue can't move at the bottom of the mouth, it is difficult to eat and swallow, the pronunciation is disordered, especially when the tongue is sounded, the sublingual nerve palsy is rare, and it can occur in the deep neck of the high neck, spinal cord. Tuberculosis, medullary cavity, early stage of malignant tumor at the base of the tongue, and rare sublingual neurofibromatosis.
2. Identification of myogenic medullary palsy The myogenic medullary palsy is not in the medulla or the medullary cranial nerve, but in the medullary innervating muscle, the symptoms are similar to neuronal medullary paralysis, usually bilateral Sex, no sensory disturbances and lingual muscle fibrillation, can be seen in myasthenia gravis, dermatomyositis, polymyositis and other diseases.
