Hypoglossal Nerve

Palsy: A Segmental
Approach1
Elizabeth 0. Thompson, MB, BS2
Wendy R. K. 5’;noket MD

Hypoglossal nerve (cranial nerve XII) palsy is uncommon. Damage to

this nerve produces characteristic clinical manifestations, of which uni-

lateral atrophy of the tongue musculature is the most important. When

these features are recognized, the radiologist, armed with knowledge of
the normal anatomy of the area, can focus on each segment of the nerve
in search of a cause. The hypoglossal nerve is divided into five seg-
ments: the medullary, cisternal, skull base, nasopharyngeal/oropharyn-
geal carotid space, and sublingual segments. Because each segment is
usually affected by different disorders, localizing a lesion to a particular
segment allows the radiologist to narrow the differential diagnosis. In
this way, the most effIcient imaging strategy for evaluation of the symp-
toms can be developed. Both computed tomography and magnetic reso-
nance imaging are useful in assessing dysfunction of the hypoglossal
nerve; the choice depends on the status of the patient and the prefer-
ence of the radiologist.

. INTRODUCTION
Palsy of the hypoglossal nerve is relatively uncommon. l)aniage to the 1 2th cranial
nerve (hypoglossal nerve or cranial nerve XII) l)rodtlces characteristic clinical manifes-
tations. Nerve dysfunction may occur in isolation; more commonly, it may he associat-
ed with complex palsy of the lower nerve. ‘I’o design the most efficient imaging strate-
gy in the presence of such symptoms, one must I)e familiar with the anatomy of the hy-
poglossal nerve and the diseases that affect the nerve throughout its course from the
medulla oblongata to the tongue.

Index terms: Ncnt-s. cranial, 152.8’)’) Paral’,sis.

#{149} 2(2.82’)

RadioGraphics 1994; I A 939-958

I lr,)tA the l)caniicnr of Radiulugv. Medical (olkge t)f Virginia. M( \ Station. 1kx 6 I S. I 2(X) E Marshall St. Richnund. VA
23298. Prcsentt.-d as a scientific t.-xhihit at the 19’)2 RSNA scicittitIc asscinhly. RcccivcdJunc 25. 993: revision n.qticstt.-d
Scptcmh.r I itd rcccivcd April 28. 1994: acccl)tcd April 29 Addrtss reprint requests to W K KS.

2 .urrcnt address: l)cpannieiit ut Rdiulug . Ru al Prsitcc Altrud Iluspital. ( .aiup.-rdus U. Atistralia

. RSNA. 1994

939
 Dysfunction of the hypoglossal nerve may be
a consequence of supranuclear, nuclear, or
infranuclear disease (1). The nuclear and
infranuclear hypoglossal nerve can be divided I CISTERNAL
into five segments: the medullary, cisternal, SKULL BASE
skull base, nasopharyngeal/oropharyngeal Ca-
rotid space, and sublingual segments. Such ana-
tomie segmental analysis allows the radiologist
to develop a systematic approach to a case of
hypoglossal nerve palsy. Knowledge of the
most common pathologic conditions occurring
in each segment will permit the radiologist to
produce a more sharply focused differential di-
agnosis. The segmental approach to the anat-
omy and pathologic conditions of the hypoglos-
sal nerve is used to clarify the differential diag-
nosis.
This article reviews the normal anatomy of
the hypoglossal nerve by using a segmental ap-
proach, describes the clinical manifestations of BRANCHES TO
STRAP MUSCLES HYPOGLOSSI
hypoglossal nerve palsy, and demonstrates the
gamut of pathologic conditions affecting the hy-
poglossal nerve in each of its five segments. Figure 1. Sagittal view of the path of the hypoglos-
sal nerve in the suprahyoid neck. ICA = internal ca-
. NORMAL ANATOMY rotid artery.
The hypoglossal nerve exits the medulla oblon-
gata, extends through the skull base, and
traverses the suprahyoid neck before ramifying
to supply the tongue musculature (Fig 1). The
fibers of the hypoglossal nerve arise in the hy-
poglossal nuclei, which extend through the me-
dulla oblongata in a paramedian location (Fig
2). This is the medullary segment. The fibers
course anteriorly, lateral to the medial lemnis-
cus, to exit the medulla in the preolivary sul-
cus. The rootlets of the hypoglossal nerve lie
posterolateral to the vertebral artery within the
premedullary cistern; this is the cisternal seg-
ment of the nerve (Fig 3). The rootlets then
merge to form the hypoglossal nerve within the
HYPOGLOSSAL EMINENCE
hypoglossal (anterior condylar) canal of the oc-
Figure 2. View through the medulla oblongata
shows the hypoglossal nucleus, the nerve rootlets in
the premedullary cistern, and the hvpoglossal canal.
Iv = fourth ventricle.

940 #{149}
Scientific Exhibit Volume 14 Number 5
 Figure 3. (a) Axial view through the skull base.
Dots indicate the left hypoglossal nerve. (b) Axial
computed tomographic (CT) scan at the same
level shows the hypoglossal canals (arrowheads).
(c) Axial Ti-weighted magnetic resonance (MR)
image at the same level shows the hypoglossal
nerve roots (arrowheads) as they exit the medul-
la oblongata and pass through the premedullary
cistern toward the hypoglossal canal.

September 1994 Thompson and Smoker U RadioGraphics U 941

 Figure 4. (a) (oronal view at the level of the
hypoglossal canal. l)ot indicates the position of
the hypoglossal nerve. (b) Coronal CT scan at the
level of the hypoglossal canal, which is indicated
by a (lot. (c) Coronal Ti-weighted MR image at
the level of the hypoglossal canal. Dot indicates
the canal on the left.

cipital hone; this is the skull base segment ternal carotid artery and internal jugular
(Fig 4). from the hypoglossal
Emerging ca- ‘eiIi, superficial to the vagus nerve (Fig 5).
nal, the hypoglossal nerve enters the na- At the level of the angle of the mandible, the
sopharyngeal carotid space. At this point, nerve deviates from the path of these other
the nerve lies deep to the internal jugular lower cranial nerves. It loops anteriorly
vein, internal carotid artery, and glossopha- around the root of the occipital artery, lying
ryngeal and vagus nerves. As the nerve pass- inferior to the posterior belly of the digastric
Cs intcriorly, it comes to lie between the in- muscle, where it becomes superficial (Fig
6). At the level of the hyoid hone, the nerve
CO55C5 the lingual artery and curves anteri-
orly to run along the surface of the hyoglos-

942 #{149}
Scientific Exhibit Volume 14 Number 5
 Figures 5, 6. (5a) Line diagram at the level
of the nasophar)’ngeal carotid space. Arnw mdi-
cates the position of the hypoglossal nerve.
(5b, 5c) Axial contrast material-enhanced CT
(5b) and axial TI-weighted MR (5c) images at the
same level as in 5a. The hypoglossal nerve (ar-
rowheads) passes around the r(x)t of the occipital
artery, then lies anterior to the vessels of the ca-
rotid space. (6a) Line diagram through the carot-
id space. The posterior bellies of the digastric
(D), lateral pterygoid (1.7). and masseter (Al) mEls-
cks are identified. I)ot indicates the position of
the hypoglossal nerve. (6b) Coronal 1 I -weighted
MR image at the same level shows the left inter-
nal carotid artery (arrowheads). At this level, the
hypoglossal nerve lies deep to the posterior belly
of the digastric muscle.

Sa.

September 1994 Thompson and Smoker U RadioGraphics #{149}

943
 Figure 7. (a) Line diagram through the sublin-
goal space. I)ots indicate the position of the hy-
poglossal nerve. (b, c) Axial contrast-enhanced
CT (b) and axial Ti-weighted MR (c) images at
the same level. Coursing lateral to the hyoglossus
muscle (H), the hypoglossal nerve passes into the
sublingual space, lying between the paired
genioglossus muscles (G) and the mylohyoid
muscle (A!).

sus muscle, deep to the mylohyoid sling. This The hypoglossal nerve supplies motor inner-
segment of the nerve lies within the sublingual vation to the intrinsic and extrinsic muscles of
space (Figs 7, 8). As it passes anteriorly, the the tongue. The ansa hypoglossi contributes
nerve lies on the surface of the genioglossus motor innervation to the infrahyoid strap mus-
muscle before penetrating that muscle. des. The ansa hypoglossi is made up of fibers
from C-i that course through the carotid space
with the hypoglossal nerve.

944 . Scientific Exhibit Volume 14 Number 5

a. b.
Figure 8. (a) Line diagram through the tongue. Dot indicates the position of the hypoglossal nerve. (b) (;oro-
nal Ti-weighted MR image through the tongue. The hypoglossal nerve passes between the mylohyoid muscle
(A!) and the hyoglossus muscle (H).

S IMAGING THE HYPOGLOSSAL Supranuclear disease affecting the nerve results

NERVE in paralysis of the tongue contralateral to the
Both CT and MR imaging are used in assess- side of the lesion. Deviation of the tongue will
ment of dysfunction of the hypoglossal nerve. occur away from the side of the lesion. Fascic-
While MR imaging has the advantage of superi- ulation and atrophy of the tongue are absent.
or soft-tissue contrast, CT delineates cortical When disease affects the hypoglossal nerve at
bone with exquisite detail. At the skull base, the nuclear or infranuclear level, the clinical
the multiplanar capability of MR imaging can be signs and symptoms are ipsilateral. There is dc-
extremely useful. The high signal intensity of viation of the tongue toward the side of the le-
fat on Ti-weighted MR images allows bone mar- sion, with associated atrophy of the intrinsic
row replacement to be identified at an early and extrinsic tongue musculature and fascicu-
stage. Enhancement with gadolinium may mask lation of the tongue. This constellation may
this finding unless fat saturation techniques are lead to dysarthric speech.
employed. Below the skull base, use of either The infrahyoid strap muscles are innervated
contrast-enhanced CT or MR imaging has been by the ansa hypoglossi (C-i fibers that travel
recommended. The patient’s clinical status and with the hypoglossal nerve), not by the fibers
the radiologist’s preference for use of CT or MR of the hypoglossal nerve proper. The strap
imaging in the suprahyoid neck will influence muscles are unaffected by disease involving the
the choice. hypoglossal nerve if the lesion is proximal to
the level at which the nerve is joined by these
. CLINICAL EVALUATION OF C-I fibers (supranuclear, nuclear, and proximal
FUNCTION OF THE HYPOGLOSSAL infranuclear disease). Therefure, if function of
NERVE the strap muscles is affected, the disease can
The action of the hypoglossal nerve is entirely be specifically localized to the segments of the
motor. The balanced action of both genio- hypoglossal nerve distal to the point at which
glossus muscles is necessary to protrude the it is joined by the C-i fibers (ie, the carotid
tongue in the midline. Disorders affecting the space and sublingual segments).
function of the hypoglossal nerve lead to im-
balanced action of the genioglossus muscles,
causing tongue deviation toward the weak side.

September 1994 Thompson and Smoker #{149}

RadioGraphics S 945
 Figure 9. (a) Axial contrast-enhanced C’l scan shows niarked left-sided ttropliv of the tongue. There
is fatt) replacement of the tongue muscles as a consequence of longstanding denervation of the hypo-
glossal nerve. (Reprinted. with permission, from reference I .) A! = mylohvoid muscle. (b) Axial TI-
weighted MR iniage shows atrophy of the left hemitongue. Note the high signal intensity of the fatty
replacement of the tongue musculature on the left.

Common Pathol ogic Conditions Affe cting Each Segment of th e Hypoglossal Nerve

Medullarv Cisternil Skull Base Carotid Space Sublingual

Segment Segment Segment Segment Segment

(lioma Aneurysm Metastasis Nodal/extranodal Carcinoma

l)emyelination Basilar ectLsia Nasopharyngeal carcinoma Infection
Infarction Meningionia carcinoma Metastasis
Hemorrhage Rheumatoid Glomus tumor Dissection
arthritis Nerve sheath tumor

U RADIOLOGIC DIAGNOSIS OF PALSY ma, may simulate a nitss within the tongue.
OF CRANIAL NERVE XII Disease within the sublingual space may
t1nilaterLl atrophy of the tongue musculature is also masquerade LA5 atrophy of the tongue, par-
the most important radiologic feature of hypo- ticularly in the case of fatty lesions such as
glossal nerve palsy (Fig 9) (2-4). Once identi- lipomas and dermoid tumors. These lesions lie
fled, atrophy should pronipt a thorough assess- adjacent to the intrinsic tongue muscles, lead-
ment of the VJflOUS segments of the nerve as it ing to muscle displacement rather than fatty re-
travels from the medulla oblongata to the placement.
tongue. Iii sonic cases, changes may occur When a latient has OhVK)tIs palsy of the by-
within the tongue musculature in the setting of poglossal nerve or tongue atrophy is identified
acute paresis of the nerve. The muscles may un- at imaging, systematic evaluation of the seg-
dergo frttv change and, if associated with ede- merits of the hypoglossal nerve should be per-
formed. The most cOnImOIi diseases affecting
each segment are discussed below and are list-
eti in the Table.

946 U Scientific Exhibit Volume 14 Number 5

ha. lib.
Figures 10, 1 1. (10) Medullary glioma in a 45-year-1d man with multiple lower cranial nerve palsies.
Sagittal (a) and axial (b) ‘Il-weighted MR images show diffuse enlargement of the medulla. (11) Medul-
larv hemorrhage (Presumed cavernous angioma) in a 6-vear-.c.ld girl with sudden onset of headache and
with multiple lower cranial nerve palsies, including livpoglossal nerve a1sy. Axial TI-weighted (a) and
axial T2-weighted (b) MR images demonstrate blood breakdown products in the posterolateral aspect
of the niedulla oblongata on the right.

. Medullary Segment (7). Disease processes may involve adjacent

The hypoglossal nucleus niay he affected by a tracts or cranial nerve nuclei, leading to predict-
variety of disorders, including medullarv infirrc- able clinical manifestations. Disease often af-
non, hemorrhage, neoplasms, and multiple scle- fects nuclei of the other lower cranial nerves, in
fOSiS (Figs 10, 1 1 ). Neoplasms may he primary ac.ldition tO the hypoglossal nerve, resulting in a
(most Often glionia) or secondary. Less com- complex lower cranial neuropathy. Disease that
mon diseases may be involved, such as svringo- crosses the midline to involve both hypoglossal
bulbia (Fig I 2) (5), l)liOfli)elitiS, botulism, and nerve nuclei leads to bulbar palsy with corn-
amyotrophic lateral sclerosis (6). Isolated palsy
of the hypoglossal nerve has also been reported
in association with infectious niononucleosis

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RadioGrapbics U 947
 Figure 12. Hematomyelia and hematobulbia in a 17-year-old girl with known Arnold-Chiari malfor-
mation who experienced acute exacerbation of her symptoms and developed multiple lower cranial
nerve palsies. Sagittal Ti-weighted (a) and axial proton-density-weighted (b) MR images demonstrate
a syrinx cavity with extension into the medulla oblongata. Signal intensity on T2-weighted images was
consistent with extracellular methemoglohin.

Figure 13. Vertebrobasilar dolichoectasia in a 58-year-old man with a spontaneous intracranial hem-
orrhage. He had an unexplained left hypoglossal nerve palsy. Axial (a) and coronal (b) Ti-weighted
MR images demonstrate marked ectasia of the left vertebral and basilar arteries (arrows), leading to
considerable compression of the medulla oblongata (11 in a).

948 S Scientific Exhibit Volume 14 Number 5

 Figure 14. Thrombosed aneurysm of the posten-
or inferior cerebellar artery in a 45-year-old man
with multiple lower cranial nerve palsies. (a) Sag-
ittal Ti-weighted MR image shows the aneurysm
(A) displacing the medulla oblongata posteriorly.
(b, c) Axial Tl-weighted (b) and axial T2-weighted
(c) MR images demonstrate laminated thrombus
within the aneurysm (A).

. Cisternal Segment
Lying in the premedullary cistern, the rootlets
of the hypoglossal nerve may be affected by a
variety of pathologic processes. The vertebral
arteries lie close to the nerve rootlets, which
may be compressed by a vertebral aneurysm or
by dolichoectasia (Figs 13, 14) (8). Direct cx-
tension of neoplasms of the skull base, such as
C. chordoma of the clivus or meningioma of the
foramen magnum (Fig 1 5), may lead to nerve
dysfunction. Basal meningitis, especially tuber-
plete paralysis of the tongue. When the corti- culous meningitis, or subarachnoid hemor-
cospinal tract is involved, contralateral spastic
herniplegia develops in association with flaccid
paralysis of the hypoglossal nerve.

September 1994 Thompson and Smoker U RadioGraphics #{149}

949
 16a. 16b.
Figures 15, 16. (15) Meningioma in a 23-year-old patient with neurofibromatosis who developed multiple
cranial nerve palsies, including left hypoglossal nerve palsy. (a) Axial Ti-weighted contrast-enhanced MR image
demonstrates an enhancing, durally based lesion extending into the premedullary cistern on the left (arrows).
(b) Coronal Ti-weighted MR image reveals a right-sided acoustic neuroma (dot). (16) Longstanding rheuma-
toid arthritis in a 58-year-old woman who experienced gait disturbance and deficits of the lower cranial nerves.
(a) Sagittal Ti-weighted MR image shows extensive pannus at the atlantoaxial articulation, leading to compres-
sion of the medulla oblongata. Large dot indicates marrow within the odontoid process. Small dot indicates mar-
row of the anterior arch of C-i . (b) Coronal Ti-weighted MR image demonstrates the tip of the dens (dot) lying
in the premedullary cistern.

rhage with exudation and organization can the rootlets of the hypoglossal nerve (Fig 16)
compromise the nerve. An abnormally located (9). Displacement of the medulla oblongata
odontoid process, such as that associated with into or through the foranien magnum, as a con-
rheumatoid arthritis, may impinge on or stretch sequence of trauma or the Arnold-Chiari mal-
formation, may also lead to nerve dysfunction.

Primary tumors of the hypoglossal nerve (Fig

17), although uncommon, may also affect the
cisternal portion of the nerve (10).

950 U Scientific Exhibit Volume 14 Number 5

a. b.
Figure 17. Schwannoma of the hypoglossal nerve in a 30-year-1d man with right cranial nerve X, XI.
and XII palsies. Axial (a) and coronal (b) Ti-weighted MR images reveal a lohulated extr-aaxial tumor
( 7) displacing the medulla ohlongata (A!) and extending through the right hypoglossal canal ((lots in
a). ‘l’he niedulla ohlongata is compressed.

a. b.
Figure 18. Condylar fracture in a I 5-year-cild boy who was involved in a high-speed motor vehicle
LCCi(k1it. On eXLfl1iflItiOfl, his tongue was deviated to the left. Axial CT images through the skull has-
at (lifferent levels show a linear fracture (arrowheads) involving the left occipital condyle and the hy-
poglossal (IIill.

. Skull Base Segment struction. Metastatic tumors (Figs I 9. 20) most

Tumors, both benign and malignant, and trau- commonly derive from the lung. breast, or pros-
ma nuy damage the hypoglossal nerve as it tate, although pelvic malignancy can produce
traverses the skull base ( 1 1 ). Basal skull frac- isolated skull base metastasis as a result of
tures (Fig 18) may exteiid to involve the hypo- spread via the Batson plexus. Direct extension
glossal canal or the occipital eondyle, resulting of nasopharyngeal squamous cell carcinoma
in iii isolated oi complex palsy of the hypoglos-
sal ierve ( I 2). Tumors of the skull base may af-
feet the hypoglossal canal by expansion or de-

September 1994 Thompson and Smoker #{149}

RadioGrapbic.s U 951
 20a. 20b.
Figures 19, 20. (19) Metastatic carcinoma in a
71-year-old man with prostatic carcinoma who
experienced slurred speech and was unable to
move his tongue. (a) Axial Ti-weighted MR im-
age at the level of the hypoglossal canals shows
invasion of the clivus on the right side (dot), with
a soft-tissue mass disrupting the cortical bone.
The normal high signal intensity of bone marrow
is seen on the left side. (b) Axial Ti-weighted MR
image at the same level after administration of
contrast material shows only minimal enhance-
ment of the mass. (20) Metastatic follicular carci-
noma of the thyroid in an 83-year-old woman
with headache and left 1 2th cranial nerve palsy.
(a, b) Axial contrast-enhanced CT scans obtained
with soft-tissue (a) and bone (b) windows show
a soft-tissue mass destroying the left hypoglossal
canal (arrowheads). (c) Sagittal Ti-weighted MR
image demonstrates replacement of the clivus by
tumor (dot).

952 #{149}
Scientific Exhibit Volume 14 Number 5
a. b.
Figure 21. Nasopharyngeal carcinoma in a 61-year-old man with isolated hypoglossal nerve palsy. (a) Axial
contrast-enhanced CT scan reveals a large soft-tissue mass extending posteriorly from the nasopharynx, with cvi-
dence of hone destruction. (b) CT scan obtained with a bone window shows destruction of the left skull base
and hypoglossal canal (large arrowheads). The margins of the right hypoglossal canal are well visualized (small
arrowheads).

(Fig 2 1 ) may produce erosion of the skull base

and dysfunction of the hypoglossal nerve. Be-
nign tumors include nerve sheath tumors, gb-
mus jugulare tumors, and meningiomas. Primary
bone tumors such as cartilaginous tumors, giant
cell tumors, primary cholesteatomas, plasmacy-
tomas, and osteogenic sarcomas may also in-
volve the hypoglossal canal.
Skull base infections may lead to a variety of
cranial nerve palsies ( 1 3). Mucormycosis and
Pseudomonas infections are typically encoun-
tered in the immunocompromised and diabetic
populations. Tuberculous osteomyelitis has also
been reported to cause palsy of the hypoglossal
nerve. Primary diseases of bone, such as Paget
. ._
disease (Fig 22) and fibrous dysplasia, may also
Figure 22. Paget disease in a 69-yearuld woman affect the skull base, leading to cranial nerve
with multiple cranial nerve palsies. Axial CT scan palsy.
demonstrates diffuse changes associated with Paget
disease throughout the skull base, with involvement
of the hypoglossal canals (dots).

September 1994 Thompson and Smoker #{149}

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953
 24a. 24b.
r , , . .,f ‘::;i4

-5 _1, A
. V

‘ . -P

25a. 25b.

954 #{149}
Scientific Exhibit Volume 14 Number 5
 Figures 23-25. (23) Hodgkin disease in a 54-year-old man with a short history of difficulty in swallowing. On
examination, he had complex neuropathy of the lower cranial nerves, including the hypoglossal nerve. (a) Axi-
al Ti-weighted MR image shows a large mass (arrowheads) extending to involve the retropharyngeal, preverte-
bral, and carotid spaces. (b) Coronal Ti-weighted MR image reveals the superior extension of the tumor, with
fliaITOV replacement in the right occipital condyle. The normal marrow of the left occipital condyle is indicat-
ed by a dot. The carotid artery (arrowheads) is displaced laterally. (24) Glomus vagale in a 47-yearuld man with
a mass in the right neck and isolated right hypoglossal nerve palsy. (a) Axial contrast-enhanced CT scan shows
an enhancing, rounded soft-tissue mass in the oropharyngeal carotid space (arrows). (b) Coronal Ti-weighted
MR iniage shows numerous flow voids (arrowheads) within the lesion. (25) Vagal schwannoma in a 32-year-old
man with a 2-month history of hoarseness. On examination, he had paralysis of the left vocal cord and left hy-
poglossal nerve palsy. (a) Axial Ti-weighted MR image demonstrates a rounded tumor (7) in the left carotid
space, lateral to the hypoglossal canal. (b) Coronal Ti-weighted MR image shows the tumor (7) extending infe-
riorly iflto the nasopharyngeal carotid space.

. NopharyngeaUOropharyngeal
Carotid Space Segment
Hypogbossal nerve injury within the carotid
space may result from a range of disorders, ma-
lignant disease being the most common. This
includes both primary and nodal squamous cell
carcinoma, lymphoma (Fig 23), salivary gland
malignancies, and soft-tissue sarcomas. Extra-
nodal metastatic disease from distant primary
sites is also encountered, as are benign lesions
such as lipomas, paragangliomas (Fig 24), and
tumors of neural origin (Fig 25). Vascular dis-
ease in the neck can lead to dysfunction of the
hypoglossal nerve. The nerve lies close to the
vessels of the carotid space. As a result, ectasia
and aneurysms of the carotid artery, as well as
arterial dissection (Fig 26) and jugular thrombo-
Figure 26. Carotid dissection in a 43-year-old man sis, can compress the nerve and lead to palsy
with a history of minor neck trauma and recent on- (14- 16). Iatrogenic causes include jugular
set of tongue weakness. Axial T 1-weighted MR im- venous puncture and complicated carotid end-
age reveals high signal intensity surrounding the in- arterectomy (17). Rarely, transient hypogbossal
ternal carotid arterv on the left (arrowheads), with nerve palsy may complicate a traumatic dcliv-
diminution of the vessel lumen. T2-weighted images
cry (18). Other abnormalities affecting the hy-
( not shown) Ll5() demonstrated high signal intensity
in the vessel wall, consistent with extracellular
methemoglobin. (Courtesy of \X”illiam Kelly, MI),
I)avid (;rtnt LISAF Medical Center, Travis Air Force
Base, (:alif.)

September 1994 Thompson and Smoker #{149}

RadioGraphics #{149}
955
 a.
Figure 27. Mycobacterium avium-intracellulare infection in a 32-year-old man with positive test results for
human immunodeficiency virus who experienced right-sided swelling of the neck. He was emaciated and had a
right hypoglossal nerve palsy. (a) Axial contrast-enhanced CT scan shows an irregularly enhancing mass in the
oropharynx on the right side, extending to involve the carotid space. (b) Axial contrast-enhanced CT scan at a
lower level shows marked splaying of the vessels of the carotid space (arrowheads). Note the absence of suhcu-
taneous fat and the paucity of fat delineating the fascial spaces.

a. b.
Figure 28. Infection in a 25-year-old woman with
sepsis after a tonsillectomy. She developed multiple
lower cranial nerve palsies on the right side, fol-
lowed by left hemiparesis. (a) Axial Ti-weighted MR
image demonstrates infection involving the right
prevertebral, retropharyngeal, and nasopharyngeal
carotid spaces. (b) Contrast-enhanced Ti-weighted
MR image at a higher level shows signal intensity
typical of fluid within an abscess cavity (A). Enhance-
ment of the carotid arterial wall (arrowheads) and
marked luminal narrowing are noted. (c) Gradient-
echo MR image demonstrates absent flow in the yes-
sels of the carotid space on the right side (compare
the normal flow voids Earrowsi in the vessels on the
left side).

C.

956 U Scientific Exhibit Volume 14 Number 5

a. b.
Figure 30. Infrction of the submandibular and sublingual spaces in an 18-year-old woman with
sepsis and diminished tongue motion 5 days after extraction of the right mandibular third molar.
(a) Axial contrast-enhanced CT scan shows extensive soft-tissue swelling and gas within tissue planes.
(b) Axial contrast-enhanced CT scan at a slightly more inferior level shows dilatation of the subman-
dibular duct (arrows).

poglossal nerve within the carotid space in-

elude stab or gunshot wounds to the neck,
head or neck radiation therapy, and infections
originating from surrounding fascial spaces that
may spread to involve this space (Figs 27, 28)
(19).

. Sublingual Segment
Malignant tumors are the most common cause
of hypogbossal nerve paralysis in this region. Lo-
cally invasive squamous cell carcinoma is most
often seen (Fig 29), arising from the base or the
oral portion of the tongue. Salivary gland tu-
mors occur less commonly but may also lead to
rr;
palsy of the 1 2th cranial nerve. Odontogenic ab-
scesses involving the sublingual space may also
affect the distal portions of the nerve (Fig 30).
i1 -.
Temporary palsy of the hypoglossal nerve after
Figure 29. Carcinoma of the tongue in a 62-year- extraction of the third molar and after tonsillec-
old man who was found to have a tongue mass by
torny has been reported (20).
his dentist. Axial contrast-enhanced CT scan shows a
large soft-tissue mass (arrowheads). The mass shows
some peripheral enhancement and crosses the mid-
line.

September 1994 Thompson and Smoker #{149}

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957
 . CONCLUSION )ttl10l0giC correlation an(l rcvicv. AJNR 1986;
An uncommon cranial nerve palsy, hypoglossal 7.61-72.
nerve paralysis has characteristic clinical mani- 9. Macedo l’F. Ii. I leap S\X/, et al. Bilateral
liypoglossal l’1Y due to vertical
nerve subluxa-
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958 U Scientific Exhibit Volume 14 Number 5