Bilateral Hypoglossal Nerve Palsy After Cardiac Surgery

Hypoglossal nerve palsy is a rare perioperative complication caused by excessive stretching of the nerve. Symptoms include tongue deviation, dysarthria, hoarseness, and dysphagia. We present the case of a patient who experienced bilateral hypoglossal nerve palsy after cardiac surgery.

A 68-year-old male with hypertension, sleep apnea, and aortic insufficiency presented for aortic valve replacement. He was easily intubated using video laryngoscopy, and surgery proceeded without incident. He remained intubated overnight and was extubated on postoperative day 1. Initially, hoarseness and tongue edema were noted. Further evaluation revealed oropharyngeal dysphagia, silent aspiration, and inability to protrude the tongue, all consistent with a bilateral hypoglossal nerve injury. Because the patient was unable to swallow, a percutaneous endoscopic gastrostomy (PEG) tube was placed. Three months later, electromyography showed denervation of the tongue, suggestive of hypoglossal nerve injury, with good prognosis for recovery. The PEG tube was removed, and the patient was able to tolerate a soft diet. Eight months postoperatively, the patient was started on a normal diet, and at 18 months postoperatively, his speech and vocal fatigue had improved to approximately 90% of normal.

Although rare, hypoglossal nerve palsy is a perioperative complication that can have deleterious effects on patient well-being. Most cases are self-limited and resolve completely in 4 to 6 months; however, some patients experience more lasting effects. Anesthesiologists should take appropriate precautions when positioning a patient's head and neck during intubation and throughout the duration of surgery to help prevent hypoglossal nerve injury.