Hypoglossal nerve palsy secondary to cervical spondylosis mimicking angio-oedema

A man in his 50s, with a history of cervical spondylosis, presented with acute right-sided tongue swelling, dysarthria and dysphagia. Although tongue deviation was present, unilateral tongue oedema led to initial suspicion of angio-oedema and malignancy; however, blood tests and tongue MRI did not lead to a definitive diagnosis. Tranexamic acid was prescribed for presumed angio-oedema; however, at follow-up, rightward tongue deviation persisted without any other neurological deficits. Localised tenderness was noted over the right occipital area, corresponding to the atlanto-occipital joint. Imaging revealed an osteophyte compressing the outlet of the right hypoglossal canal with joint fluid, raising suspicion of hypoglossal nerve palsy due to cervical spondylosis with possible involvement of calcium pyrophosphate deposition disease although this was not confirmed. This case highlights the importance of considering neurogenic causes of unilateral tongue swelling and recognising cervical spondylosis as a cause.