Share this article on:

Hypoglossal Nerve Palsy After Airway Management for General Anesthesia: An Analysis of 69 Patients

Shah, Aalap C. MD*; Barnes, Christopher MD*; Spiekerman, Charles F. PhD; Bollag, Laurent A. MD*

doi: 10.1213/ANE.0000000000000495
Patient Safety: Review Article

Isolated hypoglossal nerve palsy (HNP), or neurapraxia, a rare postoperative complication after airway management, causes ipsilateral tongue deviation, dysarthria, and dysphagia. We reviewed the pathophysiological causes of hypoglossal nerve injury and discuss the associated clinical and procedural characteristics of affected patients. Furthermore, we identified procedural factors potentially affecting HNP recovery duration and propose several measures that may reduce the risk of HNP. While HNP can occur after a variety of surgeries, most cases in the literature were reported after orthopedic and otolaryngology operations, typically in males. The diagnosis is frequently missed by the anesthesia care team in the recovery room due to the delayed symptomatic onset and often requires neurology and otolaryngology evaluations to exclude serious etiologies. Signs and symptoms are self-limited, with resolution occurring within 2 months in 50% of patients, and 80% resolving within 4 months. Currently, there are no specific preventive or therapeutic recommendations. We found 69 cases of HNP after procedural airway management reported in the literature from 1926 to 2013.

From the *Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; and Institute for Translational Health Sciences, University of Washington, Seattle, Washington.

Accepted for publication August 31, 2014.

Funding: The Institute for Translational Health Sciences (ITHS) at University of Washington, Seattle, WA, provided statistical support for this project. ITHS is funded by Grant UL1TR000423 from the NIH National Center for Advancing Translational Sciences through the Clinical and Translational Sciences Awards Program (CTSA). For more information, please visit: http://www.iths.org/.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

This report was previously presented, in part, at the Academic Evening, May 6, 2014, University of Washington Department of Anesthesiology and Pain Medicine.

Address correspondence to Aalap C. Shah, MD, Department of Anesthesiology and Pain Medicine, University of Washington, 1959 N.E. Pacific St., Seattle, WA 98195. Address e-mail to shaha3@u.washington.edu.

Solitary hypoglossal nerve palsy (HNP) after airway management during general anesthesia is a rare complication that may occur after a variety of surgeries. By the end of the first postoperative day, patients typically present with ipsilateral tongue deviation and may exhibit speech and swallowing difficulties. HNP is often diagnosed postoperatively after a thorough workup to exclude stroke, hematoma, impending airway obstruction, and endotracheal trauma. Early consultation with otolaryngology and neurology can guide the diagnostic workup and help promptly identify these serious conditions. We believe that HNP is frequently missed by the anesthesia care team due to rapid hospital turnover of outpatients (i.e., same-day surgery) and delayed onset of symptoms characteristic of nerve palsy. Furthermore, residual anesthesia can hinder accurate neurological examinations and the characteristic delayed onset of symptoms. This review identifies the clinical signs and symptoms associated with HNP that help define its differential diagnosis. The current literature was reviewed for factors associated with the HNP diagnosis, including demographics, predisposing anatomical findings, and procedural and airway-related characteristics. Management options, expected clinical course, and factors affecting recovery duration as well as recommendations on preventive measures conclude the review.

Back to Top | Article Outline

METHODS

We searched the National Library of Medicine (PubMed) and MEDLINE databases for publications reporting on patients manifesting symptoms of hypoglossal nerve injury after procedural airway management from 1926 through 2013 (Appendix Figure 1). Reports of airway management techniques containing endotracheal tube (ETT), supraglottic devices such as the laryngeal mask airway (LMA), and the Combitube were included1–59 (Table 1). Cases in which hypoglossal nerve injury was likely due to the surgery itself, noted preoperatively or weeks after surgery, were excluded.60–63 We obtained demographic (age, gender), surgical (type of surgery and specific procedure, positioning, anesthetic duration), airway and anesthetic management details (laryngoscope blade type and size, ETT or LMA size, cuff pressure or volume, side of tube securement, use of nitrous oxide [N2O]), as well as neurapraxia course and time of onset. Recovery status was ascertained from each case report based on clinical observations of complete resolution (i.e., no further tongue deviation or symptoms), partial improvement (resolved tongue deviation with persistent symptoms), or no recovery (persistent tongue deviation and symptoms). The time until recovery or final clinic encounter (for patients without recovery) was recorded as the number of days after the procedure was completed. Information regarding neuromuscular blockade monitoring and recovery were inconsistently reported and thus excluded. Cases were included regardless of whether the above-stated characteristics were mentioned in each individual article. We retrieved HNP patient payment data from the American Society of Anesthesiologists Closed Claims database (1980–present), for which the data analysis methods have been previously reported.64

Appendix Fi

Appendix Fi

Table 1

Table 1

Back to Top | Article Outline

Statistical Analysis

Descriptive data are presented as mean with standard deviation and as percentage where appropriate. Patients were grouped based on the recovery status of their tongue deviation at time of follow-up (complete or partial recovery versus no recovery) and analyzed using a Kaplan-Meier survival technique. Using the statistical software R version 3.0.0 (R Foundation for Statistical Computing, Vienna, Austria), we conducted a log-rank test to compare the time-to-recovery curves between airway type, gender, diagnosis (isolated versus multiple cranial nerves), and treatment subgroups. Kaplan-Meier summary statistics provide the mean and median times to recovery, and the times to recovery for the 25th, 50th, and 75th patient quartiles. For patients with complete or partial recovery, a Pearson correlation coefficient was calculated to examine the relationship between age or operative duration and the reported follow-up interval.

Back to Top | Article Outline

RESULTS AND DISCUSSION

HNP: Airway-Related Mechanisms and Clinical Manifestations

Diagnosis

We identified 59 publications reporting 69 patients with HNP after procedural airway management in the literature through 2013 (Table 1). Diagnoses include isolated unilateral or bilateral HNP (n = 46), as well as combined hypoglossal-lingual nerve neurapraxia (n = 8) or hypoglossal-recurrent laryngeal neurapraxia (Tapia syndrome) (n = 15).

Clinical symptoms of HNP are nonspecific and include dysarthria (difficulty with articulation), dysphagia, and even dyspnea. On examination, unilateral deviation and elevation of the tongue ipsilateral to the injured side are pathognomonic for hypoglossal nerve injury and can be attributed to paralysis of the superior and inferior longitudinal muscles.65 Later physical examination findings revealed unilateral atrophy and genioglossus muscle fasciculation, signifying denervation–reinnervation injury.66,67

Radiographic imaging, including computed tomography and magnetic resonance imaging, can help exclude ischemic stroke and hemorrhage, and provides confirmation of both supraglottic airway trauma and tongue atrophy68,69 (Fig. 1). Extracranial Doppler and ultrasound studies can aid in the diagnosis of vascular dissection as a cause of HNP.11,16 In persistent cases of HNP, electromyographic and nerve conduction studies demonstrated damage to the neural elements, a pathology that is not typical of transient neurapraxia.6

Figure 1

Figure 1

Back to Top | Article Outline

Proposed HNP Mechanisms

Most reported cases of HNP after airway management suggest involvement of the extracranial section of the hypoglossal nerve, which exits the skull through the hypoglossal canal and descends caudally, along with the internal carotid artery and jugular vein. At the mandibular angle, it passes anteriorly deep to the posterior belly of the digastric muscle and reaches the submandibular region to enter the tongue.67 At the undersurface of the tongue, numerous branches pass upward to supply its intrinsic muscles.11,29,67 The 4 mechanisms of injury leading to HNP proposed in the literature are described in Figure 2. Tapia syndrome (unilateral recurrent laryngeal nerve and hypoglossal nerve paralysis), a subset of hypoglossal nerve injury, is attributed to compression injury to intersecting extracranial fibers of both the hypoglossal and vagus nerves at the base of the tongue.13,18,33,37,53

Figure 2

Figure 2

Back to Top | Article Outline

Patient Characteristics

Demographics

Table 1 and Figure 3A present the demographics of patients with HNP after procedural airway management. The majority of patients with isolated hypoglossal neurapraxia and Tapia syndrome are male. No differences in demographics are seen between cases of solitary hypoglossal injury and combined cranial nerve neurapraxia. Although reporting bias must be considered, morphometric and forensic studies of the hyoid bone demonstrate greater absolute dimensions in males.70,71 Ito et al. show that males have a longer length of the greater cornu (33.8 vs 29.8 mm) and larger hyoid volume (4.31 vs 2.95 cm3) and exhibit earlier ossification of the connection between the hyoid body and greater cornu. Given these anatomical differences, male patients are more likely to experience hypoglossal nerve compression at the hyoid cornu level.

Figure 3

Figure 3

There does not appear to be any specific age range associated with anecdotal reports of HNP. Harnett et al.72 found a higher incidence of minor airway complications in infants receiving an LMA, and multiple authors report postoperative HNP after LMA placement in adolescents.26,28,31 On the other hand, several authors report findings of a calcified stylohyoid ligament on radiographic imaging in elderly patients.17,30,38,50,59 In addition, Nagai et al.50 report a patient with rheumatoid arthritis, which is known to cause cervical (C1-C2) joint instability and bony ligamentous abnormalities. It is conceivable that these anatomical abnormalities could stretch the nerve at the angle of the mandible and cause HNP. Additionally, a short neck may predispose to nerve stretching during laryngoscopy.1,34

Back to Top | Article Outline

Laterality of HNP

An earlier report of HNP suggests that right-sided neurapraxias are more common, a finding that was originally attributed to the fact that most anesthesiologists are right-handed.8 Nevertheless, most operators would use their right hand to introduce the ETT into the trachea regardless of their handedness. Theoretically, pressure exerted from the laryngoscope blade could predispose to unilateral hypoglossal injury when sweeping the tongue from the right to left before intubation. However, multiple subsequent case reports have demonstrated the bilateral incidence of this neurapraxia. Moreover, in those reports that mention the tube being taped to the right side, there is an equal prevalence of neurapraxic symptoms on either side.7,15,16,30,52

Back to Top | Article Outline

Airway Management Characteristics

Intubation

Various case reports address airway management strategies including tube size, method of laryngoscopy, and blade type/size. All studies that provide laryngoscope information for orotracheal intubation report the use of a Macintosh blade, either size 3 or 4.2,7,8,15,27,30,45,47,48,52,54,57Figure 3B displays the reported airway management techniques that were used in patients who subsequently developed isolated or multiple cranial nerve neurapraxia. In their review, Dziewas and Ludemann11 show that HNP occurs after direct laryngoscopy and endotracheal intubation, LMA placement, and even after bronchoscopy. Zamora and Saha54 discuss HNP after Combitube placement. We found a greater number of patients with HNP after ETT placement. During orotracheal intubation, neck hyperextension stretches the hypoglossal nerve on the anterior aspect of the C1 transverse process by as much as 1.3 cm. In addition, direct pressure exerted by the Macintosh blade at the base of the tongue causes soft-tissue compression against the hyoid bone, possibly exacerbating the neurapraxia.1,3,12,15,26,30,46,49,73,74

Back to Top | Article Outline

Cuff Insufflation

Some authors suggest that ETT cuff pressure and LMA cuff insufflation may be associated with HNP, suggesting injury at the hyoid bone.21,29,31,32,37,45,53,54 Seven patients were reported to have received at least 30 minutes of N2O as part of their anesthetic management, which would predispose to diffusion of N2O into the cuff resulting in increased cuff pressures.12,19,29,32,36,45,50

Back to Top | Article Outline

ETT Cuff Pressure

In 9 patients, the ETT cuff pressure was maintained <20 cm H2O,2,7,10,12,16,22,27,52 while in 1 patient, the intracuff pressure was maintained at 30 cm H2O before surgical draping.10 Al-Benna described hypoglossal nerve injury in a patient with a maximum measured ETT cuff pressure of 34 cm H2O.45 While there is an anatomical disparity between the location of the inflated ETT cuff and the hypoglossal nerve, it is possible that ETT cuff–related damage may be explained by anatomical variants, such as a low-looping hypoglossal nerve or tongue innervation from the superior root of the ansa cervicalis.

Back to Top | Article Outline

LMA Cuff Volume

Eight cases with LMA use mention cuff insufflation volume in the range of 15 to 40 mL of air19,21,28,29,31,32,37,50 but did not mention goals for cuff pressure titration or intraoperative monitoring. Lumb and Wrigley75 demonstrated that LMA cuff pressures can increase by as much as 50% during brief periods of N2O anesthesia. Similarly, Trumpelmann and Cook32 reported on an overdistended LMA cuff after removal in a patient who had received N2O during anesthesia. Although the cuff insufflation volume varies considerably by LMA size and type, these unanticipated increases in cuff volume during longer cases can compress the hypoglossal nerve against the hyoid bone and cause HNP symptoms.

Back to Top | Article Outline

Surgical Characteristics

Operative Duration and Reintubation

Anesthetic duration and procedural duration in the reported cases vary (Table 1). Aside from the complications associated with prolonged intubation, no studies have evaluated its relative contribution specifically to HNP. On the other hand, repeated airway management attempts,5,29 intra- and postoperative reintubations,6,27,28,40,57 and prolonged ventilatory support27,35,40 increase the risk of iatrogenic trauma to the airway mucosa and underlying nerve structures. Three patients required reintubation due to respiratory failure.6,27,40 Two additional patients required LMA replacement28 or conversion to ETT34 for preoperative supraglottic airway device dislocation. All 5 patients with bilateral isolated HNP included 1 of these factors of complex airway management.6,27–29,35

Back to Top | Article Outline

Surgical Considerations

Surgical subspecialties associated with subsequent isolated HNP or combined neurapraxias are displayed in Figure 3C and listed in Appendix Table 1. However, HNP is frequently reported after otolaryngologic surgery. Dysarthria and ipsilateral tongue deviation are mentioned after rhinoplasty3,7,22,38,52 and sinus surgery,30,34 as well as after tonsillectomy1,4,49,51,58,59 and periglottic excisions.1,8,14 Throat pack placement during these surgeries can create pressure at the greater cornu of the hyoid,2 and their frequent use is linked to combined hypoglossal-recurrent (Tapia syndrome) and hypoglossal-lingual nerve palsies.12,22,52 Similarly, hematoma and other postsurgical upper airway swelling can result in delayed symptoms and dysarthria due to nerve compression.9,10,19,76 The otolaryngology team can detect tongue deviation in patients with subclinical HNP (i.e., without symptomatic dysarthria) through frequent routine neurologic examinations that are not consistently used in other specialties, contributing to an increased diagnostic rate and reporting bias.

Appendix

Appendix

Several authors report HNP after shoulder surgeries.10,11,16,19,21,23,25,50 Neck rotation and undetected head movement underneath the surgical drapes can lead to prolonged traction of the hypoglossal nerve throughout the case.5,16,37,46 During cardiac surgery, neck hyperextension and lateral flexion during sternotomy can compress the ETT cuff against the hypoglossal-recurrent laryngeal nerve, resulting in Tapia syndrome.13,42,43,57 Similarly, unanticipated position changes resulting in accidental extubation,36 LMA malposition,28 or change in airway management34 (e.g., switching from LMA to ETT) are associated with HNP.

Routine position changes after intubation, such as from semisupine (30 degrees) to the Fowler position (70 degrees), can cause pressure injury to the nerve throughout its superficial course anterior to the mandible.7,16,23,25,38,48,52 It is possible that even small position changes after airway securement, including during surgical preparation and draping, could predispose to hypoglossal nerve trauma. Conrardy et al.77 demonstrated that the ETT cuff can migrate from 3.8 to 6.4 cm with neck flexion or extension during intubation, potentially injuring the subglottis. This pattern of trauma would more likely result in recurrent laryngeal nerve injury and dysphonia as in Tapia syndrome.

Back to Top | Article Outline

Clinical Course and Management

Symptom Onset

HNP is typically diagnosed in a delayed fashion, with more than half of the reported cases diagnosed the day after surgery. Nevertheless, all but 3 patients exhibited tongue deviation by the end of the first postoperative day.10,12,33 Residual anesthesia may interfere with an early diagnosis of neurapraxia. Some patients after otolaryngology or general surgery do not exhibit signs or symptoms until their first postoperative day or later.11,15,22,24,32,52 Due to the delayed onset of symptoms, neurapraxia can potentially develop after discharge and remain undiagnosed.

Back to Top | Article Outline

Recovery

HNP appears to be largely self-limited; of 60 patients with a reported recovery status and follow-up interval, 26 patients (43.3%) achieved resolution within 6 weeks after surgery, and an additional 24 patients (40.0%) were symptom-free within 6 months of their operative date. The 25th percentile, median, and 75th percentile are 28, 60, and 120 days, respectively. Several authors reported complete resolution 1 year after diagnosis,6,9,12,14,20,22 while others found only partial recovery at variable follow-up periods.1,15,33,49 Five patients (8.3%) had persistent tongue deviation and dysarthria at follow-up intervals. The follow-up interval was not reported for 4 additional patients with persistent symptoms.1,3,4,13,55,56 Patients with partial recovery demonstrated similar demographics and operative durations when compared to fully recovered patients. More than half of the patients with partial recovery are associated with Tapia syndrome, and remaining neurologic deficits include persistent tongue deviation15 or vocal fold immobility. Patients with isolated or combined cranial nerve neurapraxias (recurrent laryngeal, lingual, or glossopharyngeal nerves) are reported to recover at similar follow-up intervals (P = 0.34). However, patients receiving an ETT exhibited later recovery postoperatively than patients in whom an LMA was used (P = 0.003) (Fig. 4). Indeed, the invasive technique (direct laryngoscopy), neck positioning, and cuff pressures associated with ETT placement can be more traumatic to the airway mucosa and require longer healing times. In addition, the reported follow-up period for patients exhibiting complete recovery is similar between genders (P = 0.09), and age is poorly correlated with the recovery follow-up interval (r = −0.090). There is a moderate positive correlation between operative duration and follow-up interval for patients with reported recovery status (r = 0.49).

Figure 4

Figure 4

A few shortcomings must be considered when interpreting these recovery estimates and analyses. The reported data are extracted retrospectively from individual publications and several authors instead of 1 study. In addition, patients may have recovered earlier than the reported follow-up period in each publication, and patients with longer recovery times may be disproportionately represented in this sample of case reports. On the other hand, the correlations between age or operative duration and time to recovery exclude patients with persistent HNP who may have needed longer recovery times past the last recorded encounter.

Back to Top | Article Outline

Possible Preventive Measures

Potentially preventive measures are deduced by the postulated mechanisms of injury, with an emphasis on the use of less invasive methods of airway management (LMA instead of ETT) (Appendix Table 2). Indeed, some authors postulate that routine cuff pressure monitoring could decrease the incidence of HNP after surgery.31,32 Although no neurapraxias were noted in their study of 200 patients receiving an LMA for ambulatory surgery, Seet et al.78 demonstrated a decrease in dysphagia and dysphonia at 1 hour and 1 day after surgery in patients whose LMA cuff pressures were limited to <60 cm H2O. Similarly, Ratnaraj et al.79 showed that maintaining ETT cuff pressure <20 cm H2O in patients undergoing cervical spine surgery significantly decreased the incidence of sore throat 24 hours after extubation. Intermittent pressure cuff lowering during long operations or pressure-relief valves can decrease the risk of nerve compression,29,75,80 and it follows that LMA or ETT cuff deflation during surgical positioning could also prevent iatrogenic injury to the hypoglossal and recurrent laryngeal nerves, respectively. Bohner et al.81 described the first use of a nerve stimulator for the successful identification and continuous monitoring of the hypoglossal nerve during an anatomically challenging carotid endarterectomy under general anesthesia.

Appendix

Appendix

Back to Top | Article Outline

Treatment

Supportive measures for HNP during initial evaluation in the immediate postoperative period may include supplemental oxygen and respiratory monitoring. Otolaryngology-guided rehabilitation measures include dietary modifications, logopedic treatment, and electrical stimulation therapy.82 Corticosteroid therapy has been shown to accelerate spontaneous recovery after Bell palsy,83 and multiple authors advocate a short course of high-dose steroids such as prednisone if airway edema is suspected.5,7,15,24,26,28,33,46,50,53 However, there are no controlled studies of the benefits of these treatments on neurapraxic patients after surgery. In our review, patients receiving corticosteroid treatment demonstrated complete or partial recovery at similar follow-up periods compared to nontreated patients.

Back to Top | Article Outline

Closed Claims Data

There are only 4 nonsurgical hypoglossal nerve injury claims in the Anesthesia Closed Claims database (1980–present: 10,093 claims). A difficult intubation with pharyngeal injury occurred in 1 claim, and an LMA was used in 2 claims. Three of the nonsurgical injuries were permanent, and 1 temporary. Only 1 of these 4 claims resulted in payment ($30,500 in 2012 inflation-adjusted dollars), a significantly smaller proportion when compared to other surgical anesthesia claims (58%, P = 0.012) (Domino KB, University of Washington Medical Center, personal communication, March 17, 2014).

Back to Top | Article Outline

CONCLUSIONS

Hypoglossal neurapraxia after airway extubation is repeatedly reported after various surgeries. Nerve compression and overstretching can occur during both unexpected and routine position changes, including neck hyperextension for laryngoscopy and surgical positioning. Male patients may be more vulnerable given their larger hyoid bone dimensions. Excessive pressure in the ETT or LMA cuff, perhaps exacerbated by the use of N2O, may produce injurious malposition of the airway devices. Early postoperative detection of tongue deviation and dysarthria, as well as consultation with neurology and otolaryngology consultants, can help exclude other serious etiologies including stroke and carotid dissection. Minimizing airway instrumentation during endotracheal intubation, along with consideration for intermittent pressure monitoring of the ETT cuff and position during long surgical procedures, may decrease the incidence of cranial nerve neurapraxias. While a short course of steroids may decrease swelling after airway removal, further studies need to be performed to ascertain their effect on the incidence of postoperative HNP and the recovery period for neurapraxic patients.

Back to Top | Article Outline

DISCLOSURES

Name: Aalap C. Shah, MD.

Contribution: This author helped prepare the manuscript, conduct the literature review, and choose and execute statistical tests.

Attestations: Aalap C. Shah approves the final manuscript, attests to the integrity of the analysis reported in the manuscript, and is the archival author.

Name: Christopher Barnes, MD.

Contribution: This author helped prepare original artwork, the figure layout, and manuscript preparation.

Attestations: Christopher Barnes approves the final manuscript, and attests to the integrity of the analysis reported in the manuscript.

Name: Charles F. Spiekerman, PhD.

Contribution: This author helped prepare the manuscript and choose and execute statistical tests.

Attestation: Charles F. Spiekerman approves the final manuscript, and attests to the integrity of the analysis reported in the manuscript.

Name: Laurent A. Bollag, MD.

Contribution: This author helped prepare the manuscript and choose and execute the statistical tests.

Attestation: Laurent A. Bollag approves the final manuscript, and attests to the integrity of the analysis reported in the manuscript.

This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).

Back to Top | Article Outline

ACKNOWLEDGMENTS

We thank Dr. Karen Domino for providing data from the ASA Closed Claims Database. We also thank Dr. Allan Goldman and Paul Constanthin for their critical review of our manuscript.

Back to Top | Article Outline

REFERENCES

1. Agnoli A, Strauss P. [Isolated paresis of hypoglossal nerve and combined paresis of hypoglossal nerve and lingual nerve following intubation and direct laryngoscopy]. HNO. 1970;18:237–9
2. Varedi P, Shirani G, Karimi A, Varedi P, Khiabani K, Bohluli B. Tapia syndrome after repairing a fractured zygomatic complex: a case report and review of the literature. J Oral Maxillofac Surg. 2013;71:1665–9
3. Baumgarten V, Jalinski W, Böhm S, Galle E. [Hypoglossal paralysis after septum correction with intubation anesthesia]. Anaesthesist. 1997;46:34–7
4. Boenninghaus HG, Denecke U. [Paralysis of the hypoglossal nerve after tonsillectomy? (author’s transl)]. Laryngol Rhinol Otol (Stuttg). 1982;61:189–92
5. Boisseau N, Rabarijaona H, Grimaud D, Raucoules-Aimé M. Tapia’s syndrome following shoulder surgery. Br J Anaesth. 2002;88:869–70
6. Bramer S, Koscielny S, Witte OW, Terborg C. [Bilateral hypoglossal nerve palsy following intubation]. Nervenarzt. 2006;77:204–7
7. Cinar SO, Seven H, Cinar U, Turgut S. Isolated bilateral paralysis of the hypoglossal and recurrent laryngeal nerves (Bilateral Tapia’s syndrome) after transoral intubation for general anesthesia. Acta Anaesthesiol Scand. 2005;49:98–9
8. Condado MA, Morais D, Santos J, Alonso-Vielba J, Miyar V. [Hypoglossal nerve paralysis after intubation and direct laryngoscopy]. Acta Otorrinolaringol Esp. 1994;45:477–9
9. Doğan M, Erdal O. [Isolated unilateral hypoglossal nerve paralysis: a report of two cases]. Kulak Burun Bogaz Ihtis Derg. 2003;11:125–8
10. Drouet A, Straboni JP, Gunepin FX. [Paralysis of the hypoglossal nerve after orotracheal intubation for general anesthesia]. Ann Fr Anesth Reanim. 1999;18:811–2
11. Dziewas R, Lüdemann P. Hypoglossal nerve palsy as complication of oral intubation, bronchoscopy and use of the laryngeal mask airway. Eur Neurol. 2002;47:239–43
12. Evers KA, Eindhoven GB, Wierda JM. Transient nerve damage following intubation for trans-sphenoidal hypophysectomy. Can J Anesth. 1999;46:1143–5
13. Gelmers HJ. Tapia’s syndrome after thoracotomy. Arch Otolaryngol. 1983;109:622–3
14. Hinze F, Linke HO. Kombinierte hypoglossus/lingualis- schädigung nach direkter laryngoskopie. Akt Neurol. 1976;3:233–5
15. Hong SJ, Lee JY. Isolated unilateral paralysis of the hypoglossal nerve after transoral intubation for general anesthesia. Dysphagia. 2009;24:354–6
16. Hung NK, Lee CH, Chan SM, Yeh CC, Cherng CH, Wong CS, Wu CT. Transient unilateral hypoglossal nerve palsy after orotracheal intubation for general anesthesia. Acta Anaesthesiol Taiwan. 2009;47:48–50
17. KAESS H. [Transitory hypoglossal paralysis following bronchoscopy] (German). HNO. 1955;5:115–6
18. Kashyap SA, Patterson AR, Loukota RA, Kelly G. Tapia’s syndrome after repair of a fractured mandible. Br J Oral Maxillofac Surg. 2010;48:53–4
19. King C, Street MK. Twelfth cranial nerve paralysis following use of a laryngeal mask airway. Anaesthesia. 1994;49:786–7
20. Konrad RM, Lakomy J. [Combined peripheral hypoglossal paralysis after intubation anesthesia]. Anaesthesist. 1960;9:206–8
21. Lo TS. Unilateral hypoglossal nerve palsy following the use of the laryngeal mask airway. Can J Neurol Sci. 2006;33:320–1
22. Lykoudis EG, Seretis K. Tapia’s syndrome: an unexpected but real complication of rhinoplasty: case report and literature review. Aesthetic Plast Surg. 2012;36:557–9
23. Mullins RC, Drez D Jr, Cooper J. Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation with the patient in the beach-chair position. A case report. J Bone Joint Surg Am. 1992;74:137–9
24. Nam SB, Chang CH, Lee YW, Lee JS, Yang HG, Jang DJ. Hypoglossal nerve injury following the use of the CobraPLA. Eur J Anaesthesiol. 2007;24:556–7
25. Rhee YG, Cho NS. Isolated unilateral hypoglossal nerve palsy after shoulder surgery in beach-chair position. J Shoulder Elbow Surg. 2008;17:e28–30
26. Rodríguez Ogando A, Miranda Herrero MC, Avellón Liaño H, Castro de Castro P, Vázquez López M. [Hypoglossal nerve palsy as a complication of the use of laryngeal mask airway]. An Pediatr (Barc). 2008;70:312
27. Rubio-Nazábal E, Marey-Lopez J, Lopez-Facal S, Alvarez-Perez P, Martinez-Figueroa A, Rey del Corral P. Isolated bilateral paralysis of the hypoglossal nerve after transoral intubation for general anesthesia. Anesthesiology. 2002;96:245–7
28. Sommer M, Schuldt M, Runge U, Gielen-Wijffels S, Marcus MA. Bilateral hypoglossal nerve injury following the use of the laryngeal mask without the use of nitrous oxide. Acta Anaesthesiol Scand. 2004;48:377–8
29. Stewart A, Lindsay WA. Bilateral hypoglossal nerve injury following the use of the laryngeal mask airway. Anaesthesia. 2002;57:264–5
30. Streppel M, Bachmann G, Stennert E. Hypoglossal nerve palsy as a complication of transoral intubation for general anesthesia. Anesthesiology. 1997;86:1007
31. Trujillo L, Anghelescu D, Bikhazi G. Unilateral hypoglossal nerve injury caused by a laryngeal mask airway in an infant. Paediatr Anaesth. 2011;21:708–9
32. Trümpelmann P, Cook T. Unilateral hypoglossal nerve injury following the use of a ProSeal laryngeal mask. Anaesthesia. 2005;60:101–2
33. Turan I, Yildirim ZK, Tan H. Bilateral Tapia syndrome secondary to oropharyngeal intubation. J Neurosurg Anesthesiol. 2012;24:78
34. Umapathy N, Eliathamby TG, Timms MS. Paralysis of the hypoglossal and pharyngeal branches of the vagus nerve after use of a LMA and ETT. Br J Anaesth. 2001;87:322
35. Uña E, Gandía F, Duque JL. Tongue paralysis after orotracheal intubation in a patient with primary mediastinal tumor: a case report. Cases J. 2009;2:9301
36. Venkatesh B, Walker D. Hypoglossal neuropraxia following endotracheal intubation. Anaesth Intensive Care. 1997;25:699–700
37. Wadełek J, Kolbusz J, Orlicz P, Staniaszek A. Tapia’s syndrome after arthroscopic shoulder stabilisation under general anaesthesia and LMA. Anaesthesiol Intensive Ther. 2012;44:31–4
38. Yelken K, Guven M, Kablan Y, Sarikaya B. Isolated unilateral hypoglossal nerve paralysis following open septoplasty. Br J Oral Maxillofac Surg. 2008;46:308–9
39. Pariente L, Camarena P, Koo M, Sabate A, Armengol J. Hypoglossal nerve neuropraxia after shoulder hemiarthroplasty. Rev Esp Anestesiol Reanim. 2014;61:277–80
40. Weissman O, Weissman O, Farber N, Berger E, Grabov Nardini G, Zilinsky I, Winkler E, Haik J. Hypoglossal nerve paralysis in a burn patient following mechanical ventilation. Ann Burns Fire Disasters. 2013;26:86–9
41. Park J, Ahn R, Weon Y, Yang D. Diagnosing Tapia syndrome using a videofluoroscopic swallowing study and electromyography after anterior cervical spine surgery. Am J Phys Med Rehabil. 2011;90:948–53
42. Nalladaru Z, Wessels A, DuPreez L. Tapia’s syndrome–a rare complication following cardiac surgery. Interact Cardiovasc Thorac Surg. 2012;14:131–2
43. Rotondo F, De Paulis S, Modoni A, Schiavello R. Peripheral Tapia’s syndrome after cardiac surgery. Eur J Anaesthesiol. 2010;27:575–6
44. Soyal OB, Turan S, Durak P, Erdemli O. Transient palsy of peripheral cranial nerves following open heart surgery. Singapore Med J. 2006;47:422–4
45. Al-Benna S. Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery. Saudi J Anaesth. 2013;7:341–3
46. Batjom E, Coron T, Mercier F, Benhamou D. [Hypoglossal nerve palsy, a rare complication of orotracheal intubation]. Ann Fr Anesth Reanim. 2006;25:541–2
47. Haslam B, Collins S. Unilateral hypoglossal neurapraxia following endotracheal intubation for total shoulder arthroplasty. AANA J. 2013;81:233–6
48. Lopes G, Denoel C, Desuter G, Docquier MA. Two cases of isolated unilateral paralysis of hypoglossal nerve after uncomplicated orotracheal intubation. Acta Anaesthesiol Belg. 2009;60:191–3
49. Michel O, Brusis T. [Hypoglossal nerve paralysis following tonsillectomy]. Laryngorhinootologie. 1990;69:267–70
50. Nagai K, Sakuramoto C, Goto F. Unilateral hypoglossal nerve paralysis following the use of the laryngeal mask airway. Anaesthesia. 1994;49:603–4
51. Smoker WRK. The hypoglossal nerve. Neuroimaging Clin N Am. 1993;3:193–206
52. Tesei F, Poveda LM, Strali W, Tosi L, Magnani G, Farneti G. Unilateral laryngeal and hypoglossal paralysis (Tapia’s syndrome) following rhinoplasty in general anaesthesia: case report and review of the literature. Acta Otorhinolaryngol Ital. 2006;26:219–21
53. Yavuzer R, Başterzi Y, Ozköse Z, Yücel Demir H, Yilmaz M, Ceylan A. Tapia’s syndrome following septorhinoplasty. Aesthetic Plast Surg. 2004;28:208–11
54. Zamora JE, Saha TK. Combitube rescue for Cesarean delivery followed by ninth and twelfth cranial nerve dysfunction. Can J Anesth. 2008;55:779–84
55. Donati F, Pfammatter JP, Mauderli M, Vassella F. [Neurological complications following tonsillectomy]. Schweiz Med Wochenschr. 1991;121:1612–7
56. Sengupta DK, Grevitt MP, Mehdian SM. Hypoglossal nerve injury as a complication of anterior surgery to the upper cervical spine. Eur Spine J. 1999;8:78–80
57. Sotiriou K, Balanika M, Anagnostopoulou S, Gomatos C, Karakitsos D, Saranteas T. Postoperative airway obstruction due to Tapia’s syndrome after coronary bypass grafting surgery. Eur J Anaesthesiol. 2007;24:378–9
58. Bumm P. [Peripheral hypoglossal paralysis (author’s transl)]. Laryngol Rhinol Otol (Stuttg). 1974;53:274–83
59. Guthrie D. Hypoglossal paralysis following tonsillectomy. J Laryng Otol. 1926;41:662–3
60. Gevorgyan A, Nedzelski JM. A late recognition of Tapia syndrome: a case report and literature review. Laryngoscope. 2013;123:2423–7
61. Johnson TM, Moore HJ. Cranial nerve X and XII paralysis (Tapia’s syndrome) after an interscalene brachial plexus block for a left shoulder Mumford procedure. Anesthesiology. 1999;90:311–2
62. Sharp CM, Borg HK, Kishore A, MacKenzie K. Hypoglossal nerve paralysis following tonsillectomy. J Laryngol Otol. 2002;116:389–91
63. Zöllner B, Herrmann IF. [Horner’s syndrome hypoglossal and laryngeal nerve paralyses as inflammatory late complications following tonsillectomy]. Monatsschr Ohrenheilkd Laryngorhinol. 1971;105:228–32
64. Cheney FW, Posner K, Caplan RA, Ward RJ. Standard of care and anesthesia liability. JAMA. 1989;261:1599–603
65. Ropper AH, Adams RD, Victor M, Samuels MA Adams and Victor’s Principles of Neurology. 2009 New York McGraw-Hill Medical
66. Gowers WR A Manual of Diseases of the Nervous System. 1970 Darien, CT Hafner Pub. Co.
67. Lin HC, Barkhaus PE. Cranial nerve XII: the hypoglossal nerve. Semin Neurol. 2009;29:45–52
68. Khoo SG, Ullah I, Wallis F, Fenton JE. Isolated hypoglossal nerve palsy: a harbinger of malignancy. J Laryngol Otol. 2007;121:803–5
69. Lindsay FW, Mullin D, Keefe MA. Subacute hypoglossal nerve paresis with internal carotid artery dissection. Laryngoscope. 2003;113:1530–3
70. Ito K, Ando S, Akiba N, Watanabe Y, Okuyama Y, Moriguchi H, Yoshikawa K, Takahashi T, Shimada M. Morphological study of the human hyoid bone with three-dimensional CT images – gender difference and age-related changes. Okajimas Folia Anat Jpn. 2012;89:83–92
71. Kindschuh SC, Dupras TL, Cowgill LW. Determination of sex from the hyoid bone. Am J Phys Anthropol. 2010;143:279–84
72. Harnett M, Kinirons B, Heffernan A, Motherway C, Casey W. Airway complications in infants: comparison of laryngeal mask airway and the facemask-oral airway. Can J Anesth. 2000;47:315–8
73. Stone M. Toward a model of three-dimensional tongue movement. J Phon. 1991;19:309–20
74. Rodrigues MA, Gillies D, Charters P. A biomechanical model of the upper airways for simulating laryngoscopy. Comput Methods Biomech Biomed Engin. 2001;4:127–48
75. Lumb AB, Wrigley MW. The effect of nitrous oxide on laryngeal mask cuff pressure. In vitro and in vivo studies. Anaesthesia. 1992;47:320–3
76. Committee on Complications of the Arthroscopy Association of North America. . Complications in arthroscopy: The knee and other joints. Arthroscopy. 1986;2:253–8
77. Conrardy PA, Goodman LR, Lainge F, Singer MM. Alteration of endotracheal tube position. Flexion and extension of the neck. Crit Care Med. 1976;4:7–12
78. Seet E, Yousaf F, Gupta S, Subramanyam R, Wong DT, Chung F. Use of manometry for laryngeal mask airway reduces postoperative pharyngolaryngeal adverse events: a prospective, randomized trial. Anesthesiology. 2010;112:652–7
79. Ratnaraj J, Todorov A, McHugh T, Cheng MA, Lauryssen C. Effects of decreasing endotracheal tube cuff pressures during neck retraction for anterior cervical spine surgery. J Neurosurg. 2002;97:176–9
80. Brimacombe J, Clarke G, Keller C. Lingual nerve injury associated with the ProSeal laryngeal mask airway: a case report and review of the literature. Br J Anaesth. 2005;95:420–3
81. Böhner H, Terörde N, Goretzki PE. Monitoring of the hypoglossal nerve during general anesthesia. J Vasc Surg. 2005;41:734
82. Laskawi R, Rohrbach S. [Impaired motor functions. Surgical and conservative procedures for restoring motor functions of the facial nerve, accessory nerve, hypoglossal nerve]. Laryngorhinootologie. 2005;84(Suppl 1):S142–55
83. Lagalla G, Logullo F, Di Bella P, Provinciali L, Ceravolo MG. Influence of early high-dose steroid treatment on Bell’s palsy evolution. Neurol Sci. 2002;23:107–12
© 2015 International Anesthesia Research Society