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Recognition of Prodromal Hypoglossal Nerve Palsy Presenting with Neck Pain as Primary Complaint: Findings from a Rare Case Report in Direct Access Physiotherapy during the COVID-19 Pandemic

PainSci » bibliography » Mourad et al 2023
Tags: diagnosis, neat, case

One page on PainSci cites Mourad 2023: Science round-up: six painful science stories from 2023

PainSci notes on Mourad 2023:

This is case report of a crazy rare cyst in the neck choking out the hypoglossal nerve, causing mainly neck and occipital pain, but also some tongue atrophy and clumsiness, and — word of the day for me — “sialorrhea,” which is better known as hypersalivation.

This was a very tough diagnosis, but made quickly despite the challenges.

A 75-year-old man had pain in his neck and the back of his skull. “Although difficult to observe” because of face masks, his speech was unclear and he was salivating excessively … and those were the clues that led to the diagnosis of hypoglossal nerve palsy.

The tongue is controlled by the hypoglossal nerve (one of twelve big cranial nerves that emerge from the base of the brain, covering an incredible variety of neurological jobs). This kind of palsy is extremely rare and mostly interferes with the tongue, but — fascinating to me as a pain guy — it can also just cause neck and head pain.

A fine example of a weird cause of a very common symptom.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

Neck pain (NP) is the second most common musculoskeletal disorder. Spinal cysts (SCs) are cystic dilatations of the synovial sheaths in joints and tendons. SCs are extremely rare in the cervical spine. Typically, patients are unaware of having an SC due to its asymptomatic nature; however, when cervical SC extends, its volume could compress the surrounding structures, such as the hypoglossal nerve. Isolated hypoglossal nerve palsy (HNP) is very rare and typically presents with unilateral atrophy of the musculature of the tongue and contralateral tongue deviation. Often, patients with HNP also report occipital/neck pain. A 75-year-old man with occipital/neck pain as a primary complaint. Although difficult to observe because of the filtering facepiece two mask, difficulties in articulation and sialorrhea during the interview were noticed. These latter were cues to consider CN examination that revealed CN XII palsy. This prompted a referral for further examination that revealed an SC compressing the right hypoglossal canal. The patient was not considered a surgical candidate and was managed conservatively. This case report outlines the relevant findings relating to the triage of a rare isolated hypoglossal nerve palsy from the physiotherapist's perspective within a complex setting because of the COVID-19 pandemic. Although referred with a diagnosis of cervical radiculopathy, our case highlights that skilled physiotherapists may play a fundamental role in both the recognition and, when applicable, subsequent novel management of a non-musculoskeletal presentation.

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