Iatrogenic Hypoglossal Nerve Palsy after Endoscopic Transnasal Transsphenoidal Pituitary Surgery

To the Editor,

Neurosurgical procedures are commonly associated with palsies of the cranial nerves that are closely involved. In this case report, we describe a case of isolated hypoglossal nerve neuropraxia following endoscopic transnasal transsphenoidal removal of a pituitary tumor. Informed written consent was obtained from the patient for the publication of this report.

A 65-year-old woman with a history of hypertension, controlled diabetes mellitus, and hypothyroidism was scheduled for resection of a nonfunctioning pituitary macroadenoma. Airway examination was unremarkable except for the presence of buck teeth and a modified Mallampati grade III. The rest of the preoperative clinical and laboratory evaluations were within normal limits. After standard anesthetic induction, the patient was intubated with a 7.5-mm cuffed polyvinylchloride endotracheal tube using videolaryngoscopy. It was fixed at the left angle of the mouth, followed by the insertion of a throat pack. The endotracheal tube cuff pressure was checked and kept at 24 mm Hg. The intraoperative course was uneventful, and the trachea was carefully extubated at the conclusion of surgery. She was then transferred to the neurointensive care unit for routine postoperative monitoring. On postoperative day (POD) 2, the patient noticed a left-sided tongue swelling associated with slight slurring of speech ([Fig. 1]). On protrusion, the tip of the tongue was deviated to the left side. A comprehensive neurological assessment, supported by imaging modalities including noncontrast computed tomography (NCCT) of the head and magnetic resonance imaging (MRI) of the brain, was completed. After systematically ruling out cerebrovascular insults and surgical complications, a final diagnosis of isolated hypoglossal nerve neuropraxia was established. She was commenced on intravenous methylprednisolone (1 g daily), following which her neurological symptoms gradually improved by POD 8. She was subsequently discharged in a stable condition.

Fig. 1 Image of the patient on postoperative day 2, showing tongue deviation to the left side, suggesting a left-sided hypoglossal nerve paresis.

Hypoglossal nerve palsy is a rare perioperative complication, with a reported incidence of 0.36 to 2.7% following direct laryngoscopy and tracheal intubation.[1] [2] Patients usually present with tongue deviation, dysarthria, dysphagia, and occasionally hoarseness. Several mechanisms have been proposed, including compression by the endotracheal tube, cuff or throat packs, stretch injury during laryngoscopy or neck extension, and ischemic neuropathy due to prolonged pressure.[3] Anatomically, the hypoglossal nerve's close relationship with the greater horn of the hyoid bone makes it especially vulnerable to compression during airway instrumentation. This case is of particular interest because most reported cases of perioperative hypoglossal nerve injury occur after difficult or forceful intubations, cervical spine surgery, or procedures requiring prolonged head positioning.[1] [2] [3] In contrast, our patient underwent an uneventful airway management and surgical course, yet developed symptoms on the second postoperative day. On literature search, we found a similar report of hypoglossal and lingual nerve neuropraxia following transsphenoidal hypophysectomy.[4] In another report, authors reported unilateral hypoglossal and vagus nerve paralysis following nasotracheal intubation in a patient undergoing repair of the mandibular fracture.[5] Tapia's syndrome is a rare airway manipulation complication caused by compression or stretching that leads to simultaneous hypoglossal and recurrent laryngeal nerve palsy.[6] However, we encountered isolated hypoglossal nerve palsy in our patient. In addition to the described risk factors, throat packing performed in cases of transsphenoidal hypophysectomy, for the prevention of trickling of pharyngeal blood into the trachea, can directly compress the nerve. This inadvertent compression of the nerve by the throat pack can be a plausible reason in our case. This delayed presentation highlights the importance of maintaining vigilance for cranial nerve injuries, even in apparently low-risk scenarios. The differential diagnosis of postoperative hypoglossal nerve palsy includes stroke, surgical trauma, and compressive hematoma, all of which must be excluded with clinical assessment and appropriate imaging. Prognosis is generally favorable, with recovery typically occurring within 2 to 12 weeks, although persistent deficits have occasionally been reported. Corticosteroids are frequently administered empirically to reduce perineural edema, and supportive measures such as speech and swallowing therapy may further aid recovery. Hypoglossal nerve neuropraxia, though rare, should be considered in patients presenting with postoperative tongue weakness and bulbar symptoms. From an anesthetic perspective, preventive measures include minimizing laryngoscope pressure, careful positioning of the endotracheal tube, avoiding excessive cuff inflation, and avoidance of tight oropharyngeal packing. Early recognition, exclusion of serious pathology, and supportive management remain the cornerstones of optimal recovery.

Conflict of Interest

None declared.

• References

• 1 Martin TJ, Smith MM, Smith BB. Hypoglossal nerve palsy after airway management for general anesthesia. Anesth Analg 1997; 84 (06) 1237-1242
• 2 Mohd Yusof J, Abu Dahari KAS, Kaur N, Azman M. Iatrogenic hypoglossal nerve palsy, a rare complication post suspension laryngoscopy. J Taibah Univ Med Sci 2021; 17 (04) 623-625
• 3 Węgiel A, Zielinska N, Głowacka M, Olewnik Ł. Hypoglossal nerve neuropathies: analysis of causes and anatomical background. Biomedicines 2024; 12 (04) 864
• 4 Evers KA, Eindhoven GB, Wierda JM. Transient nerve damage following intubation for trans-sphenoidal hypophysectomy. Can J Anaesth 1999; 46 (12) 1143-1145
• 5 Schmidt T, Philipsen BB, Manhoobi Y, Bruun Christiansen E. Vagus and hypoglossus palsy after nasotracheal intubation and throat packing. Ugeskr Laeger 2018; 180 (27) V11170844
• 6 Bakhshaee M, Bameshki AR, Foroughipour M, Zaringhalam MA. Unilateral recurrent laryngeal and hypoglossal nerve paralysis following rhinoplasty: a case report and review of the literature. Iran J Otorhinolaryngol 2014; 26 (74) 47-50

Publikationsverlauf

Artikel online veröffentlicht:
08. Januar 2026