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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 5  |  Page : 550-552

Unusual presentation of occipital condyle fracture: Contralateral hypoglossal nerve palsy


1 Department of Radiology, Sütçü Imam University School of Medicine, Kahramanmaras, Elazig, Turkey
2 Department of Neurology, Firat University School of Medicine, Elazig, Turkey
3 Department of Emergency Medicine, Firat University School of Medicine, Elazig, Turkey

Date of Web Publication3-Nov-2012

Correspondence Address:
Mehmet F Inci
Department of Radiology, Sütçü Imam University School of Medicine, Kahramanmaras, Elazig
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.103223

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How to cite this article:
Inci MF, Demir CF, Ozkan F, Yildiz M. Unusual presentation of occipital condyle fracture: Contralateral hypoglossal nerve palsy. Neurol India 2012;60:550-2

How to cite this URL:
Inci MF, Demir CF, Ozkan F, Yildiz M. Unusual presentation of occipital condyle fracture: Contralateral hypoglossal nerve palsy. Neurol India [serial online] 2012 [cited 2020 Jul 5];60:550-2. Available from: http://www.neurologyindia.com/text.asp?2012/60/5/550/103223


Sir,

Occipital condyle fracture (OCF) is a rare traumatic lesion. On account of a greater awareness and widespread use of computed tomographic (CT) scanning, OCF is being reported more frequently. [1],[2],[3],[4] OCFs can easily be missed because of their highly variable and usually nonspecific clinical features. [3],[5] However, long-term morbidity associated with pain and limited movements, serious neurological deficits, or even death may result from under-diagnosis or under-treatment of OCFs. [5] OCFs are traumatic, skull-based lesions, rather frequently, but not necessarily, associated with severe head, brain, and cervical spine trauma resulting from high-speed deceleration insults. [6] They are unusual clinical injuries because of the strategic anatomic location of the occipital condyles within the craniocervical junction (CCJ). [7] We report the case of a left occipital condyle fracture, with right hypoglossal nerve palsy.

A 40-year-old woman fell down on the right side of her face. She lost consciousness for less than two minutes at the site of injury, but by the time she visited the Emergency Department (ED), she was alert and fully oriented, with stable hemodynamics. On neurological examination, she was able to stick out her tongue with ease. She complained of headache and neck pain. The left temple was tender, but not the subaxial cervical spine. Plain cervical radiographs were considered to be unremarkable and she was discharged. Two weeks later, she noticed difficulty in moving food from the left side to the right side of her mouth. Although swallowing was not affected, she noticed slight changes in articulation. A neurological examination revealed dysphonia, right hemiatrophy of the tongue, with deviation of the tongue to the right side on protrusion [Figure 1], and a positive Lhermitte's sign. A computed tomography (CT) scan of the craniocervical junction revealed a left occipital condyle fracture [Figure 2]a and b. She was treated conservatively with a hard cervical spine collar for 12 weeks. At the follow-up examination at three months, she had relief from the neck pain. Her voice had improved and she was able to eat and drink well, although the tongue deviation improved only partially.
Figure 1: A photograph of the deviated tongue to the right side, indicating the presence of right hypoglossal nerve palsy

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Figure 2: Brain CT scan showing an occipital condyle fracture of the left side (arrows). (a) Axial, (b) Coronal image

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Cranial nerve palsies after head injury are not uncommon and are usually associated with skull or facial fractures. [8] Post-traumatic hypoglossal nerve palsy can be due to an insult to the nerve anywhere along its anatomical pathway. However, there are only a limited number of causes for isolated twelfth cranial nerve palsy following trauma to the skull base in the region of the occipital condyles. [9],[10] Cases of isolated hypoglossal nerve palsy can present early or late. A vast majority present early; the earliest to be diagnosed are bilateral palsies [5],[11],[12] because of the severity of the associated symptoms. Unilateral palsies tend to present with symptoms of hypoglossal nerve dysfunction within the first week of injury. [9],[11],[13] Cases that present late are divided into two groups: (1) The first group in which circumstances preclude an early diagnosis, such as, those patients who require lengthy intubations and the hypoglossal nerve palsy only becomes apparent following extubation [14] and (2) the second group, is made up of cases where there is a true late onset of the palsy.

In this patient, the most interesting feature was that the hypoglossal nerve palsy was late and appeared on the opposite side of the fracture. The possible explanation was that the opposite hypoglossal nerve might have been affected as a result of a traumatic contrecoup injury. The other very interesting feature was that there were no neurological deficits on the fracture side. To our knowledge this is probably the first such description in literature.

Diagnostic delay is not uncommon in patients with occipital condyle fractures. [15] Obviously the diagnosis of hypoglossal palsy had been missed during the patient's first visit to the ED. However, the fracture was identified shortly after her visit to the ED. Nevertheless, we learned from the present case that local pain originating from the fracture of the occipital condyle, a part of the craniocervical junction, and persistent neck pain in patients with a mild head injury, could indicate the presence of an occipital condyle fracture. For such patients, a high resolution cervical spine CT scan in addition to a brain CT scan, with optional three-dimensional reconstitution, may be the optimal imaging, to minimize a diagnostic delay. [3],[4] Although surgical approaches to the anterior skull base, both transoral and lateral, have been described, these procedures are dangerous, technically difficult, and often not successful in fusing the area. If no evidence of instability is present, these patients could be treated conservatively with a semi-constrained cervical orthosis. [5],[11] In conclusion, OCFs must be suspected and excluded by appropriate imaging in all patients sustaining craniocervical trauma, regardless of the clinical condition and physical examination findings.

 
 » References Top

1.Blacksin MF, Lee HJ. Frequency and significance of fractures of the upper cervical spine detected by CT in patients with severe neck trauma. AJR Am J Roentgenol 1995;165:1201-4.  Back to cited text no. 1
    
2.Bloom AI, Neeman Z, Slasky BS, Floman Y, Milgrom M, Rivkind A, et al. Fracture of the occipital condyles and associated craniocervical ligament injury: Ýncidence, CT imaging and implications. Clin Radiol 1997;52:198-202.  Back to cited text no. 2
    
3.Clayman DA, Sykes CH, Vines FS. Occipital condyle fractures: Clinical presentation and radiologic detection. AJNR Am J Neuroradiol 1994;15:1309-15.  Back to cited text no. 3
    
4.Link TM, Schuierer G, Hufendiek A, Horch C, Peters PE. Substantial head trauma: Value of routine CT examination of the cervicocranium. Radiology 1995;196:741-5.  Back to cited text no. 4
    
5.Young WF, Rosenwasser RH, Getch C, Jallo J. Diagnosis and management of occipital condyle fractures. Neurosurgery 1994;34:257-60; discussion 260-1.  Back to cited text no. 5
    
6.Goldstein SJ, Woodring JH, Young AB. Occipital condyle fracture associated with cervical spine injury. Surg Neurol 1982;17:350-2.  Back to cited text no. 6
    
7.Anderson PA, Montesano PX. Morphology and treatment of occipital condyle fractures. Spine (Phila Pa 1976) 1988;13:731-6.  Back to cited text no. 7
    
8.Saraiya PV, Aygun N. Temporal bone fractures. Emerg Radiol 2009;16:255-65.  Back to cited text no. 8
    
9.Castling B, Hicks K. Traumatic isolated unilateral hypoglossal nerve palsy*/case report and review of the literature. Br J Oral Maxillofac Surg 1995;33:171-3.  Back to cited text no. 9
    
10.Delamont RS, Boyle RS. Traumatic hypoglossal nerve palsy. Clin Exp Neurol 1989;26:239-41.  Back to cited text no. 10
    
11.Brennan RJ, Shirley JP, Compton JS. Bilateral hypoglossal nevre palsies following head injury. J Emerg Med 1993;11:167-8.  Back to cited text no. 11
    
12.Kacker A, Komisar A, Kakani RS, Reich E, Rothman L. Tongue paralysis following head trauma. J Laryngol Otol 1995;109:770-1.  Back to cited text no. 12
    
13.Dukes IK, Bannerjee SK. Hypoglossal nerve palsy following hyperextension neck injury. Injury 1993;24:133-4.  Back to cited text no. 13
    
14.Freixinet J, Lorenzo F, Hernandez Gallego J, Rodriguez De Castro F, Sole J. Bilateral traumatic hypoglossal nerve paralysis. Br J Oral Maxillofac Surg 1996;34:309-10.  Back to cited text no. 14
    
15.Chugh S, Kamian K, Depreitere B, Schwartz ML. Occipital condyle fracture with associated hypoglossal nerve injury. Can J Neurol Sci 2006;33:322-4.  Back to cited text no. 15
    


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