The tongue is on the floor of the mouth and cannot be extended

Introduction The tongue is located at the bottom of the mouth and cannot be extended. It is a clinical symptom of sublingual nerve injury. The hypoglossal nerve is the last pair of twelve pairs of cranial nerves. The damage is clinically common, often in the clinical manifestations of the medullary-related lesions and the posterior group of cranial nerves, sometimes in the form of a single lesion.

Cause

(1) Causes of the disease

Sublingual nerve injury is usually divided into two types, namely central hypoglossal nerve injury and peripheral hypoglossal nerve injury. The causes of the two types of damage are different.

Central sublingual nerve injury

(1) bilateral supraoptic supracondylar and one-sided suprarenal lingual tendon: can be caused by various causes, but most commonly in the sequela of factor or number of strokes, amyotrophic lateral sclerosis, diffuse brain Arteriosclerosis, multiple sclerosis, multiple cerebral infarction, syphilitic cerebral arteritis, medullary cavity, poliomyelitis, cerebrovascular disease, cerebral hemorrhage, cerebral embolism, intracranial tumor and craniocerebral injury.

(2) sublingual nuclear lesions: medullary vascular lesions, medullary cavity, progressive bulbar palsy; craniocerebral malformations such as skull base depression, congenital cerebellar tonsillar mandibular deformity; metastatic carcinoma infiltration at the base of the skull (such as nasopharyngeal carcinoma); lesions near the foramen magnum, such as tumors, fractures, meningitis, neck tumors.

2. Peripheral hypoglossal nerve injury

Mainly caused by sublingual nerve peripheral lesions, the most common causes are skull base fractures, aneurysms, tumors, submandibular injuries (gunshot wounds), cervical dislocation, occipital condyle fractures, anterior occipital perforostitis, and skull base or Unintentional or intentional (such as sublingual nerve and facial nerve anastomosis) injury during neck surgery, as well as primary sublingual tumor. The signs of peripheral hypoglossal nerve lesions were unilateral except for the lingual tendon, and the rest were similar to the damage of the hypoglossal nucleus.

an examination

Related inspection

EEG examination of hypoglossal nerve examination

1. Determine whether there is a hypoglossal nerve injury based on clinical manifestations, signs and complications can be diagnosed.

(1) Symptoms: Patients with simple hypoglossal nerve injury may have some sputum at the beginning, but no difficulty in swallowing. In severe cases, obvious speech and dysphagia appear. It is different in the simultaneous injury of the cranial nerves in the posterior group. It occurs first in fast meals or drinking water. When eating and drinking, speech and laughter cause coughing. Afterwards, the swallowing disorder is gradually worsened. It is also difficult to eat in a quiet and normal situation. . Dysphagia can cause food to stay in the cheeks due to facial paralysis. The paralysis of the tongue causes the food to move to the pharynx. The pharyngeal muscle paralysis makes the pharyngeal entrance not fully closed when swallowing, resulting in food, especially liquid from the nostrils. Conversely, the transportation of food in the pharynx and esophagus is also slower than normal. Finally, chewing is also difficult. The patient is unable to bite hard food and can only enter soft food and semi-liquid food. Due to difficulty in swallowing, food and a large amount of saliva are often retained in the mouth, causing frequent coughing, but coughing is often weak. In the late stage of the disease, the bilateral performance is shown, the mouth is open, the saliva is in the mouth, and speech and swallowing cannot be performed. It is necessary to rely on the nasogastric tube to maintain eating, and refractory aspiration pneumonia can occur. In the end, he often died of aspiration pneumonia, asphyxia and exhaustion. The earliest symptoms of medullary paralysis are often speech disorders, and speech is prone to fatigue, especially when it is necessary to improve the voice and aggravate the tone. Gradually speaking unclear, the first difficulty is the pharyngeal sound, then the tongue sound, and finally the throat sound, and gradually changed from this dysarthic barrier to eating.

(2) physical examination: firstly, unilateral or bilateral dyskinesia is found, followed by lingual muscle atrophy and fasciculation; the lips are often weak and unable to suffocate, that is, the use of fingers to close the nostrils often cannot be drumsticked. Drumsticks when the lips are pressed. It can be seen that the sacral palsy and the sucking reflex disappear. Tongue muscle atrophy with or without lingual muscle fibrillation, abnormal brain stem reflex.

2. Correctly distinguish between medullary palsy and simple peripheral hypoglossal nerve injury, and determine the location and type of sublingual nerve injury.

(1) medullary paralysis: the main difference between true medullary palsy and pseudobulbar paralysis: 1 no muscle atrophy, fasciculation and electrical displacement reaction, especially with or without lingual muscle atrophy, has important clinical significance for differential diagnosis. 2 The voluntary movement of the affected muscles is paralyzed, while the reflex movement dominated by the medulla oblongs. In particular, the facial muscles that are used for grinning and tooth movements are paralyzed, but there are still strong crying and strong laughing movements, and they can still swallow and still have nausea symptoms. Its main performance is dysphonia, and it is more obvious than dysphagia. Generally, it is not easy to swallow. If there is difficulty in swallowing, it is mainly because the food cannot be moved to the back of the mouth. 3 brain stem hyperthyroidism: Because pseudobulbar paralysis is an upper motor neuron paralysis, there can be a variety of brainstem reflexes (reflection center located in the brain stem) hyperthyroidism; brain stem reflex in the true medullary paralysis decreased or disappeared. Brain stem reflexes include:

A. Mandibular reflex: This reflex is hyperthyroidism, sometimes even a mandibular fissure or a closed jaw.

B. Oral sacral muscle reflex: When slamming the middle of the upper lip, the upper and lower lips protrude.

C. Looking up at the head: The patient's head is slightly bent forward, slamming its nose or middle part of the upper lip, causing a rapid contraction of the posterior neck muscles, and the head suddenly reclines (the reflex arc also includes the upper cervical spinal cord).

D. Corneal mandibular reflex: Lightly touch one side of the cornea with cotton, no contraction of the orbicularis muscle (cornea reflex), and the mandible is biased to the contralateral side (corneal mandibular reflex) due to contraction of the extrapteral muscle. The afferent and efferent corneal mandibular reflexes pass through the trigeminal nerve and do not appear at normal times, such as a positive suggestion of double cortical medullary bundle damage.

E. Palmar reflex: Stimulate the skin of the palm of the hand and cause contraction of the ipsilateral frontal muscle. These brainstems are reflected in the bilateral medullary medullary bundles above the pons.

(2) simple peripheral hypoglossal nerve injury: one side of the hypoglossal nerve paralysis, the tongue is biased to the disease side, the affected side of the tongue muscle atrophy, and often accompanied by muscle fiber fibrillation; swallowing and pronunciation generally no difficulty. When the bilateral sublingual nerves are paralyzed, complete tongue numbness occurs, and the tongue cannot move at the bottom of the mouth, resulting in difficulty in eating and swallowing, dysphonia, especially when the tongue is sounded.

Differential diagnosis

The differential diagnosis that the tongue is located at the bottom of the mouth and cannot be extended:

1. Identification of combined brain and brain injury in the posterior group:

(1) Combined damage of the glossopharyngeal nerve, vagus nerve, accessory nerve and hypoglossal nerve: the combined damage of the unilateral posterior group of cranial nerves. When these nerves are far away from the cranial cavity, their directions are more scattered, if they cause combined injury and extracranial The lesions have a wide range of lesions. In the clinical group, the extracranial tumor caused by the brain damage of the posterior group is generally more common in malignant tumors. At this time, there may be swelling of the neck lymph nodes, there may be a mass after the pharynx, and there is a manifestation of sympathetic nerve damage. Arterial angiography showed compression of the internal carotid artery before entering the internal carotid artery. In some cases, bone destruction was observed on the cervical spine.

(2) Individual paralysis of the glossopharyngeal nerve, vagus nerve, accessory nerve and hypoglossal nerve: After the brain group of the posterior group is far away from the cranial cavity, their orientation is relatively scattered. Therefore, if there is a lesion, the single brain nerve is often affected. 1 pharyngeal nerve paralysis: rare, only caused by the throat and post-lingual sensory disturbance, sometimes accompanied by parotid gland dysfunction. However, the symptoms of exercise are often not obvious because they are compensated by the vagus nerve. This condition can be seen in malignant tumors of the throat. The irritative damage of the glossopharyngeal nerve is characterized by glossopharyngeal neuralgia. 2 vagus nerve paralysis: to affect its recurrent laryngeal nerve. Common in thyroid cancer, accidental injury during thyroidectomy. One side of the sputum has paralysis of the ipsilateral vocal cord, the vocal cord position is in the right middle position, and sometimes the excessive adduction of the vocal cord on the healthy side can have no obvious pronunciation difficulties. In the bilateral recurrent laryngeal nerve, the vocal cord position is in the middle position, making the larynx narrow, hoarse, even aphasia, difficulty breathing, and sometimes throat. 3 paralysis: seen in cervical lymph node tuberculosis, neck malignant tumor, but most commonly in the neck lymph node biopsy when accidental injury.

The affected side trapezius, scapularis, and sternocleidomastoid muscle atrophy, and the scapula is displaced downward and forward. The upper limbs of the affected side are lifted, the weight is weak, and accompanied by the atrophy of the above muscles. When the paraspinal nerves are damaged on both sides, the head often leans back. Separate paraneoplastic paralysis is also rare and can be seen after trauma. It usually occurs in combination with other neurological diseases, which are caused by cervical spinal cord, occipital foramen and jugular foramen. One side of the sternocleidomastoid muscle spasm is seen in the spastic torticollis, caused by central nervous system lesions. 4 hypoglossal nerve paralysis: one side of the sublingual nerve paralysis, the tongue is biased to the side of the disease, the affected side of the tongue muscle atrophy, and often accompanied by muscle fiber fibrillation; swallowing and pronunciation generally no difficulty. When the bilateral hypoglossal nerves are paralyzed on both sides, complete tongue numbness occurs, and the tongue can not move at the bottom of the mouth, causing difficulty in eating and swallowing, and dysphonia, especially when the tongue is sounded. Separate hypoglossal nerve palsy is also rare, and can occur in deep neck injuries, spinal tuberculosis, medullary cavity, early malignant tumors of the base of the tongue, and rare sublingual neurofibromatosis.

2. Identification of myogenic medullary paralysis:

Myogenic medullary palsy is located in the medullary or cerebral nucleus, but in the medullary innervating muscle. Symptoms are similar to neuronal bulbar palsy, generally bilateral, no sensory disturbances and lingual muscle fibrillation, can be seen in myasthenia gravis, dermatomyositis, polymyositis and other diseases.

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