Cranial nerve XII: the hypoglossal nerve

Tongue reflex for speech posture control

Although there is no doubt from an empirical viewpoint that reflex mechanisms can contribute to tongue motor control in humans, there is limited neurophysiological evidence to support this idea. Previous results failing to observe any tonic stretch reflex in the tongue had reduced the likelihood of a reflex contribution in tongue motor control. The current study presents experimental evidence of a human tongue reflex in response to a sudden stretch while holding a posture for speech. The latency was relatively long (50 ms), which is possibly mediated through cortical-arc. The activation peak in a speech task was greater than in a non-speech task while background activation levels were similar in both tasks, and the peak amplitude in a speech task was not modulated by the additional task to react voluntarily to the perturbation. Computer simulations with a simplified linear mass-spring-damper model showed that the recorded muscle activation response is suited for the generation of tongue movement responses that were observed in a previous study with the appropriate timing when taking into account a possible physiological delay between reflex muscle activation and the corresponding force. Our results evidenced clearly that reflex mechanisms contribute to tongue posture stabilization for speech production.

Tissue-Targeted Transcriptomics Reveals SEMA3D Control of Hypoglossal Nerve Projection to Mouse Tongue Primordia

The mouse hypoglossal nerve originates in the occipital motor nuclei at embryonic day (E)10.5 and projects a long distance, reaching the vicinity of the tongue primordia, the lateral lingual swellings, at E11.5. However, the details of how the hypoglossal nerve correctly projects to the primordia are poorly understood. To investigate the molecular basis of hypoglossal nerve elongation, we used a novel transcriptomic approach using the ROKU method. The ROKU algorithm identified 3825 genes specific for lateral lingual swellings at E11.5, of which 34 genes were predicted to be involved in axon guidance. Ingenuity Pathway Analysis-assisted enrichment revealed activation of the semaphorin signaling pathway during tongue development, and quantitative PCR showed that the expressions of Sema3d and Nrp1 in this pathway peaked at E11.5. Immunohistochemistry detected NRP1 in the hypoglossal nerve and SEMA3D as tiny granules in the extracellular space beneath the epithelium of the tongue primordia and in lateral and anterior regions of the mandibular arch. Fewer SEMA3D granules were localized around hypoglossal nerve axons and in the space where they elongated. In developing tongue primordia, tissue-specific regulation of SEMA3D might control the route of hypoglossal nerve projection via its repulsive effect on NRP1.

The ptotic tongue-imaging appearance and pathology localization along the course of the hypoglossal nerve

CT and MRI findings of tongue ptosis and atrophy should alert radiologists to potential pathology along the course of the hypoglossal nerve (cranial nerve XII), a purely motor cranial nerve which supplies the intrinsic and extrinsic muscles of the tongue. While relatively specific for hypoglossal nerve pathology, these findings do not accurately localize the site or cause of denervation. A detailed understanding of the anatomic extent of the nerve, which crosses multiple anatomic spaces, is essential to identify possible underlying pathology, which ranges from benign postoperative changes to life-threatening medical emergencies. This review will describe key imaging findings of tongue denervation, segmental anatomy of the hypoglossal nerve, imaging optimization, and comprehensive imaging examples of diverse pathology which may affect the hypoglossal nerve. Armed with this knowledge, radiologists will increase their sensitivity for detection of pathology and provide clinically relevant differential diagnoses when faced with findings of tongue ptosis and denervation.

The Hypoglossal nerve

The hypoglossal nerve is the 12th cranial nerve, exiting the brainstem in the preolivary sulcus, passing through the premedullary cistern, and exiting the skull through the hypoglossal canal. This is a purely motor nerve, responsible for the innervation of all the intrinsic tongue muscles (superior longitudinal muscle, inferior longitudinal muscle, transverse muscle, and vertical muscle), 3 extrinsic tongue muscles (styloglossus, hyoglossus, and genioglossus), and the geniohyoid muscle. Magnetic resonance imaging (MRI) is the best imaging exam to evaluate patients with clinical signs of hypoglossal nerve palsy, and computed tomography may have a complementary role in the evaluation of bone lesions affecting the hypoglossal canal. A heavily T2-weighted sequence, such as fast imaging employing steady-state acquisition (FIESTA) or constructive interference steady state (CISS) is important to evaluate this nerve on MRI. There are multiple causes of hypoglossal nerve palsy, being neoplasia the most common cause, but vascular lesions, inflammatory diseases, infections, and trauma can also affect this nerve. The purpose of this article is to review the hypoglossal nerve anatomy, discuss the best imaging techniques to evaluate this nerve and demonstrate the imaging aspect of the main diseases that affect it.

The Glossopharyngeal, Vagus and Accessory nerves: Anatomy and Pathology

The glossopharyngeal, vagus, and accessory nerves are discussed in this article, given their intimate anatomical and functional associations. Abnormalities of these lower cranial nerves may be intrinsic or extrinsic due to various disease processes. This article aims to review these nerves' anatomy and demonstrates the imaging aspect of the diseases which most commonly affect them.

Unilateral aberrant anatomy of the hypoglossal nerve

PURPOSE

Neck dissection is often performed in patients with oral cancer to both treat and reduce the risk of subsequent neck metastases. Injury to the hypoglossal nerve may result in dysarthria, dysphagia, and profound difficulty with upper airway control. Although surgical landmarks facilitate intra-operative identification of vital structures to be preserved, they should not be an absolute measure, due to anatomical variants. We present a rare case of unilateral aberrant anatomy of the hypoglossal nerve, passing superficial to the internal jugular vein.

METHODS

A 70-year-old female presented to the emergency department with an indurated and ulcerated floor of mouth lesion, later confirmed to be a squamous cell carcinoma. She was treated with wide local excision, bilateral selective neck dissection of levels I to III, surgical tracheostomy, anterior mandibulectomy and reconstruction with a left composite radial forearm free flap.

RESULTS

A nerve-like structure was identified crossing superficially and perpendicular to the internal jugular vein within the left neck, which was later determined to be an anatomical variant of the hypoglossal nerve. This was carefully dissected and preserved, and the remainder of the surgery completed uneventfully. On the right, the hypoglossal nerve followed its normal anatomical course. The patient made a good recovery and suffered no neurological complications.

CONCLUSION

Identification, meticulous dissection and preservation of the hypoglossal nerve is essential in lymphadenectomy involving levels I and II. Detailed knowledge of both normal and variant anatomy is fundamental for surgeons, which will allow for identification and protection of important neurovascular structures, thereby minimising surgical morbidity.

Hypoglossal Nerve Lesions: The Role of a 3D IR-Prepped Fast SPGR High-Resolution 3T MRI Sequence

BACKGROUND AND PURPOSE

To assess a 3D high-resolution IR-prepped fast SPGR high-resolution MRI sequence for evaluating hypoglossal nerve lesions.

METHODS

The clinical data of 8 patients with hypoglossal nerve lesions admitted from December 2011 to February 2016 were retrospectively analyzed. MRI included contrast-enhanced conventional sequences and a 3D IR-prepped fast SPGR high-resolution T1-weighted (BRAVO) MRI sequence at 3T.

RESULTS

Eight patients had hypoglossal lesions detected by MRI. Conventional enhanced scanning could not clearly display the hypoglossal nerve and canal, while the enhanced 3D high-resolution sequence could. In addition, multiple planar reconstruction clearly displayed the hypoglossal nerve, hypoglossal canal, and lesions in multiple planes.

CONCLUSIONS

Compared with conventional MRI, we show superior results from an advanced sequence to improve image quality in characterizing hypoglossal nerve lesions.

Guidelines for radiographic imaging of cranial neuropathies

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

Unilateral isolated hypoglossal nerve palsy due to pathologically adherent PICA fusiform aneurysm - A case report

Background:

Isolated hypoglossal nerve palsy due to mechanical compression by a vascular lesion is rare.

Case Description:

We report the case of a 72-year-old man who presented with a 4-year history of swallowing disturbance and subsequently progressively worsening left-sided tongue atrophy. He was referred to our department by a neurologist due a magnetic resonance imaging detected left vertebral artery compression of the medulla. Neurological examination was unremarkable except for left hypoglossal nerve dysfunction, which presented as left-sided atrophy and impaired movement of the tongue. Three-dimensional computed tomography angiography showed proximal left posterior inferior cerebellar artery (PICA) origin fusiform aneurysm. Microvascular decompression was done through a left transcondylar fossa approach. Intraoperative findings were thickened arachnoid around the lower cranial nerves, fusiform aneurysm of the left PICA at its origin from the left vertebral artery which was severely adherent to and compressing the left hypoglossal nerve rootlets.

Conclusion:

The PICA has a very close relationship to the hypoglossal nerve, and its fusiform dilatation could cause isolated hypoglossal nerve dysfunction. Pathological adhesions between hypoglossal rootlets and the PICA aneurysm wall could be a possible contributor in the development and progression of hypoglossal nerve palsy.

Microsurgical Anatomy of the Hypoglossal and C1 Nerves: Description of a Previously Undescribed Branch to the Atlanto-Occipital Joint

OBJECTIVE

Distal branches of the C1 nerve that travel with the hypoglossal nerve have been well investigated but relationships of C1 and the hypoglossal nerve near the skull base have not been described in detail. Therefore, the aim of this study was to investigate these small branches of the hypoglossal and first cervical nerves by anatomic dissection.

METHODS

Twelve sides from 6 cadaveric specimens were used in this study. To elucidate the relationship among the hypoglossal, vagus, and first and cervical nerve, the mandible was removed and these nerves were dissected under the surgical microscope.

RESULTS

A small branch was found to always arise from the dorsal aspect of the hypoglossal nerve at the level of the transverse process of the atlas and joined small branches from the first and second cervical nerves. The hypoglossal and C1 nerves formed a nerve plexus, which gave rise to branches to the rectus capitis anterior and rectus capitis lateralis muscles and the atlanto-occipital joint.

CONCLUSIONS

Improved knowledge of such articular branches might aid in the diagnosis and treatment of patients with pain derived from the atlanto-occipital joint. We believe this to be the first description of a branch of the hypoglossal nerve being involved in the innervation of this joint.

Sternocleidomastoid innervation from an aberrant nerve arising from the hypoglossal nerve: a prospective study of 160 neck dissections

BACKGROUND

Anatomical variants of the spinal root of the accessory nerve and cervical plexus are well known but other variants are exceptionally rare.

METHODS

A prospective study of 160 selective neck dissections was undertaken following an index case, where a presumed C1 nerve (travelling with the hypoglossal nerve) was found to innervate sternocleidomastoid (SCM). A search was subsequently made for this variant while not compromising the neck dissection surgery itself. Eight cases could not be included due to metastatic disease precluding safe dissection in this area. A nerve stimulator was used to confirm the motor supply to SCM.

RESULTS

This nerve variant was found in 4/160 necks (2.5 %). In all cases, it originated directly from the hypoglossal nerve and stimulation resulted in isolated SCM contraction. No accessory nerve anomalies were found.

CONCLUSION

This finding adds to the knowledge of variants in this area. Meticulous dissection and preservation of all nerves, where possible, is important for optimising functional outcomes following surgery.

An ultrasound investigation of tongue shape in stroke patients with lingual hemiparalysis

BACKGROUND

Stroke can cause hemilateral paresis of the tongue. The present study investigated the functional consequences of a lingual hemiparalysis on the symmetry and the grooving of the tongue in the coronal plane during the production of vowel-consonant-vowel sequences. The hypotheses were that, because of the lingual hemiparalysis, the stroke patients' tongue shapes would be (1) more asymmetrical and (2) less grooved than the tongues of the control speakers.

METHODS

The participants in this prospective data collection were 9 stroke patients with lingual hemiparalysis and 6 control speakers. All participants produced vowel-consonant-vowel sequences with the vowels [a, i, and u] and the target consonants [k, t, ∫, s, and r]. The tongue shape in the coronal plane was traced and measured. The outcome measures were asymmetry and midlingual concavity. The participants and controls were compared using repeated measures analyses of variance with post hoc Scheffé tests.

RESULTS

There were no significant differences in asymmetry. There was significantly reduced midlingual concavity for the stroke patients (F[1, 13] = 8.78; P < .05). There was also a within-subjects effect for consonant (F[4, 50] = 14.26; P < .01). Post hoc testing with Scheffé tests indicated that the consonant [k] had significantly lower grooving than the other consonant sounds (P < .05).

CONCLUSIONS

The hemilateral paresis affected not the symmetry but the midlingual grooving. Residual ipsilateral innervation in the hemiparalyzed tongue may help patients compensate. More research is needed to assess the impact of the intrinsic deformation of the tongue on speech acceptability and intelligibility in patients with a lingual hemiparalysis.

Isolated unilateral hypoglossal nerve palsy due to vertebral artery dissection

We report the case of a patient with unilateral tongue weakness secondary to an isolated lower motor neuron hypoglossal nerve palsy that was caused by a right vertebral artery dissection in the lower neck. The patient had a boggy tongue with a deviation to the right side but an otherwise normal neurological examination. Magnetic resonance angiography showed a narrow lumen of the right vertebral artery in the neck. After initially treating the patient with aspirin in the emergency room and later with warfarin for three months, there was complete recanalization of the right vertebral artery. Only one other case of vertebral artery dissection and twelfth nerve palsy has been reported before.

Imaging the cranial nerves: Part I: methodology, infectious and inflammatory, traumatic and congenital lesions

Many disease processes manifest either primarily or secondarily by cranial nerve deficits. Neurologists, ENT surgeons, ophthalmologists and maxillo-facial surgeons are often confronted with patients with symptoms and signs of cranial nerve dysfunction. Seeking the cause of this dysfunction is a common indication for imaging. In recent decades we have witnessed an unprecedented improvement in imaging techniques, allowing direct visualization of increasingly small anatomic structures. The emergence of volumetric CT scanners, higher field MR scanners in clinical practice and higher resolution MR sequences has made a tremendous contribution to the development of cranial nerve imaging. The use of surface coils and parallel imaging allows sub-millimetric visualization of nerve branches and volumetric 3D imaging. Both with CT and MR, multiplanar and curved reconstructions can follow the entire course of a cranial nerve or branch, improving tremendously our diagnostic yield of neural pathology. This review article will focus on the contribution of current imaging techniques in the depiction of normal anatomy and on infectious and inflammatory, traumatic and congenital pathology affecting the cranial nerves. A detailed discussion of individual cranial nerves lesions is beyond the scope of this article.

Imaging of muscular denervation secondary to motor cranial nerve dysfunction

The effects of motor cranial nerve dysfunction on the computed tomography (CT) and magnetic resonance imaging (MRI) appearances of head and neck muscles are reviewed. Patterns of denervation changes are described and illustrated for V, VII, X, XI and XII cranial nerves. Recognition of the range of imaging manifestations, including the temporal changes in muscular appearances and associated muscular grafting or compensatory hypertrophy, will avoid misinterpretation as local disease. It will also prompt the radiologist to search for underlying cranial nerve pathology, which may be clinically occult. The relevant cranial nerve motor division anatomy will be described to enable a focussed search for such a structural abnormality.

Phenotype and contractile properties of mammalian tongue muscles innervated by the hypoglossal nerve

The XIIth cranial nerve plays a role in chewing, respiration, suckling, swallowing, and speech [Lowe, A.A., 1981. The neural regulation of tongue movements. Prog. Neurobiol. 15, 295-344.]. The muscles innervated by this nerve are functionally subdivided into three categories: those causing protrusion, retrusion, and changing the shape of the tongue. Myosin heavy chain (MHC) II isoform makes up the majority of the MHC phenotype with some variability among mammalian species and some evidence suggests between genders. In addition, there are regional differences in fiber type within some of these muscles that suggest functional compartmentalization. The transition from developmental MHC isoforms to their adult phenotype appears to vary not only from muscle to muscle but also from species to species. Motor units within this hypoglossal motor system can be categorized as predominantly fast fatigue resistant. Based on twitch contraction time and fatigue index, it appears that hypoglossal innervated muscles are more similar to fast-twitch muscles innervated by spinal nerves than, for example, extraocular muscles.

Asymmetric Tongue Muscle Uptake of F-18 FDG

A 58-year-old woman, with nonsmall cell carcinoma, had multiple metastasis on 2-F-18 FDG positron emission tomography imaging. The right hemitongue had increased activity as compared with the left. This was not the result of the presence of a metastasis to the tongue, as shown by a negative computed tomography scan of the region and failure to demonstrate a lesion over a period of weeks. Uptake was likely related to right hemiglossal muscle activity. This was made more apparent by decreased uptake on the opposite side of the tongue (up to the midline) as a result of left cranial nerve XII paralysis.