Case Presentation:

A 63‐year‐old morbidly obese woman with no known medical history presented emergently with worsening shortness of breath. She had a CT scan of the abdomen, which showed free intraperitoneal air. Because of her short neck and morbid obesity, intubation was difficult. Following intubation, an emergent exploratory laparotomy was done. After a complicated and prolonged postoperative course, she was extubated. She was then found to have severe dysarthria, which did not resolve even after 48 hours. She was noted to have complete bilateral paralysis of the tongue. Cranial nerves II–XI were intact. She had no other focal neurological deficit. CT scan of the head was normal. A presumptive diagnosis of bilateral hypoglossal nerve paralysis was made. The cause was most likely traumatic intubation.


Isolated bilateral hypoglossal nerve paralysis following intubation is exceedingly rare, having been described only a handful of times in the medical literature. It can occur following orotracheal intubation, laryngeal mask airway, or bronchoscopy. The risk factors include traumatic/difficult intubation, multiple intubations, prolonged intubation time, and hyperextension of the neck during intubation. Although the definitive pathophysiology is not known, a popular theory is that mechanical alteration during intubation leads to axonotmesis, thereby leading to nerve injury and presenting as paralysis. The cause of nerve injury can also be attributed to neuropathy provoked by compression following cuff inflation within the larynx. It has also been postulated that nerve damage can occur due to neck hyper‐extension during a difficult intubation. One case report suggests that prognosis is favorable as long as the continuity of the nerve sheath is maintained. This complication of intubation (bilateral hypoglossal nerve paralysis) can potentially be avoided by paying attention to correct positioning of the head during surgery, avoiding hyper‐extension, especially if prolonged intubation is anticipated.


It is important to recognize that intubation can cause hypoglossal nerve injury, presenting as unilateral or bilateral tongue paralysis. Isolated cases describing bilateral hypoglossal nerve paralysis are rare. Most case reports describe hypoglossal nerve paralysis in conjunction with recurrent laryngeal nerve paralysis (Tapia's syndrome).