Hypoglossal Nerve Palsy Arising from Skull Base Osteomyelitis in a 12 Year Old Boy

Isolated hypoglossal nerve palsy arising from skull base osteomyelitis is rare but has been described in an adult population (Katfiki et al, 2012). We present a case of a 12-year-old boy referred to ENT and oncology at a tertiary hospital following recurrent episodes of otitis media, mastoiditis and suspected osteomyelitis of the skull base. Osteomyelitis was confirmed by ENT. On clinical assessment by a speech and language therapist the patient presented with oral candida, severe flaccid dysarthria and moderate oral stage dysphagia, characterized by tongue paralysis and wasting. Cranial nerve examination was suggestive of an isolated injury to the hypoglossal nerve (CNXII). Magnetic Resonance Angiography indicated obstructed bilateral internal carotid artery and jugular vein and videofluroscopy (VFSS) indicated mild pharyngeal residue likely secondary to base of tongue weakness. Prednisolone steroids were commenced alongside a fourth round of antibiotics. Within one-week symptoms were alleviated and within two weeks the patient was able to manage a complete range of oral textures with no concerns. VFSS at four weeks post treatment showed complete base of tongue to posterior pharyngeal wall contact during the swallow. There was mild pharyngeal residue post swallow indicating an element of residual base of tongue weakness. On clinical assessment the patient continued to present with residual reduced range of tongue movement and moderate dysarthria seven weeks post onset of steroids, however patient reported outcomes indicated a significant improvement of function. This case emphasizes the importance of interdisciplinary working when diagnosing rare cases of cranial nerve damage in children.