Postcoital hypoglossal nerve palsy and vocal cord paralysis following the use of generic sildenafil

Introduction:

The causes of hypoglossal nerve palsy and vocal cord paralysis include peripheral and central pathologies, and therefore require an interdisciplinary assessment.

Case:

A 50-year-old male patient presented in the emergency department with a subjective feeling of tongue swelling, dyspnea and dysphonia. Five days prior, he had taken generic sildenafil. On that evening, he experienced a slight postcoital headache that worsened on the next morning, becoming mainly localized in the neck region. On the following day, the patient experienced a feeling of tongue swelling and slurred speech. On clinical examination, a right hypoglossal nerve palsy and right vocal cord paralysis were detected, no signs of Horner syndrome could be seen.

A head/neck CT with CT-angiography did not show any relevant pathology. A subsequent head/neck MRI, in conjunction with all other findings, led to the diagnosis: dissection of the right internal carotid artery without relevant stenosis.

Discussion:

The exceedingly rare dissection of the internal carotid artery should always be considered in the differential diagnosis of isolated cranial nerve palsies, as the immediate initiation of anticoagulant therapy can prevent the occurrence of thromboembolic complications. The delayed onset of isolated hypoglossal nerve palsy following dissection of the internal carotid artery may be explained pathophysiologically by the compression of the hypoglossal nerve by a subadventitial hematoma of the vessel wall. The concurrent vocal cord paralysis can be attributed to the localization of the dissection within the adjacent anatomical course of the vagus nerve and the hypoglossal nerve, lateral to the internal carotid artery.

Publication History

Publication Date:
23 April 2019 (online)