Apparent Swelling of the Tongue

A 51-year-old man was referred after unsuccessful antibiotic treatment in another institution for a suspected tongue abscess. He complained of swelling of the left side of the tongue over the past 6 days, which had been preceded by a very severe headache. On physical examination, the tongue was thicker on the left, with displacement of the midline to the right, but without any typical signs of inflammation. On protrusion of the tongue, deviation to the left and left-sided fasciculations were seen. Alongside this evident hypoglossal nerve palsy, there were also ipsilateral palsies of the facial nerve (House-Brackmann grade 2) and the vagus nerve, the latter manifested by unilateral vocal fold immobility. CT angiography of the head revealed a dissection of the left internal carotid artery below the skull base. The patient was admitted and treated with anticoagulation (intravenous heparin at first, later switched to phenprocoumon by mouth). After discharge, the facial and vagus nerve palsies resolved, but the hypoglossal nerve palsy persisted. Cranial nerve involvement in carotid dissection is rare but led to the correct diagnosis in this case.