A difficult case
Wisdom tooth extraction causing lingual nerve and styloglossus muscle damage: a mimic of multiple cranial nerve palsies
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Jump to comment:
We thank Dr Hughes for his thoughtful letter and his previous extensive comments as part of the reviewing process.
The main issue Dr Hughes has raised is the possibility of another local structural lesion. He asks that “Some cross checking with digital examination of the floor of the mouth, palpation of the tongue, or the results of attempts by a clinician to correct the position of the tongue may be all that is required to confirm or refute the working diagnosis.
We had already addressed this in our paper “The ENT and oral maxillofacial surgeons had noted a small post-traumatic neuroma/granuloma at the left retromolar space but with no other oral structural abnormality “. And expanded on this in response to the query in Dr Hughes’s first review, “No structural lesion to the tongue muscle or its attachments was observed on clinical examination by an experienced ENT surgeon or on independent examination by an oral maxillofacial surgeon”.
We feel our explanation as outlined in our paper remains the most plausible.
Dear Editors,Show More
Carr AS, et al. Pract Neurol 2017;17:218–221. doi:10.1136/practneurol-2016-001491
In the interests of enhancing our understanding of bulbar function from the perspective of the jobbing clinical neurologist, I am writing to you regarding a publication in this month’s edition of Practical Neurology (Carling et al.). As it stands I do not think the case report does justice to the scholarship of the seven authors.
I enjoyed formally refereeing the paper on two separate occasions (enclosed), and offered a third comment (“I think the patient has a lingual nerve palsy and a tethered tongue on the left, both occurring as a complication of surgery”) by email, in the hope that it could appear in a little box as “reviewer’s comments”. I now think that I would have provided a better service to PN if I had sent this single sentence to you instead of the first review.
In the report, the authors champion the careful approach required in patients with very focal abnormalities involving the lower cranial nerves and the muscles they innervate. They describe in pictures and very useful tables—copies of which are already on my office wall—the detailed knowledge that is required to avoid misattribution in the crowded and inaccessible house of the structures involved in bulbar function.
The patient concerned had a third molar removed and postoperatively had a lingual nerve palsy. This complication is anticipated, and is included in the consent pro...