Occipital condyle fracture with associated hypoglossal nerve injury.

THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES Occipital condyle fracture (OCF) is a rare injury that was first described by Bell in 1817. In fact, there have been only 96 more reported cases of occipital condyle fractures from 1817 to 1994 of which only 58 survived.1 Occipital condyle fractures can sometimes go unnoticed or under-diagnosed as they are not always evident on plain radiographs of the cervical spine. Also, in rare cases OCFs can cause damage to the hypoglossal nerve which passes through the hypoglossal canal which is near the occipital condyle. The presence of specific symptoms and clinical signs should lead to the correct diagnosis. This paper describes a patient who was diagnosed with OCFs, but not hypoglossal nerve damage until 20 days following admission to hospital. We point out many factors that contributed to this delayed diagnosis, which ultimately caused severe discomfort to the patient. A 25-year-old male was involved in a motor vehicle accident in which he was the passenger. When admitted he had a Glasgow Coma Score (GCS) of E4V4M6 and had a hemotympanum on the left. He was also complaining of cervical pain and tenderness as well as difficulty breathing and speaking. Radiographic investigation revealed that the patient had suffered fractures of the 9th and 10th ribs. Furthermore, this individual had undisplaced fractures of the anterior arch of C1 and of both occipital condyles. A computerized tomographic (CT) scan of the cranial vertebral junction showed that the occipital condyles were medially and inferiorly fractured. The CT scans revealed no other spinal fracture. Although the patient was conscious on admission he had respiratory obstruction which was due to a retropharyngeal hematoma and also to pharyngeal edema. The patient was intubated the same day and attempts to extubate the patient failed twice. Because of these problems (swallowing difficulty in both oral phase and pharyngeal phase) which were confirmed by bedside testing and a video swallow study done 20 days after admission, bilateral hypoglossal nerve palsy was diagnosed. The patient was managed expectantly and mobilized in an Aspen collar. Because the patient could not move his tongue, a percutanous endogastric (PEG) tube was inserted until hypoglossal nerve function recovered. Three weeks following insertion, his tongue movements appeared to be improving to the point that he was no longer having difficulty swallowing secretions. Fracture of the occipital condyle is a rare entity. As a result, there is very limited knowledge concerning this subject. We can speculate that this injury is more common than reported. The Occipital Condyle Fracture with Associated Hypoglossal Nerve Injury