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Introduction
The combination of tongue hemianaesthesia, dysgeusia, dysarthria and dysphagia suggests the involvement of multiple cranial nerves. Trigeminal nerve (V3 ), carrying predominantly somatic sensory afferents from the tongue, oral and nasal cavities and the face;
Facial nerve (VII), providing special sensory taste afferents from the anterior two-thirds of the tongue;
Glossopharyngeal nerve (IX), carrying special sensory taste fibres from the posterior one-third of the tongue and somatic sensory information from the pharynx;
Vagus nerve (X), contributing sensory and motor innervation to the palate facilitating swallowing;
Hypoglossal nerve (XII), giving somatic motor supply to all the intrinsic and extrinsic muscle of the tongue, except palatoglossus.
The anatomical localisation of multiple cranial nerve lesions requires extensive investigations to consider disease of the skull base, brainstem or supranuclear structures. Here we present a case with sudden onset of these symptoms immediately following wisdom tooth extraction and highlight the clinical features that allowed localisation of the lesion. We also discuss features that exclude alternative diagnoses.
Case report
A 22-year-old woman had undergone uncomplicated removal of right lower third molar tooth under local anaesthetic. One month later, due to discomfort and anxiety, she underwent the same procedure under general anaesthetic on the opposite side. She had been previously well other than a history of polycystic ovarian syndrome and being slightly overweight (body mass index of 28kg/m 2 ). She took no regular medications, drank no alcohol and did not smoke. There was no family history of neurological disease. She was married with one son and worked in telesales. Immediately postoperatively, she described numbness over her left cheek, tongue, lower lip and jaw and her speech was unclear. Within 24hours the sensory disturbance had regressed to the left half of the tongue and lower gum but she remained dysarthric, describing a 'sticking of the tongue' when speaking. She bit the side of her tongue while chewing on several occasions; her swallowing was difficult though without regurgitation, aspiration or weight loss. She reported reduced intensity of taste on the left side. There was no immediate perioperative pain, and no right-sided mouth or face symptoms, and no neurological disturbance in her limbs. One month later, she developed short bursts of severe pain radiating from the angle of the jaw towards...