Good clinical examination is so important in what we do. I say, just have a look, sometimes you’ll be surprised what you pick up. In this month’s NEJM‘s image challenge, this image was presented. Where is the lesion?

 

Is it: (a) Left facial nerve (b) Left glossopharyngeal nerve (c) Left hypoglossal nerve (d) Right glossopharyngeal nerve (e) Right hypoglossal nerve

The answer is…left hypoglossal secondary to extracranial dissection of the left carotid artery. Remember that the hypoglossal nerve pushes the tongue out and makes it straight. If one side is not pushing, the tongue deviates to the side of the lesion. This is a peripheral type of lesion. The other thing to be aware of is that facial asymmetries can sometimes make it look like the tongue is asymmetrical, when it is not. So take everything into account.