A tardy tongue palsy

A 76-year-old man presented with insidious onset of slurred speech and difficulty swallowing over 1 year. Initial symptoms were episodic imprecise articulation, tongue swelling, tongue deviation, and mild right-sided headache. Progressive deterioration of speech and swallowing function had occurred; at the time of presentation, the patient was struggling to swallow food and saliva. He had undergone C1-C5 posterior fusion following a C2 fracture 50 years prior. There was no relevant medical history and the patient was systemically well. Examination found hemiatrophy of the right side of the tongue with visible fasciculations. The tongue protruded to the right and there was associated dysarthria. There was no evidence of other cranial nerve involvement, cervical myelopathy, or a diffuse motor neuron disorder.