Background <p>Combined palsy of the hypoglossal and lingual nerves following laryngeal mask airway (LMA) use is a rare complication. This case report delineates the clinical course and management of this unique entity.</p> Case presentation <p>A 71-year-old male developed left-sided tongue paralysis and sensory loss in the anterior two-thirds of the tongue 24 hours after hand surgery under LMA anesthesia. Central lesions were excluded via neuroimaging. Electromyography (EMG) confirmed a left hypoglossal nerve conduction delay, consistent with neuropraxia. A multimodal treatment regimen comprising a 5-day course of intravenous methylprednisolone followed by a 2-week oral prednisone taper, murine nerve growth factor for two weeks, and targeted rehabilitation was implemented. Complete neurological recovery was achieved within three months, as confirmed by clinical assessment and normalized electrophysiological studies.</p> Conclusions <p>This case underscores that prolonged LMA use can lead to compound cranial neuropathy, likely due to mechanical compression at the tongue base. Early diagnosis, exclusion of central causes, and prompt initiation of combined anti-inflammatory, neurotrophic, and rehabilitative therapy are crucial for optimal recovery. Emphasis on individualized airway management and pressure monitoring in elderly patients is recommended to mitigate this risk.</p>