Tympanic Plexus Neurectomy for Intractable Otalgia

Case Report: Inflamed Jacobson nerve: an uncommon cause of persisting otalgia after an acute otitis media

Introduction

Otalgia can have multiple causes. Mostly otalgia is caused by a tubal dysfunction or an acute middle ear infection. This case describes a patient with an inflammation of the Jacobson's nerve causing severe persistent otalgia after an acute otitis media. The patients complaints completely disappeared after neurolysis of the Jacobson's nerve.

Case presentation

We describe a case of a 21-year-old female caucasian patient with acute otitis media and persistent intractable otalgia. Infection was first successfully controlled by antibiotics. But the patient reported a persistent otalgia not responding to analgetics. We performed a CT scan, which exhibited a regular aerated middle ear finding, and a diagnostic tympanoscopy to examine the middle ear structures particularly the tympanic Jacobson's nerve as a possible cause for persistent pain. The following neurolysis of Jacobson's nerve under general anaesthesia led to a resolution of otalgia.

Conclusion

An inflamed tympanic Jacobson's nerve is a rare observation and a persisting otalgia after an acute otitis media not responding to conservative treatment can be treated by a neurolysis.

Review of the caroticotympanic nerves: Anatomy, function and pathology

The caroticotympanic nerves provide postganglionic sympathetic fibres to the tympanic plexus. However, there are scant reports in the literature detailing with these nerves in great depth. As the caroticotympanic plexus lies near the often-operated tympanic nerve, it is important for the surgeon to understand the anatomy, pathology and surgical implications of it. Here, we present a review of the available literature regarding the caroticotympanic nerves.

Glossopharyngeal Neuralgia Characterized by Otalgia: A Retrospective Study

Glossopharyngeal neuralgia (GPN) is an uncommon facial pain syndrome and is characterized by paroxysms of excruciating pain in the distributions of the auricular and pharyngeal branches of cranial nerves IX and X. Glossopharyngeal neuralgia characterized by otalgia alone is rare. Herein, the authors analyzed 2 patients with GPN with otalgia as the main clinical manifestation. The clinical features and prognosis of this rare group of patients with GPN were discussed. They both presented with paroxysmal pain in the external auditory meatus and preoperative magnetic resonance imaging suggested the vertebral artery were closely related to the glossopharyngeal nerves. In both patients, compression of the glossopharyngeal nerve was confirmed during microvascular decompression, and the symptoms were relieved immediately after surgery. At 11 to 15 months follow-up, there was no recurrence of pain. A variety of reasons can cause otalgia. The possibility of GPN is a clinical concern in patients with otalgia as the main complaint. The authors think the involvement of the glossopharyngeal nerve fibers in the tympanic plexus via Jacobson nerve may provide an important anatomic basis for GPN with predominant otalgia. Surface anesthesia test of the pharynx and preoperative magnetic resonance imaging is helpful for diagnosis. Microvascular decompression is effective in the treatment of GPN with predominant otalgia.

A Case Report of Refractory Postherpetic Neuralgia After Ramsay Hunt Syndrome Treated With Tympanic Nerve Neurectomy

Ramsay Hunt syndrome is a facial nerve palsy that arises from herpes zoster infection. In rare cases, postherpetic neuralgia is a complication following Ramsay Hunt syndrome. Pain management to address postherpetic neuralgia includes facial nerve blocks, medications such as gabapentin, carbamazepine and botulinum toxin injections, and pulsed radiofrequency. Despite the reported benefits for patients with glossopharyngeal nerve pain, neurectomy as a treatment has rarely been described. A 45-year-old patient visited our ENT clinic for chronic right-sided facial, ear, and jaw pain that persisted for 9 years following the development of Ramsay Hunt syndrome. She trialed multiple medications including gabapentin, carbamazepine, and botulinum toxin injections with minimal relief to her symptoms. The patient underwent a diagnostic myringotomy with topical application of lidocaine to the tympanic nerve. This resulted in temporary relief of her pain until the effects of the lidocaine subsided. The patient was subsequently offered lysis of the right tympanic nerve for more definitive management. The patient experienced significant pain reduction after the right tympanic neurectomy procedure. Chronic postherpetic neuralgia following Ramsay Hunt syndrome can cause significant impairment in a patient's quality of life. For patients with ear pain refractory to conservative management, a tympanic neurectomy can be considered.

Aetiology and management options for secondary referred otalgia: a systematic review and meta-analyses

OBJECTIVES OF REVIEW

To review the literature for the evidence base for the aetiology and management of referred otalgia, looking particularly at non-malignant, neuralgic, structural and functional issues.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A systematic literature search was undertaken from the databases of EMBASE, CINAHL, MEDLINE®, BNI, and Cochrane Library according to predefined inclusion and exclusion criteria.

EVALUATION METHOD

All relevant titles, abstracts and full text articles were reviewed by three authors who resolved any differences by discussion and consultation with senior author.

RESULTS

44 articles were included in our review. The overall quality of evidence was low, with the vast majority of the studies being case-series with three cohort and four randomised-controlled trials included. The prime causes and management strategies were focussed on temporomandibular joint dysfunction (TMJD), Eagle syndrome and neuralgia. Our meta-analyses found no difference on the management strategies for the interventions found.

CONCLUSIONS

Referred otalgia is common and treatment should be aimed at the underlying pathology. Potential aetiologies are vast given the extensive sensory innervation of the ear. An understanding of this and a structured approach to patient assessment is important for optimal patient management.

Anatomic features of the fetal round and oval windows, and their relations with the tympanic nerve

OBJECTIVE

The study aimed to examine morphometric properties of the round window (RW) and oval window (OW) and to show their relation with the tympanic nerve (the Jacobson's nerve, JN) in human fetuses from the otologic surgeon's perspective.

METHODS

Thirty temporal bones of 15 fetal cadavers (8 males, 7 females) aged with 24.40 ± 3.71 weeks were included in the study. The height, width and surface area of the RW and OW and also distance from the JN to the OW and RW were measured.

RESULTS

The height, width and surface area of the RW in this work were measured as 1.48 ± 0.25 mm, 1.57 ± 0.37 mm, and 2.05 ± 0.69 mm², respectively. The RW was detected as round-shaped (8 cases, 26.7%), oval-shaped (15 cases, 50%), and dome-shaped (7 cases, 23.3%). The height, width and surface area of the OW were measured as 1.42 ± 0.26 mm, 2.90 ± 0.44 mm, and 3.63 ± 0.74 mm², respectively. The OW was observed as oval-shaped (15 cases, 50%), kidney-shaped (10 cases, 33.3%), D-shaped (4 cases, 13.3%), and trapezoid-shaped (1 case, 3.3%). The JN was found 1.21 ± 0.60 and 1.18 ± 0.54 mm away from the RW and OW, respectively.

CONCLUSION

This study containing morphological data about the shapes, diameters and area of the RW and OW may be useful to predict surgical difficulty, and to select implants of suitable size preoperatively for the windows. Knowing the relationship between the JN and the windows can be helpful to avoid iatrogenic injuries of the nerve.