Glossopharyngeal neuralgia associated with cardiac arrest. Case report

Clinical and physiopathological aspects of the glossopharyngeal neuralgia

Introduction Glossopharyngeal neuralgia is a rare syndrome characterized by paroxysms of unilateral and severe stabbing pain occurring in the nerve’s distribution. Although other neuralgias are well described in the medical literature, glossopharyngeal neuralgia and its physiopathology are not. The vascular compression at the nerve root entry zone is the primary explanation for the disease. The first-line treatment is pharmacological, including carbamazepine, oxcarbazepine, and gabapentin. Surgical treatment is offered to medication-refractory patients, and microvascular decompression surgery has the best outcomes. Objective To investigate the pathophysiological and clinical aspects of the different presentations of glossopharyngeal neuralgia. Method: A systematic review of the literature including case reports and clinical trials, was done. Results A search of the literature yielded 31 papers that regarded glossopharyngeal neuralgia or its variants. Eight of these reports regarded vagoglossopharyngeal neuralgia. Seven regarded the glossopharyngeal neuralgia followed by or caused by another disease. Conclusion Glossopharyngeal neuralgia is a rare disease and requires further studies on its mechanism and clinical assessment; the physician needs to know how to distinguish it from its variants and underlying causes.

Glossopharyngeal neuralgia

In this review, the clinical characteristics, differentiating features from other forms of neuralgia, etiology and treatment options of glossopharyngeal neuralgia will be discussed.

Current neurosurgical management of glossopharyngeal neuralgia and technical nuances for microvascular decompression surgery

Glossopharyngeal neuralgia (GPN) is an uncommon facial pain syndrome often misdiagnosed as trigeminal neuralgia. The rarity of this condition and its overlap with other cranial nerve hyperactivity syndromes often leads to a significant delay in diagnosis. The surgical procedures with the highest rates of pain relief for GPN are rhizotomy and microvascular decompression (MVD) of cranial nerves IX and X. Neurovascular conflict at the level of the root exit zone of these cranial nerves is believed to be the cause of this pain syndrome in most cases. Vagus nerve rhizotomy is usually reserved for cases in which vascular conflict is not evident. A review of the literature reveals that although the addition of cranial nerve X rhizotomy may improve the chances of long-term pain control, this maneuver also increases the risk of permanent dysphagia and vocal cord paralysis. The risks of this procedure have to be carefully weighed against its benefits. Based on the authors' experience, careful patient selection with a thorough exploratory operation most often leads to identification of the site of vascular conflict, obviating the need for cranial nerve X rhizotomy.

Compression of the Rostral Ventrolateral Medulla by a Vagal Schwannoma of the Cerebellomedullary Cistern Presenting with Refractory Neurogenic Hypertension: Case Report

OBJECTIVE:

The rostral ventrolateral medulla is thought to serve as a final common pathway for the integration of central cardiovascular information and to be important for the mediation of central pressor responses. An association between essential hypertension and neurovascular compression of the rostral ventrolateral medulla has been reported. This may be mediated by an increase in sympathetic tone.

CLINICAL PRESENTATION:

Schwannomas arising from the lower cranial nerves (Cranial Nerves IX-XI) are rare, constituting only 3% of all intracranial schwannomas unassociated with neurofibromatosis. The majority of these tumors present as jugular foramen lesions and, less commonly, they occur along the extracranial course of these nerves. An intracisternal location is extremely rare. Fewer than 15 cases of pathologically proven intracisternal vagal schwannomas in the absence of neurofibromatosis have been reported.

INTERVENTION:

We report a case of vagal schwannoma in the cerebellomedullary cistern causing distortion of the vagal root entry zone and presenting with refractory neurogenic hypertension. Total microsurgical excision of this tumor, arising from one of the rootlets of the vagus nerve, was achieved. Immediately postoperatively, blood pressure decreased markedly, and despite our effort to maintain the blood pressure with fluids, the patient developed a cerebral infarction in the watershed zone.

CONCLUSION:

We discuss the proposed mechanism of hypertension, and the perioperative management, stressing blood pressure control. A review of the literature regarding vagal schwannomas is also presented. To the best of our knowledge, this is the first case report of a cerebellomedullary cistern vagal schwannoma presenting with neurogenic hypertension.

Vagal schwannoma of the cerebello-medullary cistern presenting with hoarseness and intractable tinnitus: a rare case of intra-operative bradycardia and cardiac asystole

Schwannomas arising from the lower cranial nerves (IX-XI) are rare, constituting only 3% of all intracranial schwannomas unassociated with neurofibromatosis. A great majority of these tumours present as jugular foramen lesions and less commonly they occur along the extracranial course of these nerves. An intracisternal location is extremely rare. We report a case of vagal schwannoma purely in the cerebello-medullary cistern causing distortion of the medulla oblongata. Total microsurgical excision of this tumor, arising from one of the rootlets of the vagus nerve, was achieved with preservation of the 9th, 10th and 11th cranial nerves.The intraoperative course was complicated by two episodes of complete cardiac asystole, each lasting for 4(s), and six episodes of severe bradycardia. The patient was relieved of his intractable tinnitus but continued to have a hoarse voice due to an ipsilateral partial vocal cord palsy.

Glossopharyngeal neuralgia: a study of 6 cases

Glossopharyngeal neuralgia is a rare disease. In this report; six cases of glossopharyngeal neuralgia have been studied. At first, drug therapy was used in all of the 6 cases. In 2 of the 6 cases which were resistant to medical therapy intracranial section of the 9th nerve as well as the upper two rootlets of the 10th nerve were performed. This resolved the symptoms completely. One of these two cases, had, in addition to pain paroxyms, hypotension, bradycardia and syncope, which were controlled by temporary cardiac pacemaker. In the other 4 cases, drug therapy was able to control the paroxysms of pain. In addition, two patients with weight loss and one patient with bradycardia rapidly responded to drug therapy as well. Reviewing the literature, we discuss the medical and surgical treatment of glossopharyngeal neuralgia and possible mechanisms of associated cardiovascular disturbances.

Glossopharyngeal neuralgia with cardiac syncope

Glossopharyngeal Neuralgia is an uncommon craniofacial pain syndrome that is occasionally associated with cardiac syncope. Involvement of the glossopharyngeal nerve may be painless or may be marked by true episodic neuralgia, and this justifies the term neuralgia reported here. We present 5 cases of this uncommon syndrome, of a total of 15 observed cases of glossopharyngeal neuralgia, successfully treated by section of the rootlets of Cranial Nerves IX and X or by microvascular decompression in the posterior cranial fossa. We also analyze the relevant literature and discuss the pathogenesis and treatment of the syndrome.

Diagnostic evaluation of syncope

Syncope is a common medical problem and is caused by a wide variety of diseases ranging from physiologic derangements with few consequences to conditions that may be immediately life-threatening. Because of the large differential diagnosis, many diagnostic tests are available for its evaluation. However, a cause of syncope is not established in 38% to 47% of patients despite these tests. In those patients in whom a diagnosis can be assigned, the history and physical examination identify a potential cause in 49% to 85%. Furthermore, in 8% of additional patients, history and physical examination are suggestive of causes that need confirmation by specific tests. Routine blood tests rarely yield diagnostically helpful information. In those patients in whom a potential cause for syncope is identified, arrhythmias are diagnosed by electrocardiogram in 2% to 11% of patients, cardiac monitoring in 3% to 27% (telemetry or Holter), stress test in less than 1%, carotid massage in less than 1%, and electrophysiologic studies in less than 3%. Diagnosis of arrhythmias as a cause of syncope is problematic because symptomatic correlation during electrocardiographic monitoring is rarely found (approximately 4%), and as a result, there is no uniform agreement on diagnostic criteria for abnormalities. Similar problems exist in the use of electrophysiologic studies. Upright tilt testing and psychiatric examination may be useful in evaluation of recurrent syncope of unknown cause in patients without organic heart disease. Based on the results of recent studies, strategies for evaluation of patients with syncope are possible that utilize selective and goal-directed diagnostic testing.

Glossopharyngeal neuralgia with cardiac syncope. A case successfully treated by microvascular decompression

A case of glossopharyngeal neuralgia associated with episodic cardiac arrest and syncope is presented. Posterior fossa exploration showed that the left glossopharyngeal and vagus nerves were compressed by the posterior inferior cerebellar artery. Microvascular decompression resulted in complete relief of glossopharyngeal neuralgia, cardiac syncope, and seizure. The mechanism of glossopharyngeal neuralgia associated with cardiac syncope is discussed.

Glossopharyngeal neuralgia

A review is presented of the clinical features of glossopharyngeal neuralgia, as analysed from 304 reported instances. The sex-ratio of the condition is equal, the peak-age at onset is between 40 and 60 yrs, and left-side involvement predominates in females. The clinical features are detailed in 18 specific items. In a review of the aetiology it is argued that the so-called "idiopathic" type of IXth nerve neuralgia (which, upon careful analysis, may still rest upon either an obscure tumor or infection or elongated styloid process) should be primarily attributed to vascular elongation and looping ("Jannetta mechanism"). The cardiovascular type of the neuralgia, with bradycardia, or asystole and convulsions or coma, receives special emphasis. The differential diagnosis, particularly in view of the not-infrequently occurring combination with trigeminal neuralgia, is set out briefly.

Facial pain of neurologic origin mimicking oral pathologic conditions: some current concepts and treatment

A variety of pain syndromes of the face can arise from extradental pathologic conditions that can, at times, be confusing. Awareness of pain syndromes of neurologic origin that can mimic pathologic dental conditions is helpful. When doubt persists, rather than extract or endodontically treat a tooth, injection of a local anesthetic to the most sensitive areas can be a helpful diagnostic test. We recognize that there are many entities, including dental and temporomandibular joint syndromes, that much more often account for facial pain. However, we believe that those who most often treat these patients should also be aware of some of the advances in the understanding of the causes and treatment of the neurologic syndromes that can mimic pathologic oral conditions.

Glossopharyngeal neuralgia with syncope

Thirty-two cases of glossopharyngeal neuralgia complicated by syncope, cardiac arrhythmias or convulsions, singly or together, have been reported in the world literature. A further case is described and the clinical features of these thirty-three are reviewed. It is recommended that treatment should be undertaken as a matter of urgency. In the first place, Carbamezapine, with often the addition of Atropine, may prove effective. However, surgical intervention appears to give a better chance of permanent relief. Four alternative methods of surgery are discussed and the cervical or the intracranial approach recommended. Surgery should not be delayed in patients who fail to respond to medical treatment or in whom recurrence of symptoms occurs.

Glossopharyngeal neuralgia

Various factors have been considered in the etiology and pathogenesis of glossopharyngeal neuralgia. Vascular compression of the involved cranial nerves has been demonstrated in sporadic cases. In this series of six patients, it was noted with the aid of the operating microscope that the ninth and tenth cranial nerves were compressed by a tortuous vertebral artery or posterior inferior cerebellar artery at the nerve root entry zone in five cases. In selected patients, microvascular decompression without section of the nerves may result in a cure.

Cardiovascular complications on upper vagal rootlet section for glossopharyngeal neuralgia; case report

Acute hypotension and right bundle-branch block occurred when the authors sectioned the uppermost rootlet of the vagus nerve in a case of glossopharyngeal neuralgia. Hypotension lasted for 20 minutes and arrhythmia for 4 days. A possible mechanism is discussed and cardiovascular disorders are reviewed in similar cases.