Compressive lesions of the head and neck: Common and uncommon must-know entities

There are many lesions that cause compression of nerves and vessels in the head and neck, and they can often be overlooked in the absence of adequate history or if not suspected by the radiologist. Many of these lesions require a high index of suspicion and optimal positioning for imaging. While a multimodality approach is critical in the evaluation of compressive lesions, an MRI utilizing high-resolution (heavily weighted) T2-weighted sequence is extremely useful as a starting point. In this review, we aim to discuss the radiological features of the common and uncommon compressive lesions of the head and neck which are broadly categorized into vascular, osseous, and miscellaneous etiologies.

Long-Term Follow-Up of Ultrasound-Guided Glossopharyngeal Nerve Block Treatment for Glossopharyngeal Neuralgia: A Retrospective Clinical Study of 43 Cases

Background

Glossopharyngeal neuralgia (GPN) is a rare chronic neuropathic pain disorder that significantly impacts quality of life. Ultrasound-guided glossopharyngeal nerve blocks (UGPNB) have gained popularity due to their various advantages. However, there have been no studies reporting the long-term outcomes of UGPNB in a larger cohort of GPN patients.

Aim

This study aims to evaluate the efficacy and safety of UGPNB in patients with GPN.

Methods

We reviewed the electronic medical records of patients with GPN who received UGPNB at the Department of Pain Medicine of the First Medical Center, PLA General Hospital between June 1, 2011, and June 1, 2022. The effect of UGPNB was evaluated using the Barrow Neurological Institute (BNI) scale. Improvement was defined as a reduction in pain category by comparing pain categories before and after therapy. Recovery was defined as achieving BNI I after treatment. Patients who responded to treatment but then regressed to the category before therapy were considered to have experienced pain relapse.

Results

A total of 43 patients with GPN who received UGPNB were included in the analysis. At discharge, 35 (81.4%) patients experienced pain improvement after treatment, and among them, 13 (30.2%) patients achieved recovery. After discharge, 13 patients (37.1%) out of the 35 effective patients experienced pain relapse at different time intervals: 0.5, 0.7, 1, 1, 3, 3, 4, 12, 15, 36, 45, 63, and 96 months. The cumulative recurrence-free survival rates were 88.85% at month 1, 82.83% at month 3, 77.04% at month 12, 70.31% at month 36, and 54.66% at month 120. Among the 13 patients who experienced relapse, four patients received a second UGPNB treatment, and pain improved in two patients (50%). No severe adverse reactions were documented.

Conclusion

UGPNB is an effective, repeatable, safe, and minimally invasive treatment for patients with GPN. It may be preferable to consider UGPNB before undergoing invasive intracranial surgery or neurodestructive methods.

Long-term outcomes of Gamma Knife radiosurgery in treating glossopharyngeal neuralgia

Glossopharyngeal neuralgia (GPN) is an unusual disorder causing severe, brief pain episodes in the areas supplied by the glossopharyngeal nerve. Initial treatment involves medications like carbamazepine, but if these are ineffective or cause side effects, interventional pain management techniques or surgery may be considered. Gamma Knife radiosurgery is becoming popular in managing GPN due to its lower risk of complications than surgical interventions like microvascular decompression or rhizotomy. In this retrospective case series, we examined the outcomes of Gamma Knife radiosurgery in eight patients with GPN. The decision to utilize Gamma Knife radiosurgery was made following specific criteria, including failed surgical interventions, patient preference against surgery, or contraindications to surgical procedures. Patients were administered radiation doses within the range of 80 to 90 Gy, targeting either the cisternal glossopharyngeal nerve or glossopharyngeal meatus of the jugular foramen. Evaluations were conducted before the Gamma Knife radiosurgery; at 3, 6, and 12 months after Gamma Knife radiosurgery; and annually thereafter. Pain severity was assessed using the modified Barrow Neurological Institute scale grades, with patients achieving grade I-IIIa considered to have a good treatment outcome and grade IV-V to have a poor treatment outcome. Pain control and absence of radiosurgery-related complications were primary endpoints. The median age of the patients was 46.5 years, varying from 8 to 72 years. The median duration of pain was 32 months (range, 12-120 months). All patients, except one, were on polydrug therapy. All cases exhibited preoperative grade V pain. The median follow-up duration after Gamma Knife radiosurgery was 54.5 months, varying from 14 to 90 months. The overall clinical assessments revealed a gradual neurological improvement, particularly within the first 8.5 weeks (range, 1-12 weeks). The immediate outcomes at 3 months revealed that all patients (8/8, 100%) experienced pain relief, with 25% (2/8) achieving a medication-free status (Grade I). Three patients (37%) experienced a recurrence during the follow-up and were managed with repeat Gamma Knife radiosurgery (n = 2) and radiofrequency rhizotomy (n = 1). At the last follow-up, 88% (7/8) of patients had pain relief (Grades I-IIIa), with three (37%) achieving a medication-free status (Grade I). No adverse events or neurological complications occurred. The patient who underwent radiofrequency rhizotomy continued to experience inadequately controlled pain despite medication (Grade IV). Gamma Knife radiosurgery is a non-invasive, efficacious treatment option for idiopathic GPN, offering short- and long-term relief without permanent complications.

Case report: Significance of the large rhomboid lip in microvascular decompression: insights from two clinical cases

The rhomboid lip (RL) is a layer of neural tissue that extends outside the fourth ventricle and is connected to the lateral recess of the fourth ventricle. Although this anatomical structure has been rigorously studied, it is often overlooked in microvascular decompression (MVD) surgery. In this report, we present two cases, one of hemifacial spasm (HFS) and one of glossopharyngeal neuralgia (GPN), in which a large RL was observed during surgery. We found that a large RL is easily confused with arachnoid cysts, and accurate identification and dissection are important to protect the lower cranial nerves.

Microvascular decompression using a fully transcranial neuroendoscopic approach

OBJECTIVE

To evaluate the effectiveness and safety of microvascular decompression (MVD) using a fully transcranial neuroendoscopic approach.

METHODS

Thirty-one patients who underwent MVD using a fully transcranial neuroendoscopic approach in our department between May 2016 and September 2019 were retrospectively reviewed.

RESULTS

All patients successfully underwent MVD, and immediate pain relief was achieved in all 17 cases of trigeminal neuralgia (TGH) and 3 cases of glossopharyngeal neuralgia (GPN). Hemifacial spasm (HFS) was completely resolved in all 11 patients. No mortality or permanent complication was seen.

CONCLUSIONS

The endoscope is a useful tool for confirming vascular conflict identified by the microscope and is helpful in detecting the vessel responsible for neuralgia without retracting the brain and nerves. MVD using a fully transcranial neuroendoscopic approach is an effective and safe alternative to endoscopic-assisted MVD and traditional MVD.

Comparative analysis of MVD and RHZ in the treatment of primary glossopharyngeal neuralgia: A clinical report on 61 cases

Objective

Clinical data on 61 patients (grouped by their treatment with MVD or RHZ) with glossopharyngeal neuralgia were analyzed retrospectively. A summary analysis of the effective rate and surgical complications of MVD and RHZ in the treatment of glossopharyngeal neuralgia was performed to observe the new surgical options for GN.

Method

From March 2013 to March 2020, 63 patients with GN were admitted to our hospital by the professional group of cranial nerve diseases. Two patients diagnosed with tongue and pharynx pain secondary to tongue cancer and upper esophageal cancer, respectively were excluded from the group. The remaining patients all met the diagnosis of GN, some of them were treated with MVD and others were treated with RHZ. The pain relief rate, long-term results, and complications of the patients in the two groups were well-organized and analyzed.

Result

Of the 61 patients, 39 were treated with MVD and 22 were treated with RHZ. In the early-stage patients (the first 23 patients), all of them were operated on with the MVD procedure except one patient without vascular compression. In the later-stage patients, MVD was performed for evident single arterial compression according to the intraoperative situation. And for compression of arteries with greater tension or PICA + VA complex compression, RHZ was performed. It was also performed in cases where vessels with tight adhesions to the arachnoid and nerves could not be easily separated, or where it was easy to damage the perforating arteries after separating the blood vessels, causing vasospasm, which affects the blood supply to the brainstem and cerebellum. RHZ was also performed if there was no clear vascular compression. The efficiency of both groups was 100%. In the MVD group, one case recurred 4 years after the initial operation, and RHZ was performed for reoperation. Complications related to the operation included one case of swallowing and coughing in the MVD group, and three cases in the RHZ group; two cases of uvula not centering in the MVD group, and five cases in the RHZ group. There was 2 patients in RHZ group lost taste in 2/3 of the backing of the tongue, though these symptoms mostly disappeared or decreased after follow-up. One patient in the RHZ group had developed tachycardia by the time of the long-term follow-up, but whether it was related to the surgery is still uncertain. In terms of serious complications, there were two cases of postoperative bleeding in the MVD group. Based on the clinical characteristics of the patients' bleeding, it was judged that the cause of the bleeding was ischemia and was related to an intraoperative injury to the penetrating artery of the PICA artery and vasospasm.

Conclusion

MVD and RHZ are effective methods for the treatment of primary glossopharyngeal neuralgia. MVD is recommended for cases where vascular compression is clear and easy to handle. However, for cases with complex vascular compression, tight vascular adhesions, difficult separation, and without clear vascular compression, RHZ could be performed. Its efficiency is equivalent to MVD, and there is no significant increase in complications such as cranial nerve disorders. There are few cranial nerve complications that seriously affect the quality of life of patients. RHZ helps to reduce the risk of ischemia and bleeding during surgery by reducing the risk of arterial spasms and injury to the penetrating arteries by separating the vessels due to separation of vessels during MVD. At the same time, it may reduce the postoperative recurrence rate.

Ultrasound-guided repetitive pulsed peripheral magnetic stimulation provides pain relief in refractory glossopharyngeal neuralgia: A case report

Aims

Repetitive peripheral magnetic stimulation (rPMS) is a novel nonpharmacological treatment modality. This noninvasive approach can stimulate peripheral nerves to provide analgesia through neuromodulation. We report the first case of ultrasound-guided rPMS to treat a case of severe refractory glossopharyngeal neuralgia.

Methods

A 70-year-old female with an 8-year history of glossopharyngeal neuralgia reported refractory pain unresponsive to pharmacological and interventional treatments. After consenting to treatment, the patient received high-frequency rPMS in three different sessions using intermittent theta burst stimulation below motor thresholds. rPMS was applied over the skin directed at the glossopharyngeal nerve identified using ultrasound guidance. Session 1 included 20 min of continuous treatment, session 2 included 40 min of treatment (two 20-min treatments separated by a 10-min break), session 3 included 40 min of treatment (similar to Session 2) repeated daily for 5 days. Pre- and postintervention pain levels were collected with a daily 1-week pain diary and pain questionnaires.

Results

Session 1 led to an immediate 30% decrease in pain after treatment. Session 2 led to a 75% decrease in pain immediately after treatment that remained reduced for approximately 2 days. Session 3 produced complete pain relief immediately after treatment and remained lower for 5 days after treatment and returned to baseline levels at 1 week.

Conclusion

rPMS provided immense but temporary relief in a severe case of refractory glossopharyngeal neuralgia. Further work is needed to determine the most effective regimen to treat complex pain disorders in the head and neck.

Case report: Trigeminal neuralgia misdiagnosed as glossopharyngeal neuralgia

Background

Trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GPN) are cranial nerve neuralgias with the same clinical manifestations, pathological features, and trigger factors; their affected sites are adjacent. Performing a magnetic resonance imaging (MRI) examination alone can easily lead to a misdiagnosis.

Case presentation

A 72-year-old man had visited another hospital with severe left-sided tongue pain. On MRI, vascular compression of the glossopharyngeal nerve had been visible, with unclear evidence of trigeminal nerve involvement. He had been diagnosed with left-sided GPN and underwent microvascular decompression (MVD) of the left glossopharyngeal nerve. However, no improvement was observed after surgery. During a second surgery at our hospital, MVD of the trigeminal nerve was performed, and the trigeminal nerve was fully explored and separated. The patient's pain resolved after surgery. Ultimately, the patient was definitively diagnosed with left-sided TN.

Discussion and conclusion

MVD is currently the most efficacious surgical option for treating cranial nerve neuralgia. To select patients for MVD, having an MRI criteria for identifying true neurovascular compression will be helpful. However, clinicians should focus more on a patient's clinical symptoms and not rely solely on MRI findings. This patient's case can help clinicians distinguish between TN and GPN, improve the understanding of these diseases, avoid misdiagnosis, and reduce the possibility of secondary damage.

Case report: Fully endoscopic microvascular decompression for glossopharyngeal neuralgia

With the advances in endoscopic technology, endoscopy is widely used in many neurosurgical procedures, such as microvascular decompression, which is an effective method to treat glossopharyngeal neuralgia, trigeminal neuralgia, and facial spasm. The purpose of this study was to determine the efficacy of fully endoscopic microvascular decompression in the treatment of glossopharyngeal neuralgia. We managed a patient with glossopharyngeal neuralgia in our department, whose main clinical manifestation was recurrent left ear and facial pain for 3 years. The patient underwent a fully endoscopic microvascular decompression. The pain in the left ear and face was significantly relieved postoperatively, and there was no recurrence at the 6-month follow-up evaluation. We describe a case of glossopharyngeal neuralgia that was successfully treated by fully endoscopic microvascular decompression, which showed that endoscopy has advantages in microvascular decompression, and fully endoscopic microvascular decompression is an effective method for glossopharyngeal neuralgia.

Refractory glossopharyngeal neuralgia successfully treated with onabotulinumtoxinA: A case report

BACKGROUND

Glossopharyngeal neuralgia is a rare but severe and disabling pain condition often caused by vascular compression of the glossopharyngeal nerve. Treatment is similar to that of trigeminal neuralgia, but some patients may be refractory to both medical and surgical approaches. Here we present a case of refractory glossopharyngeal neuralgia that responded well to onabotulinumtoxinA (BTX-A).

CASE

We report a case of a 65-year-old man with well-controlled human immunodeficiency virus disease with glossopharyngeal neuralgia symptoms since 2015. He had partial response to medications but was limited by side-effects. He underwent microvascular decompression twice with initial relief both times, but experienced recurrence of attacks 1-3 years after each surgery. He was treated with BTX-A using the chronic migraine PREEMPT protocol (i.e., 31-39 injection sites in head and neck muscles), which led to significant relief of his glossopharyngeal neuralgia pain.

CONCLUSIONS

This is the first case to our knowledge of glossopharyngeal neuralgia treated with BTX-A. BTX-A can be an effective treatment for glossopharyngeal neuralgia, even when injections are not administered directly over the sensory distribution of the glossopharyngeal nerve.

Avellis syndrome with ipsilateral prosopalgia, glossopharyngeal neuralgia, and central post-stroke pain: A case report and literature review

RATIONALE

Avellis syndrome is a rare bulbar syndrome. The main lesions may involve nucleus ambiguus and the lateral spinothalamic tract. The typical reported clinical manifestations are hoarseness, dysphagia, pain, and temperature disturbance of contralateral body. The manifestations, however, may vary. We aim to report new manifestations of Avellis syndrome in this report.

PATIENT CONCERNS

A 47-year-old Chinese peasant woman who felt sudden dizziness, nausea when she was doing the laundry was referred to our department from other hospital. She vomited the stomach contents once and complained numbness of the left trunk and limbs as well as coughing while drinking. The patient presented with palatopharyngeal paralysis, Horner syndrome, and diminished pain as well as temperature sensation in the contralateral face, trunk, and limbs. She also presented with ipsilateral prosopalgia, glossopharyngeal neuralgia, and central poststroke pain.

DIAGNOSES

T2-weighted MRI images demonstrated a high-signal intensity lesion in the right medulla oblongata which indicated a banded infarction site. The patient was diagnosed with medulla oblongata infarction, Avellis syndrome, Horner syndrome, dysphagia, hemiparesthesia, ipsilateral prosopalgia, glossopharyngeal neuralgia, and central poststroke pain.

INTERVENTIONS

The patient was administrated aspirin to prevent the aggregation of platelet and rosuvastatin tablets to regulate lipids as well as to stabilize vascular plaque. She was injected with butylphthalide sodium chloride to improve nerve nutritional status and carbamazepine was prescribed to deal with prosopalgia and glossopharyngeal neuralgia. Gabapentin and pregabalin were administrated to deal with the central poststroke pain.

OUTCOMES

The symptoms of prosopalgia as well as glossopharyngeal neuralgia were gone, and dizziness, dysphagia, and Horner syndrome were significantly alleviated when she was discharged from the hospital while the interventions showed little effect on central poststroke pain.

LESSONS

We reported a case of Avellis syndrome who manifested as the typical reported manifestations. The patient, what's more, presented with ipsilateral trigeminal, glossopharyngeal neuralgia, and central poststroke pain which were described for the first time. It is of great significance for clinicians to recognize the typical as well as other manifestations which helps to make a clear diagnosis.

Glossopharyngeal Neuralgia: Epidemiology, Risk factors, Pathophysiology, Differential diagnosis, and Treatment Options

Purpose of Review

This is a comprehensive review of the most recent literature on glossopharyngeal neuralgia (GPN), a relatively rare form of neuropathic facial pain. It covers the epidemiology, risk factors, pathophysiology, and differential diagnosis given that glossopharyngeal neuralgia can often be confused with other facial pain syndromes. Finally, we extensively review recent findings regarding medical or conservative measures, minimally invasive, and surgical options for potentially treating and managing glossopharyngeal neuralgia.

Recent Findings

An in-depth analysis of the recent literature indicates that glossopharyngeal neuralgia is not only rare but its etiology and pathophysiology are complex and are often secondary to other disease processes. Regardless, current management options are shown to be effective in controlling pain. Conservatively, first-line management of GPN is carbamazepine, but gabapentin and eslicarbazepine acetate are suitable alternatives. In terms of current minimally invasive pain management techniques, pulsed radiofrequency ablation, nerve blocks, or percutaneous radiofrequency thermocoagulation are effective. Finally, surgical management involves microvascular decompression and rhizotomy.

Summary

While there are currently many viable options for addressing glossopharyngeal neuralgia pain ranging from conservative to surgical management, the complex nature of GPN etiology, pathophysiology, and involved anatomical structures prompts further research for more effective ways to treat the disease.

Prognostic factors for long-term outcomes of microvascular decompression in the treatment of glossopharyngeal neuralgia: a retrospective analysis of 97 patients

OBJECTIVE

The authors aimed to investigate predictors of postoperative outcomes of microvascular decompression (MVD) for the treatment of glossopharyngeal neuralgia (GPN).

METHODS

A cohort of 97 patients with medically refractory GPN who underwent MVD at the authors' institution between January 2010 and July 2019 was retrospectively reviewed. Univariate and multivariate regression models were used to identify predictors of long-term outcome in patients after MVD.

RESULTS

Eighty-nine patients (91.8%) reported immediate and complete relief of pain after the procedure. Of the remaining 8 patients (8.2%), 6 achieved partial pain relief and pain gradually diminished within 2 weeks after surgery, and 2 did not experience postoperative pain relief. In univariate Cox regression analysis, venous compression of the glossopharyngeal nerve root entry zone (HR 3.591, 95% CI 1.660-7.767, p = 0.001) and lower degree of neurovascular conflict (HR 2.449, 95% CI 1.177-5.096, p = 0.017) were significantly associated with worse pain-free survival. In multivariate Cox regression analysis, venous compression (HR 8.192, 95% CI 2.960-22.669, p < 0.001) and lower degree of neurovascular conflict (HR 5.450, 95% CI 2.069-14.356, p = 0.001) remained independently associated with worse pain-free survival.

CONCLUSIONS

Venous compression of the glossopharyngeal nerve root entry zone and lower degree of neurovascular conflict were significantly correlated with shorter pain-free survival in patients who underwent MVD for GPN. Microvascular decompression is a safe, feasible, and durable approach with a low complication rate for the treatment of GPN.

Posterior condylar canal dural arteriovenous fistula as a rare cause of glossopharyngeal neuralgia: A case report

BACKGROUND

The symptoms of dural arteriovenous fistula (dAVF) vary according to the location of the fistula and the pattern of venous drainage. Here, we report the case of a patient with a dAVF-induced glossopharyngeal neuralgia.

CASE DESCRIPTION

We report a case of a patient with right glossopharyngeal neuralgia caused by a posterior condylar canal (PCC) dAVF. The glossopharyngeal neuralgia was accompanied by persistent tinnitus and repetitive right side otalgia, as well as ipsilateral shoulder and throat pain, lasting for about 30 s. However, there were no specific findings on otoscopic examination. Cranial magnetic resonance imaging was performed to determine the cause of the symptoms, and a right PCC dAVF was observed. The dAVF was successfully obliterated using transvenous coil embolization. After embolization, the patient's symptoms were completely resolved.

CONCLUSION

Although glossopharyngeal neuralgia caused by dAVF is rare, it can present due to intracranial lesions located adjacent to the glossopharyngeal nerve or vagus nerve. Brain MRI is therefore required to identify secondary causes in all patients with glossopharyngeal neuralgia.

Microvascular Decompression for Glossopharyngeal Neuralgia in the Semi-Sitting Position: A Report of Two Cases

The semi-sitting position is well known to neurosurgeons. However, there are few reports of microvascular decompression surgery for glossopharyngeal neuralgia performed using the semi-sitting position. The semi-sitting position is not widely adopted in Japan, but it is considered to be a very useful neurosurgical position. Microvascular decompression surgery for glossopharyngeal neuralgia is a relatively rare procedure, and the semi-sitting position is very effective, considering the possibility of intraoperative cardiac arrest and postoperative complications of lower cranial nerve palsy. This report describes two cases of glossopharyngeal neuralgia operated in the semi-sitting position. Microvascular decompression was performed on both patients, and postoperative pain controls were good and no complications were observed. We show that the use of the semi-sitting position to perform microvascular decompression for glossopharyngeal neuralgia provides an excellent surgical view of the brainstem.

Endoscopic Microvascular Decompression for Vagoglossopharyngeal Neuralgia

Glossopharyngeal neuralgia (GN) is a nerve compression syndrome that presents with episodes of unilateral sharp, stabbing pain in the distribution of the ninth cranial nerve. This syndrome may present with cardiac and autonomic manifestations - a condition termed vagoglossopharyngeal neuralgia (VGPN). Most cases of VGPN arise from neurovascular insult at the cerebellopontine angle. Conservative treatment for VGPN includes antiepileptic medications. Surgical treatments include trigeminal tractotomy-nucleotomy, Gamma Knife® stereotactic radiosurgery, radiofrequency thermocoagulation, rhizotomy, and, as shown in this paper, endoscopic microvascular decompression (E-MVD). In this article, we present two cases. Case 1 demonstrates a 53-year-old male with right-sided GN symptoms that began to experience syncopal episodes 10-years after the initial presentation. Case 2 presents a 61-year-old female with a history of Ehlers-Danlos syndrome, and the malignant vasovagal syndrome that became associated with painful, shooting left anterior neck spasms consistent with GN. Both patients underwent E-MVD, leading to complete relief of neuralgia and cardiac symptoms. Our outcomes support previously published reports of successful treatment of VGPN using microvascular decompression (MVD) and describe a purely endoscopic surgical technique. MVD is the preferred treatment option for VGPN with evident neurovascular insult.

Comparison of extraoral and intraoral routes of glossopharyngeal nerve block for pain relief in patient with carcinoma tongue: A prospective randomized study

Background and Objective

Glossopharyngeal nerve block (GNB) technique has been used as alternative of treatment of cancer and noncancer pain of the oral cavity. The objective of the study is to compare the two approaches (extraoral and intraoral) of GNB in patients of carcinoma of the tongue in terms of efficacy, duration, and complications.

Materials and Methods

This was a prospective comparative randomized study over a period of 1 year. Fifty patients of either sex of ASA physical status and 2, between 21 and 70 years of age, suffering from carcinoma of the tongue, were selected. The patients were randomly divided into two groups. Group I received 4 mL of 0.5% bupivacaine combined with 40 mg, of triamcinolonacetonide by extraoral approach of GNB, and Group II received the same amount of drug by intraoral approach of GNB. Hemodynamic parameters, degree of pain relief using visual analog scale (VAS), number of attempts, effect on quality of life (QOL), and complication were noted during the performance of GNB.

Results

Demographic profile in both groups was comparable. Rate of complication and number of attempts to complete intervention were higher in Group I, which was found to be statistically significant. However, mean VAS scores in Group I were significantly higher as compared to those in Group II during most of the study period starting from the 1^st follow-up at 30 min to the 2^nd month postintervention (P < 0.05). No statistically significant difference in mean QOL scores of two groups was observed for the entire study period except at 1 week when mean scores in Group I were higher as compared to those in Group II (P = 0.011).

Conclusion

The intraoral approach of GNB was better with respect to pain control and improvement in QOL whereas the rate of complication and number of attempts was lower in extraoral approach of GNB.

Craniofacial neuralgias

While non-headache, non-oral craniofacial neuralgia is relatively rare in incidence and prevalence, it can result in debilitating pain. Understanding the relevant anatomy of peripheral branches of nerves, natural history, clinical presentation, and management strategies will help the clinician better diagnose and treat craniofacial neuralgias. This article will review the nerves responsible for neuropathic pain in periorbital, periauricular, and occipital regions, distinct from idiopathic trigeminal neuralgia. The infratrochlear, supratrochlear, supraorbital, lacrimal, and infraorbital nerves mediate periorbital neuralgia. Periauricular neuralgia may involve the auriculotemporal nerve, the great auricular nerve, and the nervus intermedius. The greater occipital nerve, lesser occipital nerve, and third occipital nerve transmit occipital neuralgias. A wide range of treatment options exist, from modalities to surgery, and the evidence behind each is reviewed.

Microvascular Decompression Surgery for Elderly Patients: A Study Based on Proposals from the Joint Committee of the Japan Gerontological Society and the Japan Geriatrics Society

The present study evaluated the indications for microvascular decompression (MVD) in elderly patients based on the new classification of the elderly population proposed by the joint committee of the Japan Gerontological Society and the Japan Geriatrics Society in 2017.

Retrospective analysis of 171 patients with hemifacial spasm (HFS), trigeminal neuralgia (TN), and glossopharyngeal neuralgia (GPN) who underwent MVD in 2018. Patients were divided into three groups based on the proposal: old group, 75–89 years; pre-old group, 65–74 years; and not-old group, 64 years or younger. Preoperative comorbidities were divided into five types and the American Society of Anesthesiologists Physical Status (ASA-PS) was recorded. Outcome of the surgery and neurological complications were evaluated in June 2019.

No decrease in activity of daily living occurred in any patient and surgical results showed no difference among the three groups. Rate of preoperative cardiovascular diseases was higher in both the pre-old and old groups compared with the not-old group (p <0.001 and Cramer V = 0.429). In terms of ASA-PS classification, only ASA-PS I and II were found, and rate of ASA-PS II was higher in the pre-old and old groups compared with the not-old group (p <0.001 and Cramer V = 0.407). Some patients suffered from elevated blood pressure after surgery, but were successfully managed.

In conclusion, MVD for elderly patients can be achieved safely with careful patient selection and perioperative management. Data should be continuously accumulated for the future development of decision-making algorithm for MVD in the elderly.

Glossopharyngeal neuralgia as initial symptom in combined hyperactive dysfunction syndrome: case report

OBJECTIVES

Hyperactive dysfunction syndrome (HDS) is defined as symptoms arising from overactivities in cranial nerves, like trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN). A combination of these cranial nerve neuralgias, that might or might not occur in one or both sides, either synchronously, or metachronously is called combined hyperactive dysfunction syndrome (CHDS).

CASE PRESENTATION

We presented a 73 years-old male patient with CHDS presenting with GPN as the initial symptom, with total relief from GPN, TN, and HFS after microvascular decompression. Up to date, only nine patients have been reported in the literature with symptomatic.

CONCLUSIONS

TN-HFS-GPN. Our case is the first case with GPN as the initial symptom. The combination of arterial and venous origin of the offending vessels makes the case picturesage.

Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia

OBJECTIVE

Glossopharyngeal neuralgia (GN) is a rare pain condition in which patients experience paroxysmal, lancinating throat pain. Multiple surgical approaches have been used to treat this condition, including microvascular decompression (MVD), and sectioning of cranial nerve (CN) IX and the upper rootlets of CN X, or a combination of the two. The aim of this study was to examine the long-term quality of life and pain-free survival after MVD and sectioning of the CN X/IX complex.

METHODS

A combined retrospective chart review and a quality-of-life telephone survey were performed to collect demographic and long-term outcome data. Quality of life was assessed by means of a questionnaire based on a combination of the Barrow Neurological Institute pain intensity scoring criteria and the Brief Pain Inventory-Facial. Kaplan-Meier analysis was performed to determine pain-free survival.

RESULTS

Of 18 patients with GN, 17 underwent sectioning of the CN IX/X complex alone or sectioning and MVD depending on the presence of a compressing vessel. Eleven of 17 patients had compression of CN IX/X by the posterior inferior cerebellar artery, 1 had compression by a vertebral artery, and 5 had no compression. One patient (6%) experienced no immediate pain relief. Fifteen (88%) of 17 patients were pain free at the last follow-up (mean 9.33 years, range 5.16-13 years). One patient (6%) experienced throat pain relapse at 3 months. The median pain-free survival was 7.5 years ± 10.6 months. Nine of 18 patients were contacted by telephone. Of the 17 patients who underwent sectioning of the CN IX/X complex, 13 (77%) patients had short-term complaints: dysphagia (n = 4), hoarseness (n = 4), ipsilateral hearing loss (n = 4), ipsilateral taste loss (n = 2), and dizziness (n = 2) at 2 weeks. Nine patients had persistent side effects at latest follow-up. Eight of 9 telephone respondents reported that they would have the surgery over again.

CONCLUSIONS

Sectioning of the CN IX/X complex with or without MVD of the glossopharyngeal nerve is a safe and effective surgical therapy for GN with initial pain freedom in 94% of patients and an excellent long-term pain relief (mean 7.5 years).

Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal neuralgia: a retrospective study

Objective

To examine the effectiveness and safety of ultrasound-guided glossopharyngeal nerve block via the styloid process for primary glossopharyngeal neuralgia.

Methods

This retrospective study included all patients receiving glossopharyngeal nerve block via the styloid process under ultrasound guidance for primary glossopharyngeal neuralgia between January 2015 and May 2018 at our hospital. The primary outcome of the study was pain relief as assessed using the visual analog scale (VAS). Treatment was considered effective if the VAS score decreased by more than 2 points.

Results

Twelve patients were included in the analysis. The baseline VAS scores ranged from 5 to 9. All patients received previous pharmacotherapy. Other previous treatments included pulsed mode radiofrequency (n=4), microvascular decompression (n=2), and glossopharyngeal nerve block (not under ultrasound guidance; n=2). The patients completed a total of 48 injections for glossopharyngeal nerve block. At discharge from the hospital, and at 6, 12, and 18 months thereafter, 10/12, 10/12, 7/12, and 4/12 patients achieved pain relief and the effective rate was 83.3% at discharge, 83.3% at 6 months, 58.3% at 1 year, and 33.3% at 18 months, respectively.

Conclusion

Ultrasound-guided glossopharyngeal nerve block via the styloid process is a safe, radiation-free, repeatable, convenient, and effective treatment. It can provide a treatment option for patients with glossopharyngeal neuralgia.

Gradual aggravation of idiopathic glossopharyngeal neuralgia due to chronic tonsillitis: A case report

RATIONALE

Glossopharyngeal neuralgia (GPN) is a rare type of neuralgia. Depending on the cause, it is classified as idiopathic GPN and secondary GPN. Secondary GPN can also be caused by a mass effect or inflammation of the tonsils, the innervation area of glossopharyngeal nerve.

PATIENT CONCERNS

The patient was diagnosed idiopathic GPN 8 years ago. The patient had intermittent pain, but the pain was well controlled. From 5 months ago, the pain gradually worsened, the patient complained severe pain which impaired chewing and swallowing function.

DIAGNOSES

Idiopathic GPN, secondary GPN, chronic tonsillitis INTERVENTIONS:: Percutaneous glossopharyngeal nerve block, glossopharyngeal neurolysis, and pulsed radiofrequency neuromodulation of glossopharyngeal nerve were performed. After the diagnosis of tonsillitis, antibiotic therapy was performed OUTCOMES:: Two weeks after the antibiotic treatment, the pain decreased simultaneously with the patient's tonsillitis recovery.

LESSONS

In a Patient who had already been diagnosed with idiopathic GPN, both pain control and its cause should be considered when the pain is aggravated.

Glossopharyngeal Neuralgia with Syncope Caused by Recurrence of Esophageal Squamous Cell Carcinoma

We herein report a case of glossopharyngeal neuralgia with repeated syncope caused by the recurrence of esophageal carcinoma. The typical symptoms of glossopharyngeal neuralgia are paroxysmal, stabbing, electric shock-like pain in the pharynx and/or base of the tongue on swallowing and talking. In addition, syncope can also be caused by glossopharyngeal neuralgia. The diagnosis of glossopharyngeal neuralgia is not always easy because of its rarity. In the present case, we suspected that repeated syncope was caused by glossopharyngeal neuralgia due to the recurrence of esophageal carcinoma. Concurrent chemoradiation therapy was effective in reducing the tumor size, which resulted in the complete resolution of the symptoms.

Endoscope-Assisted Microneurosurgery for Neurovascular Compression Syndromes: Basic Principles, Methodology, and Technical Notes

Background:

Microscopic microvascular decompression (MVD) has a low but not negligible failure rate due to some missed conflicts, especially in case of multiple offending vessels. The reported study is aimed to assess the principles, methodology, technical notes, and effectiveness of the endoscope-assisted (EA) MVD for neurovascular compression syndromes (NVCS) in the posterior fossa.

Materials and Methods:

A series of 43 patients suffering from an NVCS and undergone to an EA MVD were retrospectively reviewed. Syndromes were trigeminal neuralgia in 25 cases, hemifacial spasm in nine cases, positional vertigo in six cases, glossopharyngeal neuralgia in two cases, and spasmodic torticollis in one case. In all cases, a 0°–30° specially designed endoscope was inserted into the surgical field to find/treat those conflicts missed by the microscopic exploration. Each procedure was judged in terms of the effectiveness of the adjunct of the endoscope according to a three types classification system: Type I – improvement in the visualization of the nerve's root entry/exit zone; Type II – endoscopic detection of one or more conflicts involving the ventral aspects of the nerve and missed by the microscope; Type III – endoscope-controlled release of the neurovascular conflict otherwise difficult to treat under the only microscopic view.

Results:

A total of 55 conflicts were found and treated. Twenty-eight procedures were classified as Type I, nine as Type II, and six as Type III. All the patients had a full recovery from their symptoms.

Conclusions:

In selected cases, EA MVD offers some advantages in the detection and treatment of neurovascular conflicts in the posterior fossa.

MRI Findings and Outcomes in Patients Undergoing Microvascular Decompression for Glossopharyngeal Neuralgia

BACKGROUND AND PURPOSE

Glossopharyngeal neuralgia causes extreme paroxysmal pain in the posterior pharynx, tonsillar region, base of tongue, or deep ear, that is, the distribution of the glossopharyngeal nerve. Some cases of glossopharyngeal neuralgia are associated with neurovascular conflict, usually by the posterior inferior cerebellar artery. Such symptomatic compression occurs only in proximal, centrally myelinated portions of the glossopharyngeal nerve near the brainstem. Microvascular decompression provides effective and durable pain relief for properly selected patients with medically refractory glossopharyngeal neuralgia. The purpose of this study is to describe a tailored MRI evaluation of neurovascular conflict in glossopharyngeal neuralgia to improve candidate selection for microvascular decompression.

METHODS

Our team developed a glossopharyngeal neuralgia imaging and evaluation protocol including a grading system for neurovascular conflict of the glossopharyngeal nerve and applied it to evaluate candidates for microvascular decompression.

RESULTS

Our team grades neurovascular conflict as "contact" (vessel touching nerve without intervening cerebrospinal fluid) versus "deformation" (deviation or distortion of nerve from its normal course by the offending vessel). MRIs of patients with glossopharyngeal neuralgia demonstrate proximal neurovascular conflict. Postoperative MRI demonstrates separation of the glossopharyngeal nerve from the offending vessel.

CONCLUSION

A tailored glossopharyngeal neuralgia imaging evaluation protocol is presented. We believe this approach has helped improve microvascular decompression outcomes and reduce unnecessary procedures at our institution. Further research may elucidate whether clinical and imaging features, including neurovascular conflict severity, predict surgical outcome for glossopharyngeal neuralgia.

Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: an international multicenter study

OBJECTIVE The goal of this study was to evaluate the outcomes of Gamma Knife stereotactic radiosurgery (SRS) when used for patients with intractable idiopathic glossopharyngeal neuralgia. METHODS Six participating centers of the International Gamma Knife Research Foundation identified 22 patients who underwent SRS for intractable glossopharyngeal neuralgia between 1998 and 2015. The median patient age was 60 years (range 34-83 years). The median duration of symptoms before SRS was 46 months (range 1-240 months). Three patients had unsuccessful prior surgical procedures, including microvascular decompression (MVD) (n = 2) and balloon compression (n = 1). The radiosurgical target was the glossopharyngeal meatus. The median maximum dose was 80 Gy. RESULTS The median follow-up was 45 months after SRS (range 6-120 months). Twelve patients (55%) had < 4 years of follow-up. Thirteen patients (59%) had initial complete pain relief at a median of 12 days after SRS (range 1-60 days). Three patients (14%) had partial pain relief at a median of 70 days after SRS (range 60-90 days). Six patients (27%) had no pain relief. Among 16 patients with initial pain relief, 5 maintained complete pain relief without medication (Barrow Neurological Institute [BNI] pain intensity score Grade I), 1 maintained occasional pain relief without medication (BNI Grade II), 3 maintained complete pain relief with medication (BNI Grade IIIb), and 7 patients had pain recurrence at a median of 20 months after SRS (range 6-120 months). The rates of maintenance of adequate pain relief (BNI Grades I-IIIb) were 63% at 1 year, 49% at 2 years, 38% at 3 years, 38% at 5 years, and 28% at 7 years. When 7 patients without pain recurrence within 4 years of follow-up were excluded, the rates of maintenance of adequate pain relief were 38% at 5 years and 28% at 7 years. Ten patients required additional procedures (MVD, n = 4; repeat SRS, n = 5; glossopharyngeal nerve block, n = 1). Four of 5 patients who underwent repeat SRS maintained pain relief (BNI Grade I, n = 3; and BNI Grade IIIb, n = 1). No adverse effects of radiation were observed after a single SRS. Two patients developed hyperesthesia in the palatoglossal arch 5 and 8 months after repeat SRS, respectively. CONCLUSIONS Stereotactic radiosurgery for intractable, medically refractory glossopharyngeal neuralgia provided lasting pain reduction in 55% of patients after 1 or 2 SRS procedures. Patients who had a poor response or pain recurrence may require additional procedures such as repeat SRS, MVD, nerve blocks, or nerve section. No patient developed changes in vocal cord function or swallowing disorders after SRS in this study.

[Cause analysis of one case multiply misdiagnosed patient with hypopharyngeal carcinoma]

The clinical manifestations were pharyngalgia anddysphagia. Physical examination found that the size of a mobilizable and hard lymph node in the area of the right neck Ⅱ was about 2.0 cm×2.0 cm. Ultrasound examination demonstrated abnormal lymphadenopathy in bilateral neck which was considered metastatic cancer. Neck CT showed occupation of the hypopharynx, thickening bilateral aryepiglottic folds and false vocal cords, and enlargement lymph node in the bilateral neck Ⅱ area. Upper gastrointestinal radiography: The mucosa from the lower border of right pear-shaped fossa to the entrance of the esophagus was disrupted, and the partial lumen was narrowed. There were no abnormalities in the remaining segments. Pathologicalexamination of postoperative: hypopharyngealmoderately differentiated squamous cell carcinoma,invasion of the muscularis propria, lymph node cancerometastasis in the left cervical Ⅱ, Ⅲ, and Ⅳ regions (1/19); lymph node cancerometastasis in the right cervical Ⅱ, Ⅲ, and Ⅳ regions (6/12).

Continuous radiofrequency thermocoagulation under CT-guidance for glossopharyngeal neuralgia: Two case reports

RATIONALE

Glosssopharyngeal neuralgia (GPN) is a painful syndrome characterized by paroxysmal neuropathic pain in the pharynx, tonsil, posterior base of tongue, inner ear, and mandibular angle. The traditional therapies of GPN, including medication and surgical operation, are not always effective in pain controlling. Radiofrequency therapy is a minimally interventional technique to provide analgesia in chronic pain.

PATIENT CONCERNS

Two patients who were refractory to medical treatment were hospitalized for primary GPN.

DIAGNOSES

Two patients were diagnosed by symptoms, physical signs and imaging examination.

INTERVENTIONS

The first patient underwent pulsed radiofrequency of the glossopharyngeal nerve under CT-guidance as a preferred method. The pulsed radiofrequency (PRF) was performed at 42°C for 10 minutes with a pulsed frequency of 2 Hz and a pulse width 20 ms. There is no symptom improvement after PRF procedure. Three days later, continuous radiofrequency (CRF) thermocoagulation was performed. The pain disappeared after CRF within 36 months followed-up. CRF thermocoagulation under CT-guidance was accepted by the second patient as the first choice.

OUTCOMES

An overall reduction of pain was reported after the procedure and telephone consult for 24-months follow-up confirmed the persistence of the pain relief.

LESSONS

The CRF thermocoagulation produced no complications or side effects in the two cases, and was proved effective in the treatment of GPN.

Use of Selective Serotonin Reuptake Inhibitor and Midodrine in a Patient With Autonomic Instability 2/2 Compressive Squamous Cell Carcinoma and Pain

A rare cause of reflex syncope is metastatic cancers involving the head and neck. These can irritate the glossopharyngeal nerve and lead to glossopharyngeal neuralgia with associated syncope. This type of syncope is difficult to treat since it commonly involves both a vasodepressor and cardioinhibitory response, and typically requires removal of the irritative focus. We report a case of a 52-year-old male who presented from home with syncope. He endorsed a 5-week history of progressively worsened positional headaches and dramatic 40-pound weight loss with night sweats over 6 months. In the emergency department, his heart rate was noted to drop into the 20s with associated hypotension 60/31 mm Hg. Heart rate and blood pressure increased with intravenous atropine. Physical examination revealed a large ulcerative lesion in the left tonsillar area. After biopsy of the lesion, a diagnosis of stage IV squamous cell carcinoma of the neck was made; computed tomography angiogram and positron emission tomography/computed tomography confirmed involvement in the posterior tongue extending to the left palatine tonsil in addition to the left jugular chain. The patient was started on cisplatin and radiation therapy, but continued to have episodes of syncope associated with bradycardia and hypotension. After a failed trial of benztropine, the patient was started on sertraline and midodrine with resolution of syncope. This could be a potential treatment option in those with compressive mixed syncope who are not candidates for surgery or chemotherapy or are awaiting definitive treatment.

Glossopharyngeal Nerve Block: The Premolar Approach

This is a technical note describing hard tissue landmarks to simplify the intraoral glossopharyngeal nerve block. Our literature review revealed no specific mention of the same procedure in documented data.

Long-term outcomes of percutaneous radiofrequency thermocoagulation for glossopharyngeal neuralgia: A retrospective observational study

The aim of this study was to investigate the long-term results of computed tomography (CT)-guided percutaneous radiofrequency thermocoagulation (PRT) for glossopharyngeal neuralgia (GPN).A retrospective review of medical records for patients with GPN who were treated with CT-guided PRT between 2003 and 2014 was performed to investigate baseline characteristics and immediate outcomes during the hospitalization. Long-term pain relief outcomes and complications were obtained via telephone survey. Duration of pain-free was assessed by Kaplan-Meier analysis.Eighty patients with GPN were treated with CT-guided PRT, and 71 patients could be contacted for the follow-up. The mean length of follow-up after PRT was 56.2 ± 43.3 months. Pain relief occurred in 63 patients (78.8%) immediate after the PRT procedure. The percentage of patients who remained in an "excellent" or "good" pain relief condition was 73.2%, 63.0%, 53.2%, and 43.0% at 1, 3, 5, and 10 years. Postprocedure complication included dysesthesias, dysphagia, and diminished gag reflex. No mortality was observed during or after PRT procedures.This study indicates that CT-guided PRT is a safe and effective method for patients with GPN and should be considered as an alternative treatment for these patients.

Tympanic Plexus Neurectomy for Intractable Otalgia

Objective

The goal of this study was to analyze whether tympanic plexus neurectomy is a successful surgical option in patients with intractable otalgia.

Study Design

A retrospective single institution study from the experience of two surgeons was conducted.

Methods

Records of adult patients with intractable unilateral otalgia of likely glossopharyngeal origin were reviewed, with institutional review board approval. Patients who responded to a tympanic plexus block were considered for tympanic neurectomy. Twelve patients (13 ears) underwent the procedure. Surgical outcomes and the presence of persistent otalgia were evaluated.

Results

Persistent otalgia was present for 16.7 months ± 8.6 standard‐error‐of‐the‐mean months prior to an intervention. Narcotic medication was used in 41.7% of patients prior to surgery. Patients received tympanic plexus blocks (median: 1, range 1–3) prior to tympanic neurectomy to evaluate candidacy for surgery. Intractable otalgia resolved in six of 13 ears (46.2%) after one surgery, with an average follow‐up of 25.5 months. A significant reduction in pain occurred in two of 13 ears (15.4%) after an initial surgery. One patient received no benefit from the initial procedure. Revision surgery occurred in four ears, resulting in pain relief in three of four cases. All together, nine of 13 ears received complete resolution of pain, and an additional two of 13 ears received partial benefit using our algorithm for treatment of intractable otalgia of tympanic plexus origin.

Conclusion

Intractable otalgia treated with tympanic neurectomy is a viable treatment option in cases of failed medical management. These findings provide important information that will aid clinicians in counseling chronic otalgia patients.

Level of Evidence

NA.

A simple bracing technique to correct kinking of arterial branches to avoid ischemic sequelae during neurovascular surgery

Background:

During microscopic procedures for neurovascular disease, we sometimes encounter kinking of arterial branches resulting in ischemic sequelae. A simple and useful technique that involves inserting a small, ball-like prosthesis made of oxidized cellulose or shredded Teflon with fibrin glue that corrects the arterial branch kinking and avoids subsequent compromise is reported.

Methods:

Between January and December 2014, three patients developed arterial kinking during microscopic procedures, including two in the caudal loop of the posterior inferior cerebellar artery during microvascular decompression for glossopharyngeal neuralgia and one in a branch of the middle cerebral artery (MCA) during clipping for an unruptured MCA aneurysm. Blood flow insufficiency was confirmed by microvascular Doppler ultrasonography (MDU) and indocyanine green (ICG) videoangiography. The prosthesis, which was made of shredded Teflon in two cases and oxidized cellulose in one case, was inserted into the crotch of the kinked arteries to correct the kinking of the arteries and restore the proper vascular shape and normal blood flow.

Results:

The small, ball-shaped prosthesis corrected the kinked arteries and maintained the proper shape, which was confirmed by ICG videoangiography and MDU during the operation and three-dimensional computerized tomography angiography postoperatively. Postoperatively, the patients did not manifest any ischemic sequelae related to the kinked arteries.

Conclusion:

The insertion of prostheses with fibrin glue into the crotch of a kinked artery for repair is considered a simple and useful method for correcting a kinked artery that avoids ischemic sequelae.

Classification of neurovascular compression in glossopharyngeal neuralgia: Three-dimensional visualization of the glossopharyngeal nerve

BACKGROUND

We introduce a method of noninvasive topographical analysis of the neurovascular relationships of the glossopharyngeal nerve (CN IX) by three-dimensional (3D) visualization. Patients with glossopharyngeal neuralgia (GN) resulting from neurovascular compression (NVC) were studied.

METHODS

15 patients with GN were prospectively examined with 3D visualization using high-resolution magnetic resonance imaging with constructive interference in steady state (MR-CISS). The datasets were segmented and visualized with the real, individual neurovascular relationships by direct volume rendering. Segmentation and 3D visualization of the CN IX and corresponding blood vessels were performed. The 3D visualizations were interactively compared with the intraoperative setup during microvascular decompression (MVD) in order to verify the results by the observed surgical-anatomical findings.

RESULTS

15 patients (female/male: 5/10) were examined. All of them underwent MVD (100%). Microvascular details were documented. The posterior inferior cerebellar artery (PICA) was the most common causative vessel in 12 of 15 patients (80%), the vertebral artery (VA) alone in one case (6.7%), and the combination of compression by the VA and PICA in 3 patients (13.3%). We identified three distinct types of NVC within the root entry zone of CN IX.

CONCLUSION

3D visualization by direct volume rendering of MR-CISS data offers the opportunity of noninvasive exploration and anatomical categorization of the CN IX. It proves to be advantageous in supporting to establish the diagnosis and microneurosurgical interventions by representing original, individual patient data in a 3D fashion. It provides an excellent global individual view over the entire neurovascular relationships of the brainstem and corresponding nerves in each case.

Conventional and 3-Dimensional Computerized Tomography in Eagle's Syndrome, Glossopharyngeal Neuralgia, and Asymptomatic Controls

OBJECTIVE

Eagle's syndrome (ES) is an aggregate of symptoms, including recurrent throat pain, foreign body sensation, dysphagia, or facial pain related to an elongated styloid process (SP). It resembles glossopharyngeal neuralgia and has been linked to irritation of the glossopharyngeal nerve. This study was designed to determine whether computerized tomography (CT) imaging of the stylohyoid chain (SHC) differs between asymptomatic controls (ACs), patients with glossopharyngeal neuralgia (GN), and patients with ES.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary otolaryngology practice.

SUBJECTS AND METHODS

Conventional and 3-dimensional CT reconstructions of the SHC were reviewed for 10 ES, 17 GN, and 30 AC patients. Demographic and clinical symptom data were recorded. Anatomic data collected from CT scans included length of the ossified SP, anterior-posterior and medial-lateral styloid process angulation, ossification pattern of the SHC, and minimum distances between the SP tip, the internal carotid artery, and the tonsillar fossa.

RESULTS

The average distance from the SP tip to the tonsillar fossa was significantly shorter in ES (12.7 mm) compared with GN (21.4 mm; P = .027) or AC (24.8 mm; P < .0005) patients. No other variables were significantly different between groups, including average SP length (ES: 48.0 vs GN: 40.3 vs AC: 40 mm; P > .05).

CONCLUSION

The SP was significantly closer to the tonsillar fossa in patients with ES compared with ACs. No significant differences were found in other measures. Distance to the tonsillar fossa may be a more appropriate diagnostic criterion for ES than SP length and may contribute to the pathophysiology of ES.

Glossopharyngeal neuralgia and radiosurgery

OBJECT

Glossopharyngeal neuralgia is difficult to treat. On the basis of results obtained by using Gamma Knife surgery (GKS) to treat trigeminal neuralgia, the authors have used GKS to treat glossopharyngeal neuralgia in a series of patients since 2007. Their objectives with this study were to demonstrate the usefulness and safety of GKS for treating glossopharyngeal neuralgia and to describe a simple treatment method.

METHODS

From 2007 through 2013, the authors treated glossopharyngeal neuralgia in 5 patients (4 women and 1 man), who ranged in age from 36 to 74 years. One patient had previously undergone treatment for trigeminal neuralgia at the Ruber International Hospital, Department of Functional Neurosurgery and Gamma Knife Radiosurgery. For all patients, before GKS, medical management did not control the pain. Three patients had previously undergone surgery (2 microvascular decompression and 1 rhizotomy) without improvement. For the GKS procedure, the nerve was localized by MRI and CT under stereotactic conditions and the target was located at the level of the glossopharyngeal meatus of the jugular foramen. For 1 patient, a maximum dose of 80 Gy was administrated with a 4-mm collimator, and for the others, the maximum dose was 90 Gy. The nerves located near the glossopharyngeal nerve received between 63 and 10 Gy, and the brainstem received less than 10 Gy. The mean follow-up time was 43 months (range 14-83 months).

RESULTS

All patients improved within 3-6 months after undergoing GKS. All 5 are without pain; 3 patients take no medication, but the other 2 patients continue to take medication. No neurological deficits after GKS were observed.

CONCLUSIONS

GKS is useful and safe for treating glossopharyngeal neuralgia, even for patients who have previously undergone surgery. GKS should be considered as the initial therapy for glossopharyngeal neuralgia.

An uncommonly common: Glossopharyngeal neuralgia

Glossopharyngeal neuralgia is a relatively rare condition characterized by severe, paroxysmal episodes of pain localized to the external ear canal, the base of the tongue, the tonsil or the area beneath the angle of the jaw. This pain is many a times confused with Trigeminal Neuralgia and mistreated. There are various diagnostic and management dilemmas which are herein addressed in this review.

Diagnosis and neurosurgical treatment of glossopharyngeal neuralgia: clinical findings and 3-D visualization of neurovascular compression in 19 consecutive patients

Glossopharyngeal neuralgia is a rare condition with neuralgic sharp pain in the pharyngeal and auricular region. Classical glossopharyngeal neuralgia is caused by neurovascular compression at the root entry zone of the nerve. Regarding the rare occurrence of glossopharyngeal neuralgia, we report clinical data and magnetic resonance imaging (MRI) findings in a case series of 19 patients, of whom 18 underwent surgery. Two patients additionally suffered from trigeminal neuralgia and three from additional symptomatic vagal nerve compression. In all patients, ipsilateral neurovascular compression syndrome of the IX cranial nerve could be shown by high-resolution MRI and image processing, which was confirmed intraoperatively. Additional neurovascular compression of the V cranial nerve was shown in patients suffering from trigeminal neuralgia. Vagal nerve neurovascular compression could be seen in all patients during surgery. Sixteen patients were completely pain free after surgery without need of anticonvulsant treatment. As a consequence of the operation, two patients suffered from transient cerebrospinal fluid hypersecretion as a reaction to Teflon implants. One patient suffered postoperatively from deep vein thrombosis and pulmonary embolism. Six patients showed transient cranial nerve dysfunctions (difficulties in swallowing, vocal cord paresis), but all recovered within 1 week. One patient complained of a gnawing and burning pain in the cervical area. Microvascular decompression is a second-line treatment after failure of standard medical treatment with high success in glossopharyngeal neuralgia. High-resolution MRI and 3D visualization of the brainstem and accompanying vessels as well as the cranial nerves is helpful in identifying neurovascular compression before microvascular decompression procedure.

Glossopharyngeal and limited vagal neurectomy for cancer-related carotid sinus syncope

Head and neck cancer patients with cervical disease involving the glossopharyngeal or vagus nerves can experience dangerous cardiovascular phenomena, including carotid sinus syncope (CSS). Medical and minimally invasive interventions, including pacemaker placement, incompletely address the etiologies of syncopal episodes and therefore often provide limited benefit. The objectives of this report are to highlight the difficulties of managing cancer-related CSS, to present a highly effective surgical intervention, and to review the literature regarding the pathophysiology and treatment options for patients with cancer-related CSS. Two patients with cancer-related CSS continued to experience syncopal episodes despite medical and pacemaker therapy. Consequently, these patients underwent a suboccipital craniotomy for glossopharyngeal and limited vagal neurectomy. After surgery, both patients had uncomplicated postoperative courses with resolution of syncope.

Transcondylar fossa (supracondylar transjugular tubercle) approach: anatomic basis for the approach, surgical procedures, and surgical experience

The authors clarify the anatomic basis and the usefulness of the transcondylar fossa approach (T-C-F A), in which the posterior portion of the jugular tubercle is removed extradurally through the condylar fossa with the atlanto-occipital joint intact. The authors first performed an anatomic study to identify the area to be removed using cadaveric specimens and then applied the T-C-F A to foramen magnum surgeries. The surgeries included clipping a vertebral artery-posterior inferior cerebellar artery aneurysm in 11 cases, microvascular decompression for glossopharyngeal neuralgia in 15 cases, and removing intradural foramen magnum tumors in 17 cases. Only the condylar fossa was removed, but the approach offered very good visualization of the lateral part of the foramen magnum and sufficient working space. These surgeries were performed safely without major complications. This skull base approach is minimally invasive and is not difficult. Therefore, it can be a standard approach for accessing intradural lesions of the foramen magnum. It can be combined with the transcerebellomedullary fissure approach from the lateral side and can also be easily changed to the transcondylar approach, if necessary.

Severe pain attack associated with neurocardiogenic syncope induced by glossopharyngeal neuralgia: successful treatment with carbamazepine and a permanent pacemaker -a case report-

Glossopharyneal neuralgia (GPN) is generally considered to be a pain disease. However, it can be also be a life-threatening cardiac cause of syncope. Neuralgia in the throat and neck can trigger severe bradycardia up to the point of asystole, which can progress to cardiac syncope with or without seizures. A 65 year-old male patient diagnosed with glossopharyngeal neuralgia complained of severe paroxysmal pain in his right chin and ear followed by bradycardia, aystole and syncope. We report a case successfully treated with a permanent pacemaker and carbamazepine in a patient with GPN who had syncopal attacks preceded by paroxysms of pain.

Cranial Nerves IX, X, XI, and XII

This article concludes the series on cranial nerves, with review of the final four (IX-XII). To summarize briefly, the most important and common syndrome caused by a disorder of the glossopharyngeal nerve (craniel nerve IX) is glossopharyngeal neuralgia. Also, swallowing function occasionally is compromised in a rare but disabling form of tardive dyskinesia called tardive dystonia, because the upper motor portion of the glossopharyngel nerve projects to the basal ganglia and can be affected by lesions in the basal ganglia. Vagus nerve funtion (craniel nerve X) can be compromised in schizophrenia, bulimia, obesity, and major depression. A cervical lesion to the nerve roots of the spinal accessory nerve (craniel nerve XI) can cause a cervical dystonia, which sometimes is misdiagnosed as a dyskinesia related to neuroleptic use. Finally, unilateral hypoglossal (craniel nerve XII) nerve palsy is one of the most common mononeuropathies caused by brain metastases. Supranuclear lesions of cranial nerve XII are involved in pseudobulbar palsy and ALS, and lower motor neuron lesions of cranial nerve XII can also be present in bulbar palsy and in ALS patients who also have lower motor neuron involvement. This article reviews these and other syndromes related to cranial nerves IX through XII that might be seen by psychiatry.

Glossopharyngeal neuralgia with syncope: a case report

We present the case of a 60-year-old woman with known glossopharyngeal neuralgia who was admitted to hospital because of recurrent syncopes associated with episodes of painful sensations in the caudal region of her tongue. Rhythm observation showed prolonged asystole, which was accompanied by a loss of consciousness. The asystole was preceded by an episode of pain. We concluded that the bradyarrhythmia and syncopes where associated with the glossopharyngeal neuralgia. Because of the life-threatening condition, we inserted a permanent dual-chamber pacing device. After implantation of the pacemaker, the patient had no further syncopes, although she still complained of episodic tongue pain.

Surgical treatment of chronic orofacial pain

There are many conditions in which chronic orofacial pain is a major diagnostic and therapeutic problem. It is generally accepted that surgical treatment for these chronic pain problems should be resorted to only when more conservative treatments have been ineffective. Literature concerning selected orofacial pain problems is reviewed and the indications for surgical management are discussed.