Trigeminal and Glossopharyngeal Neuralgia

Trigeminal neuralgia and glossopharyngeal neuralgia are craniofacial pain syndromes characterized by recurrent brief shock-like pains in the distributions of their respective cranial nerves. In this article, the authors aim to summarize each condition's characteristics, pathophysiology, and current pharmacotherapeutic and surgical interventions available for managing and treating these conditions.

A woman in her forties with ear pain

Background

A woman in her forties developed intermittent pain in her ear and pharynx which worsened when talking and swallowing. Multidisciplinary approach confirmed a rare diagnosis.

Case presentation

The patient reported left-sided ear fullness, followed by otalgia and burning pain in the palate. Numbness in the palate and nasal cavity, and soreness upon palpation of the external ear canal were noted upon examination. Magnetic resonance imaging (MRI) with contrast showed a vessel located in close proximity to the glossopharyngeal nerve on the left side. A diagnosis of glossopharyngeal neuralgia was made, and the patient was treated with antiepileptic medications without substantial effect. Microvascular decompression of the glossopharyngeal nerve was therefore performed. A large vein located along the glossopharyngeal nerve was separated and fixated away from the nerve. The patient reported pain alleviation after the operation, which has continued to improve on follow-ups.

Interpretation

Glossopharyngeal neuralgia is a rare condition characterised by intermittent, unilateral pain in the base of the tongue, oropharynx, and/or angle of the mandible which radiates to the ipsilateral ear. The condition should be treated medically, but open surgical treatment should be considered in refractory cases. Early diagnosis and treatment are essential.

Fully endoscopic microvascular decompression for the treatment of hemifacial spasm, trigeminal neuralgia, and glossopharyngeal neuralgia: a retrospective study

BACKGROUND

Microvascular decompression (MVD) is already the preferred surgical treatment for medically refractory neurovascular compression syndromes (NVC) such as hemifacial spasm (HFS), trigeminal neuralgia (TN), and glossopharyngeal neuralgia (GPN). Endoscopy has significantly advanced surgery and provides enhanced visualization of MVD. The aim of this study is to analyze the efficacy and safety of fully endoscopic microvascular decompression (E-MVD) for the treatment of HFS, TN, and GPN, as well as to present our initial experience.

MATERIALS AND METHODS

This retrospective case series investigated fully E-MVD performed in 248 patients (123 patients with HFS, 115 patients with TN, and 10 patients with GPN ) from December 2008 to October 2021 at a single institution. The operation duration, clinical outcomes, responsible vessels, intra- and postoperative complications, and recurrences were recorded. Preoperative and immediate postoperative magnetic resonance imaging (MRI) and computerized tomography (CT) were performed for imageological evaluation. The Shorr grading and Barrow Neurological Institute (BNI) pain score were used to evaluate clinical outcomes. The efficacy, safety, and risk factors related to the recurrence of the operation were retrospectively analysed, and the surgical techniques of fully E-MVD were summarised.

RESULTS

A total of 248 patients (103 males) met the inclusion criteria and underwent fully E-MVD were retrospectively studied. The effective rate of 123 patients with HFS was 99.1%, of which 113 cases were completely relieved and 9 cases were significantly relieved. The effective rate of 115 patients with TN was 98.9%, of which 105 cases had completely pain relieved after surgery, 5 cases had significant pain relieved, 4 cases had partial pain relieved but still needed to be controlled by medication. The effective rate of 10 patients with GPN was 100%, 10 cases of GPN were completely relieved after surgery. As for complications, temporary facial numbness occurred in 4 cases, temporary hearing loss in 5 cases, dizziness with frequent nausea and vomiting in 8 cases, headache in 12 cases, and no cerebral hemorrhage, intracranial infection, and other complications occurred. Follow-up ranged from 3 to 42 months, with a mean of 18.6 ± 3.3 months. There were 4 cases of recurrence of HFS and 11 cases of recurrence of TN. The other effective patients had no recurrence or worsening of postoperative symptoms. The cerebellopontine angle (CPA) area ratio (healthy/affected side), the length of disease duration, and the type of responsible vessels are the risk factors related to the recurrence of HFS, TN, and GPN treated by fully E-MVD.

CONCLUSIONS

In this retrospective study, our results suggest that the fully E-MVD for the treatment of NVC such as HFS, TN, and GPN, is a safe and effective surgical method. Fully E-MVD for the treatment of NVC has advantages and techniques not available with microscopic MVD, which may reduce the incidence of surgical complications while improving the curative effect and reducing the recurrence rate.

Glossopharyngeal Neuralgia: A Multidimensional Challenge

Glossopharyngeal neuralgia is an underreported condition characterized by discomfort elicited through involvement of the ninthcranial nerve. Triggering phenomena and associated vagal nerve involvement creates the potential for an unexpected clinical presentation. In this case report, we present a 60-year-old male who described a shock-like pain throughout his neck and jaw. The patient initially responded to carbamazepine but the clinical course was complicated by cardiac pauses with syncope requiring pacemaker implantation. Failure of pharmacologic treatment led to surgical intervention.

Vagoglossopharyngeal Neuralgia Occurred Concomitantly with Ipsilateral Hemifacial Spasm and Versive Seizure-Like Movement: A First Case Report

Vagoglossopharyngeal neuralgia (VGPN) is a very rare condition. VGPN with convulsive like attack is even rarer All of the cases had their head turned to the opposite side of facial pain. Hemifacial spasm occurring concurrently with VGPN has never been reported. Herein, we present the first case of VGPN that had ipsilateral hemifacial spasm and versive seizure-like movement to the same side of facial pain. We reported a 71-year-old man presenting with multiple episodes of intermittent sharp shooting pain arising on the right middle neck, followed by hemifacial spasm on right face. Then the patient became syncope while his head and gaze turned to the same side of the painful neck. Electrocardiography showed sinus arrest. Interictal Electroencephalography was normal. This patient initially responded to pregabalin for two weeks, then the symptoms became worse. Microvascular decompression and carbamazepine resulted in the complete remission of all symptoms after six months of follow-up. We could not explain the pathophysiology of unilateral versive seizure like movement.

[Glossopharyngeal neuralgia and syncope]

BACKGROUND

The causes of neuralgia are usually not known, but the condition can be caused by an underlying condition.

CASE DESCRIPTION

A 58-year-old man presented at the accident and emergency department with a 6-week history of continuous nagging pain in the region of his right ear, extending to the lower jaw and the right side of his neck; this worsened in progressive attacks, which were sometimes followed by non-rotatory dizziness and loss of consciousness. This clinical picture lead us to suspect glossopharyngeal neuralgia (GPN) because of the distribution of the pain and the secondary syncope, but the continuous nature of the pain was atypical and a reason for further investigation. This revealed metastatic parotid gland carcinoma with compression of the right glossopharyngeal nerve. Following palliative radiotherapy, the pain improved and there were no further episodes of loss of consciousness.

CONCLUSION

When GPN is suspected and there is continuous pain, or neurological investigations reveal abnormalities, an underlying condition should be considered and additional investigations should be carried out.

[A case of combined glossopharyngeal and trigeminal neuralgia]

It is well-known that idiopathic neuralgias of the trigeminal and glossopharyngeal nerves are caused by vascular compression at the root entry zone of the cranial nerves. Because they are functional diseases, initial treatment is medical, especially with carbamazepine. However, if medical therapy fails to adequately manage the pain, microvascular decompression (MVD) is prescribed. Glossopharyngeal neuralgia is rare, and combined trigeminal and glossopharyngeal neuralgia is an extremely rare disorder. A 70-year-old woman presented herself to Hokkaido Neurosurgical Memorial Hospital because of paroxysms of lancinating pain in her left pharynx and another lancinating pain in her left cheek. Carbamazepine, which was prescribed at another hospital, favorably relieved the pain; however, drug eruption compelled her to discontinue the medication. The multi-volume method revealed that a root entry zone of the left glossopharyngeal nerve was compressed by the left posterior inferior cerebellar artery, and the left trigeminal artery was compressed by the left superior cerebellar artery. MVD for both nerves was performed employing a left lateral suboccipital craniotomy. She experienced complete relief of pain immediately after MVD. Combined trigeminal and glossopharyngeal neuralgia is extremely rare, but some groups noted a relatively high incidence of concurrent trigeminal neuralgia in patients with glossopharyngeal neuralgia up until the 1970's. Glossopharyngeal neuralgia includes pain near the gonion; therefore, there is an overlap of symptoms between glossopharyngeal and trigeminal neuralgias. By virtue of recent progress in imaging technology, minute preoperative evaluations of microvascular compression are possible. Until the 1970's, there might have been some misunderstanding regarding the overlap of symptoms because of lack of the concept of microvascular compression as a cause of neuralgia and rudimentary imaging technology. Minute evaluations of both symptoms and imaging are very important.

[Endoscopic assistance in microvascular decompression of cranial nerves]

Microvascular decompression (MVD) is an effective method for treatment of trigeminal neuralgia (TN), hemifacial spasm (HFS), glossopharyngeal neuralgia (GPN). The aim of this study was to assess the role of endoscopic assistance in MVD for the treatment of cranial neuropathies. Since 2009 till 2011 133 patients with cranial neuropathies were treated by MVD in Burdenko Neurosurgical Institute, Moscow. In 22 patients (11 patients with HFS, 10 patients with TN, 1 with GPN) endoscopic assistance was applied during the MVD. We used minimally invasive retrosigmoid approach in a unilateral position. Cerebellopontine angle was explored by 30-degree or 70-degree telescope to visualize the root entry zone of trigeminal, facial or glossopharyngeal nerves and to locate the neurovascular conflict. In 9 patients with HFS and in 1 patient with TN and in another patient with GPN endoscopy discovered offending vessels that were not visible through the microscope. In all cases endoscope was used to exclude another site of compression and to verify decompression and to identify position of teflon and offending vessel after MVD. Immediately after the surgery excellent outcome was observed in 10 patients with HFS (89%), one patient was reoperated 1.5 years after first operation with positive effect. Relief of pain in early postoperative period was observed in patients with TN and GPN. There were no major complications and postoperative mortality in our series. Endoscopic assistance is very effective and helpful technique in MVD of cranial nerves, especially in cases with HFS. In this study the use of the endoscope allowed to identify the site of compression and to confirm the position of teflon after MVD.

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.

[Vascular compression syndromes of the cranial nerves]

The blood vessels which are running nearby the cranial nerves and the brainstem can be elongated; curves and loops of the vessels may develop mostly due to the degenerative alterations of ageing and these vessels can compress the surrounding neural elements. The authors report a review of vascular compression syndromes based on the literature and their own experience. The typical clinical symptoms of the syndromes subserving the proper diagnosis, the pathomechanism, the significance of imaging especially the magnetic resonance angiography, the experience with the surgical technique of microvascular decompression which is the only causal treatment of the syndromes are discussed. In cases of non-responsible medical treatment the microvascular decompression should be the eligible treatment in certain syndromes (trigeminal and glossopharyngeal neuralgia, hemifacial spasm) for it is a highly effective and low risk method.

A review of neuropathic pain conditions affecting teeth

Occasionally, dentists must face the complex challenge of diagnosing and treating pain of a neuropathic origin in the orofacial region, since persistent and chronic pain is more common in the head and neck region than in any other part of the body. This article reviews various neuropathic pain conditions that affect orofacial structures (including teeth) and are of clinical significance to dental and endodontic practice.

[Vagoglossopharyngeal neuralgia treated with vascular decompression]

This case report describes a 63-year-old man referred with right-sided glossopharyngeal neuralgia. Magnetic resonance imaging (MRI) demonstrated asymmetry of the PICA vessels. A microvascular decompression was performed and complete remission of symptoms followed. After 14 months the neuralgia recurred, this time accompanied by sinus bradycardia/sinus arrest during attacks causing discomfort and syncopes. An MRI now demonstrated an arterial loop at the site of the vagoglossopharyngeal complex leaving the brainstem. After another microvascular decompression, complete remission of symptoms was observed.

Eagle syndrome: case report and review of the literature

Eagle syndrome, which is an uncommon sequela of elongation of the styloid process, can manifest as pain in the anterolateral neck, often with referred pain to the ear. In most cases, the elongation is an acquired condition, often occurring as a result of a traumatic incident, including tonsillectomy. We describe the case of a 57-year-old man who experienced unremitting right neck pain for several years following an accidental fall. A multidisciplinary investigation identified an elongated styloid process. Surgical shortening of the structure provided definitive relief of the patient's symptoms. We review the anatomy of the peristyloid structures and discuss the etiology, diagnosis, and treatment of Eagle syndrome.

[A patient with glossopharyngeal neuralgia: a (un)known trap]

A man visited the dentist regularly during the past 6 years with a complaint about severe pain. Treatment met with uneven success. The patient now complained about severe, radiating pain which resulted from contact between the tongue and the bridge. The teeth that seemed to be involved were inspected and, after diagnostic testing, restoratively and endodontically treated. When the pain persisted, an oral and maxillofacial surgeon was consulted; the surgeon diagnosed the problem as a glossopharyngeal neuralgia. The neuralgia was treated with carbazamzepine, after which the pain diminished. Pain that seems to be pulpitis pain may be caused by a neuralgia, in this case a glossopharyngeal neuralgia. Triggers for the pain can be swallowing, chewing, talking, coughing or yawning. Although the incidence is low, when pain persists after initial treatment, a (glossopharyngeus) neuralgia should be seriously considered.

[Craniofacial neuralgias]

Craniofacial neuralgias are characterized by sudden paroxysmal pain along the distribution of one or more of the cranial or upper cervical spinal nerves. The most significant neuralgia of the craniofacial region is trigeminal neuralgia, while geniculate neuralgia, glossopharyngeal neuralgia and occipital neuralgia are less common. Trigeminal neuralgia may be primary or secondary. Idiopathic trigeminal neuralgia or tic douloureux has been recognized for centuries as an extremely painful disorder most commonly involving the maxillary nerve. Recurrent lancinating, shocklike unilateral pain lasting for seconds to minutes is provoked by non noxious stimulation of the skin at specific sites around the face and less frequently by movement of the tongue. The trigger zones are usually within the same dermatome as the painful sensation. After each episode, there is usually a refractive period during which stimulation of the trigger zone will not induce pain. Idiopathic trigeminal neuralgia occurs somewhat more frequently in women and usually begins in individuals 50 to 70 years of age. There is no pain between attacks, and the frequency of painful episodes can range from several per day to only a few per year. With time, the features may become more atypical, with greater areas of more enduring and dull pain and occasionally bilateral pain, rarely on both sides simultaneously. No sensory or reflex deficit is detectable by routine neurologic testing. Diagnostic local anesthetic blocks will identify the specific nerves involved and the trigger point distribution. Neurologic and neuroradiologic examination is advised in all cases to rule out diseases such as intracranical tumors, vascular malformations or multiple sclerosis.

[Improvement of diagnosis and treatment of glossopharyngeal neuralgia]

Differential diagnosis of neuralgias affecting the cranial nerves and of facial pain is often difficult. Glossopharyngeal neuralgia is much less common than trigeminal neuralgia and is not well known. Idiopathic neuralgia of the glossopharyngeal nerve sometimes occurs in association with neurovascular compression syndrome of the vagus and trigeminal nerves. High-resolution MRI of the brain stem with three-dimensional visualization allows a secure diagnosis of neurovascular compression and is useful in the planning of appropriate microsurgical decompression (Jannetta's operation).

Glossopharyngeal schwannoma: diagnostic and therapeutic aspects

Among posterior fossa tumours, schwannomas arising from glossopharyngeal nerves are extremely rare, and only 39 cases of glossopharyngeal schwannomas have been described. The clinical and imaging features of glossopharyngeal schwannomas closely resemble that of acoustic schwannomas. Despite its accuracy, magnetic resonance imaging is not diagnostic of a ninth nerve schwannoma. This is because the schwannoma may be primarily localised to the cerebellopontine angle and may not cause enlargement of the jugular foramen. The diagnosis is possible only at surgery, once attachment to the ninth cranial nerve is seen. Because of the different surgical implications and management, preoperative recognition will help in determining the operative approach. We review the relevant literature and discuss the clinical presentation, radiological features and surgical findings in a 52-year-old woman with glossopharyngeal schwannoma.

[Pathology of the cerebellopontine angle]

The pathology of the cistern of the cerebellopontine angle is primarily that of the nervous and vascular structures that it contains and of the meninges that line it. Knowledge of its anatomy makes it possible to understand and search for a rare pathology, the hemifacial spasm, due to a conflict between the facial nerve and the vertebral artery and the posterior inferior cerbellerar artery. However, the pathology of the cerebellopontine angle remains especially tumoral. Imaging should not only make the diagnosis but also make an exhaustive, pretherapy, and accurate assessment of the three main tumours found in this area: the vestibular schwannoma, the meningioma, and the epidermoid cyst.

Mixed cranial nerve neuroma revealing itself as baroreflex failure

We report here the first case of baroreflex failure due to a mixed cranial nerve neuroma in which the clinical manifestations (recurrent severe hypertensive crisis, hypotension) due to baroreflex arc impairment preceded the clinical diagnosis of brain tumour and neurosurgery by a few months. Given the clinical suspicion of baroreflex failure, even in the absence of iatrogenic clues, we propose that the patient's study should include neuroradiologic evaluation of the ponto-cerebellar angulus.

[Peripheral facial palsy as the first symptom of a metastatic bronchogenic carcinoma]

BACKGROUND

We present a case of a facial palsy as the initial symptom of a bronchogenic carcinoma.

METHODS

Case-report. A 56-year-old patient presented with a peripheral facial palsy. The clinical picture as well as the temporal bone CT were without pathological findings. A 10-day rheologic therapy as well as anti-viral medication were not successful. Five days after rheological therapy had been completed, the patient presented a swelling of the neck. In the computer tomography we found a bilateral thrombosis of the internal jugular vein. In addition, the clinical picture of a left-sided glossopharyngeal palsy appeared. The following thorax CT as well as the diagnostic extirpation of an enlarged cervical lymph node lead to the diagnosis of a metastasized smallcell neuro-endocrine bronchogenic carcinoma with a compression of the right primary bronchus and the vena cava superior as well as an upper inflow congestion. In the cMRT we furthermore found a metastasis in the area of the foramen stylomastoideum. The patient underwent emergency radiation and chemotherapy.

RESULTS

According to the present findings, this metastasis lead to the facial palsy as the initial symptom of the bronchogenic carcinoma.

CONCLUSION

Therefore, therapy resistant facial palsy should be further diagnosed in detail, especially examined by imaging procedures.

[Case of Fisher syndrome with impairment of taste]

A 38-year-old man developed dysesthesia, diplopia, and an unsteady gait following an upper respiratory infection. IgG anti-GQ1b antibody was detected in his serum and he was diagnosed as Fisher syndrome. The patient also complained of loss of taste sensation, and it resolved along with improvement of other neurological manifestations. In Guillain-Barré syndrome, cranial nerve involvement is very common, though taste disturbance is a rare complaint. Impairment of taste has been reported in association with severe facial nerve involvement, but taste disturbance developed without facial nerve palsy in the present case and taste sensation was diminished in the area of all four nerves involved in taste sensation. These findings suggest that the impaired taste sensation in the present patient was not a complication of facial nerve palsy as in previous cases, but rather due to taste sensory specific involvement.

Extracranial internal carotid artery aneurysm presenting as symptomatic hypoglossal and glossopharyngeal nerve paralysis

Aneurysms of the extracranial portion of the internal carotid artery are rare, particularly in young patients. They usually develop following trauma, or secondary to infection involving the parapharyngeal space that extends to the vessel wall. This is a case of an internal carotid artery aneurysm presenting acutely following chiropractic neck manipulation with hypoglossal and glossopharyngeal nerve palsy. The imaging findings and subsequent operative management are described.

Basicranium Malformation With Anterior Dislocation of Right Styloid Process Causing Stylalgia

Differential diagnosis of stylalgia is broad, and many causes should be taken into account, such as temporomandibular joint disorders, carotidynia, compression of nerve fibers by neoplasms, cranial nerve neuralgias, chronic pharyngotonsillitis, pharyngeal or base of tongue tumors and elongation of styloid process, or Eagle syndrome. Basicranium malformation can determine a rare form of stylalgia that is caused by dislocation of styloid process. This can produce a reduction of maxillo-vertebropharyngeal space and irritation of nerve fibers together with stylopharyngeal muscular chronic contraction. This case report illustrates the diagnostic dilemma and surgical strategy experienced in a rare case of stylalgia caused by a dislocation of styloid process produced by a basicranium malformation. Basicranium malformation should be considered in the pathogenesis of stylalgia when a styloid process with normal dimension is encountered.

[Jugular foramen schwannomas: a review of 17 cases]

OBJECTIVE

To analysis the clinical presentation, radiological findings, surgical techniques and outcomes of jugular foramen (JF) schwannomas.

METHODS

We reviewed our 10-year experience in the surgical treatment of 17 patients suffered from JF schwannomas in Hua Shan Hospital, Shanghai. A total of 8 males and 9 females with a mean age of 42 years underwent surgical procedures. A relative long period of 53-month symptomatic history was shown before surgery. The main clinical presentation are vertigo and hearing difficulty in 10 cases, atrophy of unilateral muscles of tongue in 9 cases, involvement of lower cranial nerve in 8 cases. The classification of tumors was type A (at cerebellopontine angle with minimal enlargement of the JF) in five cases, type B (JF with intracranial extension) in 3 cases, type C (extracranial tumors with JF extension) in 2 cases and type D (dumbbell-shaped with both intra-and extracranial components) in 7 cases.

RESULTS

Far lateral approaches were used in 10 cases, retrosigmoid suboccipital approaches were used in 5 cases. Submandibular approaches were selected in other 2 cases. Gross total removal was achieved in 12 cases, and subtotal removal in 5 cases. Follow-up revealed marked improvement from preoperative symptoms in 9 cases and no additional deficits in 3 cases. 5 cases suffered from additional neurological deficits. There were two cases of temporary hoarseness and gradually improved within follow-up. Two patients suffered from swallowing problems as a new deficit. One patient had facial palsy.

CONCLUSIONS

JF schwannomas can be surgically treated with relative good outcomes. Surgical approaches should be tailored according to the tumor extension.

A case of Collet-Sicard syndrome associated with traumatic atlas fractures and congenital basilar invagination

An 18 year old man with congenital basilar invagination developed multiple lower cranial nerve (CN) palsies including CN IX to XII after a traffic accident. Computed tomography of his skull base revealed a two part atlas Jefferson fracture. Normally, lower cranial nerves (CN IX-XII) pass through a space between the styloid process and the atlas transverse process. Atlas burst fractures rarely cause neurological deficits because of a greater transverse and sagittal diameter of the spinal canal at the atlas, and a tendency of the lateral masses to slide away from the cord after injury. However, when associated with a rare condition-congenital basilar invagination-atlas fractures can compromise the space and make CN IX-XII more vulnerable to compression injury. This report discusses the correlation between the anatomical lesions and clinical features of this patient.

[Peculiarities of the investigation, clinics and treatment of stylohyoid syndrome and glossopharyngeal neuropathy]

The aim of the study was to investigate the causes and the clinics of stylohyoid syndrome and its tendency to convert into glossopharyngeal nerve neuropathy; to investigate clinical peculiarities of glossopharyngeal neuropathy; to estimate differential diagnosis criteria for the glossopharyngeal neuropathy and stylohyoid syndrome; as well as to propose optimal treatment of the neuropathy.

MATERIAL AND METHODS

Sixty-five patients with stylohyoid syndrome and 53 patients with glossopharyngeal neuropathy have been treated on. The diagnosis was estimated according to the data of clinical and X-ray investigation. For the localization of affected zone we performed modified facial straight plain radiograms of the patients in open bite position, facial oblique contact radiograms, orthopantomograms and cervical spondylograms.

RESULTS

The majority of the patients were females; they comprised 61.5% of patients with stylohyoid syndrome and 56.6% of glossopharyngeal neuropathy sufferers. Older persons had neuropathy, younger--stylohyoid syndrome. The mean age of neuropathy patients was 63.8 years, and of stylohyoid syndrome--57.1 years. Seven years and longer duration of disease was observed in 73.3% of glossopharyngeal neuropathy patients, while duration of 7 and more years was observed in only 3.1% of stylohyoid syndrome patients. The mean duration of glossopharyngeal neuropathy was 10.9 years, and of stylohyoid syndrome--2.6 years. The analysis of etiological factors showed they are the same for both diseases.

CONCLUSIONS

The core of the glossopharyngeal neuropathy pathogenesis is destruction at the glossopharyngeal nerve or at the perivascular plexus of carotid artery, because of elongation or dislocation of styloid processus in case of neck osteochondrosis and compression by ossified styloid ligament. In case of stylohyoid syndrome, inflammatory processes occur at the above-mentioned nervous elements.

[Glossopharyngeal neuralgia]

BACKGROUND

Glossopharyngeal neuralgia is a rare but nevertheless important condition as it can be very incapacitating and as effective treatment is available.

MATERIAL AND METHODS

We provide a review of the epidemiology, aetiology, differential diagnosis and treatment of this condition based on a Medline search.

RESULTS AND INTERPRETATION

Glossopharyngeal neuralgia is characterised by severe unilateral pain in the posterior pharynx, tonsillar fossa, and base of the tongue. It is commonly provoked by swallowing, talking and coughing. In most cases the condition is caused by compression of the nerve by an artery, usually the postero inferior cerebellar artery. Medical treatment with carbamazepin or gabapentin is considered first choice. In patients not responding to medical treatment, surgery should be considered; microvascular decompression is considered the first choice of surgical treatment.

Transient Foix-Chavany-Marie syndrome after surgical resection of a right insulo-opercular low-grade glioma: case report

OBJECTIVE AND IMPORTANCE

We describe an atypical case of transient Foix-Chavany-Marie syndrome, or faciopharyngoglossomasticatory diplegia with automatic voluntary dissociation, occurring after surgical resection of a right insulo-opercular glioma.

CLINICAL PRESENTATION

A 26-year-old right-handed man experienced partial seizures that were poorly controlled by antiepileptic drugs during a 2-year period as a result of a right insulo-opercular low-grade glioma, leading to the proposal of surgical resection. In addition, 1 year before the operation, the patient experienced a severe brain injury that resulted in a coma. A computed tomographic scan revealed left opercular contusion. The patient recovered completely within 6 months.

INTERVENTION

Intraoperative corticosubcortical electrical functional mapping was performed along the resection, allowing the identification and preservation of the facial and upper limb motor structures. A subtotal removal of the glioma was achieved. The patient had postoperative anarthria, with loss of voluntary muscular functions of the face and tongue, and he had trouble chewing and swallowing. All of these symptoms resolved within 3 months.

CONCLUSION

These findings provide insight into the use of surgery to treat a right insulo-opercular tumor. First, surgeons must be particularly cautious in cases with a potential contralateral lesion (e.g., history of head injury), even if such a lesion is not visible on magnetic resonance imaging scans; preoperative metabolic imaging and electrophysiological investigations should be considered before an operative decision is made. Second, surgeons must perform intraoperative functional mapping to identify and to attempt to preserve the corticosubcortical facial motor structures. A procedure performed while the patient is awake should be discussed to detect the structures involved in chewing and swallowing in cases of suspected bilateral lesions. Third, the patient must be informed of this particular risk before surgery is performed.

Schwannomatosis in a child--or early neurofibromatosis type 2

A case of multiple cervical schwannomas in a five-year-old boy, without other evidence of neurofibromatosis type 2, is described. Schwannomatosis is a disorder characterized by the presence of multiple schwannomas in the absence of neurofibromatosis type 2 that has only been recognized in the last 15 years. The clinical and genetic features of neurofibromatosis types 1 and 2 and schwannomatosis are compared and contrasted. This patient with possible schwannomatosis is presented to illustrate the potential pitfalls of making this diagnosis in the paediatric age group and to increase awareness of the debate on whether this is a distinct entity or a form fruste of neurofibromatosis type 2.

Glossopharyngeal schwannoma : a case report and review of literature

We report a rare case of glossopharyngeal schwannoma whose clinical presentation and the radiological work up suggested an acoustic schwannoma. The diagnosis was made at surgery, once attachment to ninth cranial nerve was seen. The clinical presentation, radiological features and surgical findings of the glossopharyngeal schwannoma are presented along with the review of literature.

Eagle syndrome produced by a granular cell tumor

Eagle syndrome includes elicitation of pain on swallowing, turning the head, or extending the tongue. The syndrome is thought to be caused by irritation of the glossopharyngeal nerve, most commonly caused by its impingement against an elongated styloid process. We present a rare case of a granular cell tumor presenting as Eagle syndrome. Granular cell tumors orignate from Schwann cells and are most common in the subcutaneous tissue of the head, neck, and oral cavity, especially the tongue. A granular cell tumor is typically benign and solitary, rarely malignant. The differential diagnosis, diagnostic algorithm, and treatment are presented.

[Assessment of tasting disorder in alcoholics]

To clarify the influence of chronic and excessive alcohol consumption on gustatory function, we examined taste functions of 20 male alcoholics by total oral gustometry using salty, sweet, sour, bitter and glutamate solutions. As results, all patients showed markedly impaired taste in all kinds of solutions comparing with age and sex matched healthy persons, nevertheless none of them recognized their impaired taste. Serum zinc levels of all patients were within reference range, but the most of them were within lower part of reference level. Although average serum zinc level increased significantly after 5 weeks of admission, serum zinc level showed no significant correlation with taste function. From these findings, we concluded that alcoholics had impaired taste functions probably due to impaired peripheral nervous system.

Sensory neuropathy of the trigeminal, glossopharyngeal, and vagal nerves in Sjögren's syndrome

Isolated cranial nerve involvement in primary Sjögren's syndrome (primary SS) has rarely been described. We report the case of a patient with sensory neuropathy of the trigeminal and also the glossopharyngeal and vagal nerves, which has not been identified previously. The electrophysiological findings in our patient with primary SS confirmed trigeminal sensory neuropathy with abnormal blink reflexes and abnormal cutaneous masseter inhibitory reflexes.

Surgical treatment of glossopharyngeal neuralgia as vascular compression syndrome via transcondylar fossa (supracondylar transjugular tubercle) approach

OBJECTIVE

These are the first reported cases in whom the transcondylar fossa approach was applied for the treatment of glossopharyngeal neuralgia (GPN) as a vascular compression syndrome.

CASES PRESENTATION

All three cases presented with severe paroxysmal pharyngeal pain which could not be controlled by medical treatment. The patients all underwent microvascular decompression surgery (MVD) via transcondylar fossa approach. The posterior inferior cerebellar artery or the anterior inferior cerebellar artery was clearly verified to be compressing the glossopharyngeal nerve and then was safely and completely moved and fixed to the dura mater by the sling retraction technique to effect decompression. No patient has since experienced any further pain or permanent neurological deficit after surgery. TECHNICAL ADVANTAGE: The transcondylar fossa approach is one of the lateral approaches which is different from the transcondylar approach. In this approach, the posterior part of the jugular tubercle is extradurally removed without injuring the atlanto-occipital joint. The entire course of the cisternal portion of the glossopharyngeal nerve can be sufficiently seen with gentle retraction of the cerebellar hemisphere, when using this approach.

CONCLUSION

This approach makes the MVD for GPN both effective and safe.

Jacobson's nerve schwannoma presenting as middle ear mass

Schwannoma is one of the common benign middle ear space tumors. Middle ear space schwannomas may originate from the nerves of the tympanic cavity or by extensions from outside the middle ear space. In the English-language literature, the facial nerve and chorda tympani nerve, but not yet the tympanic branch of glossopharyngeal nerve (Jacobson's nerve), have been reported as the origins of intrinsic middle ear space schwannomas. We present the clinical and radiologic features of a middle-space schwannoma originating from Jacobson's nerve, and suggest that such a tumor be included in the differential diagnosis of middle ear tumors.

Tonsillar pain mimicking glossopharyngeal neuralgia as a complication of vagus nerve stimulation: case report

An adolescent girl presented with severe, lancinating tonsillar pain exacerbated by swallowing 6 weeks after initiation of left vagus nerve stimulation for intractable epilepsy. Her symptoms mimicked those seen in glossopharyngeal neuralgia and were relieved by temporary cessation of stimulation. Gradual reinstitution of therapy with alteration in stimulus parameters resulted in improved seizure control as well as cessation of pain symptoms. Direct stimulation of the vagus nerve may result in vagoglossopharyngeal neuralgia, which, in this case, was amenable to stimulus modification.

Imaging findings in schwannomas of the jugular foramen

BACKGROUND AND PURPOSE

Tumors of the cranial nerve sheath constitute 5% to 10% of all intracranial neoplasms, yet few articles have described their CT and MR characteristics. We report the imaging findings in a relatively large series of schwannomas of the jugular foramen, contrasting them with other disease entities, especially vestibular schwannomas and tumors of the glomus jugulare.

METHODS

CT and/or MR studies of eight patients who underwent surgery for histologically proved schwannomas were reviewed retrospectively. One additional patient with an assumed schwannoma of the jugular foramen, who did not have surgery, was also included.

RESULTS

Surgical findings showed schwannomas of the glossopharyngeal nerve in seven patients and tumor involvement of both the glossopharyngeal and vagal nerves in one patient. All tumors were partially located within the jugular foramen. Growth extending within the temporal bone was typical. Tumor extended into the posterior cranial fossa in all nine patients and produced mass effect on the brain stem and/or cerebellum in seven patients; in five patients, tumor extended below the skull base. On unenhanced CT scans, tumors were isodense with brain in six patients and hypodense in two. In seven patients, CT scans with bone algorithm showed an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. On MR images, T1 signal from tumor was low and T2 signal was high relative to white matter in all patients. Contrast enhancement on CT and/or MR studies was strong in eight patients and moderate in one.

CONCLUSION

Schwannoma of the jugular foramen is characteristically a sharply demarcated, contrast-enhancing tumor, typically centered on or based in an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. Intraosseous extension may be marked.