Trigeminal and glossopharyngeal neuralgia

Diagnostic and treatment pitfalls in glossopharyngeal neuralgia: evidence from a case series

BACKGROUND

Glossopharyngeal neuralgia (GN) is a rare pain syndrome often underdiagnosed. This study aimed to assess the challenges in diagnosing GN and identify patients at risk of misdiagnosis.

METHODS

Between 2010 and 2019, nine patients underwent microvascular decompression (MVD) of the glossopharyngeal nerve at two tertiary care hospitals. A retrospective analysis examined symptom characteristics, time to correct diagnosis, operative technique, and clinical outcomes. Barrow Neurological Institute (BNI) pain scores were assessed before surgery and on follow-up.

RESULTS

Six women and three men, aged 55 ± 14.3 years, with unilateral GN were included. Pain was predominantly in the ear (otalgic type) in four patients (44.4%), the pharynx or base of the tongue (pharyngeal type) in four (44.4%), and mixed in one (11.1%). Five patients reported pain radiating to the mandible, all initially misdiagnosed with trigeminal neuralgia (TN) and treated for 2.4(± 3.1) years before presenting to our institution. One case resulted in MVD of the trigeminal nerve and subsequent thermocoagulation of the Gasserian ganglion due to persistent pain. The correct diagnosis of GN was established later in patients with otalgic or mixed pain (3.8 ± 3.4 years) compared to those with pharyngeal pain (0.5 ± 1.0 years), showing a trend (U = 17.0, p = 0.07). There was a significant association between pain radiation to the mandible and misdiagnosis (x2 = 9.00, p = 0.003). Endoscopically assisted MVD via the median suboccipital subtonsillary approach was performed, resolving neurovascular conflicts with the PICA (9/9) and vertebral artery (3/9). Follow-up after 15.7(± 18.2) months showed significant pain reduction according to the BNI (preoperative BNI = 5.0 ± 0.0, postoperative BNI = 1.7 ± 1.0,t (8) = 10,CI [1.6-5.1], p < 0.001). No permanent surgery-related deficits occurred.

CONCLUSION

Patients with GN, especially those with predominant otalgic pain and pain radiating to the mandible, are at higher risk of misdiagnosis due to similarities with TN. Despite the rarity of GN, increased awareness of its various pain manifestations may lead to earlier correct diagnoses, which is crucial for surgical treatment.

Ablation Procedures

Although ablation has a limited role in the management of chronic noncancer pain, ablation continues to help patients with treatment of refractory cancer-related pain. Interdisciplinary treatment involving supportive care, pain medicine, oncology, and neurosurgery is critical to optimizing the timing and outcome of neurosurgical ablative options for pain management. In this review, 3 targets for ablative surgery-the spinothalamic tract, the dorsal column's visceral pain pathway, and the anterior cingulate cortex-are discussed with a focus on patient selection and key aspects of surgical technique.

Perceived Practitioner Barriers to the Management of Orofacial Pain in the Kingdom of Saudi Arabia: A Cross-sectional Study

Background:

Orofacial Pain (OFP) is a group of non-dental painful conditions affecting the oral cavity and facial area.

Objectives:

The objective of this study was to explore which barriers to manage the patient with chronic OFP as perceived by general dentists versus dental specialists and to investigate whether if professionals with degrees from their home country versus another country or number of years of professional experience differ in their perceptions.

Methods:

A closed-end questionnaire was hand-delivered to 600 participants [300 general dentists and 300 dental specialists] in four major provinces in Saudi Arabia. Demographic data were expressed as frequency. Proportional t-tests and chi-square tests were used to analyse intergroup differences. Statistical significance for all analyses was set at P-value < 0.05.

Results:

Overall, the response rate was 56.6% (340/600). Around two-thirds of the participants were general dentists (60.9%), while the remainder were dental specialists (39.1%). There was an obvious consensus by the participants that “Low payment/reimbursement” and “Lack of OFP knowledge” were among the most common barriers (85% and 83.5%, respectively). In contrast, “Legal risks” were the least frequently reported factor (38.8%). The most commonly reported barrier by general dentists was “Shortage of patients/lack of demand;” this was significantly different from the experience of dental specialists (87% vs. 72.2%; P- value < 0.01). In terms of the country of graduation or years of experience, there were no significant differences.

Conclusion:

The study demonstrates the existence of many significant barriers other than OFP knowledge, such as reimbursement, facility and demand that could present obstacles and challenges to the management of OFP by general dentists and dental specialists. Most participants believed that dentists should manage this condition and that OFP courses should be included in the dental school curriculum.

The Long-Term Outcome of CT-Guided Pulsed Radiofrequency in the Treatment of Idiopathic Glossopharyngeal Neuralgia: A Retrospective Multi-Center Case Series

Background

Safer and minimal invasive treatment options with minor side effects are in great demand in the treatment of glossopharyngeal neuralgia (GPN). Pulsed radiofrequency (PRF) is a micro-destructive procedure that could be applied repeatedly without irreversible damage to target tissue. However, few studies have reported the long-term clinical outcomes of PRF in the management of idiopathic GPN patients.

Methods

We retrospectively investigated the efficacy and safety of computed tomography (CT)-guided PRF in the treatment of 30 patients with idiopathic GPN in a multi-center clinical study. Numeric rating scale (NRS) score was used to evaluate pain intensity before and after PRF treatment. The effective rate was defined as the percentage of patients with NRS reduction of more than 50%. Baseline characteristics, surgical records, initial pain relief, time to take effect, long-term outcomes, patient satisfaction using a five-level Likert Scale, the incidence of recurrence as well as subsequent treatment choices, intraoperative and postoperative complications were retrieved from electronic medical records.

Results

A total of 30 idiopathic GPN patients who received PRF under CT-guidance were included in our study and the initial effective rate was 93.3%. The cumulative proportion of patients with satisfactory pain relief survival was 93.3% at 12 months, 89.6% at 24 months, 85.3% at 36 months, 79.6% at 48 months, 73.0% at 60 months and 72 months, and 54.8% at 84 months, 108 months as well as 120 months. No serious morbidity or mortality were observed in any of the cases. The median patient satisfaction in Likert scale rating was 4.0 (IQR, 3.0–5.0).

Conclusion

According to our results, PRF is an effective and safe therapy for patients with idiopathic GPN. This minimally invasive, micro-destructive, neuro-modulatory technique could be a potential intervention of choice for the treatment of GPN patients who respond poorly to pharmacological treatment.

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).

Neurologic Disorders of the Maxillofacial Region

The maxillofacial region is complex in its anatomy and in its variation in the presentation of neurologic disorders. The diagnosis and management of neurologic disorders in clinical practice remains a challenge. A good understanding of the neurologic disorder in its entirety helps dentists in the diagnosis and appropriate referral to a specialist for further investigations and management of the condition. Neurologic disorders described in this article are under broad categories of sensory and motor disturbances as well as movement disorders and infections. This article summarizes the most common maxillofacial neurologic disorders that dentists might encounter in clinical practice.

Anesthesia and Chronic Pain Management

The reasons for development of chronic pain are poorly understood. Chronic postoperative pain is linked to severe acute postoperative pain. Head and neck pain is often a complex phenomenon that requires meticulous diagnosis and treatment. Institution of early multimodal analgesic regimens by multidisciplinary teams may attenuate chronic pain formation and propagation in the otolaryngologic patient.

A Case of Ophthalmic Branch Trigeminal Neuralgia in the Emergency Department

This case report describes a middle-aged patient with a past history of migraine headaches, who presented to the emergency department with a new onset of headaches around his left eye that were different from the pattern and character of his usual migraine headaches. The pain was severe, brief, and stabbing in nature, lasting only seconds, and occurring over intervals of a few minutes. His vital signs, including glucose, were normal. He had no constitutional symptoms, a normal neurological examination, and a normal head, eyes, ears, nose, and throat examination. The painful paroxysms could not be elicited on palpation of his face, head, or oral mucosa. His blood investigations were reported as within normal limits. He was not using alcohol or any illicit drugs and was not taking any medication. A diagnosis, with supportive imaging, of ophthalmic branch trigeminal neuralgia (TN) was made. His pain responded well to treatment with carbamazepine. TN is characterized by brief and intermittent lancinating pain with or without a constant background level of pain in the sensory distribution of one or more branches of the trigeminal nerve. There are three main causes for TN: idiopathic, the classical type resulting from neurovascular compression, and the secondary type typically due to multiple sclerosis, a space-occupying lesion, or a skull base abnormality. The mandibular and maxillary branches are most affected and can often be affected simultaneously. Ophthalmic branch TN is relatively rare. Virtually all of TN cases are unilateral and most are the classical type. Distinguishing TN from other cephalalgias, ocular pain, dental pain, or other pathology is critical to a proper diagnosis and initiation of effective therapy. Identifying trigger zones is important and carries a high diagnostic yield; however, they may be anatomically difficult to access, or in a refractory period during a physical examination. Physicians should be aware of several red flags associated with a suspected case of TN. Carbamazepine is the first-line treatment for TN, capable of reducing pain in 90% of patients. Failure to respond to medication requires further investigation and/or specialist referral. Untreated or unrecognized TN can have significant impacts on a patient's quality of life.

Facial pain: sinus or not?

Facial pain remains a diagnostic and therapeutic challenge for both clinicians and patients. In clinical practice, patients suffering from facial pain generally undergo multiple repeated consultations with different specialists and receive various treatments, including surgery. Many patients, as well as their primary care physicians, mistakenly attribute their pain as being due to rhinosinusitis when this is not the case. It is important to exclude non-sinus-related causes of facial pain before considering sinus surgery to avoid inappropriate treatment. Unfortunately, a significant proportion of patients have persistent facial pain after endoscopic sinus surgery (ESS) due to erroneous considerations on aetiology of facial pain by physicians. It should be taken into account that neurological and sinus diseases may share overlapping symptoms, but they frequently co-exist as comorbidities. The aim of this review was to clarify the diagnostic criteria of facial pain in order to improve discrimination between sinogenic and non-sinogenic facial pain and provide some clinical and diagnostic criteria that may help clinicians in addressing differential diagnosis.

Guidelines for radiographic imaging of cranial neuropathies

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

Immediate and Long-Term Outcomes of Microvascular Decompression for Mixed Trigeminal Neuralgia

BACKGROUND

Classic trigeminal neuralgia (TN) involves sharp, shooting pain in any trigeminal nerve distribution, whereas atypical TN presents with constant aching, numbness, or burning that can appear with classic features, leading to a mixed presentation. Microvascular decompression (MVD) is an effective treatment for classic TN, but its utility in treating mixed TN has been less well studied.

METHODS

We retrospectively studied 73 adult patients with mixed TN and 386 patients with classic TN who underwent MVD between December 2007 and October 2016. Recorded variables included demographic data, graded radiologic and intraoperative findings, and graded pain outcomes in the immediate postoperative period (up to 3 months after MVD) and during long-term follow-up.

RESULTS

The mean age of the 73 patients with mixed TN was 53.2 years. In terms of immediate postoperative outcomes, 67 patients (91.8%) experienced pain relief including improvement of atypical pain, whereas 6 patients (8.2%) had no pain relief. Having a preexisting pain syndrome (P = 0.001) or distortion of the trigeminal nerve intraoperatively (P = 0.001) was associated with poor surgical outcome in the patients with mixed TN. The mean duration of follow-up was 20.6 months. Forty-four patients (60.3%) developed recurrence of any TN pain. In comparison, 93% of the patients with classic TN experienced pain relief in the immediate postoperative period, and the recurrence rate was 19.9% in these patients.

CONCLUSIONS

Patients with mixed TN suffer from both classic and atypical TN symptoms. Following MVD, 91.8% of our patients with mixed TN reported partial or complete pain relief, including improvement of atypical pain, in the immediate postoperative stage, compared with 93% of those with classic TN. Recurrence eventually developed in 60.3% of the patients with mixed TN.

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.

Combined Hyperactive Dysfunction Syndrome of the Cranial Nerves: A Retrospective Systematic Study of Clinical Characteristics in 44 Patients

BACKGROUND

Combined hyperactive dysfunction syndrome (HDS) is defined as the combination symptoms arising from overactivity in cranial nerves, specifically, trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN), without an obvious explanatory structural lesion. This study retrospectively analyzes the clinical characteristics of combined HDS treated with microvascular decompression (MVD) in a single institution.

METHODS

A total of 1450 patients with HDS were treated with MVD in our department during a 10-year period, among which 44 cases of combined HDS were identified. Clinical records and follow-ups were reviewed.

RESULTS

Combined HDS comprised 3.03% (44/1450) of all HDS in our series, with female predominance compared with single HDS (P = 0.002), including combined TN-HFS (14 cases), combined TN-GPN (26 cases), bilateral TN (2 cases), and combined TN-HFS-GPN (2 cases). The average age at diagnosis of patients with combined HDS (60.9 years) was significantly older than that of patients with single HDS (53.5 years) (P = 0.035). Hypertension was closely associated with the prevalence of combined HDS compared with single HDS (P = 0.009). The curative rate was 97.7% (43/44) after MVD, and the recurrence rate was 3.33%. The incidence rates of postoperative cardiac, pulmonary, thromboembolic, and delirium complications were higher in combined HDS than in single HDS (P < 0.05).

CONCLUSIONS

Combined HDS is a rarely occurring syndrome usually observed in older females, and the most common types are combined TN-GPN and combined TN-HFS. Age and gender seemed to be causes for developing combined HDS, and MVD shows potential as a favorable treatment choice.

Management of Skull Base Tumor-Associated Facial Pain

Cancer-associated facial pain can be caused by a variety of pathologic conditions. Here the authors describe the symptoms and incidence of facial pain secondary to three separate anatomic subcategories of cancer. The authors subsequently discuss the effectiveness and drawbacks of the most common methods of treatment.

Surgical variation of microvascular decompression for trigeminal neuralgia: A technical note and anatomical study

Background:

In this article, the authors described their experience in microvascular decompression for trigeminal neuralgia.

Methods:

The microvascular decompression technique used in the authors’ institution is described in a step by step manner with some illustrative cases as well as a cadaver dissection to highlight the differences with other previously described techniques.

Results:

Since 2013, 107 patients were operated in the Neurosurgery Division of the University of São Paulo using the described technique, with a shorter operative time and avoiding cerebellar retractor compared with classic techniques.

Conclusion:

Our modified microvascular decompression technique for trigeminal neuralgia can be used with safety and efficiency for treating trigeminal neuralgia.

Neuralgia of the glossopharyngeal nerve in a patient with posttonsillectomy scarring: recovery after local infiltration of procaine-case report and pathophysiologic discussion

We describe a patient with a three-year history of severe progressive left-sided glossopharyngeal neuralgia (GPN) that failed to adequately respond to various drug therapies. The application of lidocaine spray to the posterior pharyngeal wall provided no more than short-term relief. Apart from a large hypertrophic tonsillectomy scar on the left side all clinical and radiologic findings were normal. In terms of therapeutic local anaesthesia, the hypertrophic tonsillectomy scar tissue was completely infiltrated with the local anaesthetic (LA) procaine 1%. The patient has been almost completely pain-free ever since, and the lidocaine spray is no longer needed. Six weeks after the first treatment a repeat infiltration of the tonsillectomy scar led to the complete resolution of all symptoms. The patient has become totally symptom-free without the need to take any medication now for two and a half years. This is the first report of a successful therapeutic infiltration of a tonsillectomy scar using an LA in a patient with GPN that has been refractory to medical treatment for several years. A possible explanation may be that the positive feedback loop maintaining neurogenic inflammation is disrupted and “sympathetically maintained pain” resolved by LA infiltration.