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Sone M, Mizokami D, Takihata S, Shiotani A, Araki K. Characteristic Video Laryngeal Endoscopic "Pharyngeal Rotation" in Unilateral Pharyngeal Constrictor Muscle Paresis: A Case of Herpes Zoster Pharyngitis. Cureus 2024; 16:e51781. [PMID: 38322054 PMCID: PMC10846659 DOI: 10.7759/cureus.51781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Herpes zoster pharyngitis (HZP) is a rare condition that should be considered as a differential diagnosis of acute dysphagia secondary to unilateral glossopharyngeal and/or vagal nerve palsy. Although early treatment is important to avoid adverse sequelae, serological diagnosis of varicella zoster virus (VZV) takes over a few days. Therefore, it is important to actively suspect VZV infection based on physical findings. Mucocutaneous lesions, curtain signs, and laryngeal palsy are well-known characteristic physical findings. In addition to these findings, the video laryngeal endoscopic finding that the pharyngeal constrictor muscles contract on only one side during swallowing, showing an appearance of "pharyngeal rotation", is one of the characteristic findings of glossopharyngeal/vagal nerve palsy and can support the diagnosis. We report the case of an 82-year-old Asian female who presented with acute dysphagia, sore throat, left ear pain, and fever that persisted for several days. Initial video laryngeal endoscopy revealed a markedly decreased pharyngeal reflex and significant salivary retention without mucosal vesicular lesions. Repeat videoendoscopic evaluation of swallowing revealed characteristic pharyngeal rotation, which was helpful in diagnosing unilateral pharyngeal constrictor muscle paresis, thus suggesting unilateral glossopharyngeal/vagal nerve palsy. An increase in serum antibody titers (IgG and IgM) against VZV was observed. Bilateral differences and rotation of the pharynx during pharyngeal contraction can be detected endoscopically in pharyngeal constrictor muscle paresis caused by glossopharyngeal/vagal nerve palsy and should be evaluated during video laryngeal endoscopy in patients with dysphagia.
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Affiliation(s)
- Megumi Sone
- Otolaryngology-Head and Neck Surgery, National Defense Medical College, Tokorozawa, JPN
| | - Daisuke Mizokami
- Otolaryngology-Head and Neck Surgery, Nishisaitama Chuo National Hospital, Tokorozawa, JPN
| | - Saki Takihata
- Otolaryngology-Head and Neck Surgery, Nishisaitama Chuo National Hospital, Tokorozawa, JPN
| | - Akihiro Shiotani
- Otolaryngology-Head and Neck Surgery, National Defense Medical College, Tokorozawa, JPN
| | - Koji Araki
- Otolaryngology-Head and Neck Surgery, National Defense Medical College, Tokorozawa, JPN
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Fang J, Lv G, Wang D, Liu R. The Distance Between the Cranial Nerve IX-X Root Entry/Exit Zone and the Pontomedullary Sulcus: MR Imaging Study in Patients With Hemifacial Spasm. Front Neurol 2022; 13:819488. [PMID: 35265027 PMCID: PMC8899112 DOI: 10.3389/fneur.2022.819488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/27/2022] [Indexed: 11/24/2022] Open
Abstract
Subject To quantitatively describe the distance between the cranial nerve (CN) IX-X root entry/exit zone (REZ) and the pontomedullary sulcus in patients with hemifacial spasm (HFS). Methods A total of 215 outpatients with HFS were recruited. Finally, 108 patients who yielded high-quality images were enrolled in the study. MRIs were reconstructed to measure the distance between the bilateral CN IX-X REZs and the corresponding pontomedullary sulcus. Results Among the 108 patients, the ratio of males to females was 39/69, and the mean age was 57.9 ± 6.5 years. The ratio of left to right HFS involvement was 47/61. The average height was 1.62 ± 0.07 m, and the average body mass index (BMI) was 24.65 ± 2.97 kg/m2. The distance between the cephalic end of the CN IX-X REZ and the pontomedullary sulcus was 2.7 ± 0.9 mm. The distance between the caudal end of the CN IX-X REZ and the pontomedullary sulcus was 7.6 ± 1.1 mm. No monotonic relationship was found between distance and height or BMI in the scatter diagrams. Conclusions The CN IX-X REZ is closely related to the pontomedullary sulcus in patients with HFS, and there is no difference between the left and right sides. The distances were not correlated with height or BMI in patients with HFS.
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Affiliation(s)
- Jixia Fang
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Gaoquan Lv
- Department of Radiology, Peking University People's Hospital, Beijing, China
| | - Dongliang Wang
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Ruen Liu
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
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Gutierrez S, Iwanaga J, Pekala P, Yilmaz E, Clifton WE, Dumont AS, Tubbs RS. The pharyngeal plexus: an anatomical review for better understanding postoperative dysphagia. Neurosurg Rev 2020; 44:763-772. [PMID: 32318923 DOI: 10.1007/s10143-020-01303-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 01/22/2023]
Abstract
The pharyngeal plexus is an essential anatomical structure, but the contributions from the glossopharyngeal and vagus nerves and the superior cervical ganglion that give rise to the pharyngeal plexus are not fully understood. The pharyngeal plexus is likely to be encountered during various anterior cervical surgical procedures of the neck such as anterior cervical discectomy and fusion. Therefore, a detailed understanding of its anatomy is essential for the surgeon who operates in and around this region. Although the pharyngeal plexus is an anatomical structure that is widely mentioned in literature and anatomy books, detailed descriptions of its structural nuances are scarce; therefore, we provide a comprehensive review that encompasses all the available data from this critical structure. We conducted a narrative review of the current literature using databases like PubMed, Embase, Ovid, and Cochrane. Information was gathered regarding the pharyngeal plexus to improve our understanding of its anatomy to elucidate its involvement in postoperative spine surgery complications such as dysphagia. The neural contributions of the cranial nerves IX, X, and superior sympathetic ganglion intertwine to form the pharyngeal plexus that can be injured during ACDF procedures. Factors like surgical retraction time, postoperative hematoma, surgical hardware materials, and profiles and smoking are related to postoperative dysphagia onset. Thorough anatomical knowledge and lateral approaches to ACDF are the best preventing measures.
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Affiliation(s)
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.
| | | | - Emre Yilmaz
- Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | | | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.,Department of Anatomical Sciences, St. George's University, St. George's, West Indies, Grenada.,Department of Neurosurgery, Ochsner Health System, Ochsner Neuroscience Institute, New Orleans, LA, USA.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
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Krüger M, Dong C, Honey C. Defining the Anatomy of the Vagus Nerve and Its Clinical Relevance for the Neurosurgical Treatment of Glossopharyngeal Neuralgia. Stereotact Funct Neurosurg 2019; 97:244-248. [DOI: 10.1159/000504263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 10/20/2019] [Indexed: 11/19/2022]
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Duque-Parra JE, Barco-Ríos J, Barco-Cano JA. El verdadero origen aparente de los nervios glosofaríngeo, vago y accesorio. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n2.68096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Existe un vacío conceptual asociado con los sitios precisos por donde emergen las raíces de los nervios glosofaríngeo, vago y accesorio, un conocimiento que es de suma importancia para los neurocirujanos.Objetivo. Determinar el sitio preciso por donde las raíces de los nervios glosofaríngeo, vago y accesorio emergen como origen aparente en la médula oblongada.Materiales y métodos. Se valoraron 67 troncos encefálicos humanos que con anterioridad habían sido fijados en solución de formalina al 10%. Mediante inspección directa, luego de retirar las meninges, se examinó y registró el sitio preciso por donde emergen las raíces de tales nervios y se comparó con lo registrado en la literatura.Resultados. En el 100% de los troncos encefálicos estudiados se encontró que las raíces nerviosas emergen entre 2mm a 3mm por detrás del surco retro-olivar, distinto a lo reportado en la literatura consultada.Conclusión. Hay disparidad de criterios en cuanto al origen aparente de los nervios glosofaríngeo, vago y accesorio, lo que amerita un estudio más amplio que permita llegar a un consenso generalizado sobre el sitio preciso por donde las raíces de tales nervios hacen su aparición.
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Pediatric glossopharyngeal neuralgia: a comprehensive review. Childs Nerv Syst 2019; 35:395-402. [PMID: 30361762 DOI: 10.1007/s00381-018-3995-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Debilitating facial pain can seriously affect an individual's daily living. Given that the pathophysiology behind neuropathic and myofascial pain is not fully understood, when chronic facial pain goes undiagnosed, it has been proposed that one of the two is the likely cause. Since their discovery, glossopharyngeal neuralgia (GN) and Eagle's syndrome have been considered mostly conditions afflicting the adult population. However, when pediatric patients present with symptoms resembling GN or Eagle's syndrome, physicians are less apt to include these as a differential diagnosis simply due to the low prevalence and incidence in the pediatric population. MATERIALS AND METHODS A literature review was performed with the aim to better understand the history of reported cases and to provide a comprehensive report of the anatomical variations that lead to these two conditions as well as the way these variations dictated medical and surgical management. Articles were obtained through Google Scholar and PubMed. Search criteria included key phrases such as pediatric glossopharyngeal neuralgia and pediatric Eagle syndrome. These key phrases were searched independently. PubMed was searched primarily then cross-referenced articles were found via Google Scholar. Results from non-English articles were excluded. RESULTS A total of 58 articles were reviewed. Most of the articles focused on adult glossopharyngeal neuralgia, and the majority was comprised of case reports. When searched via PubMed, a total of 16 articles and 2 articles returned for glossopharyngeal neuralgia and Eagle's syndrome, respectively. After criteria selection and cross-referencing, a total of seven articles were found with respect to pediatric glossopharyngeal neuralgia. CONCLUSIONS While they are rare conditions, there are multiple etiologies that lead to the debilitating symptoms of GN and Eagle's syndrome. The clinical anatomy proved notable as multiple causes of GN and Eagle's syndrome are due to variation in the anatomy of the neurovascular structures surrounding the glossopharyngeal nerve, an elongated styloid process, a calcified stylohyoid ligament as well as a calcified stylomandibular ligament. Due to the success of different treatment modalities, the treatment of choice is dependent on clinical judgment.
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Sakamoto Y. Morphological Features of the Glossopharyngeal Nerve in the Peripharyngeal Space, the Oropharynx, and the Tongue. Anat Rec (Hoboken) 2018; 302:630-638. [DOI: 10.1002/ar.23924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/19/2018] [Accepted: 06/26/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Yujiro Sakamoto
- Basic Sciences of Oral Health Care, Graduate School of Medical and Dental SciencesTokyo Medical and Dental University 1‐5‐45 Yushima, Bunkyo‐ku Tokyo 113‐8549 Japan
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Romagna A, Rachinger W, Schwartz C, Mehrkens JH, Betz C, Briegel J, Schnell O, Tonn JC, Schichor C, Thon N. Endotracheal Tube Electrodes to Assess Vocal Cord Motor Function During Surgery in the Cerebellopontine Angle. Neurosurgery 2015; 77:471-8; discussion 478. [PMID: 26103443 DOI: 10.1227/neu.0000000000000854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The 10th cranial nerve (CN X) is at risk during surgery in the lower cerebellopontine angle (CPA). OBJECTIVE To evaluate endotracheal surface electrodes for assessment of CN X motor function during CPA surgery. METHODS Twenty patients were enrolled. Electrophysiological recordings were analyzed and retrospectively correlated with clinical, imaging, and intraoperative data. RESULTS Recordings from endotracheal surface electrodes were reliable and eligible for analyses in 17 patients; in 3 patients, no surface electrode compound motor action potentials (CMAPs) could be obtained. Those patients with sufficient recordings underwent surgery in the CPA for tumors in 14 patients and for nontumor pathologies in 3 patients. In 12 patients, bipolar stimulation of motor rootlets in the CPA resulted in simultaneous CMAPs recorded from both surface electrodes and needle electrodes placed in the soft palate. Coactivation was particularly seen in patients with an intricate relationship between lower cranial nerves and tumor formations (n = 9/10). Amplitudes and latencies of vocal cord CMAPs showed high interindividual but low intraindividual variability. Parameters were not well correlated with the type of surgery (tumor vs nontumor surgery) and lower CN anatomy (displaced vs undisplaced). In 2 patients, vocal cord CMAPs were lost during tumor surgery, which was associated with postoperative dysphagia and hoarseness in 1 patient. CONCLUSION Endotracheal surface electrodes allow identification of vocal cord motor rootlets in the CPA. Worsening of CMAP parameters might indicate functional impairment. These aspects support the use of endotracheal surface electrodes in selected patients in whom the vagus nerve might be at risk during CPA surgery.
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Affiliation(s)
- Alexander Romagna
- *Departments of Neurosurgery, ‡Otorhinolaryngology, and §Anesthesiology, Ludwig-Maximilians-University, Munich, Germany
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Zhang W, Chen M, Zhang W, Chai Y. Use of electrophysiological monitoring in selective rhizotomy treating glossopharyngeal neuralgia. J Craniomaxillofac Surg 2014; 42:e182-5. [DOI: 10.1016/j.jcms.2013.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 06/18/2013] [Accepted: 08/28/2013] [Indexed: 10/26/2022] Open
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Shoja MM, Oyesiku NM, Shokouhi G, Griessenauer CJ, Chern JJ, Rizk EB, Loukas M, Miller JH, Tubbs RS. A comprehensive review with potential significance during skull base and neck operations, Part II: glossopharyngeal, vagus, accessory, and hypoglossal nerves and cervical spinal nerves 1-4. Clin Anat 2013; 27:131-44. [PMID: 24272888 DOI: 10.1002/ca.22342] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/04/2013] [Accepted: 10/07/2013] [Indexed: 11/10/2022]
Abstract
Knowledge of the possible neural interconnections found between the lower cranial and upper cervical nerves may prove useful to surgeons who operate on the skull base and upper neck regions in order to avoid inadvertent traction or transection. We review the literature regarding the anatomy, function, and clinical implications of the complex neural networks formed by interconnections between the lower cranial and upper cervical nerves. A review of germane anatomic and clinical literature was performed. The review is organized into two parts. Part I discusses the anastomoses between the trigeminal, facial, and vestibulocochlear nerves or their branches and other nerve trunks or branches in the vicinity. Part II deals with the anastomoses between the glossopharyngeal, vagus, accessory and hypoglossal nerves and their branches or between these nerves and the first four cervical spinal nerves; the contribution of the autonomic nervous system to these neural plexuses is also briefly reviewed. Part II is presented in this article. Extensive and variable neural anastomoses exist between the lower cranial nerves and between the upper cervical nerves in such a way that these nerves with their extra-axial communications can be collectively considered a plexus.
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Affiliation(s)
- Mohammadali M Shoja
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama; Division of Neurological Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Rey-Dios R, Cohen-Gadol AA. Current neurosurgical management of glossopharyngeal neuralgia and technical nuances for microvascular decompression surgery. Neurosurg Focus 2013; 34:E8. [PMID: 23451790 DOI: 10.3171/2012.12.focus12391] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Glossopharyngeal neuralgia (GPN) is an uncommon facial pain syndrome often misdiagnosed as trigeminal neuralgia. The rarity of this condition and its overlap with other cranial nerve hyperactivity syndromes often leads to a significant delay in diagnosis. The surgical procedures with the highest rates of pain relief for GPN are rhizotomy and microvascular decompression (MVD) of cranial nerves IX and X. Neurovascular conflict at the level of the root exit zone of these cranial nerves is believed to be the cause of this pain syndrome in most cases. Vagus nerve rhizotomy is usually reserved for cases in which vascular conflict is not evident. A review of the literature reveals that although the addition of cranial nerve X rhizotomy may improve the chances of long-term pain control, this maneuver also increases the risk of permanent dysphagia and vocal cord paralysis. The risks of this procedure have to be carefully weighed against its benefits. Based on the authors' experience, careful patient selection with a thorough exploratory operation most often leads to identification of the site of vascular conflict, obviating the need for cranial nerve X rhizotomy.
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Affiliation(s)
- Roberto Rey-Dios
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Tubbs RS, Griessenauer CJ, Hogan E, Loukas M, Cohen-Gadol AA. Neural interconnections between portio minor and portio major at the porus trigeminus: Application to failed surgical treatment of trigeminal neuralgia. Clin Anat 2013; 27:94-6. [DOI: 10.1002/ca.22299] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 06/07/2013] [Accepted: 06/21/2013] [Indexed: 11/11/2022]
Affiliation(s)
- R. Shane Tubbs
- Department of Pediatric Neurosurgery, Children's Hospital of Alabama; Birmingham Alabama
- Section of Neurosurgery; University of Alabama; Birmingham Alabama
| | | | - Elizabeth Hogan
- Department of Pediatric Neurosurgery, Children's Hospital of Alabama; Birmingham Alabama
| | - Marios Loukas
- Department of Anatomical Sciences; St. George's University; St. George's Grenada
| | - Aaron A. Cohen-Gadol
- Department of Neurological Surgery; Goodman Campbell Brain and Spine; Indiana University School of Medicine; Indianapolis Indiana
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Park JH, Jo KI, Park K. Delayed Unilateral Soft Palate Palsy without Vocal Cord Involvement after Microvascular Decompression for Hemifacial Spasm. J Korean Neurosurg Soc 2013; 53:364-7. [PMID: 24003372 PMCID: PMC3756130 DOI: 10.3340/jkns.2013.53.6.364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 04/05/2013] [Accepted: 06/19/2013] [Indexed: 11/27/2022] Open
Abstract
Microvascular decompression is a very effective and relatively safe surgical modality in the treatment of hemifacial spasm. But rare debilitating complications have been reported such as cranial nerve dysfunctions. We have experienced a very rare case of unilateral soft palate palsy without the involvement of vocal cord following microvascular decompression. A 33-year-old female presented to our out-patient clinic with a history of left hemifacial spasm for 5 years. On postoperative 5th day, patient started to exhibit hoarsness with swallowing difficulty. Symptoms persisted despite rehabilitation. Various laboratory work up with magnetic resonance image showed no abnormal lesions. Two years after surgery patient showed complete recovery of unitaleral soft palate palsy. Various etiologies of unilateral soft palate palsy are reviewed as the treatment and prognosis differs greatly on the cause. Although rare, it is important to keep in mind that such complication could occur after microvascular decompression.
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Affiliation(s)
- Jae Han Park
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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