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Case of vago-glossopharyngeal neuralgia secondary to metastatic oropharyngeal cancer

Glossopharyngeal neuralgia (GN) is a rare pain syndrome caused by compression of the glossopharyngeal nerve. It is typically idiopathic and often goes misdiagnosed because of its similarities to trigeminal neuralgia. Vago-glossopharyngeal neuralgia, an even rarer subset of GN, occurs when the pain is accompanied by syncope and/or arrhythmia.
Here, we present the case of a 54-year-old man with oropharyngeal cancer that metastasised to areas within his left carotid sheath. He presented with numerous intermittent episodes of pain, accompanied by vagal episodes. While this presentation is similarly described in prior case reports, our case is unique in that the syndrome occurred as a direct sequelae of a metastatic tumour completely encasing the left internal carotid artery.

Reoperation after failed microvascular decompression for glossopharyngeal neuralgia.

Microvascular decompression (MVD) is known as a safe and effective procedure to treat glossopharyngeal neuralgia (GN). However, some patients experienced poor pain relief after MVD, for which the mechanism is not clear yet. Reviewing the intraoperative findings and postoperative effect of reoperation for patients who failed the first MVD, is helpful to figure out why the first MVD for GN failed.There were eight patients with GN who failed first MVD. The possibilities for secondary GN were eliminated by physical and radiological examination. The reoperation through the previous incision was conducted, and appropriately, treatment was provided according to the intraoperative findings.
The video data and prognosis of the reoperation were retrospectively reviewed. The reasons for the invalid first MVD were analyzed.To the end of follow-up, there were 7 patients of pain-free, and one patient with occasional mild pain attacks (VAS 2). There was one patient who experienced transient hoarseness in 3 months after the reoperation. We summarized the causes for failed first MVD which were omission of the offending vessel in 3 cases, inadequate decompression of the nerve root in 2 cases, and excessive decompression materials which caused iatrogenic nerve root compression in 3 cases.
For patients with recurrent or failed after MVD, a thorough examination should be carried out to eliminate the possibility of secondary GN. Reoperation through the previous incision is safe and effective. The bone window should be close enough to the sigmoid sinus to aid the exposure of the nerve root. The nerve transection could be adopted if no offending vessels were found. And a multi-site decompression could be used when the vertebral artery is the offending vessel.

Glossopharyngeal Neuropathy / Neuralgia with Hemodynamic Instability and Associated Syncope Treated with Stereotactic Radiosurgery: Case Report.

The incidence of glossopharyngeal neuralgia (GPN)/neuropathy (GPNo) is rare, with approximately 0.4-0.8 cases per 100,000 person-years with less than 3 percent of those cases being associated with cardiac arrhythmias or syncope1-7. The exact relationship between GPN and cardiac arrhythmias remains unknown; however, it is suspected that GPN also involves vagal dysfunction, which can lead to syncope, cardiac dysfunction, or even seizures8.
Most of these cases are successfully treated with medical management with or without placement of a cardiac pacemaker. We present the only reported case of GPNo with cardiac dysfunction refractory to medical management and pacemaker placement that was successfully treated with Gamma Knife Radiosurgery (GKR).
Case of vago-glossopharyngeal neuralgia secondary to metastatic oropharyngeal cancer

Randomized Controlled Trial Comparing Landmark and Ultrasound-Guided Glossopharyngeal Nerve in Eagle Syndrome.

The glossopharyngeal nerve lies posterior to the internal carotid artery at the submandibular region. The primary objective of this study was to compare ultrasound-guided glossopharyngeal nerve block (UGPNB) and landmark glossopharyngeal nerve block (GPNB).Inclusion criteria were patients with unilateral Eagle syndrome and ear pain. Group UGPNB (N = 25) received three UGPNBs at weekly intervals with 1.5 mL of 0.5% ropivacaine and 20 mg of methylprednisolone.
Group GPNB (N = 26) received landmark GPNB. Pain intensity was evaluated with the numerical rating scale (NRS) before every block, 30 minutes after every block, and at one, three, and five weeks after the third block. Quality of life, assessed using the Brief Pain Inventory (BPI), and satisfaction scores were noted.NRS scores before the second and third blocks and a week after were significantly lower in group UGPNB and comparable at weeks 3 and 5.
NRS scores 30 minutes after every block were significantly decreased from the preblock values but were comparable between groups. In 68% of patients, a curvilinear probe delineated the internal carotid artery (ICA). Out-of-plane needle trajectory was required in 64% of patients. BPI and satisfaction scores were significantly better in the UGPNB group in the “block” weeks.UGPNB with 1.5 mL of 0.5% ropivacaine and 20 mg of methylprednisolone injected posterior to the ICA in the submandibular region provides better pain relief for at least a week compared with an extraoral landmark technique when three weekly consecutive blocks are given. In most patients, a curvilinear probe and out-of-plane needle trajectory are most suitable for ultrasound block.

Microvascular Decompression Alone without Rhizotomy Is an Effective Way of Treating Glossopharyngeal Neuralgia: Clinical Analysis of 46 Cases.

Microvascular decompression (MVD) has been the right choice for glossopharyngeal neuralgia (GPN) patients. However, whether glossopharyngeal/vagal nerve root rhizotomy should be combined with MVD is still controversial.To evaluate whether glossopharyngeal/vagal nerve root rhizotomy during MVD is necessary for the treatment of GPN.We performed a retrospective study of 46 GPN patients who underwent MVD surgery alone in our hospital, and their patient demographics, clinical presentations, and intraoperative findings are shown.
The immediate and long-term follow-up outcomes were investigated to show the treatment’s efficiency and safety; the outcome was also compared with our previous study. The relevant literature was reviewed to show complications for GPN patients undergoing glossopharyngeal/vagal nerve root rhizotomy with MVD.The most common offending vessel was the posterior inferior cerebellar artery (60.9%). 100% of the patients were pain-free (score of I on the Barrow Neurological Institute pain intensity [BNI-P] scale) immediately after MVD surgery, while 1 patient relapsed with occasional pain 12 months after the operation (score of III on the BNI-P scale).
Poor wound healing and hearing loss were found in 1 case each. No complications related to the glossopharyngeal nerve/vagal nerve were reported. Some surgical techniques, such as thorough exploration of the CN IX-X rootlets, full freeing from arachnoid adhesions, and usage of a moist gelatin sponge, can improve the success rate of the operation.MVD alone without rhizotomy is an effective and safe method for patients with GPN.
Alexander Sanchez