Department of
Anesthesiology, Harput State Hospital, Ministry
of Health of Turkey, Elazig, Turkey
We describe the case of a 65-year-old
patient with glossopharyngeal neuralgia. Pain
was triggered by swallowing, yawning, or cold
food. We used the anterior tonsillar pillar
method for the injection of drugs; a relatively
new glossopharyngeal nerve (GPN) block which was
described by Benumof (Anesthesiology
1991;75:1094&endash;1096). Performing this GPN
block, daily levobupivacaine (Chirocaine 5
mg/ml) and oral amitriptyline (Laroxyl 10 mg)
were given, as well as methylprednisolone
acetate injectable suspension (Depo- Medrol 40
mg/ml) once only at the beginning of the
treatment. A 0&endash;10 point visual analogue
scale was used daily to evaluate the pain. Pain
was successfully controlled with a steroid added
to the GPN block and orally administered
tricyclic antidepressant. We think that this
treatment is effective for glossopharyngeal
neuropathy and could be of interest to pain
management physicians.
Glossopharyngeal neuropathy is characterized
by paroxysms of lancinating or burning pain in
the oropharynx, whereas vagal neuropathy
presents similarly but can also include symptoms
of vocal cord dysfunction, such as hoarseness.
Glossopharyngeal neuralgia is estimated to be 75
times less frequent than trigeminal neuralgia
[1]. Electromyography can be performed
to confirm the diagnosis [2].
In this report, we describe the case of a
patient with glossopharyngeal neuralgia. Pain
was triggered by swallowing, yawning or
cold food.
A 65-year-old man reported 4 months' history
of paroxysmal pain attacks originating from the
right lower jaw, disseminating to the right ear
region when eating, and also triggered by
swallowing, yawning and cold food. The
duration of the pain attacks were measured in
seconds. These pain paroxysms had occurred 5 or
6 times daily at the initial stage of the
disease. Three months ago, the patient had been
admitted to the Department of Neurology with
complaints of paroxysmal glossopharyngeal pain
attacks, and hospitalized. During his
hospitalization, he received carbamazepine
(Tegretol® 600 mg p.o. daily).
After a 2-month time period, paroxysmal
glossopharyngeal pain attacks gradually recurred
and increased. The pain attacks were not
completely controlled by carbamazepine at a
daily dose of 1,200 mg. The patient was referred
to the chronic pain center by a neurologist in a
final effort to treat his pain before surgery.
General physical examination, cardiovascular and
neurological examination was normal. Magnetic
resonance images and magnetic resonance
angiography of the brain and brain stem were
normal; there was no sign of compression on the
glossopharyngeal or vagal nerves and also on the
brain stem. Carbamazepine was stopped. The
patient was given a tricyclic antidepressant
(amitriptyline (Laroxyl®) 10 mg/daily p.o.).
We used the anterior tonsillar pillar (ATP)
method, a relatively new glossopharyngeal nerve
(GPN) block for the injection of drugs, which
was described by Benumof [3]. We chose
the ATP method, because the ATP is easily
exposed and tongue movement does not elicit the
gag reflex, besides patient tolerence is good.
In this method, the tongue is swept to the
opposite side. A 25-gauge spinal needle is
inserted 0.5 cm deep, just lateral to the base
of the ATP (fig. ?(fig.1)1) and 2 ml of
levobupivacaine (Chirocaine® 5mg/ml) is
injected on both sides daily.
We also injected methylprednisolone acetate
injectable suspension (Depo-Medrol® 40
mg/ml) 20 mg to each ATP. This was done once
only at the beginning of the therapy. The
patient was asked to evaluate his pain using a
0&endash;10 point visual analogue scale (0 = no
pain, 10 = worst possible pain). Over the course
of 2 weeks after starting the glossopharyngeal
block, the patient's right-sided sore throat and
pain began to resolve and continued to improve
for approximately 1 month. Before starting block
therapy, the patient had described his pain as 9
on a 10-point scale, whereas after a month of
therapy, he described it as 1&endash;2 out of
10. The GPN block was stopped at that time;
orally administered amitriptyline was
continued.
A 65-year-old man reported 4 months' history
of paroxysmal pain attacks originating from the
right lower jaw, disseminating to the right ear
region when eating, and also triggered by
swallowing, yawning and cold food. The
duration of the pain attacks were measured in
seconds. These pain paroxysms had occurred 5 or
6 times daily at the initial stage of the
disease. Three months ago, the patient had been
admitted to the Department of Neurology with
complaints of paroxysmal glossopharyngeal pain
attacks, and hospitalized. During his
hospitalization, he received carbamazepine
(Tegretol® 600 mg p.o. daily).
After a 2-month time period, paroxysmal
glossopharyngeal pain attacks gradually recurred
and increased. The pain attacks were not
completely controlled by carbamazepine at a
daily dose of 1,200 mg. The patient was referred
to the chronic pain center by a neurologist in a
final effort to treat his pain before surgery.
General physical examination, cardiovascular and
neurological examination was normal. Magnetic
resonance images and magnetic resonance
angiography of the brain and brain stem were
normal; there was no sign of compression on the
glossopharyngeal or vagal nerves and also on the
brain stem. Carbamazepine was stopped. The
patient was given a tricyclic antidepressant
(amitriptyline (Laroxyl®) 10 mg/daily p.o.).
We used the anterior tonsillar pillar (ATP)
method, a relatively new glossopharyngeal nerve
(GPN) block for the injection of drugs, which
was described by Benumof [3]. We chose
the ATP method, because the ATP is easily
exposed and tongue movement does not elicit the
gag reflex, besides patient tolerence is good.
In this method, the tongue is swept to the
opposite side. A 25-gauge spinal needle is
inserted 0.5 cm deep, just lateral to the base
of the ATP (fig. ?(fig.1)1) and 2 ml of
levobupivacaine (Chirocaine® 5mg/ml) is
injected on both sides daily.
We also injected methylprednisolone acetate
injectable suspension (Depo-Medrol® 40
mg/ml) 20 mg to each ATP. This was done once
only at the beginning of the therapy. The
patient was asked to evaluate his pain using a
0&endash;10 point visual analogue scale (0 = no
pain, 10 = worst possible pain). Over the course
of 2 weeks after starting the glossopharyngeal
block, the patient's right-sided sore throat and
pain began to resolve and continued to improve
for approximately 1 month. Before starting block
therapy, the patient had described his pain as 9
on a 10-point scale, whereas after a month of
therapy, he described it as 1&endash;2 out of
10. The GPN block was stopped at that time;
orally administered amitriptyline was
continued.
Glossopharyngeal neuralgia was first
described by Weisenburg in 1910 [4] in a
patient with a tumor of the cerebellopontine
angle. The cause of this disorder was usually
undetermined, though in a few reported cases,
cerebellopontine angle tumors [5], an
elongated styloid process or a calcified
stylohyoid ligament or the last two together
[6] were identified as etiological
factors. Most of these cases of 'idiopathic'
glossopharyngeal neuralgia are caused by
vascular compression of the GPN [7, 8].
The other secondary causes of glossopharyngeal
neuralgia are Eagle's syndrome, cerebellopontine
angle tumors, parapharyngeal space lesions,
multiple sclerosis, arachnoiditis, posterior
fossa arteriovenous malformation, direct carotid
puncture, metastatic head and neck tumors, and
Chiari I malformation [7, 8, 9, 10,
11].
The paroxysms of pain are triggered by
swallowing, particularly cold, salted, bitter,
or acid foods [6, 12] and by mechanical
stimulation of the tonsillar fossa on the
affected side (trigger zone). Local anesthesia
of the pharynx and nerve block with mepivacaine
(Carbocaine) are additional measures that
produce temporary benefit [13, 14].
Anticonvulsant treatment (phenytoin) has been
advocated as the long-term treatment of choice
[15] and carbamazepine may also be an
alternative to surgical resection of the GPN
[9]. Several recent studies recommend
gabapentin, pregabalin, or a tricyclic
antidepressant as equivalent first-line agents
for treatment of neuropathic pain [12,
16]. Carbamazepine is the drug of choice for
the initial treatment of neuralgia. In the case
of partial pain relief with carbamazepine, a
second agent can be added or the drug can be
changed [17]. Gabapentin has been used
as a first-line agent or in cases of neuralgia
resistant to the traditional therapy, with
complete or almost total remission in 27% of the
cases [18, 19]. Gabapentin is considered
a second-line medication and definitive
scientific evidence of its efficacy in the
treatment of neuralgia does not exist
[18].
Our patient's clinical symptoms of
spontaneous paroxysmal burning pain in the
tonsillar area that radiated to the right ear
and did not resolve with previous treatment were
strongly indicative of glossopharyngeal
neuropathy. The patient's pain was triggered by
eating, swallowing, yawning, or cold
food. Therefore we had to reduce the pain
quickly, which is why we did not choose
gabapentin therapy, since the usage of this drug
might prolong the total treatment time. The
patient used amitriptyline therapy for about 12
months; during this time, he had no pain
attacks. We think a GPN block and steroid
therapy is more effective in the earlier periods
of glossopharyngeal neuropathy and amitriptyline
is more effective in the later periods of the
disease. Screening for neuropathic pain is
extremely important because misdiagnosis may
cause unnecessary diagnostic and invasive
procedures, increased patient suffering, and
decreased quality of life. Therefore, patients
presenting with lancinating, burning, localized
throat pain should be evaluated and treated for
neuropathic pain if other possible causes have
been ruled out. Had our patient not come to the
pain center, he might have undergone potentially
unnecessary surgery with no guarantee that his
pain would have resolved. In this case report,
we discussed the administration of a GPN block
using the ATP method, injecting a local
anesthetic with steroid, as well as oral
amitriptyline usage to effectively treat
glossopharyngeal neuropathy in a patient. We
stress the importance of screening patients with
unexplained throat pain for pain of neuropathic
etiology. The mechanism was idiopatic, there was
no sign of compression on the GPN region. We
suggest that this treatment is effective for
this kind of glossopharyngeal neuropathy and
could be of interest to pain management
physicians.
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