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29 janvier 2004
The New England
J of medicine
1996;333(26):1786-1787
Headphone neuralgia
A Skelton, R Fried
Maine Medical Center, Portland, USA
Glossopharyngeal neuralgia and MS A Minagar
Primary yawning headache DE Jacome

Chat-logomini
Glossopharyngeal neuralgia is an uncommon cause of head or facial pain. A review of the epiderniologic data base at the Mayo Clinic identified only 217 cases in 55 years. Trauma is a rare cause of this disorder, but contemporary life can produce trauma from uncconventional sources. We report a case of glossopharyngcal neuralgia caused by the use of headphones with hard plastic earpieces.
 
A 37 year-old woman suddendly had paroxysmal, lancinating pain ni the left ear. The pain radiated from the external auditory meatus to the ipsilateral parietal area of the head.
 
Over a period of several hours, it spread to the left shoulder, the neck and the left side of the pharynx. Yawning, eructation, swallowing and raising the left arm while driving all triggered the pain. No motor or sensory deficit was noted, and no neurologic abnormalities were found. The pain was partly relieved by nonsteroidal anti-inflammatory medication. Without other treatment, it gradually improved and resolved entirely after five days.
 
An additional history revealed that on the ttow days before the onset of pain, the patient had worn headphones with hard plastic earpiceces that rested in the external auditory canal. The earpieces had been in place for eight hours each day. The patient noted only mild discomfort in the canal while wearing them; she discontinued their use altogether when the symptoms of neuralgia developed.
 
Glossopharyngeal neuralgia was first described in 1910. It shares some characteristics with the more common trigeminal neuralgia but is often milder. In most cases, the cause of glossopharyngeal neuralgia is not found. Vascular diseases, local infection and inflammation, and neoplasms, such as cerebellopontine -angle tumors and tumors of the oropharynx, have resulted in glossopharyngeal neuralgia, Trauma is a rare cause.
 
In our patient, local irritation of the extracranial portion of the nerve is presumed to have caused the neuralgia, which was self-limited. As headphones with hard plastic earpieces become more popular, physicians may encounter this disorder more frequently. Similarly shaped objects in the auditory canal, such as stethoscope earpieces and hearing aids, may put patients at risk for glossopharyngeal neuralgia. Traumatic neuralgia produced in this manner should be self-limited after the object is removed, and costly diagnostic and therapeutic maneuvers should be avoidable.
  1. Bruyn GW. Glossopharyngeal neuralgia. Cephalalgia 1983; 3; 143-57
  2. Weisenburg TH. Cerebello-pontine tumor diagnosed for six years as tic douloureux. JAMA 1910; 54:; 1600-4
  3. Waga S, Kojima T. Glossopharyngeal neuralgia of traumatic origin, Surg Neurol 1982;17; l; 77-9.
More on headphone neuralgia
Osvaldo Bustos
Office of U.S. Army Surgeon General, the Falls Church, VA 22041
The New england J of medicine 1996;334(22):1480-181
 
Skelton and Fried recently coined the phrase "headphone neuralgia" .The external ear, unlike its middle and internal counterparts, is a major neurologic crossroads. Its canal and the outer surface of the tympanic membrane are supplied by general somatic afferent fibers (for pain, temperature, and touch) from three cranial nerves: the trigeminal, facial, and vagus nerves (cranial nerves V, VII, and X, respectively). In turn, the skin of the auricle and retroauricular area are supplied by the cervical plexus, with a small contribution from cranial nerves VII and X. However, most modern neuroanatomists and clinicians specializing in the ear agree that the glossopharyngeus (cranial nerve IX), the nerve of the third branchial arch, does not have any cutaneous representation. To attribute the patient's syndrome exclusively to cranial nerve IX represents a misunderstanding of the embryologic, anatomical, and clinical complexity of the external ear.
 
The patient probably had a craniofacial polyneuralgia, possibly of viral origin, involving cranial nerves V and VII ("the pain radiated from the external auditory meatus to the ipsilateral parietal area of the head"), cranial nerves IX and X (pain on the side of the neck and pharynx), and cranial nerve XI and the cervical plexus ("over a period of several hours, il spread to the left shoulder"). Such polyneuralgia would also explain why "yawning, eructation, swallowing, and raising the left arm while driving all triggered the pain," whereas glossopharyngeal neuralgia would not. In fact, the shoulder is anatomically and clinically unrelated to the third branchial arch; therefore, it can never be a "trigger zone" for glossopharyngeal neuralgia.
 
Because the patient was a 37-year-old woman, she was at high risk for vagoglossopharyngeal neuralgia. "Paroxysmal, lancinating pain in the left ear" with a pattern of radiation consistent with an idiopathic craniofacial polyneuralgia calls for careful ear, nose, and throat and neurologie evaluation, for the headphone hypothesis advanced by the authors is a bit far-fetched.
  1. Head and neck. In: Mathers LUI Jr, Chase RA, Dolph J, Glasgow EF, Gosling JA. Clinical anatomy principles. St. Louis: Mosby, 1996:133-305.
  2. Mandel S. Facial pain: -Why does rny face hurt, doctor?" Posigrad Med 1990;87:77-80.
  3. Trauma. In: Rowland LP, cd. Merfitt's textbook of neurology. 9th cd. Baltimore: Williams & Wilkins, 1995:417-95.
Dr. Skelton replies:
 
Dr. Bustos correctly points out the complex innervation of the ear. He does not mention the tympanic branch of the glossopharyngeal nerve (Jacobson's nerve), which may overlap the vagal territory in the external auditory meatus.
Glossopharyngeal neuralgia is a well-defined syndrome with characteristic pain, radiation of pain, and triggers. Our patient's symptoms were entirely consistent with glossopharyngeal neuralgia as described in modern textbooks.
 
To postulate that a viral craniofacial polyneuralgia involving five cranial nerves caused the patient's symptoms is more "far-fetched" than the theory that the immediately preceding trauma to the external auditory meatus caused unilateral symptoms all attributable to the glossopharyngeal nerve. Although glossopharyngeal neuralgia of this origin had not been described previously, I maintain that we presented the most likely explanation for the symptoms.
 
Further neurologic evaluation was not warranted because the diagnosis was clear and the symptoms resolved once the cause was removed. To date, two years later, there has been no recurrence of glossopharyngeal neuralgia or any other craniofacial pain.
  1. Diseases of the cranial nerves. In: Adams RD, Victor M, eds. Principles of neurology. 5th cd. New York: McGraw-Hill, 1993:1170-83
  2. Victor M, Martin JB. Disorders of the cranial nerve. In: Wilson ID, Braunwald E, Isselbacher KI, et al., cris. Harrison's principles of internal medicine. 12th cd . Vol. 2. New York: McGraw-Hill, 1991:2076-8 1