Vagoglossopharyngeal Neuralgia

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Vagoglossopharyngeal neuralgia is described as pain in the ear, tonsillar fossa, throat, larynx, pharynx, or tongue, typically with periods of long remissions. Pain is triggered by swallowing and by other movements of the face or mouth (e.g., chewing, sneezing, coughing) (23). Vagoglossopharyngeal neuralgia occurs for many reasons, mostly compression or irritation of the nervous tissue by surrounding structures that include abscess, tumor, aneurysm, tonsillitis, arachnoiditis, styloid process, styloid ligament, vertebral artery, or trauma (24,25).

Primary treatment, as for other neuralgias, includes medications such as baclofen, carbamazepine, and phenyl hydantoin. When medical therapy fails, surgical options are considered. Patient selection may be instrumental in predicting pain relief with RFL. Evaluation of vagoglossopharyngeal neuralgia includes clinical history and radiographic imaging to exclude a more critical pathology (i.e., tumor, abscess, aneurysm). Test dosing of local anesthetics to the tonsillar fossa during pain attacks is a reliable diagnostic test for glos-sopharyngeal neuralgia. Pain relief with anesthetics to the pyriform fossa or jugular foramen is more likely diagnostic of vagal neuralgia (26).

RFL of the glossopharyngeal nerve in the nervous portion of the jugular canal is possible using techniques similar to treatment of trigeminal pain. During the senior author's early experience with trigeminal neuralgia rhizotomy (5), safe penetration of the jugular foramen was performed inadvertently. As with trigeminal neuralgia, percutaneous RFL for vagoglossopharyngeal neuralgia is performed in the radiographic suite. The target of the electrode is the pars nervosa of the jugular foramen. The pars nervosa (glossopharyngeal nerve) is isolated from the larger lateral pars venosa (jugular bulb, vagal nerve, accessory nerve) by a fibrous band. The patient receives small doses of methohexital for pain. The surgeon performs RFL with free-hand electrode placement and confirms the trajectory with a lateral fluoroscopic view. The needle is inserted

Electrode Foramen Ovale

Fig. 6. Various projections show the approach trajectories to the foramen ovale and jugular foramen. (A) Composite illustration shows that the sagittal plane is identical for both targets. (B) Illustration of a lateral projection of the head shows that the needle is inserted 27-33 mm below the sella floor; it lies posterior to the temporomandibular joint and anterior to the occipital condyle. (C) Illustration shows the needle insertion into the anteromedial pars nervosa of the jugular foramen; this foramen is in a direct line with and 2-2.5 cm inferior to the foramen ovale. (A,C: courtesy of the Mayfield Clinic. B, from Tew JM Jr, Taha JM: Surgical management of glossopharyngeal and other uncommon facial neuralgias, in The Practice of Neurosurgery (Tindall GT, Cooper PR, Barrow DL, eds.), Williams & Wilkins, Baltimore, 1995. Reprinted by permission.)

Fig. 6. Various projections show the approach trajectories to the foramen ovale and jugular foramen. (A) Composite illustration shows that the sagittal plane is identical for both targets. (B) Illustration of a lateral projection of the head shows that the needle is inserted 27-33 mm below the sella floor; it lies posterior to the temporomandibular joint and anterior to the occipital condyle. (C) Illustration shows the needle insertion into the anteromedial pars nervosa of the jugular foramen; this foramen is in a direct line with and 2-2.5 cm inferior to the foramen ovale. (A,C: courtesy of the Mayfield Clinic. B, from Tew JM Jr, Taha JM: Surgical management of glossopharyngeal and other uncommon facial neuralgias, in The Practice of Neurosurgery (Tindall GT, Cooper PR, Barrow DL, eds.), Williams & Wilkins, Baltimore, 1995. Reprinted by permission.)

2.5 cm lateral to the oral commissure using the same sagittal trajectory necessary for the foramen ovale. The pars nervosa is in direct sagittal alignment with the foramen ovale. An angle of 14° caudal to the trigeminal target is sufficient to obtain access to the pars nervosa. The jugular foramen is posterior to the tem-poromandibular joint and anterior to the occipital condyle 30 mm below the sella (Fig. 6). This trajectory passes below the hard palate, medial to the ramus of the mandible, and medial to the carotid canal. Although lateral approaches have been described, their use during RFL may result in vagal nerve injury (27).

Electrophysiologic localization is accomplished by 1-ms-duration stimulations at 10-75 pulses/s with 100-300 mV current. Resulting pain in the throat and ear identifies the correct location. Stimulation with higher currents may cause coughing or contraction of the sternocleidomastoid. Creation of thermal lesions begins at 60°C for 90 s, increasing in increments of 5°C until the pharynx is analgesic and triggers no longer cause pain (18).

Immediate risks of vagoglossopharyngeal neuralgia include procedural hypotension, hypertension, bradycardia, syncope, or cardiac arrest related to injury to vagal nerve or nerve of herding (28,29). Complications or procedural side effects also include vocal cord dysfunction that results in hoarseness and sensory losses with a decreased gag reflex and dysphagia. Physiologic monitoring, including electrical stimulation or heating tests, allows accurate localization and electrode position testing before the creation of a permanent lesion (30-32). Stimulation causing hypotension, bradycardia, coughing, or sternoclei-

domastoid contraction is an indication to reposition the electrode. Lesion production of the glossopharyngeal rootlets requires less heat than trigeminal lesions because of anatomic differences, that is, glossopharyngeal rootlets are not located in a spinal-fluid filled cistern (33). Because of reduced heat dissipation, lesions are successfully created with repetitive low energy trials of shorter duration and intervening neurological exams.

Glossopharyngeal RFL has been successful in 70% of cervicofacial pain from neoplastic processes and 90% of idiopathic neuralgias (31-35). Opinions vary considerably about the appropriate use of glossopharyngeal RFL. Arguments against RFL include the possibility of serious and frequent side effects and recommend its restriction for patients with neoplastic disease. Advocates of RFL for the treatment of idiopathic glossopharyngeal neuralgia suggest its safety when used conservatively, that is, avoiding the creation of dense lesions and reducing the risks of serious complications by careful localization.

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