Diagnosis and neurosurgical treatment of glossopharyngeal neuralgia: clinical findings and 3-D visualization of neurovascular compression in 19 consecutive patients

Abstract

Glossopharyngeal neuralgia is a rare condition with neuralgic sharp pain in the pharyngeal and auricular region. Classical glossopharyngeal neuralgia is caused by neurovascular compression at the root entry zone of the nerve. Regarding the rare occurrence of glossopharyngeal neuralgia, we report clinical data and magnetic resonance imaging (MRI) findings in a case series of 19 patients, of whom 18 underwent surgery. Two patients additionally suffered from trigeminal neuralgia and three from additional symptomatic vagal nerve compression. In all patients, ipsilateral neurovascular compression syndrome of the IX cranial nerve could be shown by high-resolution MRI and image processing, which was confirmed intraoperatively. Additional neurovascular compression of the V cranial nerve was shown in patients suffering from trigeminal neuralgia. Vagal nerve neurovascular compression could be seen in all patients during surgery. Sixteen patients were completely pain free after surgery without need of anticonvulsant treatment. As a consequence of the operation, two patients suffered from transient cerebrospinal fluid hypersecretion as a reaction to Teflon implants. One patient suffered postoperatively from deep vein thrombosis and pulmonary embolism. Six patients showed transient cranial nerve dysfunctions (difficulties in swallowing, vocal cord paresis), but all recovered within 1 week. One patient complained of a gnawing and burning pain in the cervical area. Microvascular decompression is a second-line treatment after failure of standard medical treatment with high success in glossopharyngeal neuralgia. High-resolution MRI and 3D visualization of the brainstem and accompanying vessels as well as the cranial nerves is helpful in identifying neurovascular compression before microvascular decompression procedure.

Fig. 1

3D visualization of the neurovascular relationships in a case with left-sided glossopharyngeal neuralgia. With the presented method, we obtain a global overview of the neurovascular relations. We can move the picture in any direction and detect the presence of relevant vessels and cranial nerves and demonstrate the neurovascular compression at the root entry zone of the cranial nerves IX and X. The position as seen during microsurgery (compared to Fig. 2). BA basilar artery, VA vertebral artery, PICA posterior inferior cerebellar artery, V rigeminal nerve, VII and VIII facial and vestibulocochlear nerve, IX glossopharyngeal nerve, X vagus nerve, NVC neurovascular compression

Fig. 2

Intraoperative finding of the visualized case in a–c. The vertebral artery runs from caudal to rostral, while the (a) PICA runs in an upward loop close to the surface of the medulla and the root entry zone of the cranial nerves IX and X (b) inducing a neurovascular compression at this site. Adequate decompression was (c) achieved by insertion of Teflon. The intraoperative findings correspond very clearly to the results of the 3D visualization