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Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 4  |  Page : 442-444

Glossopharyngeal neuralgia due to ectatic anterior inferior cerebellar artery


1 Department of Neurosurgery, Suraksha Hospital, Vijayawada, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Sri Saraswati Dhanwantari Dental College and Hospital, Parbhani, Maharashtra, India
3 Department of Oral and Maxillofacial Surgery, Family Dental Hospital, Vijayawada, Andhra Pradesh, India
4 Department of Radiology, Suraksha Hospital, Vijayawada, Andhra Pradesh, India

Date of Web Publication6-Sep-2012

Correspondence Address:
Rajesh K Ghanta
Department of Neurosurgery, Suraksha Hospital, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.100731

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How to cite this article:
Ghanta RK, Kattimani V, Koneru V, Dandamudi S. Glossopharyngeal neuralgia due to ectatic anterior inferior cerebellar artery. Neurol India 2012;60:442-4

How to cite this URL:
Ghanta RK, Kattimani V, Koneru V, Dandamudi S. Glossopharyngeal neuralgia due to ectatic anterior inferior cerebellar artery. Neurol India [serial online] 2012 [cited 2021 Oct 19];60:442-4. Available from: https://www.neurologyindia.com/text.asp?2012/60/4/442/100731


Sir,

Glossopharyngeal neuralgia is a rare condition with neuralgic sharp pain in the pharyngeal and auricular region with a reported incidence of 0.2-0.7 per 100,000 population. [1]

A 46-year-old female presented with history of paroxysms of severe pain at the base of tongue extending up to pinna on right side of 4 years duration. Initially, the pain subsided with carbamazepime, but started to experience severe pain not responding to increased dose of carbamazepime since 4 months. She had difficulty in taking even liquid diet due to the severity of pain. In addition to routine magnetic resonance imaging (MR) study, 3D constructive interference in steady state (CISS) sequence and 3D time of flight MR angiography (MRA) of intracranial vessels was performed. These imaging sequences showed ectasia of basilar artery with a large tortous right anterior inferior cerebellar artery (AICA) in contact with right glossopharyngeal nerve at the supraolivary fossette [Figure 1] and [Figure 2]. Endoscope-assisted microvascular decompression (MVD) was done in supine position with head turned to left and fixed in sugita head frame, by retrosigmoid suboccipital approach. Endoscopic visualization of ectatic right AICA vessel confirmed the preoperative radiological findings. AICA was seen adherent to the ninth and tenth cranial nerves [Figure 3]. Arachnoid adhesions between AICA and glossopharyngeal and vagus nerves were divided. AICA was separated from the cranial nerves, and Teflon felt was inserted between the vessel and the nerve. Patient had immediate relief of pain following surgery. There were no postoperative complications. Patient did not have dysphonia, dysphagia, or dysarthria during the perioperative period. There was no recurrence of pain at 6 months of follow-up.
Figure 1: Source image from 3D TOF MRA showing right AICA and right vertebral artery relation

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Figure 2: MRI image showing contact between right AICA and right glossopharyngeal nerve on 3D CISS axial images

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Figure 3: Intraoperative endoscopic image showing large right anterior inferior cerebellar artery in contact with glossopharyngeal and vagal cranial nerves

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Glossopharyngeal neuralgia is characterized by repeated episodes of severe pain in the tongue, throat, ear, and tonsils, which can last from a few seconds to a few minutes. The pain can also be felt in the areas innervated by the auricular and pharyngeal branches of the vagus nerve, thus also described as "vagoglossopharyneal neuralgia." [2] It is commonly provoked by swallowing, talking, and coughing. It can rarely be life-threatening as a result of associated cardiovascular consequences like syncope, bradycardia, and hypotension. [3] Classical glossopharyngeal neuralgia is caused by neurovascular compression at the root entry zone of the nerve. [1] The primary goal of diagnostic procedures is to rule out symptomatic glossopharyngeal neuralgia. Three-dimensional CISS and MRA are helpful in visualizing the offending artery in contact with the glossopharyngeal nerve in supraolivary rosette. [4] The supraolivary fossette is the most medial portion of the cerebellopontomedullary angle and the rootlet of the glossopharyngeal nerve is located at this fossette. [4],[5] As reported in literature, the posterior inferior cereberllar artery (PICA) is the most frequent causative vessel, which compressed the root entry zone of the glossopharyngeal nerve, followed by vertebral artery and AICA. [4] Glossopharyngeal neuralgia due to neurovascular compression by AICA is rare and accounts for only 5 to 10% of cases. [1],[6] AICA as offending vessel is rare and imaging of such neurovascular conflict was reported in very few case reports. [4]

Surgery in glossopharyngeal neuralgia is considered when initial medical treatment fails or when unacceptable side effects occur with medical treatment. Surgery, MVD, for glossopharyngeal neuralgia can be approached either by retromastoid suboccipital approach [7] or by transcondylar fossa (supracondylar transjugular tubercle) approach. [8] The offending vessel is separated from the nerve, and further contact of the vessel with the nerve can be prevented by either a Teflon felt or by stitched sling retraction technique. [8] Endoscope- assisted MVD helps in better visualization of the anatomy than with microscopy. [9] Glossopharyngeal rhizotomy along with MVD has also been reported. [6] Postoperative complications include common risks of anesthesia, bleeding, infection, hearing loss, hoarseness, and difficulties in swallowing. MVD has been standard surgical treatment for trigeminal neuralgia as reported previously in our series. [10] MVD of the glossopharyngeal nerve is an effective treatment of patients with glossopharyngeal neuralgia. In the present case, patient had immediate and persisting relief of pain following surgery. Other treatment modalities for glossopharyngeal neuralgia include percutaneous radiofrequency rhizotomy for glossopharyngeal nerve and gamma knife radiosurgery.

 
  References Top

1.Gaul C, Hastreiter P, Duncker A, Naraghi R. Diagnosis and neurosurgical treatment of glossopharyngeal neuralgia: Clinical findings and 3-D visualization of neurovascular compression in 19 consecutive patients. J Headache Pain 2011;12:527-34.  Back to cited text no. 1
[PUBMED]    
2.Bruyn GW. Glossopharyngeal neuralgia. Cephalalgia 1983;3:143-57.  Back to cited text no. 2
[PUBMED]    
3.Kim SH, Han KR, Kim do W, Lee JW, Park KB, Lee JY, et al. Severe pain attack associated with neurocardiogenic syncope induced by glossopharyngeal neuralgia: Successful treatment with carbamazepine and a permanent pacemaker -a case report-. Korean J Pain 2010;23:215- 8.  Back to cited text no. 3
[PUBMED]    
4.Hiwatashi A, Matsushima T, Yoshiura T, Tanaka A, Noguchi T, Togao O, et al. MRI of glossopharyngeal neuralgia caused by neurovascular compression. AJR Am J Roentgenol 2008;191:578-81.  Back to cited text no. 4
[PUBMED]    
5.Naidich TP, Kricheff II, George AE, Lin JP. The normal anterior inferior cerebellar artery: Anatomic-radiographic correlation with emphasis on the lateral projection. Radiology 1976;119:355-73.  Back to cited text no. 5
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6.Xiong NX, Zhao HY, Zhang FC, Liu RE. Vagoglossopharyngeal neuralgia treated by microvascular decompression and glossopharyngeal rhizotomy: Clinical results of 21 cases. Stereotact Funct Neurosurg 2012;90:45-50.  Back to cited text no. 6
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7.Ferroli P, Fioravanti A, Schiariti M, Tringali G, Franzini A, Calbucci F, et al. Microvascular decompression for glossopharyngeal neuralgia: A long-term retrospectic review of the Milan-Bologna experience in 31 consecutive cases. Acta Neurochir (Wien) 2009;151:1245-50.  Back to cited text no. 7
[PUBMED]    
8.Kawashima M, Matsushima T, Inoue T, Mineta T, Masuoka J, Hirakawa N. Microvascular decompression for glossopharyngeal neuralgia through the transcondylar fossa (supracondylar transjugular tubercle) approach. Neurosurgery 2010;66:275-80.  Back to cited text no. 8
[PUBMED]    
9.Rak R, Sekhar LN, Stimac D, Hechl P. Endoscope-assisted microsurgery for microvascular compression syndromes. Neurosurgery 2004;54:876- 81.  Back to cited text no. 9
    
10.Chakravarthi PS, Ghanta R, Kattimani V. Microvascular decompression treatment for trigeminal neuralgia. J Craniofac Surg 2011;22:894-8.  Back to cited text no. 10
[PUBMED]    


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