Issue Date: May 2010, Posted On: 5/1/2010

MRI findings in a patient with glossopharyngeal neuralgia

y Ri!!ardo "en#i, MD, $ndrea De %ito, MD, Ia!opo Dallan, MD, and "u!a Mus!atello, MD
&euralgia of the glossopharyngeal ner'e is a rare entity, with an esti(ated in!iden!e of 0)* !ases
per 100,000)1 +he relati'e fre,uen!y !o(pared with tri-ge(inal neuralgia is appro.i(ately 1/)2
0lossopharyngeal neuralgias are !lassified as either !lassi!al or sy(pto(ati!1 these two types
differ (ostly y the inter!riti!al pain and sensory defi!it in the ner'e2s territories of distriution
seen in the latter type)3 +he International Classification of Headache Disorders, 2nd edition
4I5D6-II78 in!ludes diagnosti! !riteria for the !lassi!al type of glossopharyngeal neuralgia,
whi!h is asso!iated with neuro'as!ular !o(pression in the !ereellopontine angle) +he (ost
!o((on offending 'essel is the posteroinferior !ereellar artery 4PI5$7, followed y the
'erteral artery, the anteroinferior !ereellar artery 4$I5$7, and other 'essels or !o(inations of
'essels)5 $n endos!opi! anterior 'iew of the nor(al anato(y of the !ereellopontine angle is
shown in figure 1)
Figure 1. This anterior endoscopic view shows a normal right cerebellopontine angle in a
cadaver head. The anteroinferior cerebellar artery (AICA) forms a loop close to the facial
(II) and vestibulocochlear (III) nerves! the posteroinferior cerebellar artery ("ICA)
forms a loop anterior to the roots of the lower cranial nerves ("# $ petrous bone)
+he ai( of this report is not to des!rie a new !lini!al !ondition, ut to show a rare, e.e(plary
!ase of glossopharyngeal neuralgia in whi!h a step-y-step diagnosti! wor9up allowed us to
(a9e a definiti'e diagnosis)
$ 8*-year-old (an presented to us with a 13-(onth history of se'ere paro.ys(al pain lo!ated in
the left tonsillar fossa and radiating to the posterior wall of the pharyn., lower :aw, and ear) 6is
;&+ e.a(ination was unre(ar9ale, and pre'ious !o(puted to(ography i(aging was negati'e
for lesions of the rain, s9ull, and ne!9)
<9ull .-rays did not re'eal an elongated styloid pro!ess or !al!ifi!ation of the stylohyoid
liga(ent, ruling out the possiility of ;agle syndro(e)= 5ontrast-enhan!ed (agneti! resonan!e
i(aging 4MRI7 of the !ereellopontine angle showed a neuro'as!ular !o(pression etween the
left PI5$ and the roots of the lower !ranial ner'es 4figure 27)
Figure %. A&ial T%'weighted ()I reveals the vascular loop of the "ICA (blac* arrow)
compressing the glossopharyngeal nerve against the cerebellum. The course of the
glossopharyngeal nerve is visible (white arrow)
>e initiated treat(ent with !ara(a#epine, !onsidering surgery a se!ond-line treat(ent that
!ould e proposed if (edi!al treat(ent pro'ed unsu!!essful) +he patient2s response to (edi!al
therapy was only partially satisfa!tory, ut he de!ided to wait efore !onsidering surgery)
5auses of sy(pto(ati! glossopharyngeal neuralgia in!lude !ereellopontine angle tu(ors,
nasopharyngeal !ar!ino(as, !arotid aneurys(s, tonsillar as!esses, neurile((o(as of !ranial
ner'e I?, (ultiple s!lerosis, and ;agle syndro(e) +reat(ent !an e (edi!al or surgi!al)
5ara(a#epine or gaapentin !an e effe!ti'e in suppressing painful paro.ys(s) <urgi!al
(ethods in!lude ner'e se!tion and (i!ro'as!ular de!o(pression) +he latter !an pro'ide
!o(plete relief of pain in @=/ of patients and sustantial i(pro'e(ent in an additional 1=/,
a!!ording to Resni!9 et al)@
0lossopharyngeal neuralgia 4in oth its !lassi!al and sy(pto(ati! for(s7 should e !onsidered
in the differential diagnosis of paro.ys(al oropharyngeal pain) MRI !an e useful in
de(onstrating neuro'as!ular !o(pression in !lassi!al glossopharyngeal neuralgia)
Aro( the 1st Bnit of Otorhinolaryngology, Depart(ent of &euros!ien!e, Bni'ersity of Pisa,
Italy)
)eferences
1) Catusi! <, >illia(s DD, Deard 5M, et al) ;pide(iology and !lini!al features of
idiopathi! trige(inal neuralgia and glossopharyngeal neuralgia: <i(ilarities and
differen!es) &euroepide(iology 1EE11 10 :2@=-*1)
2) Chan &u, Iyer $) 0lossopharyngeal neuralgia asso!iated with ano(alus
glossopharyngeal ner'e) Ototlaryngol 6ead &e!9 <urg 200@1 13= 437: 502-3)
3) De <i(one R, Ranieri $, Dilo ", et al) 5ranial neuralgias: Aro( physiopathology to
phar(a!ologi!al treat(ent) &eurol <!i 200*1 2E:<=E - <@*)
8) 6eada!he 5lassifi!ation <u!o((ittee of the International 6eada!he <o!iety) +he
International 5lassifi!ation of 6eada!he Disorders: 2nd ed 5ephalgia 20081 28 4<uppl 17:
E - 1=0)
5) 6iwatashi $, Matsushi(a +, Foshiura +, et al) MRI of glossopharyngeal neuralgia
!aused y neuro'as!ular !o(pression) $GR $( G Roentgenol 200*1 1E1 427: 5@*-*1)
=) Montaletti ", Aerrandi D, Perga(i P, <a'oldi A) ;longated styloid pro!ess and ;agle2s
syndro(e) 5ephalalgia 1EE51 15:*0 - E3)
@) Resni!9 DC, Gannetta PG, Dissonnette D, et al) Mi!ro'as!ular de!o(pression for
glossopharyngeal neuralgia) &eurosurgery 1EE51 3=:=8 - E)
;ar &ose +hroat G) 2010 May1*E457:210-212