Glossopharyngeal neuralgia with syncope

Abstract

Thirty-two cases of glossopharyngeal neuralgia complicated by syncope, cardiac arrhythmias or convulsions, singly or together, have been reported in the world literature. A further case is described and the clinical features of these thirty-three are reviewed. It is recommended that treatment should be undertaken as a matter of urgency. In the first place, Carbamezapine, with often the addition of Atropine, may prove effective. However, surgical intervention appears to give a better chance of permanent relief. Four alternative methods of surgery are discussed and the cervical or the intracranial approach recommended. Surgery should not be delayed in patients who fail to respond to medical treatment or in whom recurrence of symptoms occurs.

Glossopharyngeal Neuralgia

“…The effect of atropine clinched the long-surmised ACh-ergic vagal-discharge pathogenesis of the cardiovascular type (60,74,77,79,123,134,136,146,153,155,156,159,162,163). Administration of orciprenalin or of isoproterenol (ß-sympathicomimetic) proved ineffective; so did a pacemaker.…”

“…This type is rare: 42 instances among 304 reported in which the inherent statistical bias toward description of special cases should be taken into account; Rush-ton's series of 217 cases (1) included 4 of the cardiovascular type, whereas Parsons (9) saw 2 instances of cardiac arrest in his series of 15 cases. In 40 anecdotal reports 45 patients have been described (16 female, 26 male) in whom the attacks of pain (17 on the right, 24 on the left side; the youngest patient was , the oldest 76-Torres Ruiz (154); 90% of them were older than 40 years) were associated with either or all of the following symptoms: -Bradycardia, over a time-span of between 10 and 60 sec (59,75,77), during which the pulse-rate may drop to 16 min -1 (48) over even 10 min -1 (83,139), but usually drops some 50% to values ranging between 27 and 45 min -1 (41,60,74,123,136,155,156). Kunc's report (10) is unique in that it has the exclusive distinction of describing a patient with tachycardia (200 min -1 ) during attacks; in St. John's case (157) there was ataxia.…”

Syncope from head and neck cancer

“…Glossopharyngeal neuralgia caused by head and neck tumors has been recognized since Weisenburg in 1910 reported a man with a posterior fossa tumor pressing upon the glossopharyngeal nerve (17 22). Furthermore, since the report of two cases of 'cardiac arrest' from glossopharyngeal neuralgia by Riley et al in 1942 (23), syncope has been recognized as a complication of glossopharyngeal neuralgia (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33). The combination of glossopharyngeal neuralgia with syncope due to a head and neck tumor is believed to be rare 261 (5 7, 9-11).…”

“…The painful paroxysms of glossopharyngeal neuralgia are thought due to spontaneous afferent discharges in the glossopharyngeal nerve that arise either on an idiopathic basis or from an irritative lesion of the nerve due to compression or invasion by tumor, aberrant vessels or other processes, and are transmitted via the glossopharyngeal nerve to the spinal tract of the trigeminal nerve in the medulla and upper cervical spinal cord. Syncope from glossopharyngeal neuralgia 263 has been attributed to the triggering of a carotid sinus-like reflex due to either excitation of fibers originating in the carotid sinus by the precipitating process or by ephaptic conduction within the glossopharyngeal nerve between general sensory afferent fibers responsible for pain and visceral sensory afferent fibers from the carotid sinus (and perhaps also with efferent motor fibers (21,22,24,30,33). In many patients, the pain was not typical of glossopharyngeal neuralgia but was more reminiscent of pain referred to scalp, teeth, gums, eye, nose, cheek or jaw, when the wall of the carotid artery is electrically stimulated (82,83).…”

“…Most cases of glossopharyngeal neuralgia with syncope have cardioinhibitory syncope as well (22)(23)(24)(25)(27)(28)(29)(30)(31)(32), although a few cases of pure vasodepressor syncope have been reported, often following the use of anticholinergics or a cardiac pacemaker to prevent bradycardia (6,9,10,26).…”