Neurosurgery notes/Functional/Craniofacial pain/Otalgia

Otalgia

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Craniofacial pain
  • Because of redundant innervation of the region of the ear, primary otalgia may have its source in the
    • 5th cranial nerves
    • 7th cranial nerves
    • 9th cranial nerves
    • 10th cranial nerves
    • The occipital nerves.
  • As a result, sectioning of the 5th, 9th or 10th nerve or a component of the 7th (nervus intermedius, chorda tympani, geniculate ganglion) has been performed with varying results.
  • MVD of the corresponding nerve may also be done.
  • Work-up includes:
    • Neurotologic evaluation to rule out causes of secondary otalgia (otitis media or externa, temporal bone neoplasms…).
    • CT or MRI
  • Primary otalgia
    • Unilateral in most (≈ 80%).
    • Trigger mechanisms
      • Only 50% have
      • With cold air or water being the most common
    • Associated aural symptoms:
      • Present in 75%
      • Hearing loss
      • Tinnitus
      • Vertigo
      • Pain relief upon cocainization or nerve block of the pharyngeal tonsils suggests glossopharyngeal neuralgia
      • However, the overlap of innervation limits the certainty.
    • Treatment
      • An initial trial with medications used in trigeminal neuralgia (carbamazepine, phenytoin, baclofen…)
        • In intractable cases not responding to pharyngeal anesthesia, suboccipital exploration of the 7th (nervus intermedius) and lower cranial nerves may be indicated.
          • If significant vascular compression is found, one may consider MVD alone.
            • If MVD fails, or if no significant vessels are found, Rupa et al recommend sectioning
              • The nervus intermedius,
              • The 9th and upper 2 fibers of 10th nerve,
              • A geniculate ganglionectomy (or, if glossopharyngeal neuralgia is strongly suspected, just 9th and upper 2 fibers of 10th).