13.2.1 Glossopharyngeal neuralgia

Previously used term:

Vagoglossopharyngeal neuralgia.

Description:

A disorder characterised by unilateral brief stabbing pain, abrupt in onset and termination, in the distributions not only of the glossopharyngeal nerve but also of the auricular and pharyngeal branches of the vagus nerve. Pain is experienced in the ear, base of the tongue, tonsillar fossa and/or beneath the angle of the jaw. It is commonly provoked by swallowing, talking or coughing and may remit and relapse in the fashion of trigeminal neuralgia.

Diagnostic criteria:
  1. Recurring paroxysmal attacks of unilateral pain in the distribution of the glossopharyngeal nerve1 and fulfilling criterion B
  2. Pain has all of the following characteristics:
    1. lasting from a few seconds to 2 minutes
    2. severe intensity
    3. electric shock-like, shooting, stabbing or sharp in quality
    4. precipitated by swallowing, coughing, talking or yawning
  3. Not better accounted for by another ICHD-3 diagnosis.
Note:

Within the posterior part of the tongue, tonsillar fossa, pharynx or angle of the lower jaw and/or in the ear.

Comments:

13.2.1 Glossopharyngeal neuralgia can occur together with 13.1.1 Trigeminal neuralgia.

The superior laryngeal nerve is a branch of the vagus. Neuralgia of the superior laryngeal nerve presents similarly to 13.2.1 Glossopharyngeal neuralgia in its location and clinically can be difficult to distinguish from it.

Imaging may show neurovascular compression of the glossopharyngeal nerve.

Prior to development of 13.2.1 Glossopharyngeal neuralgia, unpleasant sensations may be felt in affected areas for weeks to several months.

The pain of 13.2.1 Glossopharyngeal neuralgia may radiate to involve the eye, nose, chin or shoulder. It can be severe enough for patients to lose weight. In rare cases, attacks of pain are associated with vagal symptoms such as cough, hoarseness, syncope and/or bradycardia. Some authors propose distinguishing between pharyngeal, otalgic and vagal subforms of neuralgia, and have suggested using the term vagoglossopharyngeal neuralgia when pain is accompanied by asystole, convulsions and syncope.

Clinical examination usually fails to show sensory changes in the nerve distribution but, if mild sensory deficits are encountered, they do not invalidate the diagnosis. Major changes or a reduced/missing gag reflex should prompt aetiological investigations.

13.2.1 Glossopharyngeal neuralgia is usually responsive, at least initially, to pharmacotherapy (especially carbamazepine or oxcarbazepine). It has been suggested that application of local anaesthetic to the tonsil and pharyngeal wall can prevent attacks for a few hours.