Glossopharyngeal neuralgia - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Introduction Glossopharyngeal nerve is a mixed cranial nerve with both sensory and motor components. Regarding its sensory distribution, it receives somatic sensory fibers from the oropharynx, posterior third of the tongue, eustachian tube, middle ear, mastoid, special sensory fibers for taste in the posterior third of the tongue and chemoreceptor and baroreceptor afferents from the carotid body and carotid sinuses respectively. It gives motor supply to the stylopharyngeus muscle and secretomotor parasympathetic fibers to the parotid gland. It also gives the carotid sinus nerve to supply the carotid body and carotid sinus.
Glossopharyngeal neuralgia (GPN) is a relatively rare condition causing throat, ear, and neck pain. It is commonly confused with Trigeminal Neuralgia.
In majority of patients, the aetiology is idiopathic and sometimes there are secondary causes such as cerebellopontine angle masses, oropharyngeal tumors, arachnoiditis, stylohyoid ligament ossification, multiple sclerosis, and vascular malformation.
Introduction
Glossopharyngeal nerve is a mixed cranial nerve with both sensory and motor components. Regarding its sensory distribution, it receives somatic sensory fibers from the oropharynx, posterior third of the tongue, eustachian tube, middle ear, mastoid, special sensory fibers for taste in the posterior third of the tongue and chemoreceptor and baroreceptor afferents from the carotid body and carotid sinuses respectively. It gives motor supply to the stylopharyngeus muscle and secretomotor parasympathetic fibers to the parotid gland. It also gives the carotid sinus nerve to supply the carotid body and carotid sinus.
Glossopharyngeal neuralgia (GPN) is a relatively rare condition causing throat, ear, and neck pain. It is commonly confused with Trigeminal Neuralgia.
In majority of patients, the aetiology is idiopathic and sometimes there are secondary causes such as cerebellopontine angle masses, oropharyngeal tumors, arachnoiditis, stylohyoid ligament ossification, multiple sclerosis, and vascular malformation.
Type and site of pain GPN causes unilateral severe, sharp, stabbing, and shooting paroxysmal type of pain which is localized to the external ear canal, the base of the tongue, the tonsil or the area beneath the angle of the jaw. Pain tends to shoot from the pharynx, tonsil, and posterior tongue base upwards to the eustachian tube and inner ear or to the mandibular angle. Depending on the site of pain GPN isdevided in to otitic type where the pain in and around the ear and oropharyngeal type where the pain is in and around throat and face region. Type and site of pain
GPN causes unilateral severe, sharp, stabbing, and shooting paroxysmal type of pain which is localized to the external ear canal, the base of the tongue, the tonsil or the area beneath the angle of the jaw. Pain tends to shoot from the pharynx, tonsil, and posterior tongue base upwards to the eustachian tube and inner ear or to the mandibular angle. Depending on the site of pain GPN isdevided in to otitic type where the pain in and around the ear and oropharyngeal type where the pain is in and around throat and face region.
Frequency and duration of pain Onset is subtle with a duration of 30 seconds. There are brief periods without pain, pain may persist in the same region. Recurrences may occur over days, weeks, or months. Frequency and duration of pain
Onset is subtle with a duration of 30 seconds. There are brief periods without pain, pain may persist in the same region. Recurrences may occur over days, weeks, or months.
Triggering factors for the pain Swallowing is the most common trigger factor. Other factors such as chewing, talking, sneezing, cleaning the throat, and touching the gums or oral mucosa, sudden movements of the head, raising the arm on the side of the pain, touching the external auditory canal, the side of the neck, and the skin anterior to the ear may also trigger the pain. Triggering factors for the pain
Swallowing is the most common trigger factor. Other factors such as chewing, talking, sneezing, cleaning the throat, and touching the gums or oral mucosa, sudden movements of the head, raising the arm on the side of the pain, touching the external auditory canal, the side of the neck, and the skin anterior to the ear may also trigger the pain.
Tinnitus, vomiting, vertigo, swelling sensation, and involuntary movements These are other rare features of GPN can sometimes be confused with intermedius neuralgia due to the complex anatomical relationship between the intermedius. Tinnitus, vomiting, vertigo, swelling sensation, and involuntary movements
These are other rare features of GPN can sometimes be confused with intermedius neuralgia due to the complex anatomical relationship between the intermedius.
Palpitations, syncopal attacks Carotid sinus nerve supplies the carotid body and carotid sinus. It conveys chemoreceptor and stretch baroreceptor information needed for respiratory, circulatory reflex function and arrhythmogenicity. Hyperstimulation of glossopharyngeal nerve feedback onto the nucleus of the tractus solitarius of the midbrain and via collaterals reach the dorsal motor nucleus of the vagus nerve during severe neuralgic pain may cause exaggerated vagal response manifesting as cardiac dysrhythmia, bradycardia, and hypotension, with cerebral hypoxia. Palpitations, syncopal attacks
Carotid sinus nerve supplies the carotid body and carotid sinus. It conveys chemoreceptor and stretch baroreceptor information needed for respiratory, circulatory reflex function and arrhythmogenicity. Hyperstimulation of glossopharyngeal nerve feedback onto the nucleus of the tractus solitarius of the midbrain and via collaterals reach the dorsal motor nucleus of the vagus nerve during severe neuralgic pain may cause exaggerated vagal response manifesting as cardiac dysrhythmia, bradycardia, and hypotension, with cerebral hypoxia.
Involutary moments Above mentioned mechanism with cerebral hypoxia will lead to convulsive movements, limb clonus, automatic smacking movements of the lips, and upward turning of the eyes are signs of cerebral hypoxia induced by the bradycardia. Involutary moments
Above mentioned mechanism with cerebral hypoxia will lead to convulsive movements, limb clonus, automatic smacking movements of the lips, and upward turning of the eyes are signs of cerebral hypoxia induced by the bradycardia.
Sharp unilateral facial pain Glossopharyngeal neuralgia is associated with trigeminal neuralgia. Sharp unilateral facial pain
Glossopharyngeal neuralgia is associated with trigeminal neuralgia.
Features of multiple sclerosis Patients can have associated multiple sclerosis. Sensory disturbances like paresthesias (numbness and tingling), dysesthesias (burning and “pins and needles”) which will resolve or lead to chronic neuropathic pain, diplopia, ataxia, vertigo, optic neuritis causing visual problems and bladder disturbances. Features of multiple sclerosis
Patients can have associated multiple sclerosis. Sensory disturbances like paresthesias (numbness and tingling), dysesthesias (burning and “pins and needles”) which will resolve or lead to chronic neuropathic pain, diplopia, ataxia, vertigo, optic neuritis causing visual problems and bladder disturbances.
History of other etiological factors (trauma, malignancy, Surgery etc) Trauma like skull base fractures, penetrating injury and post radiation, neoplasms of pharynx, tongue, tonsils, cerebelopontine angle, surgeries like neck dissection, tonsillectomy and craniotomy etc may be the causative factors for glossopharyyngeal neuralgia. History of other etiological factors (trauma, malignancy, Surgery etc)
Trauma like skull base fractures, penetrating injury and post radiation, neoplasms of pharynx, tongue, tonsils, cerebelopontine angle, surgeries like neck dissection, tonsillectomy and craniotomy etc may be the causative factors for glossopharyyngeal neuralgia.

Clinicals - Examination

Fact Explanation
Throat examination This will reveal odema and congestion over the posterior pharyngeal area, tonsils, and uvular area. Throat examination
This will reveal odema and congestion over the posterior pharyngeal area, tonsils, and uvular area.
Trigger zone Trigger zone is usually situated in the peritonisilar fossa on the same side of the pain and these are less commoner than in trigeminal neuralgia. Touching the trigger zone with a cotton wool or ethyl chloride will induce an typical attack of glossopharyngeal neuralgia. Trigger zone
Trigger zone is usually situated in the peritonisilar fossa on the same side of the pain and these are less commoner than in trigeminal neuralgia. Touching the trigger zone with a cotton wool or ethyl chloride will induce an typical attack of glossopharyngeal neuralgia.
Hypotension, slow heart rate Hyper-stimulation of glossopharyngeal nerve feedback onto the nucleus of the tractus solitarius of the midbrain and via collaterals reach the dorsal motor nucleus of the vagus nerve with vasovagal stimulation will cause hypotension, bradycardia and cerebral ischaemia. Hypotension, slow heart rate
Hyper-stimulation of glossopharyngeal nerve feedback onto the nucleus of the tractus solitarius of the midbrain and via collaterals reach the dorsal motor nucleus of the vagus nerve with vasovagal stimulation will cause hypotension, bradycardia and cerebral ischaemia.
Hypersensittivity of the carotid sinus Carotid sinus massage does not produce the signs of glossopharyngeal neuralgia. Therefore hypersensitivity is not seen in these patients. Hypersensittivity of the carotid sinus
Carotid sinus massage does not produce the signs of glossopharyngeal neuralgia. Therefore hypersensitivity is not seen in these patients.
Tonic clonic moments of the body Transient cerebral ischaemia may cause convulsions. Tonic clonic moments of the body
Transient cerebral ischaemia may cause convulsions.
Cerebellar signs (nystagmus, pendular knee jerk, dysarthria, ataxic gait, tremor) May be the presenting features of cerebello pontine angle tumours. Cerebellopontine angle masses are associated with glossopharyngeal neuralgia. Cerebellar signs (nystagmus, pendular knee jerk, dysarthria, ataxic gait, tremor)
May be the presenting features of cerebello pontine angle tumours. Cerebellopontine angle masses are associated with glossopharyngeal neuralgia.
Cranial nerve palsies Cranial nerve VIII is involved in the can majority of patients with meningiomas and vestibular schwannoma. Fifth cranial nerve and cranial nerve VII impairment is observed in some patients. Cranial nerve palsies
Cranial nerve VIII is involved in the can majority of patients with meningiomas and vestibular schwannoma. Fifth cranial nerve and cranial nerve VII impairment is observed in some patients.
Oral ulcers/growths Occasionally oropharyngeal tumors may be a cause for the glossopharyngeal neuralgia. Oral ulcers/growths
Occasionally oropharyngeal tumors may be a cause for the glossopharyngeal neuralgia.
Focal neurological signs, visual problems Patients may have associated multiple sclerosis or a tumor as a causative lesion. Focal neurological signs, visual problems
Patients may have associated multiple sclerosis or a tumor as a causative lesion.

Investigations - Diagnosis

Fact Explanation
Diagnosis based on the clinical picture Usually diagnosis is based on the characteristic picture of the pain. No investigations are required. Neuralgic pain is severe, episodic, and lancinating and of short duration, and is associated with intervening periods of a low-grade dull ache. It has to be differentiated from the inflammatory or neoplastic pain which is more constant, of longer duration, and of deep-seated boring quality. The diagnosis can be confirmed by disappearance of pain when this nerve is blocked with injected lignocaine 2% or bupivacaine 0.5% at the jugular foramen or when topical anesthesia of the pharynx stops the pain. Diagnosis based on the clinical picture
Usually diagnosis is based on the characteristic picture of the pain. No investigations are required. Neuralgic pain is severe, episodic, and lancinating and of short duration, and is associated with intervening periods of a low-grade dull ache. It has to be differentiated from the inflammatory or neoplastic pain which is more constant, of longer duration, and of deep-seated boring quality. The diagnosis can be confirmed by disappearance of pain when this nerve is blocked with injected lignocaine 2% or bupivacaine 0.5% at the jugular foramen or when topical anesthesia of the pharynx stops the pain.
Imaging of neck (X-ray, ultrasound scan) Imaging of neck (X-ray, ultrasound scan)
is done to rule out tumor of the hypo pharynx, larynx, or piriform sinus.
Imaging of neck (X-ray, ultrasound scan)
Imaging of neck (X-ray, ultrasound scan)
is done to rule out tumor of the hypo pharynx, larynx, or piriform sinus.
Orthopantomogram Panoramic radiograph is helpful to exclude the Eagle's syndrome with elongated styloid process which is a recognized cause of lossopharyngeal neuralgia. Orthopantomogram
Panoramic radiograph is helpful to exclude the Eagle's syndrome with elongated styloid process which is a recognized cause of lossopharyngeal neuralgia.
Glossopharyngeal nerve block Rapid palliation of pain can be achieved with non-neurolytic agents (local anesthetic agents) with or without additives (steroid, ketamine, etc.) or with neurolytic agents (phenol, alcohol, glycerol, etc.). It may be done either intra orally or extra orally. Complications of nerve block are intravascular injection into the carotid artery or into the internal jugular vein, difficulty in swallowing and hoarseness and bilateral vocal cord paralysis in a case of bilateral injection. Glossopharyngeal nerve block
Rapid palliation of pain can be achieved with non-neurolytic agents (local anesthetic agents) with or without additives (steroid, ketamine, etc.) or with neurolytic agents (phenol, alcohol, glycerol, etc.). It may be done either intra orally or extra orally. Complications of nerve block are intravascular injection into the carotid artery or into the internal jugular vein, difficulty in swallowing and hoarseness and bilateral vocal cord paralysis in a case of bilateral injection.
Erythrocyte sedimentation rate Infections, inflammation and malignancies may be causative factors and ESR would be elevated in such situations. Erythrocyte sedimentation rate
Infections, inflammation and malignancies may be causative factors and ESR would be elevated in such situations.

Investigations - Management

Fact Explanation
Complete blood count Myelosuppression and aplastic anaemia causing low blood cell counts and reduction in the level of haemoglobin is seen with carbamazepine which is a pharmacological management option for the glossopharyngeal neuralgia. Complete blood count
Myelosuppression and aplastic anaemia causing low blood cell counts and reduction in the level of haemoglobin is seen with carbamazepine which is a pharmacological management option for the glossopharyngeal neuralgia.
Serum electrolytes Hyponatremia is a complication of medical therapy. Serum electrolytes
Hyponatremia is a complication of medical therapy.
Liver function tests Elevation of transaminasescan and hepatotoxicity occur due to carbamazepine and other drugs. Liver function tests
Elevation of transaminasescan and hepatotoxicity occur due to carbamazepine and other drugs.
Electrocardiogram Hyper-stimulation of glossopharyngeal nerve feedback onto the nucleus of the tractus solitarius of the midbrain and via collaterals reach the dorsal motor nucleus of the vagus nerve with vasovagal stimulation will cause bradycardia and cerebral ischaemia. ECG during cardiac syncopal attack may show sinus arrest and junctional escape beats. Electrocardiogram
Hyper-stimulation of glossopharyngeal nerve feedback onto the nucleus of the tractus solitarius of the midbrain and via collaterals reach the dorsal motor nucleus of the vagus nerve with vasovagal stimulation will cause bradycardia and cerebral ischaemia. ECG during cardiac syncopal attack may show sinus arrest and junctional escape beats.
Prothrombin time and International normalized ratio To detect any bleeding diathesis before surgery. Prothrombin time and International normalized ratio
To detect any bleeding diathesis before surgery.
Random blood sugar To assess the patient's sugar control as if diabetic, the control should be optimized before the surgical management. Random blood sugar
To assess the patient's sugar control as if diabetic, the control should be optimized before the surgical management.
Serum electrolytes and Creatinine To assess baseline renal functions and to identify any renal compromise due to any ongoing diseases. Serum electrolytes and Creatinine
To assess baseline renal functions and to identify any renal compromise due to any ongoing diseases.
Diagnostic criteria by International Headache Society's classification of headaches Criteria for diagnosis of glossopharyngeal neuralgia according to the International Headache Society's classification of headaches, is as follows. Paroxysmal attacks of facial pain lasting from fraction of a second to 2 minutes and fulfilling the following, unilateral sharp stabbing severe pain, with the distribution in the areas pharynx, tonsil, and posterior tongue beneath the angle of lower jaw and/or in the ear, precipitated by swallowing, talking, chewing, etc. tacks are sereotyped in the individual patient, there are no other neurological deficits, not attributed to other disorder, There are two types of glossopharyngeal neuralgia as classical and symptomatic which was described under the history. Diagnostic criteria by International Headache Society's classification of headaches
Criteria for diagnosis of glossopharyngeal neuralgia according to the International Headache Society's classification of headaches, is as follows. Paroxysmal attacks of facial pain lasting from fraction of a second to 2 minutes and fulfilling the following, unilateral sharp stabbing severe pain, with the distribution in the areas pharynx, tonsil, and posterior tongue beneath the angle of lower jaw and/or in the ear, precipitated by swallowing, talking, chewing, etc. tacks are sereotyped in the individual patient, there are no other neurological deficits, not attributed to other disorder, There are two types of glossopharyngeal neuralgia as classical and symptomatic which was described under the history.
Computer Tomography (CT) scan and Magnetic Resonance Imaging (MRI) These investigations are important to identify any lesions in the brain that causes glossopharyngeal neuralgia such as cerebellopontine angle tumours. . With contrast-enhanced computed tomography (CT), meningiomas appear as markedly hyperintense, homogeneous masses. Meningiomas are better seen on MR scans with and without adolinium administration. C and MRI are also important to see any other bony structure or signs of demyelination. Computer Tomography (CT) scan and Magnetic Resonance Imaging (MRI)
These investigations are important to identify any lesions in the brain that causes glossopharyngeal neuralgia such as cerebellopontine angle tumours. . With contrast-enhanced computed tomography (CT), meningiomas appear as markedly hyperintense, homogeneous masses. Meningiomas are better seen on MR scans with and without adolinium administration. C and MRI are also important to see any other bony structure or signs of demyelination.
3-dimensional computed tomography angiography (3D-CTA) This is important to rule out nerve compression by a vessel particularly posterior inferior cerebellar artery (PICA), the anterior inferior cerebellar artery (AICA), and their courses as these vessels often related to the site of origin of glossopharyngeal nerve. 3-dimensional computed tomography angiography (3D-CTA)
This is important to rule out nerve compression by a vessel particularly posterior inferior cerebellar artery (PICA), the anterior inferior cerebellar artery (AICA), and their courses as these vessels often related to the site of origin of glossopharyngeal nerve.

Management - Supportive

Fact Explanation
Patient education Educating the patient about the nature of the disease, particularly about the idiopathic nature, complications, treatment options and their side effects are important to ensure the compliance. Particularly carbamazepine induces serious adverse effects including the allergic rash, myelosuppression, hepatotoxicity, systemic lupus erythematosus, Stevens–Johnson syndrome and aplastic anaemia and warning signs have to be informed. Patient education
Educating the patient about the nature of the disease, particularly about the idiopathic nature, complications, treatment options and their side effects are important to ensure the compliance. Particularly carbamazepine induces serious adverse effects including the allergic rash, myelosuppression, hepatotoxicity, systemic lupus erythematosus, Stevens–Johnson syndrome and aplastic anaemia and warning signs have to be informed.
Treat the underlying disease When there is a cause for the neuralgia Treatment should target to treat the underlying problem.
Cerebellopontineangle tumours like meningiomas may benefit from the subtotal resection stereotactic radiotherapy or gamma knife radiosurgery. Tumor resection, posterior fossa decompression in Chiari malformation, embolization of an arteriovenous malformation, coagulation of choroid plexus overgrowth, stylectomy for Eagle's Syndrome are the other procedures that may need to treat the underlying cause.
Treat the underlying disease When there is a cause for the neuralgia
Treatment should target to treat the underlying problem.
Cerebellopontineangle tumours like meningiomas may benefit from the subtotal resection stereotactic radiotherapy or gamma knife radiosurgery. Tumor resection, posterior fossa decompression in Chiari malformation, embolization of an arteriovenous malformation, coagulation of choroid plexus overgrowth, stylectomy for Eagle's Syndrome are the other procedures that may need to treat the underlying cause.
Pain management Aim of management is to control pain. Aspirin and acetaminophen are not much effective for relieving glossopharyngeal neuralgia. Antiepleptics are the effective treatment for glossopharyngeal neuralgia. Pain management
Aim of management is to control pain. Aspirin and acetaminophen are not much effective for relieving glossopharyngeal neuralgia. Antiepleptics are the effective treatment for glossopharyngeal neuralgia.

Management - Specific

Fact Explanation
Pharmacological management with antiepileptics Aim of management is to control pain. Aspirin and acetaminophen are not much effective for relieving glossopharyngeal neuralgia. Antiepleptics are the effective treatment for glossopharyngeal neuralgia. The medications of choice are membrane stabilizers like carbamazepine, gabapentin, and pregabalin. Carbamazepine is usually given at a dose of 10mg/kg/day. It takes around two months to give an adequate pain relief and then gradually tapered down to achieve much lower maintenance doses. Pain improvement with the treatment, recurrrance, potential side effects of therapy, eg:- Carbamazepine : drowsiness, nausea, dizziness, diplopia, ataxia, elevation of transaminases and hyponatremia, allergic rash, myelosuppression, hepatotoxicity, lymphadenopathy, systemic lupus erythematosus, Stevens–Johnson syndrome and aplastic anaemia need to be monitored during follow up. Pharmacological management with antiepileptics
Aim of management is to control pain. Aspirin and acetaminophen are not much effective for relieving glossopharyngeal neuralgia. Antiepleptics are the effective treatment for glossopharyngeal neuralgia. The medications of choice are membrane stabilizers like carbamazepine, gabapentin, and pregabalin. Carbamazepine is usually given at a dose of 10mg/kg/day. It takes around two months to give an adequate pain relief and then gradually tapered down to achieve much lower maintenance doses. Pain improvement with the treatment, recurrrance, potential side effects of therapy, eg:- Carbamazepine : drowsiness, nausea, dizziness, diplopia, ataxia, elevation of transaminases and hyponatremia, allergic rash, myelosuppression, hepatotoxicity, lymphadenopathy, systemic lupus erythematosus, Stevens–Johnson syndrome and aplastic anaemia need to be monitored during follow up.
Pharmacological management with other drugs Antidepressants may help certain people. Low doses of selective serotonin reuptake inhibitors (SSRI) and vitamin B12 can be used. Pharmacological management with other drugs
Antidepressants may help certain people. Low doses of selective serotonin reuptake inhibitors (SSRI) and vitamin B12 can be used.
Glossopharyngeal nerve block Rapid palliation of pain can be achieved with non-neurolytic agents (local anesthetic agents) with or without additives (steroid, ketamine, etc.) or with neurolytic agents (phenol, alcohol, glycerol, etc.). It may be done either intra orally or extra orally. Complications of nerve block are intravascular injection into the carotid artery or into the internal jugular vein, difficulty in swallowing and hoarseness and bilateral vocal cord paralysis in a case of bilateral injection. Glossopharyngeal nerve block
Rapid palliation of pain can be achieved with non-neurolytic agents (local anesthetic agents) with or without additives (steroid, ketamine, etc.) or with neurolytic agents (phenol, alcohol, glycerol, etc.). It may be done either intra orally or extra orally. Complications of nerve block are intravascular injection into the carotid artery or into the internal jugular vein, difficulty in swallowing and hoarseness and bilateral vocal cord paralysis in a case of bilateral injection.
Surgical management In severe cases, where the pain is not responding to the pharmacological treatment, surgery is required. Available techniques are peripheral procedures which may be either extra cranial direct surgical neurotomies or percutaneous radiofrequency thermal rhizotomy or intracranial, such as direct section of glossopharyngeal and vagal nerves in the cerebello-pontine angle and central procedures like percutaneous or open trigeminal tractotomy-nucleotomy or nucleus caudalis DREZ operation. Extracranial neurotomy and percutaneous radiofrequency rhizotomy are preserved for patients who failed medical therapy and are unable to tolerate an open intracranial procedure. Microvascular decompression is a safe and successful treatment particularly in patients with failure or several side effects of medical treatment. Surgical management
In severe cases, where the pain is not responding to the pharmacological treatment, surgery is required. Available techniques are peripheral procedures which may be either extra cranial direct surgical neurotomies or percutaneous radiofrequency thermal rhizotomy or intracranial, such as direct section of glossopharyngeal and vagal nerves in the cerebello-pontine angle and central procedures like percutaneous or open trigeminal tractotomy-nucleotomy or nucleus caudalis DREZ operation. Extracranial neurotomy and percutaneous radiofrequency rhizotomy are preserved for patients who failed medical therapy and are unable to tolerate an open intracranial procedure. Microvascular decompression is a safe and successful treatment particularly in patients with failure or several side effects of medical treatment.
Management of a relapse Dose can be increased and a different agent can be tried if there is no response. Management of a relapse
Dose can be increased and a different agent can be tried if there is no response.

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  1. BROGGI G, FERROLI P, FRANZINI A, SERVELLO D, DONES I. Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis J Neurol Neurosurg Psychiatry [online] 2000 Jan, 68(1):59-64 [viewed 02 October 2014] Available from: doi:10.1136/jnnp.68.1.59
  2. GAITOUR E, NICK ST, ROBERTS C, GONZALEZ-TOLEDO E, MUNJAMPALLI S, MINAGAR A, VROOMAN B, SOUZDALNITSKI D, ZAMNIFEKRI B. Glossopharyngeal neuralgia secondary to vascular compression in a patient with multiple sclerosis: a case report J Med Case Rep [online] :213 [viewed 01 November 2014] Available from: doi:10.1186/1752-1947-6-213
  3. 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 [online] 2011 Oct, 12(5):527-534 [viewed 01 November 2014] Available from: doi:10.1007/s10194-011-0349-x
  4. GOLDENBERG MM. Multiple Sclerosis Review P T [online] 2012 Mar, 37(3):175-184 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.
  5. ISBIR CA. Treatment of a Patient with Glossopharyngeal Neuralgia by the Anterior Tonsillar Pillar Method Case Rep Neurol [online] , 3(1):27-31 [viewed 03 October 2014] Available from: doi:10.1159/000324093
  6. JOHNSTON RT, REDDING VJ. Glossopharyngeal neuralgia associated with cardiac syncope: long term treatment with permanent pacing and carbamazepine. Br Heart J [online] 1990 Dec, 64(6):403-405 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1224821
  7. MALLUCCI C, WARD V, CARNEY A, O'DONOGHUE G, ROBERTSON I. Clinical features and outcomes in patients with non-acoustic cerebellopontine angle tumours J Neurol Neurosurg Psychiatry [online] 1999 Jun, 66(6):768-771 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1736400
  8. OBERMANN M. Treatment options in trigeminal neuralgia Ther Adv Neurol Disord [online] 2010 Mar, 3(2):107-115 [viewed 03 October 2014] Available from: doi:10.1177/1756285609359317
  9. ONG KS, KENG SB. Evaluation of surgical procedures for trigeminal neuralgia. Anesth Prog [online] 2003, 50(4):181-188 [viewed 02 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2007453
  10. PENMAN J. The Differential Diagnosis and Treatment of Tic Douloureux Postgrad Med J [online] 1950 Dec, 26(302):627-636 [viewed 02 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2530375
  11. SAVIOLO R, FIASCONARO G. Treatment of glossopharyngeal neuralgia by carbamazepine. Br Heart J [online] 1987 Sep, 58(3):291-292 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1216453
  12. SINGH PM, KAUR M, TRIKHA A. An uncommonly common: Glossopharyngeal neuralgia Ann Indian Acad Neurol [online] 2013, 16(1):1-8 [viewed 01 November 2014] Available from: doi:10.4103/0972-2327.107662
  13. SPRINGBORG JB, POULSGAARD L, THOMSEN J. Nonvestibular Schwannoma Tumors in the Cerebellopontine Angle: A Structured Approach and Management Guidelines Skull Base [online] 2008 Jul, 18(4):217-227 [viewed 01 November 2014] Available from: doi:10.1055/s-2007-1016959
  14. ST JOHN JN. Swallow syncope: a form of glossopharyngeal neuralgia? CMAJ [online] 1986 Feb 15, 134(4):309 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490820
  15. ZAMBOURI A. Preoperative evaluation and preparation for anesthesia and surgery Hippokratia [online] 2007, 11(1):13-21 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464262