Glossopharyngeal Neuralgia Treated with an Endoscopic Assisted Midline Suboccipital Subtonsillar Approach: Technical Note

Abstract

Background Glossopharyngeal nerve neuralgia (GPN) is an exceptionally rare skull-based disorder. It is treated similar to other neurovascular conflicts. The approach, however, is debatable, as the caudal cranial nerves and especially the exit zones at the brainstem are barely visible via the retrosigmoid approach.

Clinical Presentation We demonstrate a case of a typical GPN with microsurgical neurovascular decompression according to standard procedures. Continuous electrophysiological monitoring, including motor-evoked potentials of the glossopharyngeal nerve in addition to somatosensory evoked potential (SSEP) monitoring, was set up. In prone position a midline suboccipital osteoplastic craniotomy was performed. Intradurally, an endoscopic-assisted subtonsillar exposure of the lateral recess and the nerve root exit zone of the glossopharyngeal nerve has been chosen. A large compressing branch of the posterior inferior cerebellar artery (PICA) was identified as the cause of the neurovascular conflict and transposed.

Conclusions A midline subtonsillar approach with endoscopic assistance to the lateral brainstem is a straightforward time- and morbidity-sparing procedure.

Keywords

endoscopy-assisted microsurgery - endoscopy-skull base - minimally invasive endoscopy - skull base

• References

• 1 Pearce JM. Glossopharyngeal neuralgia. Eur Neurol 2006; 55: 49-52
• 2 Moretti R, Torre P, Antonello RM, Bava A, Cazzato G. Gabapentin treatment of glossopharyngeal neuralgia: a follow-up of four years of a single case. Eur J Pain 2002; 6: 403-407
• 3 Resnick DK, Jannetta PJ, Bissonnette D, Jho HD, Lanzino G. Microvascular decompression for glossopharyngeal neuralgia. Neurosurgery 1995; 36: 64-68 , discussion 68–69
• 4 Sampson JH, Grossi PM, Asaoka K, Fukushima T. Microvascular decompression for glossopharyngeal neuralgia: long-term effectiveness and complication avoidance. Neurosurgery 2004; 54: 884-889 , discussion 889–890
• 5 Kandan SR, Khan S, Jeyaretna DS, Lhatoo S, Patel NK, Coakham HB. Neuralgia of the glossopharyngeal and vagal nerves: long-term outcome following surgical treatment and literature review. Br J Neurosurg 2010; 24: 441-446
• 6 Ferroli P, Fioravanti A, Schiariti M , et al. Microvascular decompression for glossopharyngeal neuralgia: a long-term retrospectic review of the Milan-Bologna experience in 31 consecutive cases. Acta Neurochir (Wien) 2009; 151: 1245-1250
• 7 Patel A, Kassam A, Horowitz M, Chang YF. Microvascular decompression in the management of glossopharyngeal neuralgia: analysis of 217 cases. Neurosurgery 2002; 50: 705-710 , discussion 710–711
• 8 Kawashima M, Matsushima T, Inoue T, Mineta T, Masuoka J, Hirakawa N. Microvascular decompression for glossopharyngeal neuralgia through the transcondylar fossa (supracondylar transjugular tubercle) approach. Neurosurgery 2010; 66 (6, Suppl Operative) 275-280 , discussion 280
• 9 Hitotsumatsu T, Matsushima T, Inoue T. Microvascular decompression for treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia: three surgical approach variations: technical note. Neurosurgery 2003; 53: 1436-1441 , discussion 1442–1443
• 10 Matsushima T, Goto Y, Natori Y, Matsukado K, Fukui M. Surgical treatment of glossopharyngeal neuralgia as vascular compression syndrome via transcondylar fossa (supracondylar transjugular tubercle) approach. Acta Neurochir (Wien) 2000; 142: 1359-1363
• 11 Mairs AP, Stewart TJ. Surgical treatment of glossopharyngeal neuralgia via the pharyngeal approach. J Laryngol Otol 1990; 104: 12-16
• 12 Wu A, Zabramski JM, Jittapiromsak P, Wallace RC, Spetzler RF, Preul MC. Quantitative analysis of variants of the far-lateral approach: condylar fossa and transcondylar exposures. Neurosurgery 2010; 66 (6, Suppl Operative) 191-198 , discussion 198
• 13 Ma Z, Li M, Cao Y, Chen X. Keyhole microsurgery for trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia. Eur Arch Otorhinolaryngol 2010; 267: 449-454
• 14 Jean WC, Abdel Aziz KM, Keller JT, van Loveren HR. Subtonsillar approach to the foramen of Luschka: an anatomic and clinical study. Neurosurgery 2003; 52: 860-866 , discussion 866
• 15 Tatagiba M, Koerbel A, Roser F. The midline suboccipital subtonsillar approach to the hypoglossal canal: surgical anatomy and clinical application. Acta Neurochir (Wien) 2006; 148: 965-969
• 16 Ziyal IM, Sekhar LN, Salas E. Subtonsillar-transcerebellomedullary approach to lesions involving the fourth ventricle, the cerebellomedullary fissure and the lateral brainstem. Br J Neurosurg 1999; 13: 276-284
• 17 Seki Y, Samejima N, Kumakawa K, Komatsuzaki A. Subtonsillar placement of auditory brainstem implant. Acta Neurochir Suppl (Wien) 2003; 87: 85-87
• 18 King WA, Wackym PA, Sen C, Meyer GA, Shiau J, Deutsch H. Adjunctive use of endoscopy during posterior fossa surgery to treat cranial neuropathies. Neurosurgery 2001; 49: 108-115 , discussion 115–116
• 19 Miyazaki H, Deveze A, Magnan J. Neuro-otologic surgery through minimally invasive retrosigmoid approach: endoscope assisted microvascular decompression, vestibular neurotomy, and tumor removal. Laryngoscope 2005; 115: 1612-1617