cranial neuralgias · superior laryngeal neuralgia described as an anterior neck pain syndrome that...
TRANSCRIPT
CRANIALNEURALGIAS
Presented by: Neha Sharma M.D.
Date: September 27th, 2019
TYPES OF NEURALGIAS
❖ TRIGEMINAL NEURALGIA
❖ NASOCILIARY NEURALGIA
❖ SUPRAORBITAL NEURALGIA
❖ SPHENOPALATINE NEURALGIA
❖ NERVUS INTERMEDIUS NEURALGIA
❖ GLOSSOPHARYNGEAL NEURALGIA
❖ SUPERIOR LARYNGEAL NEURALGIA
❖ OCCIPITAL NEURALGIA
❖ GREAT AURICULAR NEURALGIA
❖ TROCHLEAR NEURALGIA
WHAT IS CRANIAL NEURALGIA?
❖ Paroxysmal pain of head, face and/or neck
❖ Unilateral sensory nerve distribution
❖ Pain is described as sharp, shooting, lancinating
❖ Primary or Secondary causes
❖ Multiple triggers
TRIGEMINAL (CN V)
NEURALGIA
TRIGEMINAL NEURALGIA
❖ Also called Tic Douloureux
❖ Sudden, unilateral, electrical, shock-like, shooting, sharp
pain. Presents affecting Cranial Nerve V; primarily V2 and
V3 branches
❖ F>M; 3:1
TRIGEMINAL NEURALGIA
https://www.nf2is.org/cn5.php
❖ Anatomy of Trigeminal
Nerve
❖ Cranial Nerve V
❖ Three Branches:
Ophthalmic,
Maxillary and
Mandibular
❖ Sensory supply to
forehead/supraorbital,
cheeks and jaw
TRIGEMINAL NEURALGIA – TRIGGERS
❖ Mastication (73%)
❖ Touch (69%)
❖ Brushing Teeth (66%)
❖ Eating (59%)
❖ Talking (58%)
❖ Cold wind (50%)
TYPES OF TRIGEMINAL NEURALGIA
❖ Primary/Classic/Idiopathic
❖ Vascular compression of the nerve – superior cerebellar artery
❖ Secondary/Symptomatic
❖ Caused by intracranial lesions
❖ Tumors, Strokes, Multiple Sclerosis (4%)
❖ Typical vs. Atypical
❖ Paroxysmal (79%) vs. Continuous (21%)
IASP/IHS & CLASSIFICATIONS OF TRIGEMINAL NEURALGIA
❖ IASP – International Association
for the Study of Pain
❖ Sudden, unilateral, brief,
intermittent pain in at least
one branch of CN V
❖ IHS – International Headache
Society
❖ Excruciating, unilateral,
electric pain in at least one
branch of CN V
❖ Classifications
❖ I – idiopathic, sharp, shooting, electric,
episodic
❖ II – idiopathic, aching, burning, >50%
constant
❖ III – secondary to injury, trauma, surgery to
face/cranium, stroke
❖ IV – deafferentation by intentional injury
(ex: rhizotomy)
❖ V – associated with MS
❖ VI – postherpetic neuralgia
❖ VII – facial pain with somatoform disorder
PRIMARY TRIGEMINAL NEURALGIA
❖ Pathophysiology
Vascular compression of nerve/root
Demyelination of CN V
Hyperexcitability, ectopic discharge and impaired inhibition
DIAGNOSING TRIGEMINAL NEURALGIA
❖ History
❖ Physical Examination
❖ Pain mapping
❖ Labs and MRI/MRA
❖ To rule out other
underlying pathology
http://www.austinfacepain.com/faqs/
TREATMENT OF TRIGEMINAL NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine (80% symptomatic relief)
❖ Others – oxcarbazine, phenytoin, baclofen, lamotrigine, gabapentin, valproate – best to be used with carbamezapine
❖ 2nd line therapy
❖ Local anesthetics – alcohol, tetracaine, bupivacaine, botulinum A
❖ Inhibits signal transmission
❖ Surgical interventions – rhizotomy, ablation, microvascular decompression, cryotherapy
❖ Help to alleviate pressure along the nerve or inhibit signal altogether
NASOCILIARY
NEURALGIA
NASOCILIARY NEURALGIA
❖ Described as sharp, stabbing pain in distribution of nasociliary nerve (conjunctiva
and nose)
❖ Triggers include pressure to nasal bridge and touching ipsilaterally affected nostril
❖ Charlin's Syndrome – additional symptoms include unilateral nasal congestion,
rhinorrhea, sneezing, keratitis, photophobia, conjunctivitis
NASOCILIARY NEURALGIA
❖ Anatomy of Nasociliary nerve
❖ Branch of Ophthalmic
nerve; V1 branch
❖ Passes through orbital
cavity anteroinferior to
ethmoid enters nasal
septum
❖ Sensory supply to nasal
mucosa, nasal tip, medial
canthus and conjunctivahttps://www.slideshare.net/drhaydarmuneer/nervouse-system-chapter-two
ETIOLOGY OF NASOCILIARY NEURALGIA
❖ Primary causes – vascular compression of the
nerve – nasociliary artery
❖ Secondary causes – inflammation, infection,
tumors, fractures, surgery (rhinoplasty)
DIAGNOSIS OF NASOCILIARY NEURALGIA
❖History
❖ Physical Exam
❖ Pain mapping
❖MRI/XR to rule out underlying pathology
TREATMENT FOR NASOCILIARY NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine, gabapentin
❖ 2nd line therapy
❖ Local anesthetics – nerve block – lidocaine and
triamcinolone
❖ Surgical – transection of nerve or neurovascular
bundle electro-cauterization
SUPRAORBITAL
NEURALGIA
SUPRAORBITAL NEURALGIA
❖ Described as constant pain with intermittent shock like
paresthesia along nerve distribution, especially in
supraorbital notch
❖ Known as "goggle headache" or "swimmer's headache"
❖ Triggered by exertion such as exercise or sexual activity or
compression (by helmet or goggles)
❖ Can have additional autonomic symptoms such as
lacrimation and rhinorrhea
SUPRAORBITAL NEURALGIA
❖ Anatomy of Supraorbital nerve
❖ Terminal branch of CN V; V1 – Ophthalmic –Frontal nerve
❖ Sensory supply to conjunctiva, forehead, and mid-anterior scalp
https://link.springer.com/chapter/10.1007/978-3-319-27482-9_14
ETIOLOGY OF SUPRAORBITAL NEURALGIA
❖ Primary causes – vascular compression –
supraorbital artery or muscular compression of the
nerve
❖ Secondary causes – infection, trauma,
tumors, surgery (plastic reconstruction to
eyelid/eyebrow region)
DIAGNOSIS OF SUPRAORBITAL NEURALGIA
❖ History
❖ Physical Exam
❖ Pain mapping
❖ MRI/XR to rule out underlying pathology
❖ Diagnostic local anesthesia alleviating pain and symptoms
TREATMENT FOR SUPRAORBITAL NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine, gabapentin
❖ Alternative – acupuncture and physio/massage
therapy
❖ 2nd line therapy
❖ Local anesthetics – nerve block – bupivacaine and
triamcinolone, botulinum toxin
❖ Surgical – endoscopic supraorbital nerve neurolysis,
microvascular decompression, radiofrequency
ablation
SPHENOPALATINE
NEURALGIA
SPHENOPALATINE NEURALGIA
❖ Described as pressure/fullness, unilateral pain in head, gums,
maxillary teeth that can radiate to neck and upper back
❖ Additional symptoms – nasal congestion, rhinorrhea,
orbit pain, paresthesia over mandible, lacrimation
❖ Known as Sluder's neuralgia
❖ Triggered by exposure to irritants or infection through nasal
mucosa, stress, smoking
SPHENOPALATINE
NEURALGIA
❖ Anatomy of Sphenopalatine nerve
❖ Also known as Pterygopalatine nerve
❖ Sensory branch of CN V; V2 maxillary
❖ Connected to Nervusintermedius nerve as well
❖ Located in pterygopalatine fossa posterior to middle turbinate
❖ Sensory supply to soft palate, pharynx, nasal membrane, lacrimal gland
http://cden.tu.edu.iq/images/New/2016/Lectures/Dr.ban/2/7Pterygopalatine-fossa.pdf
ETIOLOGY OF SPHENOPALATINE NEURALGIA
❖ Primary causes – vascular compression of ganglion
or nerve – sphenopalatine artery
❖ Secondary causes – infection, inflammation, nasal
bone or septal abnormalities, surgery (rhinoplasty)
DIAGNOSIS OF SPHENOPALATINE NEURALGIA❖ History
❖ Physical Exam
❖ Pain mapping
❖ MRI/CT to rule out underlying pathology
❖ Diagnostic local anesthesia alleviating pain
and symptoms
TREATMENT FOR SPHENOPALATINE NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine
❖ 2nd line therapy
❖ Local anesthetics – nerve block – lidocaine soaked
cotton tip applicator
❖ Surgical – radiofrequency ablation, neurostimulation
NERVUS INTERMEDIUS
NEURALGIA
NERVUS INTERMEDIUS NEURALGIA
❖ Described as brief, paroxysms of stinging and burning pain deep in
the auditory canal that can radiate to parieto-occipital regions and
mandibular region
❖ Diagnostic criteria per International Classification of
Headache Disorder 3 (ICHD-3)
❖ Sub-organization of IHS
❖ Also known as Geniculate neuralgia
❖ Triggered by stimulation of external acoustic meatus
NERVUS INTERMEDIUS NEURALGIA
❖ Anatomy of Nervus Intermedius
❖ Branch of Facial Nerve (CN VII)
❖ Sits between motor component of CN
VII and CN VIII
❖ Sensory branch supplies skin of external
acoustic meatus, mucous membrane of
nasopharynx, soft palate and taste from
anterior 2/3 of tongue
https://www.sciencedirect.com/science/arti
cle/pii/B9780124103900000251
ETIOLOGY OF NERVUS INTERMEDIUS NEURALGIA
❖ Primary causes – vascular compression of the nerve
–AICA/PICA
❖ Secondary causes – herpes zoster, TMJ dysfunction,
tumor, infection, surgery (to face/ear)
DIAGNOSIS OF NERVUS INTERMEDIUS NEURALGIA
❖ History
❖ Physical Exam
❖ Pain mapping
❖ Labs, Cultures, MRI/MRA to rule out underlying pathology
❖ Can be difficult to visualize nervus intermedius nerve
TREATMENT FOR NERVUS INTERMEDIUS NEURALGIA
❖ 1st line therapy
❖Pharmaceutical – carbamezapine, amitriptyline,
lamotrigine, prednisolone
❖ 2nd line therapy
❖Surgical – transection of the nerve or ablation of
geniculate nucleus, microvascular decompression
GLOSSOPHARYNGEAL
(CN IX)
NEURALGIA
GLOSSOPHARYNGEAL NEURALGIA
❖ Described as spasmodic, brief, severe, sharp shooting pains in
pharynx, tonsillar fossa, ear canal, base of tongue and inferior to
gonial angle
❖ International Association for the Study of Pain (IASP)
definition
❖ Triggered by deglutition (cold water), tussive action, mastication,
yawning, talking, touching the ear, and sudden head/neck
movement
❖ Middle aged females commonly affected; L>R for Females; R>L
for Males
GLOSSOPHARYNGEAL NEURALGIA
❖ Anatomy of Glossopharyngeal
nerve (CN IX)
❖Somatic sensory for
oropharynx, posterior 1/3
tongue, eustachian
tube, middle ear, and
mastoid region
http://www.clinicalexams.co.uk/9th-cranial-nerve-tests-for-the-
glossopharyngeal-nerve/
ETIOLOGY OF GLOSSOPHARYNGEAL NEURALGIA
❖ Primary causes – vascular compression of the nerve
– PICA/AICA
❖ Secondary causes – trauma, radiation,
tumors, surgery, Multiple Sclerosis
IASP/IHS & CLASSIFICATIONS OF GLOSSOPHARYNGEAL NEURALGIA
❖ IASP – International
Association for the Study
of Pain
❖Sudden, severe, brief,
recurrent pain in
distribution of CN IX
❖ IHS – International
Headache Society
❖ Classifications
❖ I – classic – episodic
❖Tympanic or peritonsillar –
history of surgery
❖ II – symptomatic – constant
DIAGNOSIS OF GLOSSOPHARYNGEAL NEURALGIA
❖ History
❖ Physical Exam
❖ Pain mapping
❖ CT-A, MRI/MRA
❖ Identify vascular compression or malignancies
❖ Panoramic X-ray/CT to rule out Eagle's syndrome
❖ EKG to rule out cardiac pathology
TREATMENT FOR GLOSSOPHARYNGEAL NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine, gabapentin, Vitamin B12,
SSRIs (low-dose)
❖ Secondary – baclofen, dextromethorphan, lamotrigine
❖ 2nd line therapy
❖ Local anesthetics – nerve block -- alcohol, bupivacaine, steroids
❖ Surgical – transection of nerve or gamma-knife surgery
SUPERIOR LARYNGEAL
NEURALGIA
SUPERIOR LARYNGEAL NEURALGIA
❖ Described as an anterior neck pain syndrome that presents as
unilateral, paroxysmal stabbing and burning pain
❖ Pain is sharp and begins posterolateral to thyrohyoid cartilage,
radiates up to gonial angle and inferior to earlobe and can radiate
inferiorly along anterolateral neck
❖ Triggered by deglutition, coughing, talking, ipsilateral head
turning, and foreign body sensation is common
SUPERIOR LARYNGEAL NEURALGIA
❖ Anatomy of Superior Laryngeal nerve
❖ Branch of the vagus nerve
❖ From inferior ganglion of vagus
nerve
❖ Located at posterior thyrohyoid
space
❖Lateral to pharynx, posterior
to internal carotid artery
❖ Sensory branch is internal
supplying laryngeal mucosa,
epiglottis and base of tongue
https://journals.sagepub.com/doi/pdf/10.1177/0145561318823373
ETIOLOGY OF SUPERIOR LARYNGEAL NEURALGIA
❖ Primary causes – local inflammation of the nerve or
excessive talking leading to microtrauma
❖ Secondary causes – infections, trauma,
tumors, surgery to anterolateral neck region (carotid
endarterectomy)
DIAGNOSIS OF SUPERIOR LARYNGEAL NEURALGIA
❖ History
❖ Physical Exam
❖ Pressure point on thyrohyoid region elicits pain
❖ Pain mapping
❖ Diagnostic local anesthesia alleviating pain and symptoms
TREATMENT FOR SUPERIOR LARYNGEAL NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine, gabapentin,
lacosamide, amitriptyline
❖ 2nd line therapy
❖ Local anesthetics – nerve block – Lidocaine and
triamcinolone
❖ Surgical – transection of the nerve
OCCIPITAL
NEURALGIA
OCCIPITAL NEURALGIA❖ Described as paroxysmal shooting or stabbing pain in distribution of
greater occipital nerve (GON) or lesser occipital nerve (LON) with
tenderness to palpation
❖ Classified by the International Headache Society (IHS)
❖ Also known as C2 Neuralgia; Pain spreads to upper neck, posterior scalp,
behind the eyes, usually unilateral but can be bilateral, occipital allodynia
is common
❖ Triggered by compression of GON/LON, head on pillow with
hyperextension or rotation of neck elicits pain
❖ F>M; GON (90%), LON (10%)
OCCIPITAL NEURALGIA
❖ Additional symptoms include:
❖ Vision impairment or ocular pain (67%)
❖ Tinnitus (33%)
❖ Dizziness (50%)
❖ Nausea (50%)
❖ Nasal congestion (17%)
OCCIPITAL NEURALGIA
❖ Anatomy of the Occipital
nerve
❖ GON medial branch of
dorsal ramus at C2
❖ LON medial branch of
dorsal ramus at C2
and C3
❖ Sensory supply to skin
of occipital region to
vertex
https://painendshere.com/treatments/occipital-nerve-block-injections/
ETIOLOGY OF OCCIPITAL NEURALGIA
❖ Primary causes – vascular – occipital artery or
muscular compression of nerve
❖ Secondary causes – inflammation, trauma, arthritis,
cranio-cervical instability, tumors, congenital
abnormalities
DIAGNOSIS OF OCCIPITAL NEURALGIA
❖ History
❖ Physical Exam
❖ Pain mapping
❖ Tinel's sign +
❖ MRI/CT/XR to rule out underlying pathology
❖ Diagnostic local anesthesia alleviating pain and symptoms
TREATMENT FOR OCCIPITAL NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine, gabapentin, SSRIs
❖ Alternates – physical therapy, CBT
❖ 2nd line therapy
❖ Local anesthetics – nerve block – lidocaine with
steroid, botulinum toxin A
❖ Pulsed radiofrequency inhibits firing of A-delta and
small C fibers
❖ Surgical – rhizotomy, occipital neurolysis, nerve root
decompression
GREAT AURICULAR
NEURALGIA
GREAT AURICULAR NEURALGIA
❖ Presents with paroxysmal spells of unilateral, sharp
pain along the preauricular-parotid, gonial angle
and mastoid regions
❖ Triggered by head movement to the opposite side
GREAT AURICULAR
NEURALGIA
❖ Anatomy of the Great Auricular
nerve
❖ The great auricular nerve is
a purely sensory branch of
C2-C3 anastomosing with
ansa cervicalis
❖ Anterior branch
supplies parotid region
skin
❖ Posterior branch
supplies mastoid
region skin
http://www.ajnr.org/content/21/3/568
ETIOLOGY OF GREAT AURICULAR NEURALGIA
❖Primary causes – idiopathic in most cases
❖Secondary causes – surgery or tumors of the neck
DIAGNOSIS OF GREAT AURICULAR NEURALGIA
❖History
❖Physical Exam
❖MRI/CT/XR to rule out underlying pathology
TREATMENT FOR GREAT AURICULAR NEURALGIA
❖ 1st line therapy
❖Pharmaceutical – pregabalin, amitriptyline
❖ 2nd line therapy
❖Local anesthetics – nerve block – lidocaine with
steroid
TROCHLEAR
NEURALGIA
TROCHLEAR NEURALGIA
❖ Described as frontal, periorbital, with or
without eye pain, peri-trochlear inflammation
❖ Dull, achy, photophobia, binocular diplopia, pain in
superomedial orbit
❖ ICHD3/IHS
❖Aggravated by downward eye movement
TROCHLEAR NEURALGIA
❖ Anatomy of the
Trochlear nerve
❖ Trochlear nerve
cranial nerve IV
superior oblique
❖ downward and
adduct eye
http://notezonnursing.blogspot.com/2011/05/cranial-nerve-iv-trochlear-nerve-review.html
ETIOLOGY OF TROCHLEAR NEURALGIA
❖ Primary causes – idiopathic, with or without
associated headache
❖ Secondary causes – inflammation, autoimmune
disorders
DIAGNOSIS OF TROCHLEAR NEURALGIA
❖ History
❖ Physical Exam
❖ MRI/CT to rule out underlying pathology
❖ Diagnostic local anesthesia alleviating pain and symptoms
TREATMENT FOR TROCHLEAR NEURALGIA
❖ 1st line therapy
❖ Pharmaceutical – carbamezapine
❖ 2nd line therapy
❖ Local anesthetics – nerve block –
lidocaine/dexamethasone
OTHERS
TO
CONSIDER
OTHER NEURALGIAS/HEADACHES
❖ External Compression headache
❖ DDx for Supraorbital Neuralgia
❖ Cold Stimulus headache
❖ DDx for Sphenopalatine Neuralgia or Glossopharyngeal Neuralgia
OTHER NEURALGIAS/HEADACHES
❖ Eagle's Syndrome
❖ DDx for Glossopharyngeal Neuralgia
❖ Neck Tongue Syndrome
❖ DDx for Occipital Neuralgia or Glossopharyngeal
Neuralgia
THANK YOU!
QUESTIONS?
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