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Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal neuralgia: a retrospective study

Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal... Journal of Pain Research Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RE SE ARCH Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal neuralgia: a retrospective study This article was published in the following Dove Press journal: Journal of Pain Research 1, Objective: To examine the effectiveness and safety of ultrasound-guided glossopharyngeal Qian Liu * 2, nerve block via the styloid process for primary glossopharyngeal neuralgia. Qing Zhong * 1, Methods: This retrospective study included all patients receiving glossopharyngeal nerve Guoqiang Tang * 1 block via the styloid process under ultrasound guidance for primary glossopharyngeal Guanghong He neuralgia between January 2015 and May 2018 at our hospital. The primary outcome of Department of Anesthesiology, First the study was pain relief as assessed using the visual analog scale (VAS). Treatment was People’s Hospital, Zigong, Sichuan, considered effective if the VAS score decreased by more than 2 points. People’s Republic of China; Department of Anesthesiology, People’s Hospital, Results: Twelve patients were included in the analysis. The baseline VAS scores ranged Jianyang, Sichuan, People’s Republic of from 5 to 9. All patients received previous pharmacotherapy. Other previous treatments China included pulsed mode radiofrequency (n=4), microvascular decompression (n=2), and glos- *These authors contributed equally to sopharyngeal nerve block (not under ultrasound guidance; n=2). The patients completed a this work total of 48 injections for glossopharyngeal nerve block. At discharge from the hospital, and at 6, 12, and 18 months thereafter, 10/12, 10/12, 7/12, and 4/12 patients achieved pain relief and the effective rate was 83.3% at discharge, 83.3% at 6 months, 58.3% at 1 year, and 33.3% at 18 months, respectively. Conclusion: Ultrasound-guided glossopharyngeal nerve block via the styloid process is a safe, radiation-free, repeatable, convenient, and effective treatment. It can provide a treat- ment option for patients with glossopharyngeal neuralgia. Keywords: ultrasound, glossopharyngeal neuralgia, styloid process, glossopharyngeal nerve block Introduction Glossopharyngeal neuralgia, also known as vagal glossopharyngeal neuralgia, is characterized by intermittent episodes of shooting sharp pain in the jaw, throat, tongue, and ear that fall within the sensory distribution of the glossopharyngeal 1,3,4,5 nerve (cranial nerve IX). Its overall incidence is estimated to be between 0.2 and 0.7 cases per 100,000 person-years, which is much lower than that of trigeminal neuralgia (28.9 cases per 100,000 person-years). Pharmacotherapy with anticon- vulsants, tricyclic antidepressants, and anti-inflammatory agents is effective in 1,3–7 relieving paroxysmal pain in most glossopharyngeal neuralgia patients, but Correspondence: Guoqiang Tang drug toxicities such as rash, diplopia, cognitive decline, decreased blood cell Department of Anesthesiology, First count, or liver dysfunction limit their efficacy. People’s Hospital, No. 42 Shangyi Hao Road, Ziliujing District, Zigong, Sichuan Interventional and surgical options, such as gamma knife radiation, surgical dissec- 64300, People’s Republic of China Email liuqianlqlqlqlqlq@163.com tion, microvascular decompression or electrical stimulation of the motor cortex submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2503–2510 2503 DovePress © 2019 Liu et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://doi.org/10.2147/JPR.S214596 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Liu et al Dovepress ipsilateral to the side of the disease; 3) patients with mental contralateral to the pain area, are needed when conservative 8–12,15,22,23,27 disorders, local infection, or pregnancy; 4) patients with pharmacotherapy fails. Glossopharyngeal nerve abnormal coagulation function; 5) patients with local anes- block provides transitory cessation of nerve impulse conduc- thetic allergy. tion for relief of glossopharyngeal neuralgia via injection of The study protocol was approved by the local ethics local anesthetic and steroids and is usually well tolerated, and 13,16,17,21 committees of the authors’ affiliated institutions, and the it is not associated with serious adverse effects. The study was performed in accordance with the Declaration of nerve block is commonly performed by four different routes: Helsinki. Patient consent was not required due to the retro- topical application, intraoral injection, parapharyngeal space 13–15 spective nature of this study and because available data injection, and percutaneous peristyloid injection. were collected through outpatient department and tele- However, all these routes have limitations. Because of the phone. In the current report, patient data were anonymized. large number of bone structures around the glossopharyngeal nerve, the puncture needle is positioned under fluoroscopic guidance during percutaneous peristyloid injection, and con- Ultrasound-guided glossopharyngeal trast media is injected to confirm the extent of drug diffusion nerve block and whether the blood vessels are violated. Consequently, the The patient was placed in the lateral position with a thin procedure is very inconvenient during operation. pillow under the head. The area over the mastoid process Meanwhile, dependence on bone structure poses a great was scanned using a low-frequency convex array probe to 20,28 challenge to operators in localization and radiography. locate the mastoid and the mandibular angle, and a line Ultrasound can visualize bone, soft tissue, and peripheral (M1) was drawn between the two landmarks. Another line blood vessels in real time and directly observe the diffusion was drawn from 1.5 cm above the posterior edge of the of drugs, effectively avoiding important structures such as mandibular angle to the mastoid (M2) (Figure 1A). The blood vessels, and reducing the occurrence of complica- convex array probe was placed on M2 to visualize the tions. Ultrasound-guided nerve block is becoming increas- styloid process (Figure 1B). The scanning sequence was ingly popular among anesthesiologists and pain physicians, parallel to M2, moving up and down to find the clearest and ultrasound-guided glossopharyngeal nerve block has image of the styloid process (Figure 1C). Subsequently, 14,16,17,28–31 also been reported in some cases. color flow Doppler was used to identify the internal carotid In the current study, we investigated the efficacy and artery and the internal vein mixed blood flow signals below safety of ultrasound-guided glossopharyngeal nerve block or behind the styloid process (Figure 1D). A 22-gauge and via the styloid process in 12 patients with primary glosso- 3.5-inch needle was directed for ultrasound-guided lateral pharyngeal neuralgia who failed previous therapies. puncture of the mandible in plane. When the needle tip reached the styloid process, it was slid through the styloid process to the back of the styloid process, and the needle Patients and methods path is depicted in Figure 1C. When no blood or cerebrosp- Patients inal fluid appeared after careful withdrawal the needle, This retrospective study included patients with primary 0.5% lidocaine and 40 mg methylprednisolone were slowly glossopharyngeal neuralgia who received pain care injected in 3 mL under real-time ultrasound guidance. The between January 2015 and May 2018 at the Department of patient was observed for 30 mins before returning to the Pain Medicine, Department of Neurology, and Department ward. Considering the accuracy of ultrasound is different of Neurosurgery of First People’s Hospital, Zigong, from that of CT and that it is expected to achieve an Sichuan, China. Primary glossopharyngeal neuralgia was enhanced and lasting effect, patients received an injection diagnosed according to the International Headache Society 1,3 once every other day, for a total of four times for duration of diagnostic criteria. Major inclusion criteria were 1) 36–40 9 days. The procedure was performed by the same patients were diagnosed with primary glossopharyngeal physician. neuralgia; 2) patients were aged between 18 and 85 years; 3) patients who failed pharmacotherapy or other treatments. Major exclusion criteria were 1) patients with severe cardi- Patient evaluation opulmonary diseases such as myocardial infarction, and We retrieved the following data from the hospital’s elec- heart failure; 2) patients who had styloid truncation tronic record systems including patient demographics, submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 DovePress Dovepress Liu et al AB Styloid process M2 Mandible Mastoid process Glossopharyngeal M1 nerve Mandibular angle Internal jugular vein Internal carotid artery Figure 1 (A) The body surface location map: a line (M1) is drawn between the mastoid process and the mandibular angle. Another line is drawn from 1.5 cm above the posterior edge of the mandibular angle to the mastoid process (M2). The posterior part of the styloid process is adjacent to the internal carotid artery and internal jugular vein, and the glossopharyngeal nerve is located on the superficial surface of the internal carotid artery and vein. (B) M2 is the plane of ultrasonic probe. (C) The ultrasound image represents the sagittal view. The right side of the image shows the depth of investigation. The left side of the image is the mastoid process, the right side of the image is the mandible, the styloid process between the two sides is clearly visible on the image, and the arrow with dashed lines indicates puncture path. (D) Color flow Doppler shows a clear blood flow signal. The external carotid artery is close to the mandible, and the mixed blood flow signals located below or behind the styloid process are the internal carotid artery and the internal jugular vein. The styloid process is an important reference point in the process of puncture. Abbreviations: MP, mastoid process; SP, styloid process; Mand, mandible; N, puncture path; ICA, internal carotid artery; IJV, internal jugular vein; ECA, external carotid artery. onset, duration, intensity, and location of pain, predispos- Results ing factors of pain, and previous pharmacological and Patient demographic and baseline surgical interventions. The patients were followed up by characteristics telephone or outpatient visits every three months after Because of the low incidence of glossopharyngeal neur- nerve block treatment. Pain was evaluated using a 10- algia, we only found a total of 14 patients with glosso- point visual analog scale (VAS). The primary outcome of pharyngeal neuralgia who received pain care during the the study was pain relief upon discharge from the hospital, study period. One patient was excluded because of and at 6, 12, and 18 months thereafter. A 2-point reduction myocardial infarction and one patient was excluded in VAS scores was considered to be an effective due to glossopharyngeal neuralgia caused by tumor 33–35 treatment. The effective rate was the percentage of compression. Finally, 12 patients who received glosso- patients with greater than 2-point reduction in VAS scores. pharyngeal nerve block were included in the analysis. The total maintenance time was calculated from the date Patient demographic and baseline characteristics are of the last session of glossopharyngeal nerve block treat- shown in Table 1. Their median age was 64 years ment to the date of recovery or aggravation of pain. When (range 43–83 years). The median duration of pain was pain levels or VAS scores reached pre-treatment levels, the 1.5 years (range 3 months to >11 years) and their med- study and follow-up were terminated. In addition, compli- ian VAS score was 7 (range 5–9). All patients received cations were recorded. previous pharmacotherapy. Other previous treatments submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2505 DovePress Liu et al Dovepress Table 1 Patient demographic, baseline, and treatment characteristics Patient Age(years)/sex Duration of symptoms Previous surgeries/ Medications VAS no. prior to injection interventions 1 51/M 7 months None Carbamazepine 5 2 52/M >1 year None Carbamazepine, aminophenol- 7 hydroxycodone 3 65/M >1 year None Gabapentin 7 4 43/F 3 months None Carbamazepine, fentanyl patch, 6 gabapentin 5 83/F >1 year None Carbamazepine, tramadol 6 6 61/M 1 year None Oxcarbazepine, duloxetine 8 7 81/F >11 years CT-guided GNB Carbamazepine, pregabalin 6 8 70/F >3 years Fluoroscopy-guided GNB, pulsed Carbamazepine, aminophenol- 7 mode radiofrequency hydroxycodone, gabapentin 9 63/M >2 years Pulsed mode radiofrequency Carbamazepine, aminophenol- 7 hydroxycodone 10 79/F >10 years 2 x Pulsed mode radiofrequency Carbamazepine, pregabalin, 9 hydrocodone 11 52/F >2 years Microvascular decompression, Carbamazepine, morphine sulfate, 9 Pulsed mode radiofrequency tramadol, duloxetine 12 71/M >3 years Microvascular decompression Oxcarbazepine, duloxetine, 8 oxycontin Abbreviations: GNB, glossopharyngeal nerve block; VAS, visual analog scale. included radiofrequency ablation (n=4), microvascular In the remission stage, the maximum reduction in drug use decompression (n=2), and received glossopharyngeal was one third in 4/12 patients, one half in 4/12 patients, three fourthsin2/12patients, andwellcontrolledin1/12patient nerve block (n=2). who had not taken drug. Primary outcome Complications Twelve patients completed a total of 48 injections for glosso- One patient developed panic, dizziness, and nodal tachy- pharyngeal nerve block. The mean procedure time was 9.51 cardia (heart rates 110–120/min) during the treatment and ±0.89 mins (range 7–12 mins). All patients reported pain relief the symptoms were gradually relieved after intravenous within 10 mins of the injection. The median follow-up dura- injection of esmolol (20 mg). One patient suffered from tion after glossopharyngeal nerve block was 16.5 months dysphagia in the throat and one patient had hoarseness, all (range 0–24 months). At discharge, and 6, 12, and 18 months the patients returned to normal after 1 hr of observation. thereafter, 10/12, 10/12, 7/12, and 4/12 patients achieved pain No significant adverse reactions occurred in other patients relief (Table 2 and Figure 2). The effective rate was 83.3% at during the course of treatment. discharge, 83.3% at 6 months, 58.3% at 1 year, and 33.3% at 18 months, respectively. The median mitigation time was 13.5 months (range 0–24 months). After treatment, the drug was Discussion not reduced when the patients were discharged from the At present, the pathogenesis of primary glossopharyngeal hospital. During the follow-up, pain in 1/12 patient was not neuralgia is not clear. It is believed that benign peripheral 18,19 relieved after treatment, and the dose of drug treatment was stimulation or injury of cranial nerve IX is the culprit, increased until microvascular decompression was performed. which provides a basis for the treatment of glossopharyngeal submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 DovePress Dovepress Liu et al Table 2 Efficacy of glossopharyngeal nerve block for patients with glossopharyngeal nerve neuralgia No. Follow-up No. of patients whose VAS scores decreased by more than 2 Mitigation Mean of duration, time, procedure cases months months time, mins 12 3–24 Discharge 3 months 6 months 9 months 12 months 15 months 18 months 10 11 10 10 7 6 4 Effective rate (%) 83.3 91.6 83.3 83.3 58.3 41.6 33.3 Median 13.5 9.51±0.89 (range 0–24) mins Abbreviation: VAS, visual analog scale. Changes in visual analog scale (VAS) scores over time V(2,3,3,3,7) V(3,2,2,2,3,2,2,2,3) V(3,2,3,3,2,4,8) V(4,2,3,3,2,3,7) Discharge 3months 8 V(6,3,8) 6months 9months V(3,2,2,2,3,7) 12months 15months V(2,1,3,3,8) 18months 21months V(2,2,2,2,6) 24months M(5,7) V(3,2,3,3,3,2,3,4,7) V(2,1,0,0,0,1,1) V(2,2,1,1,2,2,3,6) 6 12 18 0 24 30 Months V= vas scores during study period; M= pain sustained untill microvascular decompression Figure 2 A bar graph shows the changes in visual analog scale (VAS) scores over the time for 12 patients. The color coding scores correspond to the VAS scores reported by the patient at the follow-up intervals. neuralgia by blocking nerve conductions of the glossophar- glossopharyngeal nerve trunk is located at the position of yngeal nerve. The current study demonstrated that ultra- the styloid process or at the level of the internal carotid artery sound-guided glossopharyngeal nerve block via the styloid and vein, requiring a higher blocking position. Though nerve process was safe and effective for the majority of glossophar- trunk block yields better efficacy than block at a nerve branch, it incurs greater risk of bleeding or local anesthetic yngeal neuralgia patients over 6 months, but only a small proportion of the patients at 18 months. side effects during puncture of superficial arteriovenous There are three main methods of ultrasound-guided block block through the longitudinal axis of the internal carotid of the glossopharyngeal nerve at present. The first method is artery and vein. It is prone to injury of the blood vessel and guided by ultrasound to block the parapharyngeal space of causes bleeding. Transaxial styloid process block with the the distal branch of the glossopharyngeal nerve. The sec- styloid process as a puncture target may greatly lower the risk ond method is ultrasound-guided longitudinal axis cervical of vessel injuries as the tip position can be adjusted along the internal arteriovenous surface block. The third method is posterior styloid process after reaching the styloid process. ultrasound-guided transverse axis block via the styloid pro- This method is effective in the treatment of glossopharyngeal cess. The parapharyngeal space block of the distal branch of neuralgia and also in the treatment of neuralgia caused by the the glossopharyngeal nerve is far away from the internal styloid process syndrome, local scar, and fibrotic compres- 16,24,25 carotid artery and vein, and the operative risk is obviously sion of the styloid process. Therefore, we think that the lower compared with the other two methods. However, the transverse axis block of the glossopharyngeal nerve via the location of the block is lower than that of the glossopharyn- styloid pathway is superior to the first two methods under geal nerve trunk, leading to diminished efficacy. The ultrasound guidance. submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2507 DovePress Cases Liu et al Dovepress Although x-ray-based guidance is still considered in Limitations diagnostic and interventional procedures for head and There are several limitations to the current study. The 10,11,15,21,22 neck blocks, our study showed that ultra- study is retrospective in nature and cannot establish causal sound-guided glossopharyngeal nerve block can be car- relationships, as a result, the patient’s inaccurate descrip- ried out repeatedly. The styloid is located between the tion of other treatments during the follow-up may have an mastoid process and the mandible; therefore, the acoustic impact on the outcome and we did not carry out a com- window is very small, and the styloid can be easily parative study of glossopharyngeal nerve block accuracy obscured by bones. In the current study, the convex between ultrasound-guided and CT or X-ray. Furthermore, array probe was used as the linear ultrasonic probe because of the low incidence of glossopharyngeal neural- requires a large contact surface, consequently a large gia, the cohort is small in size and also lacks a control arm acoustic window, to effectively pass the sound beam or a parallel comparison group. In addition, all the proce- dures were performed by a single operator. Therefore, our through the target. On the other hand, the convex array findings await confirmation by future randomized con- probe scans in arc; therefore, the lower part of the bone trolled studies with a larger sample size and longer fol- can be scanned readily and the near fieldofvisionis low-up duration. large. Because the mastoid process, the styloid process, and the mandible are clearly visible with the use of convex array probe, and the internal carotid artery and Conclusion vein below the styloid process can be clearly identified by In conclusion, ultrasound-guided glossopharyngeal nerve color Doppler in the puncture plane, the risk of blood block via the styloid process is a safe, radiation-free, vessel injury, local anesthetic side effects and hematoma repeatable, convenient, and effective treatment. It can pro- can be avoided during the puncture. At the same time, the vide a treatment option for patients with glossopharyngeal range of drug diffusion can be observed dynamically neuralgia. under real-time ultrasound monitoring, and the needle position can be adjusted in time to improve the success Ethics approval and consent to rate of block. Compared with X-ray or CT operation, participate nerve block under ultrasonic guidance had a very short The study was approved by the local ethics committee. procedural time, taking 7–12 mins to complete. The name of the ethics committee is Ethics Committee of Furthermore, the operation of the ultrasound-guided glos- the First People’s Hospital, Zigong, China. As the study is sopharyngeal nerve block is convenient to perform and a retrospective study, we mainly used available data col- cost-effective, and the operator and the patient can both lected through outpatient visits and telephone, so patient avoid radiation exposure. This treatment has the advan- consent to review their medical records was waived by the tages of convenience, short operative time, and effective Ethics Committee of the First People’s Hospital. In order treatment. The treatment approach can also be feasible at to protect the privacy of patients, we anonymized patient the outpatient department. However, due to the glosso- data in this report. The study was undertaken in strict pharyngeal nerve block and abundant blood vessels and accordance with the Declaration of Helsinki. nerves around the styloid process, it is necessary to have good first aid equipment and strict monitoring. It is also Availability of data and materials worthy of noting that those who had been treated with The datasets used and/or analyzed during the current study radiofrequency ablation and microvascular decompres- are available from the corresponding author on reasonable sion also achieved pain relief after block. As the time request. All data generated or analyzed during this study elapsed, the VAS score increased, pain relief was are included in this published article. decreased, and the pain recovery rate increased in 9–15 months after treatment (Figure 2). However, after relapse, patients can still achieve long-term analgesia after Acknowledgments repeated block treatments. In the future, we will investi- The authors thank the patients who participated in this gate whether the use of long-acting steroids can prolong study. Qian Liu, Guoqiang Tang, and Qing Zhong should maintenance time. be regarded as co-first authors in this work. submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 DovePress Dovepress Liu et al 16. Bedder MD, Lindsay D. Glossopharyngeal nerve block using ultra- Author contributions sound guidance: a case report of a new technique. Reg Anesth. All authors contributed to data analysis, drafting and revis- 1989;14(6):304–307. 17. Maher T, Shankar H. Ultrasound-guided peristyloid steroid injection for ing the article, gave final approval of the version to be eagle syndrome. Pain Pract. 2017;17(4):554–557. doi:10.1111/ published, and agree to be accountable for all aspects of papr.12497 the work. 18. Shereen R, Gardner B, Altafulla J, et al. Pediatric glossopharyngeal neuralgia: a comprehensive review. Childs Nerv Syst. 2018. doi:10.1007/s00381-018-3995-3 19. Dubey A, Mujoo S, Sakarde SB, Dubey AK. Paroxysmal neuralgia in Disclosure pediatric population–a diagnostic dilemma for physicians and dental The authors report no conflicts of interest in this work. practioners. Kathmandu Univ Med J (KUMJ). 2012;10(40):74–77. 20. Prades JM, Gavid M, Asanau A, et al. Surgical anatomy of the styloid muscles and the extracranial glossopharyngeal nerve. Surg Radiol Anat. 2014;36:141–146. doi:10.1007/s00276-013-1162-9 References 21. Schuster NM, Hsia-Kiung ME. Glossopharyngeal postherpetic neur- 1. Blumenfeld A, Nikolskaya G. Glossopharyngeal neuralgia. Curr algia palliated with fluoroscopic-guided nerve block: a case report. Pain Headache Rep. 2013;17(7):527–536. doi:10.1007/s11916- Headache. 2018;58(1):154–156. doi:10.1111/head.13192 013-0343-x 22. Stieber VW, Bourl JD, Ellis TL. Glossopharyngeal neuralgia treated 2. Manzoni GC, Torelli P. Epidemiology of typical and atypical cranio- with gamma knife surgery: treatment outcome and failure analysis. J facial neuralgias. Neurol Sci. 2005;26(S2):s65–S67. doi:10.1007/ Neurosurg. 2005;102(supplement):155–157. s10072-005-0410-0 23. Shah RV, Racz GB. Pulsed mode radiofrequency lesioning to treat 3. Headache Classification Subcommittee of the International Headache chronic post-tonsillectomy pain (secondary glossopharyngeal neur- Society. The international classification of headache disorders: 2nd algia). Pain Pract. 2003;3(3):232–237. doi:10.1046/j.1533- edition. Cephalalgia. 2004;24(Suppl 1):9–160. 2500.2003.03028.x 4. Reddy K, Hobson DE, Gomori A, Sutherland GR. Painless glosso- 24. Singh PM, Maya D, Mohan VK, et al. Analgesic efficacy and safety pharyngeal “Neuralgia” with syncope: a case report and literature of medical therapy alone vs combined medical therapy and extraoral review. Neurosurgery. 1987;21(6):916–919. doi:10.1227/00006123- glossopharyngeal nerve block in glossopharyngeal neuralgia. Pain 198712000-00023 Med. 2013;14(1):93–102. doi:10.1111/pme.12001 5. Jamshidi A, Masroor MA. Glossopharyngeal neuralgia with cardiac 25. Shin JH, Herrera SR, Eboli P, et al. Entrapment of the glosso- syncope: treatment with a permanent cardiac pacemaker and carba- pharyngeal nerve in patients with Eagle syndrome: surgical tech- mazepine. Arch Intern Med. 1976;136(7):843–845. nique and outcomes in a series of 5 patients. JNeurosurg. 6. Fromm GH. Clinical pharmacology of drugs used to treat head and 2009;111:1226–1230. face pain. Neurol Clin. 1990;8(1):143–151. 26. Bean-Lijewski JD. Glossopharyngeal nerve block for pain relief after 7. Moretti R, Torre P, Antonello RM, Bava A. Gabapentin treatment of pediatric tonsillectomy: retrospective analysis and two cases of life-threa- glossopharyngeal neuralgia: a follow-up of four years of a single tening upper airway obstruction from an interrupted trial. Anesth Analg. case. Eur J Pain. 2002;6(5):403–407. 1997;84(6):1232–1238. doi:10.1097/00000539-199706000-00011 8. Patel A, Kassam A, Horowitz M, Chang YF. Microvascular decom- 27. Martínez-Álvarez R, Martínez-Moreno N, Kusak ME, Rey-Portolés pression in the management of glossopharyngeal neuralgia: analysis G. Glossopharyngeal neuralgia and radiosurgery. J Neurosurg. of 217 cases. Neurosurgery. 2002;50(4):705–711. doi:10.1097/ 2014;121(Suppl):222–225. doi:10.3171/2014.8.GKS141273 00006123-200204000-00004 28. Nader A, Kendall MC, De Oliveria GS, et al. Ultrasound-guided 9. Ferroli P, Fioravanti A, Schiariti M, Broggi G. Microvascular decom- trigeminal nerve block via the pterygopalatine fossa: an effective pression for glossopharyngeal neuralgia: a long-term retrospective treatment for trigeminal neuralgia and atypical facial pain. Pain review of the Milan-Bologna experience in 31 consecutive cases. Physician. 2013;16(5):E537–E545. Acta Neurochir (Wien). 2009;151(10):1245–1250. doi:10.1007/ 29. Siegenthaler A, Haug M, Eichenberger U, et al. Block of the superior s00701-009-0330-5 cervical ganglion, description of a novel ultrasound-guided technique 10. Chua NH, Beems T, Vissers KC. Two cases of glossopharyngeal in human cadavers. Pain Med. 2013;14(5):646–649. doi:10.1111/ neuralgia successfully treated with pulsed radiofrequency treatment. pme.12061 Ann Acad Med Singapore. 2011;40(8):387–389. 30. Narouze S. Ultrasound-guided stellate ganglion block: safety and 11. Mollinedo FT, Esteban SL, Vega CG, et al. Pulsed radiofrequency efficacy. Curr Pain Headache Rep. 2014;18(6):424. doi:10.1007/ treatment in a case of Eagle’s syndrome. Pain Pract. 2013;13 s11916-014-0424-5 (5):399–404. doi:10.1111/j.1533-2500.2012.00592.x 31. Allam AE, Khalil AAF, Eltawab BA, et al. Ultrasound-guided inter- 12. Borius PY, Tuleasca C, Muraciole X, et al. Gamma knife radiosur- vention for treatment of trigeminal neuralgia: an updated review of gery for glossopharyngeal neuralgia: a study of 21 patients with long- anatomy and techniques. Pain Res Manag. 2018;2018:1–9. term follow-up. Cephalalgia. 2018;38(3):543–550. doi:10.1177/ doi:10.1155/2018/5480728 32. Ozveren MF, Türe U. The microsurgical anatomy of the glossophar- 13. Funasaka S, Kodera K. A new method of treatment for glossophar- yngeal nerve with respect to the jugular foramen lesions. Neurosurg yngeal neuralgia–intraoral nerve block (author’s transl). Nihon Focus. 2004;17(2):12–21. doi:10.3171/foc.2004.17.2.3 Jibiinkoka Gakkai Kaiho. 1977;80(9):902–906. 33. Myles PS, Urquhart N. The linearity of the visual analogue scale in 14. Ažman J, Stopar Pintaric T, Cvetko E, Vlassakov K. Ultrasound- patients with severe acute pain. Anaesth Intensive Care. 2005;33:54– guided glossopharyngeal nerve block: a cadaver and a volunteer 58. doi:10.1177/0310057X0503300108 sonoanatomy study. Reg Anesth Pain Med. 2017;42(2):252–258. 34. De Loach LJ, Higgins MS, Caplan AB, Stiff JL. The visual doi:10.1097/AAP.0000000000000561 analogue scale in the immediate postoperative period: intrasub- 15. Telischak NA, Heit JJ, Campos LW, et al. Fluoroscopic C-arm and ject variability and correlation with a numeric scale. CT-guided selective radiofrequency ablation for trigeminal and glos- sopharyngeal facial pain syndromes. Pain Med. 2018;19(1):130–141. Anesth Analg. 1998;86:102–106. doi:10.1097/00000539- doi:10.1093/pm/pnx088 199801000-00020 submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2509 DovePress Liu et al Dovepress 35. Cepeda MS, Africano JM, Polo R, Alcala R, Carr D. What decline in 38. Stout A, Friedly J, Standaert CJ. Systemic absorption and side effects pain intensity is meaningful to patients with acute pain? Pain. of locally injected glucocorticoids. Pm R. 2019;11:409–419. doi:10.1002/pmrj.12042 2003;105:151–157. 39. Armstrong RD, English J, Gibson T, Chakraborty J, Marks V. Serum 36. Vanderpol J, Jonker L. Influence of patient positioning on reported methylprednisolone levels following intra-articular injection of clinical outcomes after greater occipital nerve block for treatment of methylprednisolone acetate. Ann Rheum Dis. 1981;40:571–574. headache: results from prospective single-centre, non-randomised, doi:10.1136/ard.40.6.571 proof-of-concept study. Clin Neurol Neurosurg. 2019;176:73–77. 40. Deer T, Ranson M, Kapural L, et al. Guidelines for the proper use of doi:10.1016/j.clineuro.2018.12.001 epidural steroid injections for the chronic pain patient. Tech Reg Anesth 37. Eker HE, Cok OY, Aribogan A, Arslan G. Management of neuro- Pain Manag. 2009;13(4):0–295. doi:10.1053/j.trap.2009.06.010 pathic pain with methylprednisolone at the site of nerve injury. Pain Med. 2012;13:443–451. doi:10.1111/j.1526-4637.2011.01323.x Journal of Pain Research Dovepress Publish your work in this journal The Journal of Pain Research is an international, peer reviewed, open management system is completely online and includes a very quick access, online journal that welcomes laboratory and clinical findings in and fair peer-review system, which is all easy to use. Visit http:// the fields of pain research and the prevention and management of pain. www.dovepress.com/testimonials.php to read real quotes from pub- Original research, reviews, symposium reports, hypothesis formation lished authors. and commentaries are all considered for publication. 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Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal neuralgia: a retrospective study

Journal of Pain Research , Volume 12 – Aug 8, 2019

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10.2147/JPR.S214596
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Abstract

Journal of Pain Research Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RE SE ARCH Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal neuralgia: a retrospective study This article was published in the following Dove Press journal: Journal of Pain Research 1, Objective: To examine the effectiveness and safety of ultrasound-guided glossopharyngeal Qian Liu * 2, nerve block via the styloid process for primary glossopharyngeal neuralgia. Qing Zhong * 1, Methods: This retrospective study included all patients receiving glossopharyngeal nerve Guoqiang Tang * 1 block via the styloid process under ultrasound guidance for primary glossopharyngeal Guanghong He neuralgia between January 2015 and May 2018 at our hospital. The primary outcome of Department of Anesthesiology, First the study was pain relief as assessed using the visual analog scale (VAS). Treatment was People’s Hospital, Zigong, Sichuan, considered effective if the VAS score decreased by more than 2 points. People’s Republic of China; Department of Anesthesiology, People’s Hospital, Results: Twelve patients were included in the analysis. The baseline VAS scores ranged Jianyang, Sichuan, People’s Republic of from 5 to 9. All patients received previous pharmacotherapy. Other previous treatments China included pulsed mode radiofrequency (n=4), microvascular decompression (n=2), and glos- *These authors contributed equally to sopharyngeal nerve block (not under ultrasound guidance; n=2). The patients completed a this work total of 48 injections for glossopharyngeal nerve block. At discharge from the hospital, and at 6, 12, and 18 months thereafter, 10/12, 10/12, 7/12, and 4/12 patients achieved pain relief and the effective rate was 83.3% at discharge, 83.3% at 6 months, 58.3% at 1 year, and 33.3% at 18 months, respectively. Conclusion: Ultrasound-guided glossopharyngeal nerve block via the styloid process is a safe, radiation-free, repeatable, convenient, and effective treatment. It can provide a treat- ment option for patients with glossopharyngeal neuralgia. Keywords: ultrasound, glossopharyngeal neuralgia, styloid process, glossopharyngeal nerve block Introduction Glossopharyngeal neuralgia, also known as vagal glossopharyngeal neuralgia, is characterized by intermittent episodes of shooting sharp pain in the jaw, throat, tongue, and ear that fall within the sensory distribution of the glossopharyngeal 1,3,4,5 nerve (cranial nerve IX). Its overall incidence is estimated to be between 0.2 and 0.7 cases per 100,000 person-years, which is much lower than that of trigeminal neuralgia (28.9 cases per 100,000 person-years). Pharmacotherapy with anticon- vulsants, tricyclic antidepressants, and anti-inflammatory agents is effective in 1,3–7 relieving paroxysmal pain in most glossopharyngeal neuralgia patients, but Correspondence: Guoqiang Tang drug toxicities such as rash, diplopia, cognitive decline, decreased blood cell Department of Anesthesiology, First count, or liver dysfunction limit their efficacy. People’s Hospital, No. 42 Shangyi Hao Road, Ziliujing District, Zigong, Sichuan Interventional and surgical options, such as gamma knife radiation, surgical dissec- 64300, People’s Republic of China Email liuqianlqlqlqlqlq@163.com tion, microvascular decompression or electrical stimulation of the motor cortex submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2503–2510 2503 DovePress © 2019 Liu et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://doi.org/10.2147/JPR.S214596 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Liu et al Dovepress ipsilateral to the side of the disease; 3) patients with mental contralateral to the pain area, are needed when conservative 8–12,15,22,23,27 disorders, local infection, or pregnancy; 4) patients with pharmacotherapy fails. Glossopharyngeal nerve abnormal coagulation function; 5) patients with local anes- block provides transitory cessation of nerve impulse conduc- thetic allergy. tion for relief of glossopharyngeal neuralgia via injection of The study protocol was approved by the local ethics local anesthetic and steroids and is usually well tolerated, and 13,16,17,21 committees of the authors’ affiliated institutions, and the it is not associated with serious adverse effects. The study was performed in accordance with the Declaration of nerve block is commonly performed by four different routes: Helsinki. Patient consent was not required due to the retro- topical application, intraoral injection, parapharyngeal space 13–15 spective nature of this study and because available data injection, and percutaneous peristyloid injection. were collected through outpatient department and tele- However, all these routes have limitations. Because of the phone. In the current report, patient data were anonymized. large number of bone structures around the glossopharyngeal nerve, the puncture needle is positioned under fluoroscopic guidance during percutaneous peristyloid injection, and con- Ultrasound-guided glossopharyngeal trast media is injected to confirm the extent of drug diffusion nerve block and whether the blood vessels are violated. Consequently, the The patient was placed in the lateral position with a thin procedure is very inconvenient during operation. pillow under the head. The area over the mastoid process Meanwhile, dependence on bone structure poses a great was scanned using a low-frequency convex array probe to 20,28 challenge to operators in localization and radiography. locate the mastoid and the mandibular angle, and a line Ultrasound can visualize bone, soft tissue, and peripheral (M1) was drawn between the two landmarks. Another line blood vessels in real time and directly observe the diffusion was drawn from 1.5 cm above the posterior edge of the of drugs, effectively avoiding important structures such as mandibular angle to the mastoid (M2) (Figure 1A). The blood vessels, and reducing the occurrence of complica- convex array probe was placed on M2 to visualize the tions. Ultrasound-guided nerve block is becoming increas- styloid process (Figure 1B). The scanning sequence was ingly popular among anesthesiologists and pain physicians, parallel to M2, moving up and down to find the clearest and ultrasound-guided glossopharyngeal nerve block has image of the styloid process (Figure 1C). Subsequently, 14,16,17,28–31 also been reported in some cases. color flow Doppler was used to identify the internal carotid In the current study, we investigated the efficacy and artery and the internal vein mixed blood flow signals below safety of ultrasound-guided glossopharyngeal nerve block or behind the styloid process (Figure 1D). A 22-gauge and via the styloid process in 12 patients with primary glosso- 3.5-inch needle was directed for ultrasound-guided lateral pharyngeal neuralgia who failed previous therapies. puncture of the mandible in plane. When the needle tip reached the styloid process, it was slid through the styloid process to the back of the styloid process, and the needle Patients and methods path is depicted in Figure 1C. When no blood or cerebrosp- Patients inal fluid appeared after careful withdrawal the needle, This retrospective study included patients with primary 0.5% lidocaine and 40 mg methylprednisolone were slowly glossopharyngeal neuralgia who received pain care injected in 3 mL under real-time ultrasound guidance. The between January 2015 and May 2018 at the Department of patient was observed for 30 mins before returning to the Pain Medicine, Department of Neurology, and Department ward. Considering the accuracy of ultrasound is different of Neurosurgery of First People’s Hospital, Zigong, from that of CT and that it is expected to achieve an Sichuan, China. Primary glossopharyngeal neuralgia was enhanced and lasting effect, patients received an injection diagnosed according to the International Headache Society 1,3 once every other day, for a total of four times for duration of diagnostic criteria. Major inclusion criteria were 1) 36–40 9 days. The procedure was performed by the same patients were diagnosed with primary glossopharyngeal physician. neuralgia; 2) patients were aged between 18 and 85 years; 3) patients who failed pharmacotherapy or other treatments. Major exclusion criteria were 1) patients with severe cardi- Patient evaluation opulmonary diseases such as myocardial infarction, and We retrieved the following data from the hospital’s elec- heart failure; 2) patients who had styloid truncation tronic record systems including patient demographics, submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 DovePress Dovepress Liu et al AB Styloid process M2 Mandible Mastoid process Glossopharyngeal M1 nerve Mandibular angle Internal jugular vein Internal carotid artery Figure 1 (A) The body surface location map: a line (M1) is drawn between the mastoid process and the mandibular angle. Another line is drawn from 1.5 cm above the posterior edge of the mandibular angle to the mastoid process (M2). The posterior part of the styloid process is adjacent to the internal carotid artery and internal jugular vein, and the glossopharyngeal nerve is located on the superficial surface of the internal carotid artery and vein. (B) M2 is the plane of ultrasonic probe. (C) The ultrasound image represents the sagittal view. The right side of the image shows the depth of investigation. The left side of the image is the mastoid process, the right side of the image is the mandible, the styloid process between the two sides is clearly visible on the image, and the arrow with dashed lines indicates puncture path. (D) Color flow Doppler shows a clear blood flow signal. The external carotid artery is close to the mandible, and the mixed blood flow signals located below or behind the styloid process are the internal carotid artery and the internal jugular vein. The styloid process is an important reference point in the process of puncture. Abbreviations: MP, mastoid process; SP, styloid process; Mand, mandible; N, puncture path; ICA, internal carotid artery; IJV, internal jugular vein; ECA, external carotid artery. onset, duration, intensity, and location of pain, predispos- Results ing factors of pain, and previous pharmacological and Patient demographic and baseline surgical interventions. The patients were followed up by characteristics telephone or outpatient visits every three months after Because of the low incidence of glossopharyngeal neur- nerve block treatment. Pain was evaluated using a 10- algia, we only found a total of 14 patients with glosso- point visual analog scale (VAS). The primary outcome of pharyngeal neuralgia who received pain care during the the study was pain relief upon discharge from the hospital, study period. One patient was excluded because of and at 6, 12, and 18 months thereafter. A 2-point reduction myocardial infarction and one patient was excluded in VAS scores was considered to be an effective due to glossopharyngeal neuralgia caused by tumor 33–35 treatment. The effective rate was the percentage of compression. Finally, 12 patients who received glosso- patients with greater than 2-point reduction in VAS scores. pharyngeal nerve block were included in the analysis. The total maintenance time was calculated from the date Patient demographic and baseline characteristics are of the last session of glossopharyngeal nerve block treat- shown in Table 1. Their median age was 64 years ment to the date of recovery or aggravation of pain. When (range 43–83 years). The median duration of pain was pain levels or VAS scores reached pre-treatment levels, the 1.5 years (range 3 months to >11 years) and their med- study and follow-up were terminated. In addition, compli- ian VAS score was 7 (range 5–9). All patients received cations were recorded. previous pharmacotherapy. Other previous treatments submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2505 DovePress Liu et al Dovepress Table 1 Patient demographic, baseline, and treatment characteristics Patient Age(years)/sex Duration of symptoms Previous surgeries/ Medications VAS no. prior to injection interventions 1 51/M 7 months None Carbamazepine 5 2 52/M >1 year None Carbamazepine, aminophenol- 7 hydroxycodone 3 65/M >1 year None Gabapentin 7 4 43/F 3 months None Carbamazepine, fentanyl patch, 6 gabapentin 5 83/F >1 year None Carbamazepine, tramadol 6 6 61/M 1 year None Oxcarbazepine, duloxetine 8 7 81/F >11 years CT-guided GNB Carbamazepine, pregabalin 6 8 70/F >3 years Fluoroscopy-guided GNB, pulsed Carbamazepine, aminophenol- 7 mode radiofrequency hydroxycodone, gabapentin 9 63/M >2 years Pulsed mode radiofrequency Carbamazepine, aminophenol- 7 hydroxycodone 10 79/F >10 years 2 x Pulsed mode radiofrequency Carbamazepine, pregabalin, 9 hydrocodone 11 52/F >2 years Microvascular decompression, Carbamazepine, morphine sulfate, 9 Pulsed mode radiofrequency tramadol, duloxetine 12 71/M >3 years Microvascular decompression Oxcarbazepine, duloxetine, 8 oxycontin Abbreviations: GNB, glossopharyngeal nerve block; VAS, visual analog scale. included radiofrequency ablation (n=4), microvascular In the remission stage, the maximum reduction in drug use decompression (n=2), and received glossopharyngeal was one third in 4/12 patients, one half in 4/12 patients, three fourthsin2/12patients, andwellcontrolledin1/12patient nerve block (n=2). who had not taken drug. Primary outcome Complications Twelve patients completed a total of 48 injections for glosso- One patient developed panic, dizziness, and nodal tachy- pharyngeal nerve block. The mean procedure time was 9.51 cardia (heart rates 110–120/min) during the treatment and ±0.89 mins (range 7–12 mins). All patients reported pain relief the symptoms were gradually relieved after intravenous within 10 mins of the injection. The median follow-up dura- injection of esmolol (20 mg). One patient suffered from tion after glossopharyngeal nerve block was 16.5 months dysphagia in the throat and one patient had hoarseness, all (range 0–24 months). At discharge, and 6, 12, and 18 months the patients returned to normal after 1 hr of observation. thereafter, 10/12, 10/12, 7/12, and 4/12 patients achieved pain No significant adverse reactions occurred in other patients relief (Table 2 and Figure 2). The effective rate was 83.3% at during the course of treatment. discharge, 83.3% at 6 months, 58.3% at 1 year, and 33.3% at 18 months, respectively. The median mitigation time was 13.5 months (range 0–24 months). After treatment, the drug was Discussion not reduced when the patients were discharged from the At present, the pathogenesis of primary glossopharyngeal hospital. During the follow-up, pain in 1/12 patient was not neuralgia is not clear. It is believed that benign peripheral 18,19 relieved after treatment, and the dose of drug treatment was stimulation or injury of cranial nerve IX is the culprit, increased until microvascular decompression was performed. which provides a basis for the treatment of glossopharyngeal submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 DovePress Dovepress Liu et al Table 2 Efficacy of glossopharyngeal nerve block for patients with glossopharyngeal nerve neuralgia No. Follow-up No. of patients whose VAS scores decreased by more than 2 Mitigation Mean of duration, time, procedure cases months months time, mins 12 3–24 Discharge 3 months 6 months 9 months 12 months 15 months 18 months 10 11 10 10 7 6 4 Effective rate (%) 83.3 91.6 83.3 83.3 58.3 41.6 33.3 Median 13.5 9.51±0.89 (range 0–24) mins Abbreviation: VAS, visual analog scale. Changes in visual analog scale (VAS) scores over time V(2,3,3,3,7) V(3,2,2,2,3,2,2,2,3) V(3,2,3,3,2,4,8) V(4,2,3,3,2,3,7) Discharge 3months 8 V(6,3,8) 6months 9months V(3,2,2,2,3,7) 12months 15months V(2,1,3,3,8) 18months 21months V(2,2,2,2,6) 24months M(5,7) V(3,2,3,3,3,2,3,4,7) V(2,1,0,0,0,1,1) V(2,2,1,1,2,2,3,6) 6 12 18 0 24 30 Months V= vas scores during study period; M= pain sustained untill microvascular decompression Figure 2 A bar graph shows the changes in visual analog scale (VAS) scores over the time for 12 patients. The color coding scores correspond to the VAS scores reported by the patient at the follow-up intervals. neuralgia by blocking nerve conductions of the glossophar- glossopharyngeal nerve trunk is located at the position of yngeal nerve. The current study demonstrated that ultra- the styloid process or at the level of the internal carotid artery sound-guided glossopharyngeal nerve block via the styloid and vein, requiring a higher blocking position. Though nerve process was safe and effective for the majority of glossophar- trunk block yields better efficacy than block at a nerve branch, it incurs greater risk of bleeding or local anesthetic yngeal neuralgia patients over 6 months, but only a small proportion of the patients at 18 months. side effects during puncture of superficial arteriovenous There are three main methods of ultrasound-guided block block through the longitudinal axis of the internal carotid of the glossopharyngeal nerve at present. The first method is artery and vein. It is prone to injury of the blood vessel and guided by ultrasound to block the parapharyngeal space of causes bleeding. Transaxial styloid process block with the the distal branch of the glossopharyngeal nerve. The sec- styloid process as a puncture target may greatly lower the risk ond method is ultrasound-guided longitudinal axis cervical of vessel injuries as the tip position can be adjusted along the internal arteriovenous surface block. The third method is posterior styloid process after reaching the styloid process. ultrasound-guided transverse axis block via the styloid pro- This method is effective in the treatment of glossopharyngeal cess. The parapharyngeal space block of the distal branch of neuralgia and also in the treatment of neuralgia caused by the the glossopharyngeal nerve is far away from the internal styloid process syndrome, local scar, and fibrotic compres- 16,24,25 carotid artery and vein, and the operative risk is obviously sion of the styloid process. Therefore, we think that the lower compared with the other two methods. However, the transverse axis block of the glossopharyngeal nerve via the location of the block is lower than that of the glossopharyn- styloid pathway is superior to the first two methods under geal nerve trunk, leading to diminished efficacy. The ultrasound guidance. submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2507 DovePress Cases Liu et al Dovepress Although x-ray-based guidance is still considered in Limitations diagnostic and interventional procedures for head and There are several limitations to the current study. The 10,11,15,21,22 neck blocks, our study showed that ultra- study is retrospective in nature and cannot establish causal sound-guided glossopharyngeal nerve block can be car- relationships, as a result, the patient’s inaccurate descrip- ried out repeatedly. The styloid is located between the tion of other treatments during the follow-up may have an mastoid process and the mandible; therefore, the acoustic impact on the outcome and we did not carry out a com- window is very small, and the styloid can be easily parative study of glossopharyngeal nerve block accuracy obscured by bones. In the current study, the convex between ultrasound-guided and CT or X-ray. Furthermore, array probe was used as the linear ultrasonic probe because of the low incidence of glossopharyngeal neural- requires a large contact surface, consequently a large gia, the cohort is small in size and also lacks a control arm acoustic window, to effectively pass the sound beam or a parallel comparison group. In addition, all the proce- dures were performed by a single operator. Therefore, our through the target. On the other hand, the convex array findings await confirmation by future randomized con- probe scans in arc; therefore, the lower part of the bone trolled studies with a larger sample size and longer fol- can be scanned readily and the near fieldofvisionis low-up duration. large. Because the mastoid process, the styloid process, and the mandible are clearly visible with the use of convex array probe, and the internal carotid artery and Conclusion vein below the styloid process can be clearly identified by In conclusion, ultrasound-guided glossopharyngeal nerve color Doppler in the puncture plane, the risk of blood block via the styloid process is a safe, radiation-free, vessel injury, local anesthetic side effects and hematoma repeatable, convenient, and effective treatment. It can pro- can be avoided during the puncture. At the same time, the vide a treatment option for patients with glossopharyngeal range of drug diffusion can be observed dynamically neuralgia. under real-time ultrasound monitoring, and the needle position can be adjusted in time to improve the success Ethics approval and consent to rate of block. Compared with X-ray or CT operation, participate nerve block under ultrasonic guidance had a very short The study was approved by the local ethics committee. procedural time, taking 7–12 mins to complete. The name of the ethics committee is Ethics Committee of Furthermore, the operation of the ultrasound-guided glos- the First People’s Hospital, Zigong, China. As the study is sopharyngeal nerve block is convenient to perform and a retrospective study, we mainly used available data col- cost-effective, and the operator and the patient can both lected through outpatient visits and telephone, so patient avoid radiation exposure. This treatment has the advan- consent to review their medical records was waived by the tages of convenience, short operative time, and effective Ethics Committee of the First People’s Hospital. In order treatment. The treatment approach can also be feasible at to protect the privacy of patients, we anonymized patient the outpatient department. However, due to the glosso- data in this report. The study was undertaken in strict pharyngeal nerve block and abundant blood vessels and accordance with the Declaration of Helsinki. nerves around the styloid process, it is necessary to have good first aid equipment and strict monitoring. It is also Availability of data and materials worthy of noting that those who had been treated with The datasets used and/or analyzed during the current study radiofrequency ablation and microvascular decompres- are available from the corresponding author on reasonable sion also achieved pain relief after block. As the time request. All data generated or analyzed during this study elapsed, the VAS score increased, pain relief was are included in this published article. decreased, and the pain recovery rate increased in 9–15 months after treatment (Figure 2). However, after relapse, patients can still achieve long-term analgesia after Acknowledgments repeated block treatments. In the future, we will investi- The authors thank the patients who participated in this gate whether the use of long-acting steroids can prolong study. Qian Liu, Guoqiang Tang, and Qing Zhong should maintenance time. be regarded as co-first authors in this work. submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 DovePress Dovepress Liu et al 16. Bedder MD, Lindsay D. Glossopharyngeal nerve block using ultra- Author contributions sound guidance: a case report of a new technique. Reg Anesth. All authors contributed to data analysis, drafting and revis- 1989;14(6):304–307. 17. Maher T, Shankar H. Ultrasound-guided peristyloid steroid injection for ing the article, gave final approval of the version to be eagle syndrome. Pain Pract. 2017;17(4):554–557. doi:10.1111/ published, and agree to be accountable for all aspects of papr.12497 the work. 18. Shereen R, Gardner B, Altafulla J, et al. Pediatric glossopharyngeal neuralgia: a comprehensive review. Childs Nerv Syst. 2018. doi:10.1007/s00381-018-3995-3 19. Dubey A, Mujoo S, Sakarde SB, Dubey AK. Paroxysmal neuralgia in Disclosure pediatric population–a diagnostic dilemma for physicians and dental The authors report no conflicts of interest in this work. practioners. Kathmandu Univ Med J (KUMJ). 2012;10(40):74–77. 20. Prades JM, Gavid M, Asanau A, et al. Surgical anatomy of the styloid muscles and the extracranial glossopharyngeal nerve. Surg Radiol Anat. 2014;36:141–146. doi:10.1007/s00276-013-1162-9 References 21. Schuster NM, Hsia-Kiung ME. Glossopharyngeal postherpetic neur- 1. Blumenfeld A, Nikolskaya G. Glossopharyngeal neuralgia. Curr algia palliated with fluoroscopic-guided nerve block: a case report. Pain Headache Rep. 2013;17(7):527–536. doi:10.1007/s11916- Headache. 2018;58(1):154–156. doi:10.1111/head.13192 013-0343-x 22. Stieber VW, Bourl JD, Ellis TL. Glossopharyngeal neuralgia treated 2. Manzoni GC, Torelli P. Epidemiology of typical and atypical cranio- with gamma knife surgery: treatment outcome and failure analysis. J facial neuralgias. Neurol Sci. 2005;26(S2):s65–S67. doi:10.1007/ Neurosurg. 2005;102(supplement):155–157. s10072-005-0410-0 23. Shah RV, Racz GB. Pulsed mode radiofrequency lesioning to treat 3. Headache Classification Subcommittee of the International Headache chronic post-tonsillectomy pain (secondary glossopharyngeal neur- Society. The international classification of headache disorders: 2nd algia). Pain Pract. 2003;3(3):232–237. doi:10.1046/j.1533- edition. Cephalalgia. 2004;24(Suppl 1):9–160. 2500.2003.03028.x 4. Reddy K, Hobson DE, Gomori A, Sutherland GR. Painless glosso- 24. Singh PM, Maya D, Mohan VK, et al. Analgesic efficacy and safety pharyngeal “Neuralgia” with syncope: a case report and literature of medical therapy alone vs combined medical therapy and extraoral review. Neurosurgery. 1987;21(6):916–919. doi:10.1227/00006123- glossopharyngeal nerve block in glossopharyngeal neuralgia. Pain 198712000-00023 Med. 2013;14(1):93–102. doi:10.1111/pme.12001 5. Jamshidi A, Masroor MA. Glossopharyngeal neuralgia with cardiac 25. Shin JH, Herrera SR, Eboli P, et al. Entrapment of the glosso- syncope: treatment with a permanent cardiac pacemaker and carba- pharyngeal nerve in patients with Eagle syndrome: surgical tech- mazepine. Arch Intern Med. 1976;136(7):843–845. nique and outcomes in a series of 5 patients. JNeurosurg. 6. Fromm GH. Clinical pharmacology of drugs used to treat head and 2009;111:1226–1230. face pain. Neurol Clin. 1990;8(1):143–151. 26. Bean-Lijewski JD. Glossopharyngeal nerve block for pain relief after 7. Moretti R, Torre P, Antonello RM, Bava A. Gabapentin treatment of pediatric tonsillectomy: retrospective analysis and two cases of life-threa- glossopharyngeal neuralgia: a follow-up of four years of a single tening upper airway obstruction from an interrupted trial. Anesth Analg. case. Eur J Pain. 2002;6(5):403–407. 1997;84(6):1232–1238. doi:10.1097/00000539-199706000-00011 8. Patel A, Kassam A, Horowitz M, Chang YF. Microvascular decom- 27. Martínez-Álvarez R, Martínez-Moreno N, Kusak ME, Rey-Portolés pression in the management of glossopharyngeal neuralgia: analysis G. Glossopharyngeal neuralgia and radiosurgery. J Neurosurg. of 217 cases. Neurosurgery. 2002;50(4):705–711. doi:10.1097/ 2014;121(Suppl):222–225. doi:10.3171/2014.8.GKS141273 00006123-200204000-00004 28. Nader A, Kendall MC, De Oliveria GS, et al. Ultrasound-guided 9. Ferroli P, Fioravanti A, Schiariti M, Broggi G. Microvascular decom- trigeminal nerve block via the pterygopalatine fossa: an effective pression for glossopharyngeal neuralgia: a long-term retrospective treatment for trigeminal neuralgia and atypical facial pain. Pain review of the Milan-Bologna experience in 31 consecutive cases. Physician. 2013;16(5):E537–E545. Acta Neurochir (Wien). 2009;151(10):1245–1250. doi:10.1007/ 29. Siegenthaler A, Haug M, Eichenberger U, et al. Block of the superior s00701-009-0330-5 cervical ganglion, description of a novel ultrasound-guided technique 10. Chua NH, Beems T, Vissers KC. Two cases of glossopharyngeal in human cadavers. Pain Med. 2013;14(5):646–649. doi:10.1111/ neuralgia successfully treated with pulsed radiofrequency treatment. pme.12061 Ann Acad Med Singapore. 2011;40(8):387–389. 30. Narouze S. Ultrasound-guided stellate ganglion block: safety and 11. Mollinedo FT, Esteban SL, Vega CG, et al. Pulsed radiofrequency efficacy. Curr Pain Headache Rep. 2014;18(6):424. doi:10.1007/ treatment in a case of Eagle’s syndrome. Pain Pract. 2013;13 s11916-014-0424-5 (5):399–404. doi:10.1111/j.1533-2500.2012.00592.x 31. Allam AE, Khalil AAF, Eltawab BA, et al. Ultrasound-guided inter- 12. Borius PY, Tuleasca C, Muraciole X, et al. Gamma knife radiosur- vention for treatment of trigeminal neuralgia: an updated review of gery for glossopharyngeal neuralgia: a study of 21 patients with long- anatomy and techniques. Pain Res Manag. 2018;2018:1–9. term follow-up. Cephalalgia. 2018;38(3):543–550. doi:10.1177/ doi:10.1155/2018/5480728 32. Ozveren MF, Türe U. The microsurgical anatomy of the glossophar- 13. Funasaka S, Kodera K. A new method of treatment for glossophar- yngeal nerve with respect to the jugular foramen lesions. Neurosurg yngeal neuralgia–intraoral nerve block (author’s transl). Nihon Focus. 2004;17(2):12–21. doi:10.3171/foc.2004.17.2.3 Jibiinkoka Gakkai Kaiho. 1977;80(9):902–906. 33. Myles PS, Urquhart N. The linearity of the visual analogue scale in 14. Ažman J, Stopar Pintaric T, Cvetko E, Vlassakov K. Ultrasound- patients with severe acute pain. Anaesth Intensive Care. 2005;33:54– guided glossopharyngeal nerve block: a cadaver and a volunteer 58. doi:10.1177/0310057X0503300108 sonoanatomy study. Reg Anesth Pain Med. 2017;42(2):252–258. 34. De Loach LJ, Higgins MS, Caplan AB, Stiff JL. The visual doi:10.1097/AAP.0000000000000561 analogue scale in the immediate postoperative period: intrasub- 15. Telischak NA, Heit JJ, Campos LW, et al. Fluoroscopic C-arm and ject variability and correlation with a numeric scale. CT-guided selective radiofrequency ablation for trigeminal and glos- sopharyngeal facial pain syndromes. Pain Med. 2018;19(1):130–141. Anesth Analg. 1998;86:102–106. doi:10.1097/00000539- doi:10.1093/pm/pnx088 199801000-00020 submit your manuscript | www.dovepress.com Journal of Pain Research 2019:12 2509 DovePress Liu et al Dovepress 35. Cepeda MS, Africano JM, Polo R, Alcala R, Carr D. What decline in 38. Stout A, Friedly J, Standaert CJ. Systemic absorption and side effects pain intensity is meaningful to patients with acute pain? Pain. of locally injected glucocorticoids. Pm R. 2019;11:409–419. doi:10.1002/pmrj.12042 2003;105:151–157. 39. Armstrong RD, English J, Gibson T, Chakraborty J, Marks V. Serum 36. Vanderpol J, Jonker L. Influence of patient positioning on reported methylprednisolone levels following intra-articular injection of clinical outcomes after greater occipital nerve block for treatment of methylprednisolone acetate. Ann Rheum Dis. 1981;40:571–574. headache: results from prospective single-centre, non-randomised, doi:10.1136/ard.40.6.571 proof-of-concept study. Clin Neurol Neurosurg. 2019;176:73–77. 40. Deer T, Ranson M, Kapural L, et al. Guidelines for the proper use of doi:10.1016/j.clineuro.2018.12.001 epidural steroid injections for the chronic pain patient. Tech Reg Anesth 37. Eker HE, Cok OY, Aribogan A, Arslan G. Management of neuro- Pain Manag. 2009;13(4):0–295. doi:10.1053/j.trap.2009.06.010 pathic pain with methylprednisolone at the site of nerve injury. Pain Med. 2012;13:443–451. doi:10.1111/j.1526-4637.2011.01323.x Journal of Pain Research Dovepress Publish your work in this journal The Journal of Pain Research is an international, peer reviewed, open management system is completely online and includes a very quick access, online journal that welcomes laboratory and clinical findings in and fair peer-review system, which is all easy to use. Visit http:// the fields of pain research and the prevention and management of pain. www.dovepress.com/testimonials.php to read real quotes from pub- Original research, reviews, symposium reports, hypothesis formation lished authors. and commentaries are all considered for publication. 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