Background & Aims
Glossopharyngeal neuralgia (GPN) is characterized by intermittent episodes of sharp shooting pain in the jaw, throat, tongue and ear, in the sensory distribution of the glossopharyngeal nerve. Pharmacotherapy with anticonvulsants, tricyclic antidepressants is used in patients with glossopharyngeal neuralgia but drug toxicities such as rash, decreased blood count or liver dysfunction limit their use. Glossopharyngeal nerve block provides transitory cessation of nerve impulse conduction for relief of GPN via injection of local anaesthetic. Real-time fluoroscopy relies on detecting the spread of injected contrast to confirm needle position and alert to potential needle penetration into vascular structures. It locates the GPN indirectly by approximation to bony landmarks. Research on USG assisted peristyloid approach was limited to case reports , hence, we planned a study with the hypothesis that USG would help in blockade of glossopharyngeal nerve block by peristyloid approach.
Methods
Adult patients with age 18-60 yrs as diagnosed with symptoms of GPN, as per international Headache Society 2018, with VAS more than 3, were included. Ultrasound scanning started from mastoid process in an axial view and then, caudally in a slight oblique direction to get an axial view of styloid process with head tilted to the opposite side. Then, transducer was rotated for a longitudinal view . This provided a view of the styloid process as a hyperechoic line. Coloured Doppler was done to visualize internal carotid artery (ICA) & Internal jugular vein (IJV). A 25-gauge spinal needle was inserted & visualised in relation in position to vessels . Real time, 0.5 ml of 1% lidocaine & 40 mg of methylprednisolone was administered. Depth of styloid process, depth of ICA, and total time taken to administer b were noted. Patients were observed after block for pain at rest and pain at swallowing/ talking/ sneezing after 30 minutes,60 minutes, 24 hours, 1st week, 2nd week and 4th week.
Results
22 patients, aged between 20-65 years, suffering from recurrent paroxysmal pain in distribution of glossopharyngeal nerve presented to pain clinic in the Department of Anaesthesiology at Pt. B.D. Sharma PGIMS, Rohtak. were included. Twelve patients had pain relief with pharmacological treatment, 2 patients were lost in follow up and 1 patient had an episode of cerbrovascular accident due to preexisting thrombus in Internal jugular vein and dural transverse sinus. & needed admission. Depth of styloid process was 1.37- 1.76 cm.Depth of internal carotid artery was 1.5 – 1.86cm. Needle depth was 1.56 – 1.96 cm.Total time taken to administer the block (time from start of USG scan to drug administration) was 20- 24 minutes. Pain at rest and dynamic pain decreased significantly after 30 minutes,60 minutes, 24 hours, 1st week, 2nd week and 4th week.(p,0.001) It persisted upto 3 months in few patients. Total analgesic requirement was significantly reduced at all assessment time intervals.
Conclusions
Ultrasound guided nerve block is becoming increasingly popular among anaesthesiologists and pain physicians. The popularity of ultrasound technique has facilitated the performance of regional blocks. Ultrasound can visualise bone, soft tissue and peripheral blood vessels in real time and directly observe the diffusion of drugs, effectively avoiding important structures such as blood
vessels and reducing the occurrence of complications. There are abundant blood vessels and nerves around the styloid process. The internal carotid artery and internal jugular vein has to be identified prior to the nerve block. To avoid the complications and to preserve the vital structures around the styloid process, ultrasound was planned to improve the quality of the procedure. USG guided glossopharyngeal nerve block by peristyloid approach is efficacious and helps in real -time visualization of major vessels of neck, styloid process. It is non invasive and not associated with ionizing radiations.
References
1. Bedder MD, Lindsay D. Glossopharyngeal nerve block using ultrasound guidance: a case report of a new technique. Reg Anesth 1989;14:304-7.
2 Narouze S. Glossopharyngeal nerve block. In: Narouze SN, ed. Interventional Management of Head and Face Pain.1st ed. New York: Springer; 2014. p.41-7.
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3. Ažman J, Stopar Pintaric T, Cvetko E,Vlassakov K. Ultrasound-Guided Glossopharyngeal Nerve Block. Regional Anesthesia and Pain Medicine 2017;42:252-8.
4. Maher T, Shankar H. Ultrasound-Guided Peristyloid Steroid Injection for Eagle Syndrome. Pain Practice 2016;17: 554-7.
Presenting Author
Anju Ghai
Poster Authors
anju ghai
MBBS,MD Anaesthesia
pgims,rohtak
Lead Author
Topics
- Assessment and Diagnosis