Background & Aims
Pediatric headache presents a multifaceted diagnostic puzzle, often proving to be a formidable challenge for physicians. Among the spectrum of primary headaches, including neuralgias, glossopharyngeal neuralgia (GN) emerges as one of the rarest, being only 1% of cases. With an incidence of 0.7 per 100,000 in the adult population, its occurrence is significantly lower in pediatric cohorts.
Despite the profound impact of GN on young patients, the available literature on its management remains low. This scarcity underscores the urgent need for comprehensive guidance on the management of pediatric headache disorders, particularly those as intricate as GN.
Current approaches to treating GN hinge on pharmacological and interventionist strategies. However, a significant gap persists in understanding effective pain management techniques tailored specifically to the pediatric population. Addressing this gap is paramount in providing optimal care and improving outcomes for pediatric patients
Methods
We present a successful case of glossopharyngeal neuralgia treated with pulsed radiofrequency (PRF) using hybrid imaging guide.
A nine-year-old pediatric patient presented with a long-standing pain in peritonsillar area and deep ear, compatible with GN.
Upon evaluation of the patient, no abnormalities were found. Considering the type, map and characteristics of the pain, a hybrid diagnostic block was performed guided by ultrasound/fluoroscopy
Under general anesthesia we placed the patient in the left lateral decubitus. A linear high frequency transducer was placed in a transverse oblique orientation between the angle of the mandible and the mastoid with the styloid process and carotid artery as landmarks, verifying with fluoroscopy and contrast injection the final target. In an in-plane approach, a 25G needle was advanced to the styloid and then redirected posteriorly. Negative blood aspiration was confirmed and a mixture of 3 ml of levobupivacaine 0.375% and 8 mg of dexamethasone
Results
Uvular paresis was documented as a sign of successful glossopharyngeal nerve block. As a result of the procedure, a positive block was obtained with an 80% improvement of the pain for 1 month
In the follow up the pain retrurned and it was decided to perform PRF of the glossopharyngeal nerve through an extraoral approach. The same hybrid technique was performed, with the technical difficulty of not being able to perform sensory stimulation during the procedure due to general anesthesia and subsequently lesions were performed at 42° C for 2 and 4 minutes at 65 and 85 volts respectively. There were not complications recorded during or after the procedure.
At the follow-up in-office appointment, the patient experienced a flare for one day, treated with lidocaine spray. Subsequently, there was an improvement of more than 80% of the pain. The patient remained pain-free for more than 9 months until we were lost to follow up.
Conclusions
Craniofacial pain in the pediatric population provides greater complexity than the challenges already known in adult patients. PRF may represent an interesting therapeutic alternative and minimally invasive option in pediatric population. In our case, the use of hybrid technique during the performance of interventional procedures on the glossopharyngeal nerve under general anesthesia generated greater safety and therefore a better result. More case series are required to evaluate the role of PRF in the pediatric population with glossopharyngeal neuralgia, and the efficacy and safety associated with the use of ultrasound- and fluoroscopy-guided techniques
References
1.(Katusic S, Williams DB, Beard CM, et al. Incidence and clinical features of glossopharyngeal neuralgia, Rochester, Minnesota, 1945-1984. Neuroepidemiology. 1991;10(5-6):266-75.
2. Shereen R, Gardner B, Altafulla J, Simonds E, Iwanaga J, Litvack Z, Loukas M, Shane Tubbs R. Pediatric glossopharyngeal neuralgia: a comprehensive review. Childs Nerv Syst. 2019 Mar;35(3):395-402. doi: 10.1007/s00381-018-3995-3. Epub 2018 Oct 25. PMID: 30361762.
3. Goel V, Narouze S. Glossopharyngeal Neuralgia: An Approach to Diagnosis and Management. Ann Head Med. 2020;02:07. DOI: 10.30756/ahmj.2020.02.07
Presenting Author
Carlos Restrepo
Poster Authors
Topics
- Pain in Special Populations: Infants/Children