Relation between volume of sphenoid sinuses and protrusion of Vidian nerve: possible applications to Vidian neurectomy.

PURPOSE: Vidian neurectomy is a surgical procedure applied to different pathological conditions, including chronic rhinitis and sphenopalatine neuralgia. The choice of the correct surgical approach depends upon the possible protrusion of Vidian nerve into the sphenoid sinuses. The present study analyzes the possible relationship between protrusion of Vidian nerve and volume of sphenoid sinuses. METHODS: In total, 320 maxillofacial CT-scans were retrospectively assessed. Subjects equally divided among males and females (age range 18-94 years) were divided into three groups according to the profile of Vidian nerve protrusion: type 1: Vidian nerve inside the sphenoid corpus; type 2: partially protruding into the sphenoid sinus; and type 3: entirely protruding into the sphenoid sinus through a stalk. Volume of sphenoid sinuses was extracted through the ITK-SNAP-free software and automatically calculated. Possible statistically significant differences in prevalence of the three types between males and females were assessed through Chi-squared test (p < 0.05). Differences in volume of sphenoid sinuses in subjects included within the three types were assessed through one-way ANOVA test (p < 0.05), separately for males and females. RESULTS: Type 2 was the most prevalent (46.5%), followed by type 1 (38.8%) and type 3 (14.7%), without significant differences according to sex (p > 0.05). Volume significantly increased passing from type 1 to type 3 both in males (p < 0.01) and in females (p < 0.01). CONCLUSIONS: The results prove the existence of a strict relationship between sphenoid sinuses pneumatization and protrusion of the Vidian canal and give a contribution to the knowledge of this important anatomical variant in endoscopic surgery.

Síndrome de Eagle: relato de caso / Eagle Syndrome: a case report

A síndrome de Eagle é uma condição rara e com etiologia ainda não bem estabelecida, a qual se deve ter bastante suspeição para seu correto tratamento. Seu tratamento deve ser definido em conjunto com o paciente, seja ele conservador ou cirúrgico, sempre levando em consideração as expectativas do paciente, além da maior expertise do profissional na modalidade escolhida para o tratamento. Neste artigo, apresentamos uma paciente de 35 anos atendida no Hospital Felício Rocho, discutindo os diversos aspectos da doença, inclusive a modalidade de tratamento escolhida para o caso.

Eagle syndrome is a rare condition, and its etiology has not yet been well established and its correct treatment is uncertain. Its treatment must be defined together with the patient, be it conservative or surgical, always taking into consideration the patient's expectations, in addition to a solid professional expertise in the modality chosen for the treatment. In this article, we present the case of a 35-year-old patient who was admitted to the Felício Rocho Hospital and discuss the various aspects of the disease, including the treatment modality chosen for the case.

Trigeminal Neuralgia and Other Facial Neuralgias.

Radiosurgery is an effective treatment approach for the management of type 1 trigeminal neuralgia (TN), comparable to other ablative techniques. Also, radiosurgery can effectively treat TN secondary to other causes, including multiple sclerosis, tumor-related TN, as well as other craniofacial neuralgias in select cases with minimal complications. An increasing number of patients favor radiosurgery over other more invasive approaches in order to avoid a general anesthetic, a prolonged hospital stay, and a higher risk of complications.

The neurosurgical treatment of craniofacial pain syndromes: current surgical indications and techniques.

Craniofacial pain syndromes are comprised of multiple pathological entities resulting in pain referred to the scalp, face, or deeper cranial structures. In a small subset of patients affected by those syndromes, pharmacological and physical therapies fail in alleviating pain. In some of those refractory patients surgical procedures aimed at relieving pain are indicated and have been adopted with variable results and safety profiles. In this review, the authors describe craniofacial pain syndromes that most commonly fail to respond to pharmacological therapies and may be amenable to tailored surgical procedures. In particular, trigeminal, glossopharyngeal, and occipital neuralgias are considered, as well as some primary headache syndromes such as cluster headache, short unilateral neuralgiform headache with conjunctival injection and tearing/short unilateral neuralgiform headache with autonomic symptoms, and migraine. Surgical techniques, including the implantation of deep brain or peripheral nerve electrodes with subsequent chronic stimulation, microvascular decompression of neurovascular conflicts, and percutaneous lesioning of neural structures are described. Finally, surgical indications, outcomes, and safety of these procedures are presented.

Infratrochlear neuralgia: A prospective series of seven patients treated with infratrochlear nerve blocks.

Background Infratrochlear neuralgia is a recently described painful cranial neuropathy that causes pain in the internal angle of the orbit and the medial upper eyelid, the upper bridge of the nose and/or the lacrimal caruncle. We aim to present seven new cases of infratrochlear neuralgia treated with anaesthetic nerve blocks. Methods Over an 18-month period, we prospectively identified seven cases of infratrochlear neuralgia among the patients attending the Headache Unit in a tertiary hospital. Anaesthetic blocks were performed by injecting 0.5 cc of bupivacaine 0.5% at the emergence of the nerve above the internal canthus. Results All patients were women, and the mean age was 49.1 years (standard deviation, 17.9). The pain appeared at the internal angle of the orbit and/or the medial upper eyelid in six cases, and the whole territory of the infratrochlear nerve in one case. Six patients had continuous pain and one had episodes lasting 8-24 hours. All patients showed sensory disturbances within the painful area and tenderness upon palpation of the infratrochlear nerve. Nerve blocks resulted in complete and long-lasting relief in four patients and short-lasting relief in the other three patients. Conclusions Infratrochlear neuralgia should be considered among the neuralgic causes of orbital and periorbital pain. Anaesthetic blocks may assist clinicians in the diagnosis and may also be an effective therapy.

Fluoroscopic C-Arm and CT-Guided Selective Radiofrequency Ablation for Trigeminal and Glossopharyngeal Facial Pain Syndromes.

Objectives: Percutaneous radiofrequency ablation (RFA) of the gasserian ganglion through the foramen ovale and the glossopharyngeal nerve at the jugular foramen is a classical approach to treating trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GPN), respectively. However, it can be technically challenging with serious complications. We have thus developed a novel technique utilizing C-arm and computerized tomography (CT) guidance to block TN and GPN. Our goals were to describe a three-dimensional image-based technique to improve patient comfort and to decrease procedural time associated with needle guidance. Study design: Consecutive procedures were reviewed. Setting: Academic hospital. Methods: Three patients with classical TN and GPN and 15 patients with atypical facial pain (AFP) were treated. Numeric rating scale (NRS) scores for pain at pretreatment and at one, three, and 12 months post-treatment were recorded. The primary clinical outcome (50% or more reduction in NRS) and secondary adverse clinical outcome (hematoma, facial numbness, etc.) were monitored. Results: We had a 100% technical success with respect to appropriate needle positioning. All three classical TN/GPN patients had both immediate and sustained pain relief. Complications were minimal. The 15 AFP patients, however, showed more variable results, with only five (33%) having sustained pain relief, while in the other 10 (67%) patients, we observed suboptimal response. Conclusions: We present a novel method and single-center experience with C-arm and CT-guided RFA of facial pain. Quick and accurate needle placement will help future advancements in the RFA algorithm so that more durable and consistent effects can be attained, reducing uncertainty with respect to needle placement as a confounder. The RFA procedure in our study had a satisfying effect for classical TN/GPN patients but was less successful for AFP patients, though it did mirror the results from previous studies. Limitations: This study is limited by its small sample size and nonrandomized design.

Eagle Syndrome: An Unusual Cause Limited Mouth Opening and Surgical Management.

Eagle syndrome, defined "stylalgia," occurs when an elongated styloid process or calcified stylohyoid ligament causes dysphagia, facial pain recurrent throat pain or foreign body sensation, also associated symptoms such as neck or throat pain with radiation to the ear. The symptoms related to this condition can be confused or misdiagnosed to a wide variety of facial neuralgias. The incidence of Eagle syndrome varies among population. Usually asymptomatic, it occurs in adult patients, and can be diagnosed by physical examination and radiologically. A 30-year-old male patient presented to the maxillofacial unit of Sulaimaniyah Teaching Hospital with a complaint of pain in the right side of face interfering with mouth opening and causing deviation to the right side of mouth for 6 months duration. The elongated styloid process of the right side was resected surgically by the intra-oral approach. The patient was asymptomatic and comfortably followed up for 5 months.

Intermediate nerve neuralgia can be diagnosed and cured by microvascular decompression.

Here, we present a case of a 55-year-old woman with a 10-year history of hemifacial spasm accompanied by 1-month ipsilateral paroxysmal otalgia. Magnetic resonance imaging revealed the presence of vessels around the facial nerve root. Surgical exploration via suboccipital retromastoid craniotomy showed converging compression of the facial nerve root and intermediate nerve from both sides by an anterior inferior cerebellar artery loop. The patient's hemifacial spasm and ipsilateral otalgia were completely relieved after microvascular decompression of the facial nerve root and intermediate nerve. Intraoperative findings and the postoperative result of this case confirmed that vascular compression of the intermediate nerve was the exclusive cause of paroxysmal otalgia. The presence of ipsilateral hemifacial spasm, combined with preoperative neuroimaging studies, contributed to the diagnosis of intermediate nerve neuralgia. Microvascular decompression should be considered for the management of patients with intermediate nerve neuralgia.

The neurosurgical treatment of neuropathic facial pain.

This article reviews the definition, etiology and evaluation, and medical and neurosurgical treatment of neuropathic facial pain. A neuropathic origin for facial pain should be considered when evaluating a patient for rhinologic surgery because of complaints of facial pain. Neuropathic facial pain is caused by vascular compression of the trigeminal nerve in the prepontine cistern and is characterized by an intermittent prickling or stabbing component or a constant burning, searing pain. Medical treatment consists of anticonvulsant medication. Neurosurgical treatment may require microvascular decompression of the trigeminal nerve.

The central myelin-peripheral myelin transitional zone of the nervus intermedius and its implications for microsurgery in the cerebellopontine angle.

The central myelin-peripheral myelin transitional zone, also referred to as the "Obersteiner-Redlich zone (ORZ)" or "glial/Schwann junction" of the nervus intermedius, is thought to play a role in the pathophysiology of nervus intermedius neuralgia (NIN). To evaluate the location and histological features of the ORZ of the nervus intermedius (NI), 10 NI specimens from five fresh cadavers were microscopically analyzed for structural differences between their central and peripheral myelin segments. The ORZ was analyzed under a light microscope, and the exact location of the ORZ was confirmed by immunohistochemical staining using an oligodendroglial antibody. The total diameter of the NI showed a mean of 0.62 mm. The cisternal segment of the NI from the brain stem to the porus acusticus internus had a mean length of 13.97 mm. The mean extent of central myelin was 0.5 mm from the brain stem on the medial side and 0.33 mm on the lateral side. Moreover, the mean length of the ORZ was 0.279 mm on the medial side and 0.134 mm on the lateral side. The distance between the brain stem and the most distal point of central myelin that could be detected was 0.67 mm. Accordingly, the ORZ of the NI appears closer to the brain stem compared to the other cranial nerves. The exact location of the ORZ may play a role in diagnostic preoperative imaging, in the planning of surgical procedures for NIN, and may offer suitable landmarks for surgeons performing microvascular decompression in NIN treatment.

Merged imaging and expanded target selection in gamma knife radiosurgical ablation of the sphenopalatine ganglion.

Sphenopalatine neuralgia, or Sluder's neuralgia, refers to a consistent clustering of clinical symptoms: intermittent episodes of vasomotor hyperactivity causing conjuctival injection, lacrimation, serous nasal discharge and unilateral nasal mucosal inflammation, sensory disturbances of the palate and oropharynx with distorted gustatory sensations, and lancing, unilateral pain most often located in the area of the inferomedial orbit and nasal base or at the region of the mastoid process. This particular clinical entity has also proven difficult to manage effectively, especially when not clearly secondary to other medical conditions such as paranasal sinus infection or bony nasal deformities. This condition has been treated with success using Gamma Knife radiosurgery in at least 1 other case reported in the literature. We present a second patient whose sphenopalatine neuralgia was treated successfully with stereotactic radiosurgery and discuss the possibilities of this modality as an option for patients with a refractory condition.

Pain relief after cervical ganglionectomy (C2 and C3) for the treatment of medically intractable occipital neuralgia.

Occipital neuralgia (ON) presents a diagnostic challenge because of the wide variety of symptoms, surgical findings, and postsurgical outcomes. Surgical removal of the second (C2) or third (C3) cervical sensory dorsal root ganglion is an option to treat ON. The goal of this study was to evaluate the short-term and the long-term efficacy of these procedures for management of cervical and occipital neuropathic pain. Twenty patients (mean age 48.7 years) were identified who had undergone C2 and/or C3 ganglionectomies for intractable occipital pain and a retrospective chart review undertaken. Patients were interviewed regarding pain relief, pain relief duration, functional status, medication usage and procedure satisfaction, preoperatively, immediately postoperative, and at follow-up (mean 42.5 months). C2, C3 and consecutive ganglionectomies at both levels were performed on 4, 5, and 11 patients, respectively. All patients reported preoperative pain relief following cervical nerve blocks. Average visual analog scale scores were 9.4 preoperatively and 2.6 immediately after procedure. Ninety-five percent of patients reported short-term pain relief (<3 months). In 13 patients (65%), pain returned after an average of 12 months (C2 ganglionectomy) and 8.4 months (C3 ganglionectomy). Long-term results were excellent, moderate and poor in 20, 40 and 40% of patients, respectively. Cervical ganglionectomy offers relief to a majority of patients, immediately after procedure, but the effect is short lived. Nerve blocks are helpful in predicting short-term success, but a positive block result does not necessarily predict long-term benefit and therefore cannot justify surgery by itself. However, since 60% of patients report excellent-moderate results, cervical ganglionectomy continues to have a role in the treatment of intractable ON.

Nerve resection and re-location may relieve causalgia: a case report.

This article reports the relief of severe causalgia of the right infra-orbital nerve by nerve section and re-location in a 14-year-old boy who had worsening neuropathic pain (NP) and was housebound and refractory to all analgesics for 14 months. His infra-orbital nerve was sectioned and re-located into his buccal fat pad. Severe steady burning, electric shock-like pain and allodynia disappeared and he was able to return to school and an increasingly normal life at one year post-operatively and is pain-free at 3 years and 6 months of follow-up. With NP further deafferentation can cause a worsening of the pain or anaesthesia dolorosa. In this instance there was dramatic and then sequential, gradual and complete resolution of all components of this particular form of NP. Therefore, in selected patients with causalgia this nerve re-location technique may help in symptom resolution and improve quality of life.

Peripheral nerve stimulation for the treatment of neuropathic craniofacial pain.

Treatment of neuropathic pain in the region of head and face presents a challenging problem for pain specialists. In particular, those patients who do not respond to conventional treatment modalities usually continue to suffer from pain due to lack of reliable medical and surgical approaches. Peripheral nerve stimulation (PNS) has been used for treatment of neuropathic pain for many decades, but only recently it has been systematically applied to the craniofacial region. Here we summarize published experience with PNS in treatment of craniofacial pain and discuss some technical details of the craniofacial PNS procedure.

Update on neurosurgical treatment of chronic trigeminal autonomic cephalalgias and atypical facial pain with deep brain stimulation of posterior hypothalamus: results and comments.

The objective of this study is to describe the therapeutic effect and the technical and surgical problems of deep brain stimulation (DBS) of the posterior hypothalamus over seven years, for treatment of chronic trigeminal autonomic cephalalgias and atypical facial pain. We report a surgical series of 20 patients that underwent DBS of the posterior hypothalamus. This series includes 16 patients with chronic cluster headache (CH), one patient with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and three patients with atypical facial pain. All patients of this series were resistant to any pharmacological and conservative treatment. The stimulated target was the same in the whole series even though stereotactic coordinates of the target referred to the midcommissural point differ slight in the Y anteroposterior value due to individual anatomical variability. The commissures based reference system was adapted to individual anatomical landmarks of the brainstem adding to the registration a third reference point below the commissural plane. The stimulation parameters of unipolar stimulation were similar in the whole series: 180 Hz, 60 mus, 1-3 V. In the CH series, at five years follow-up the percentage of total number of days free from pain attacks improved from 1%-2% to 71%. Ten patients of this series had a complete and persistent pain-free state at 18 months follow-up and the patient with SUNCT has complete pain relief. In the three patients with atypical facial pain, the neurostimulation procedure was absolutely unsuccessful. DBS of the posterior hypothalamus produced a significant and marked reduction of pain bouts in CH patients and in the SUNCT patient. The attempts to treat atypical facial pain in three patients failed.

[Trigeminalgia caused by neurovascular compression in 12 years old girl]. / Trigeminalgia z konfliktu naczyniowo- nerwowego u 12-letniej dziewczynki.

Trigeminalgia is one of the most frequent clinical problems, common in adults but also found in children. In this paper we described a case of 12 years old girl with symptomatic trigeminalgia caused by neurovascular compression, hospitalized in the Department of Pediatric Neurology Jagiellonian University in Kraków. It creates a very difficult diagnostic problem. The girl was first unsuccessfully treated with carbamazepine and afterwards the surgery of neurovascular decompression was performed. We emphasis the crucial role of MR and MRA in cases refractory to classic pharmacotherapy.

[Neurovascular conflicts]. / Konflikty naczyniowo-nerwowe.

Neuro-vascular conflict is a pathophysiologic phenomenon which is implicated in several cranial neuropathies. The most common are trigeminal neuralgia and hemifacial spasm. Spasmodic torticolis, glosopharyngeal neuralgia, disabling positional vertigo may be due to neural compression as well, but other pathologies such as neurogenic hypertension and limited cases of tinnitus, although rare, highly susceptible to the neurovascular conflict, should be taken into considerration. Current diagnostic approach comprises clinical and radiological evaluation. Along with thorough otoneurological examination, MRI scans are essential to diagnose the conflict. This provides information about the presence of neuro-vascular conflict and involved structures. The microvascular decompression (MVD) is a treatment of choice, based on the separation of offending vessel from the nerve. Those procedures are safe, with high rate success according to the literature ranging from 70-90%. Additionaly, in early 90. a new minimally invasive approach with use of rigid endoscopes were proposed. Those gave the possibility to reduce morbidity and improve results by providing wider insight into the operating field with smaller intraoperative injury. Authors present 9 patients diagnosed with neuro-vascular conflict in the ENT department in Poznan. Clinical findings comprised 5 cases of hemifacial spasm, 3 with unilateral tinnitus and 1 with trigeminal neuralgia. Due to variety of symptoms, it is proposed that specialized centers should be formed to diagnose and treat cranial nerves neuropathies. Team approach composed of neurologist, neurosurgeon, radiologist and otologist is essential in terms of good treatment results. Authors describe symptomatology, diagnosis and treatment options of neuro-vascular conflicts.

[Case of painful tic convulsif: discussion of the underlying mechanisms and review of the literature].

The combination of trigeminal neuralgia and ipsilateral hemifacial spasm, known as painful tic convulsif (PTC), is a relatively rare entity in neurovascular compression syndrome. A case of PTC attributable to different offending arteries is described, the mechanisms and characteristics of PTC are discussed, and a review of the literature is presented. This 80-year-old woman had a 10-year history of left trigeminal neuralgia and ipsilateral hemifacial spasm. She presented with intermittent left facial twitching and pain, especially upon swallowing. MRI revealed compression of the left trigeminal nerve by the left anterior inferior cerebellar artery and of the ipsilateral facial nerve by the posterior inferior cerebellar artery. Microvascular decompression of the lesions via left lateral suboccipital craniotomy resulted in immediate and complete symptom improvement. Our case demonstrates that different arteries can affect the trigeminal and facial nerve at a stage that precedes compression by a tortuous vertebrobasilar artery. We suggest that the presence of PTC should be considered in patients with a tortuous vertebrobasilar artery, irrespective of the offending arteries.

[Partial middle turbinatectomy and folded for nasonsociliary neuralgia by transnasal endoscopic surgery].

OBJECTIVE: To explore into the feasibility and outcome of partial middle turbinetectomy and folded for nasociliary neuralgia by transnasal endoscopic surgery. METHOD: Forty patients with nasociliary neuralgia were treated by partial middle turbinatectomy and folded. RESULT: All patients have got sufficient of factory sulcus without hyposmia. The curable rate and the improve rate were 97.5% and 2.5%, respectively, with the total effective rate 100%. CONCLUSION: This procedure present an ideal effect. It is a safe, minimally invasive and efficient procedure for nasociliary neuralgia.

Orofacial pain

Orofacial pain is one of the most common reasons why many persons seek dental consultation. Because of the complex nature of the problem, patients with orofacial pain present a real diagnostic and theraputic challenge to the practitioner. Orofacial pain results from noxious stimulation of free nerve endings in orofacial tissues. The peripheral nerve endings act as nociceptors (pain receptors) detect and convey the noxious information to the brain, where pain is perceived. Although in a majority of patients the orofacial pain is of odontogenic origin (such as the sequel of dental caries or trauma to the tooth), non-odontogenic source of pain is also frequent in clinical practice (AU)