13.2.1 Glossopharyngeal neuralgia

Identification: Male patient, 62 years old, with episodes of oropharyngeal pain for 8 months.

History of Present Illness:
Pain:

Location: Left base of the tongue, tonsillar region, and ipsilateral ear (referred pain)

Characteristic:

Stabbing paroxysms (1-30 seconds)

Excruciating intensity (10/10)

Frequency: 5-20 episodes/day

Specific triggers:

Swallowing (especially cold liquids)

Coughing or yawning

Palpation of the tonsillar region (trigger area)

Associated symptoms:

Bradycardia and syncope in 20% of episodes (vagal reflex)

Hypersalivation during paroxysms

Interictal periods:

Completely asymptomatic

Normal neurological examination

Physical/Neurological Examination:
Oropharyngeal assessment:

Hyperesthesia in the left tonsillar pillars

Exaggerated ipsilateral gag reflex

Provocative tests:

Touching the tonsil with a tongue depressor → reproduction of the painful crisis

Cardiological assessment:

Sinus pauses documented during episodes (24-hour Holter)

Complementary Exams:
3T MRI (FIESTA):

Posteroinferior cerebellar artery compressing the glossopharyngeal nerve

Absence of expansive lesions

Neck CT Angiography:

Anomalous course of the vertebral artery

Electrophysiology:

Glossopharyngeal nerve anesthetic block (lidocaine 2%) → immediate relief