13.2.2 Painful glossopharyngeal neuropathy

Identification: Female patient, 65 years old, with a history of tonsillectomy 20 years ago, presents with chronic oropharyngeal pain for 18 months.

History of Present Illness: Symptoms: Location: Right base of the tongue, tonsillar region, and ipsilateral ear

Characteristics: Continuous pain: Burning (6-8/10 VAS)

Exacerbations: Stabbing (9/10) triggered by swallowing

Neuropathic phenomena: Dysphagia for solids, ageusia in the posterior third of the tongue, allodynia on palpation of the pharyngeal pillars

Relevant History: Cervical radiotherapy for Hodgkin's lymphoma 15 years ago, no episodes of bradycardia/syncope

Physical/Neurological Examination: Oropharyngeal Assessment: Asymmetry of pharyngeal pillars (post-radiation fibrosis), ipsilateral gag reflex abolished

Sensory: Hypoesthesia in the posterior third of the tongue, hyperpathia to touch in the external acoustic meatus

General Examination: Severe xerostomia, telangiectasias on buccal mucosa

Complementary Exams: 3T MRI (FIESTA): Parapharyngeal space fibrosis, absence of vascular compression

Dynamic Laryngoscopy: Partial paralysis of the right vocal fold

Diagnostic Test: Glossopharyngeal nerve block (lidocaine 2%) → temporary pain relief