Damage to the hypoglossal nerve (neuropathy of the hypoglossal nerve, neuropathy of the hypoglossal nerve). Neuralgia of the glossopharyngeal nerve: causes, symptoms of inflammation and treatment

Glossopharyngeal nerve - paired (IX pair), mixed cranial nerve. Sensitive fibers of the glossopharyngeal nerve innervate the mucous membrane of the posterior third of the tongue, including the taste trough papillae, the mucous membrane of the pharynx, tympanic cavity, Eustachian (auditory) tube, mastoid cells, palatine tonsils and palatine arches, carotid sinus and carotid glomus; motor fibers - the stylo-pharyngeal muscle and through the pharyngeal plexus, together with the vagus nerve, the constrictors of the pharynx and muscles of the soft palate; vegetative parasympathetic secretory fibers - the parotid gland.

The glossopharyngeal nerve has three nuclei located in the medulla oblongata (see). Sensitive nucleus - the nucleus of a single path (nucl. tractus solitarii), common with the vagus and facial nerves, is located in the medulla oblongata. Axons of afferent neurons of the upper and lower nodes of the nerve (gangl. superius et inferius) approach the cells of this nucleus; their peripheral processes have receptors in the mucous membrane of the pharynx, palatine tonsils, palatine arches, in the mucous membrane of the posterior third of the tongue, tympanic cavity, Eustachian tube, mastoid cells, in the carotid (carotid, T.) sinus and carotid (carotid, T.) glomus. The upper node of the glossopharyngeal nerve is located in the region of the jugular foramen (foramen jugulare), the lower node is in the stony dimple (fossula petrosa) on the lower surface of the pyramid of the temporal bone.

The motor nucleus is a double nucleus (nucl. ambiguus), also common with the vagus nerve, located in the region of the reticular formation (see) the medulla oblongata. The neurons of the motor nucleus innervate the stylopharyngeal muscle (m. stylopharyngeus) and the constrictors of the pharynx.

The vegetative nucleus - the lower salivary nucleus (nucl. salivatorius inferior) consists of cells scattered in the reticular formation. Its secretory, parasympathetic fibers go to the ear node, and after switching in it - to the parotid gland (see).

The root of the glossopharyngeal nerve is formed as a result of the fusion of all three types of fibers and appears at the base of the brain in the region of the posterior lateral sulcus of the medulla oblongata behind the olive and exits the cranial cavity through the jugular foramen along with the vagus nerve (see) and accessory nerve (see). On the neck, the nerve goes down between the internal jugular vein and the internal carotid artery, goes around the stylo-pharyngeal muscle behind, turns anteriorly, forming a gentle arc, and approaches the root of the tongue, where it divides into terminal lingual branches (rr. linguales), containing sensory fibers going to mucous membrane of the posterior third of the tongue, including taste, innervating trough papillae (Fig. 1).

The lateral branches of the glossopharyngeal nerve are: the tympanic nerve (n. tympanicus), which includes sensory and parasympathetic fibers. It originates from the cells of the lower node (Fig. 2) and penetrates into the tympanic cavity through the tympanic tubule (canaliculus tympanicus), forming on its medial wall, together with the carotid-tympanic nerves (nn. caroticotympanici) of the internal carotid plexus, the tympanic plexus (plexus tympanicus) . Sensitive branches depart from this plexus to the mucous membrane of the tympanic cavity, the Eustachian tube and the cells of the mastoid process, and the preganglionic parasympathetic fibers form a small stony nerve (n. petrosus minor), which leaves the tympanic cavity through the cleft of the canal of this nerve and through the stony-squamous gap (fissura petro-squamosa) reaches the ear node (gangl. oticum). After switching in the node, the parasympathetic post-ganglionic fibers approach the parotid gland as part of the ear-temporal nerve (n. auriculotem-poralis), which is a branch of the mandibular nerve (n. mandibular is, the third branch of the trigeminal nerve). In addition to the tympanic nerve, the lateral branches of the glossopharyngeal nerve are the branch of the stylo-pharyngeal muscle (ramus m. Stylopharyngei), which innervates the muscle of the same name; tonsil branches (rr. tonsillares), going to the mucous membrane of the palatine tonsils and palatine arches; pharyngeal branches (rr. pharyngei), going to the pharyngeal plexus; sinus branch (r. sinus carotici) - sensory nerve of the carotid sinus reflex zone; connecting branches (rr. communicantes) with the ear and meningeal branches of the vagus nerve and with the tympanic string of the intermediate nerve, which is part of the facial nerve (see).

Pathology includes sensory, autonomic and motor disorders. With neuritis (neuropathy) of the glossopharyngeal nerve, prolapse symptoms develop: anesthesia of the mucous membrane of the upper half of the pharynx, unilateral taste disorder (ageusia) in the posterior third of the tongue (see Taste), decrease or cessation of salivation by the parotid gland; on the side of the lesion, swallowing may be difficult (see Dysphagia). The reflex from the mucous membrane of the pharynx on the side of the lesion fades away. Dryness of the mouth is usually insignificant due to the compensatory activity of the remaining salivary glands, paresis of the muscles of the pharynx may be absent, since they are mainly innervated by the vagus nerve. With bilateral damage to the glossopharyngeal nerve, motor disorders can be one of the manifestations of bulbar palsy (see), which occurs with combined damage to the nuclei, roots or trunks of the glossopharyngeal, vagus and hypoglossal cranial nerves (IX, X, XII pairs). With bilateral damage to the cortical-nuclear pathways from the cerebral cortex to the nuclei of these nerves, there are manifestations of pseudobulbar paralysis (see). Isolated lesions of the nuclei of the glossopharyngeal nerve, as a rule, do not occur. Usually they arise along with damage to other nuclei of the medulla oblongata and its pathways and are included in the clinical picture of alternating syndromes (see).

With irritation of the glossopharyngeal nerve, a spasm of the pharyngeal muscles develops - pharyngospasm. It can occur in inflammatory or neoplastic diseases of the pharynx, esophagus, hysteria, neurasthenia, etc.

The symptoms of irritation of the glossopharyngeal nerve include glossopharyngeal neuralgia (see Sicard syndrome). There are two forms of neuralgia of the glossopharyngeal nerve: neuralgia of predominantly central (idiopathic) and predominantly peripheral origin. In the development of neuralgia of the glossopharyngeal nerve of predominantly central origin, metabolic disorders, atherosclerotic changes in the vessels of the brain, as well as chronic tonsillitis, tonsillitis, influenza, allergies, intoxications (for example, tetraethyl lead poisoning), etc. nerve at the level of its first neuron, for example, due to injury to the bed of the palatine tonsil by an elongated styloid process, ossification of the stylohyoid ligament, and also with tumors in the region of the cerebellopontine angle (see), aneurysm of the carotid artery, cancer of the larynx.

Neuralgia of the glossopharyngeal nerve is manifested by bouts of unilateral pain that occurs when swallowing (especially excessively hot or cold food), rapid speech, intense chewing or yawning. The pains are localized in the region of the root of the tongue or the palatine tonsil, spread to the palatine curtain, pharynx, ear, sometimes radiating to the angle of the lower jaw, eye, neck. The attack can last 1-3 minutes. Patients have a fear of recurrence of seizures when eating, develop speech disorders (non-articulated speech) as a manifestation of "sparing". Sometimes there is a dry paroxysmal cough. Before an attack of pain, there is often a feeling of numbness of the palate and a short-term increased salivation, sometimes a painful feeling of deafness. Attacks of pain may be accompanied by syncope with bradycardia, a drop in systemic blood pressure. The development of these conditions is due to the fact that the glossopharyngeal nerve innervates the carotid sinus and carotid glomus.

A special form of neuralgia of the glossopharyngeal nerve is neuralgia of the tympanic nerve (tympanic plexus syndrome, painful tick of the tympanic, or Jacobson, nerve, Reichert's syndrome), first described by Reichert (F. L. Reichert) in 1933. This form of glossopharyngeal neuralgia is manifested by attacks of shooting pains in the external auditory canal, sometimes accompanied by unilateral pain in the face and posterior to the ear. Harbingers of an attack may be discomfort in the area of ​​the external auditory canal, which occurs mainly when talking on the phone (the “handset” phenomenon). There is pain on palpation of the external auditory canal.

The diagnosis of neuralgia of the glossopharyngeal nerve is established on the basis of characteristic complaints and data from a wedge, examination. Palpation reveals soreness of the angle of the lower jaw and individual sections of the external auditory canal, a decrease in the pharyngeal reflex, a weakening of the mobility of the soft palate, hypergeusia (increased taste sensations) to bitter in the posterior third of the tongue. With a long course of neuralgia, prolapse symptoms characteristic of neuritis of the glossopharyngeal nerve may occur. In this case, the pain becomes constant (especially in the root of the tongue, throat, upper pharynx and ear), periodically intensifying. On examination, hypesthesia and taste disturbance in the posterior third of the tongue, hypesthesia in the region of the palatine tonsil, palatine curtain and upper pharynx, decreased salivation on the affected side of the glossopharyngeal nerve are noted.

Glossopharyngeal neuralgia should be differentiated from trigeminal neuralgia (see), but the latter has a fairly clear clinical picture.

Treatment is usually conservative, but in some cases, resort to surgical intervention (see below). To stop a painful attack, the root of the tongue and throat are lubricated with a 5% solution of cocaine; prescribe injections of a 1-2% solution of novocaine into the root of the tongue, non-narcotic analgesics, synthetic derivatives of salicylic acid, pyrazolone, etc. For the treatment of the underlying disease, anti-inflammatory drugs, antipsychotics, and tonics are used. Diadynamic or sinusoidal modulated currents to the parotid-masticatory region, tonsils, and larynx are effective. In the absence of the effect of conservative treatment and in the case of an increase in the styloid process, they resort to surgical intervention.

Surgical treatment is carried out mainly with neuralgia of the glossopharyngeal nerve, predominantly of central origin, or in cases of involvement in the process of the nerve trunk with inoperable tumors of the pharynx, tonsils, tumors of the base of the skull. Perform three types of operations: extracranial intersection of the glossopharyngeal nerve, intracranial transection of the branches of the glossopharyngeal nerve and bulbar tractotomy (see). Transection of the glossopharyngeal nerve in the neck is rarely performed due to the risk of damage to the adjacent cranial nerves and blood vessels and the inability to access the nerve with locally advanced tumors of the nasopharynx, tumors of the skull base. Intracranial transection of the branches of the glossopharyngeal nerve is carried out at the place of their exit from the medulla oblongata or in the region of the internal jugular foramen. Tractotomy is performed at the level of the medulla oblongata, at the site of passage of the spinal tract of the trigeminal nerve (see), which includes fibers and the glossopharyngeal nerve. Unlike tractotomy in trigeminal neuralgia, the site of the dissection of the descending tract is medial to the projection of the trigeminal nerve root and lateral to the Burdach's bundle. The localization of the proposed incision of the conductors is specified by the patient's reaction to mechanical irritation of the sensitive conductor. After extracranial or intracranial intersection of the glossopharyngeal nerve, sensory disturbances occur in the zone of its innervation. After tractotomy in patients with advanced tumors and in cases of neuralgia of the glossopharyngeal nerve of predominant central origin, pain usually disappears. At the same time, tachycardia disappears, the area of ​​​​sensitivity disturbances outside the zone of innervation of the glossopharyngeal nerve is reduced. Complications during surgical interventions are rare, possible paralysis of the soft palate, the muscles of the pharynx. According to some researchers, tractotomy is a more physiological method of treatment than the intersection of the fibers of the glossopharyngeal nerve.

The prognosis for neuralgia of the glossopharyngeal nerve is generally favorable. However, both with neuralgia and especially with neuritis, long-term stubborn adequate treatment is required.

Bibliography: Gabibov G. A. and Labutin V. V. To the question of surgical treatment of neuralgia of the glossopharyngeal nerve, Vopr * neurosurgery., century. 3, p. 15, 1971; Guba G.P. Handbook of neurological semiology, p. 36, 287, Kyiv, 1983; Kr o-lM. B. iFedorovaE. A. Major neuropathological syndromes, p. 135, Moscow, 1966; Kunz 3. Treatment of essential neuralgia of the glossopharyngeal nerve with bulbospinal tractotomy, Vopr. neurosurgery, c. 6, p. 7, 1959; Pulatov A. M. and N and to and for r about in A. S. Reference book on the semiotics of nervous diseases, Tashkent, 1983; Sinelnikov R. D. Atlas of human anatomy, t. 3, p. 154, M", 1981; Triumfov A. V. Topical diagnosis of diseases of the nervous system, L., 1974; Clara M. Das Nervensystem des Menschen, Lpz., 1959; The cranial nerves, ed. by M. Samii a. P. J. Jannetta, B.-N. Y., 1981; Handbook of clinical neurology, ed. by P. J. Vinken a. G. W< Bruyn, v. 2, Amsterdam - N. Y., 1975; White I. C. a. S w e e t W. H. Pain. Its mechanisms and neurosurgical control, Springfield, 1955.

V. B. Grechko; V. S. Mikhailovsky (hir.), F. V. Sudzilovsky (an.).

Unilateral lesion of the IX cranial nerve, manifested by paroxysms of pain in the root of the tongue, tonsils, pharynx, soft palate and ear. It is accompanied by a violation of the taste perception of the posterior 1/3 of the tongue on the side of the lesion, a violation of salivation, a decrease in the pharyngeal and palatine reflexes. Diagnosis of pathology includes an examination by a neurologist, an otolaryngologist and a dentist, an MRI or CT scan of the brain. Treatment is mostly conservative, consisting of analgesics, anticonvulsants, sedatives and hypnotics, vitamins and restoratives, physiotherapy techniques.

General information

Neuralgia of the glossopharyngeal nerve is a rather rare disease. There are approximately 16 cases per 10 million people. People over the age of 40 usually suffer, men more often than women. The first description of the disease was given in 1920 by Sicard, in connection with which the pathology is also known as Sicard's syndrome.

Secondary neuralgia of the glossopharyngeal nerve can occur with infectious pathology of the posterior cranial fossa (encephalitis, arachnoiditis), traumatic brain injury, metabolic disorders (diabetes mellitus, hyperthyroidism) and compression (irritation) of the nerve at any site of its passage. The latter is possible with intracerebral tumors of the cerebellopontine angle (glioma, meningioma, medulloblastoma, hemangioblastoma), intracerebral hematomas, nasopharyngeal tumors, hypertrophy of the styloid process, aneurysm of the carotid artery, ossification of the stylohyoid ligament, proliferation of osteophytes of the jugular foramen. A number of clinicians say that in some cases, glossopharyngeal neuralgia may be the first symptom of cancer of the larynx or cancer of the pharynx.

Symptoms

Neuralgia of the glossopharyngeal nerve is clinically manifested by unilateral painful paroxysms, the duration of which varies from a few seconds to 1-3 minutes. Intense pain begins at the root of the tongue and quickly spreads to the soft palate, tonsils, pharynx and ear. Possible irradiation to the lower jaw, eye and neck. Painful paroxysm can be provoked by chewing, coughing, swallowing, yawning, eating excessively hot or cold food, and ordinary conversation. During an attack, patients usually feel dryness in the throat, and after it - increased salivation. However, dryness in the throat is not a constant symptom of the disease, since in many patients the secretory insufficiency of the parotid gland is successfully compensated by other salivary glands.

Swallowing disorders associated with paresis of the levator pharynx muscle are not clinically expressed, since the role of this muscle in the act of swallowing is insignificant. Along with this, there may be difficulties in swallowing and chewing food associated with a violation of various types of sensitivity, including proprioceptive - responsible for the sensation of the position of the tongue in the oral cavity.

Often, neuralgia of the glossopharyngeal nerve has an undulating course with exacerbations in the autumn and winter periods of the year.

Diagnostics

Glossopharyngeal neuralgia is diagnosed by a neurologist, although consultation with a dentist and an otolaryngologist, respectively, is required to rule out diseases of the oral cavity, ear, and throat. A neurological examination determines the absence of pain sensitivity (analgesia) in the region of the base of the tongue, soft palate, tonsils, and upper pharynx. A taste sensitivity study is conducted, during which a special flavor solution is applied to symmetrical areas of the tongue with a pipette. It is important to identify an isolated unilateral taste disorder of the posterior 1/3 of the tongue, since a bilateral taste disorder can be observed in pathology of the oral mucosa (for example, in chronic stomatitis).

The pharyngeal reflex is checked (the occurrence of swallowing, sometimes coughing or vomiting movements, in response to touching the back wall of the pharynx with a paper tube) and the palatine reflex (touching the soft palate is accompanied by a rise in the palate and its uvula). The unilateral absence of these reflexes speaks in favor of the defeat of n. glossopharyngeus, however, it can also be observed in the pathology of the vagus nerve. Identification during the examination of the pharynx and pharynx of rashes typical of a herpetic infection suggests ganglionitis of the nodes of the glossopharyngeal nerve, which has symptoms that are almost identical to neuritis of the glossopharyngeal nerve.

In order to establish the cause of secondary neuritis, they resort to neuroimaging diagnostics - CT or MRI of the brain. In the absence of such an opportunity,

In order to relieve pain paroxysm, lubrication of the pharynx and root of the tongue with 10% cocaine solution is used, which eliminates pain for 6-7 hours. With persistent pain syndrome, the introduction of 1-2% solution of novocaine into the root of the tongue is indicated. Along with this, non-narcotic analgesics (phenylbutazone, metamizole sodium, naproxen, ibuprofen, etc.) and anticonvulsants (phenytoin, carbamazepine) are prescribed for oral administration. With severe pain syndrome, it is additionally advisable to use hypnotics, sedatives, antidepressants and neuroleptic drugs.

Physiotherapeutic techniques have a good effect: diadynamic therapy or SMT on the area of ​​​​the tonsils and larynx, galvanization. Recommended vit. B1, multivitamin complexes, ATP, FiBS and other general strengthening drugs.

With the successful elimination of the causative disease, especially with the syndrome of compression of the glossopharyngeal nerve, the prognosis of recovery is favorable. However, for the complete relief of neuralgia, long-term therapy for several years is necessary.

Description:

Glossopharyngeal neuralgia has many similarities with trigeminal neuralgia and is characterized by paroxysmal pain on one side of the root of the tongue, pharynx and soft palate when taking hot, cold or hard food, talking, yawning or coughing.

Frequency. Rare (0.16 per 100,000 population). Men get sick more often than women. As a rule, people over 40 years of age get sick.

Classification. There are two forms: primary (idiopathic) and secondary (symptomatic).

Symptoms:

The disease proceeds in the form of painful paroxysms, starting in the region of the root of the tongue or tonsil and spreading to the palatine curtain, throat, ear. Pain sometimes radiates to the angle of the lower jaw, eyes, neck. Seizures last 1-3 minutes. Pain is always unilateral. During an attack, patients complain of dryness in the throat; appears after the attack. Sometimes there is pain on palpation of the angle of the mandible and individual sections of the external auditory canal (mainly during an attack), a decrease in the pharyngeal reflex, a weakening of the mobility of the soft palate, hypergesia to the bitter in the posterior third of the tongue (all taste irritations are perceived as bitter).

The disease proceeds with exacerbations and remissions. In the future, pain can be constant, aggravated by various factors (in particular, when swallowing).

A similar clinical picture, which is extremely difficult to distinguish from the symptom complex of the glossopharyngeal nerve, is ganglionitis of the upper and lower nodes of the IX cranial nerve. The diagnosis of ganglionitis is not in doubt if herpetic eruptions occur in the area of ​​​​the pharynx and pharynx.

Causes of occurrence:

In the development of the disease, they attach importance to atherosclerosis, infectious processes (chronic, tonsillitis,), intoxications, in particular tetraethyl lead poisoning. It has been established that the syndrome of glossopharyngeal nerve neuralgia occurs as a result of an injury to the tonsil bed by an excessively elongated styloid process, as well as in case of ossification of the stylohyoid ligament, with tumors of the cerebellopontine angle, aneurysm of the carotid artery, cancer of the larynx, etc.

Treatment:

For treatment appoint:

To eliminate the painful paroxysm, the root of the tongue and pharynx are lubricated with a 10% solution of cocaine, which relieves pain for 6-7 hours. ramifications of the carotid. Non-narcotic analgesics are prescribed. Diadynamic or sinusoidal modulated currents to the posterior mandibular region, tonsils, and larynx are effective. A course of galvanization is recommended (anode on the root of the tongue, and cathode on the posterior jaw area). Vitamin B1, chlorpromazine are prescribed intramuscularly, difenin, finlepsin are administered orally. Fortifying agents are recommended (vitamins, aloe extract, FiBS, ATP, phytin, ginseng, strychnine, etc.). With an increase in the styloid process, its resection is performed. In the absence of effect, they resort to radicotomy at the level of the posterior cranial fossa or to tractotomy or chordotomy.

IMPAIRMENT OF THE SYSTEM OF THE GLOSOPHARYNGEAL AND VAGA NERVES

The system of the glossopharyngeal and vagus nerves are two separate anatomical and functional complexes, the activity of which is closely related to each other. Each nerve system includes central and peripheral motor neurons for the pharyngeal muscles, receptors and pathways, subcortical and cortical structures, fibers and autonomic nodes involved in providing taste sensitivity to salivation, the activity of internal organs - all structures that ensure the activity of IX and X pairs cranial nerves.

Nerve lesions are rarely isolated, and in some cases it is not possible to determine which nerve is affected more. However, there are separate nosological forms and syndromes of predominant lesions of the glossopharyngeal and vagus nerve systems. Of the lesions of the glossopharyngeal nerve system, the most common in clinical practice is neuralgia of the glossopharyngeal nerve.

Neuralgia of the glossopharyngeal nerve

Glossopharyngeal neuralgia is often misdiagnosed as trigeminal neuralgia because the two conditions share many similarities.

In recent years, the opinion has been strengthened that there are two forms of the disease: primary (idiopathic) and secondary (symptomatic). It is known that people who get sick, as a rule, are older than 40 years. Probably, as in trigeminal neuralgia, two forms of glossopharyngeal neuralgia should be distinguished, predominantly of central and predominantly peripheral origin.

In the development of the disease, they attach importance to metabolic disorders and atherosclerotic changes, as well as infectious processes (chronic tonsillitis, tonsillitis, influenza), intoxications, in particular tetraethyl lead poisoning, etc. It has been established that the syndrome of glossopharyngeal nerve neuralgia occurs as a result of traumatization of the tonsil bed an excessively elongated styloid process, as well as with ossification of the stylohyoid ligament, with tumors of the cerebellopontine angle, carotid artery aneurysm, laryngeal cancer, etc.

Features of clinical manifestations. The disease proceeds in the form of painful paroxysms, starting in the region of the root of the tongue or tonsil and spreading to the palatine curtain, throat, ear. Pain sometimes radiates to the angle of the lower jaw, eyes, neck. Attacks are usually short-lived and last 1-3 minutes. They are provoked by movements of the tongue, especially when talking loudly, eating hot or cold food, irritation of the root of the tongue or tonsils (trigger zones). Pain is always unilateral. During an attack, patients complain of dryness in the throat, and after an attack, hypersalivation appears. The amount of saliva on the side of the pain is always reduced, even during the period of salivation (compared to the healthy side). The saliva on the side of pain is more viscous, its specific gravity increases and the content of mucus increases.

In some cases, during an attack, patients develop presyncopal or syncope. They are manifested by short-term lightheadedness, dizziness, loss of consciousness, and a drop in blood pressure. Probably, the development of these conditions is due to the fact that with neuralgia of the glossopharyngeal nerve, irritation of the p. depressor occurs, which is part of the IX pair of cranial nerves. As a result, oppression of the vasomotor center and a drop in blood pressure occur.

When examining patients with neuralgia of the glossopharyngeal nerve, usually significant deviations from the norm from the nervous system are not detected. Only some of them report pain on palpation of the angle of the mandible and certain areas of the external auditory canal (mainly during an attack), a decrease in the pharyngeal reflex, a weakening of the mobility of the soft palate, hypergesia to bitter in the posterior third of the tongue (all taste stimuli are perceived as bitter ).

The disease proceeds with exacerbations and remissions. After several attacks, remissions of various durations are noted, sometimes up to a year. However, as a rule, with the development of the disease, the attacks gradually become more frequent, the intensity of the pain syndrome increases. In the future, pain can be constant, aggravated by various factors, in particular when swallowing.

In some patients, in the clinical picture of the disease, symptoms of prolapse may be detected, corresponding to the zone of innervation of the glossopharyngeal nerve. In these cases, they speak of the neuritic stage of neuralgia of the glossopharyngeal nerve or its neuritis.

Neuritis is manifested by constant pains in the root of the tongue, pharynx, upper pharynx and even the ear, which periodically increase and last for several hours.

When examining patients, hypesthesia is revealed in the posterior third of the tongue, the tonsil area, the palatine curtain and the upper part of the pharynx, taste disturbance in the root of the tongue, and a decrease in salivation due to the parotid salivary gland.

A similar clinical picture, which is extremely difficult to distinguish from the symptom complex of neuralgia of the glossopharyngeal nerve, is ganglionitis of the superior and petrosal nodes of the IX cranial nerve. The diagnosis of ganglionitis is not in doubt if herpetic eruptions occur in the area of ​​​​the pharynx and pharynx.

differential diagnosis. Glossopharyngeal neuralgia must be differentiated from trigeminal neuralgia. The difference is as follows. With neuralgia of the glossopharyngeal nerve, pain is mainly localized in the region of the root of the tongue, tonsils, pharynx, and there is a painful point in the region of the angle of the lower jaw, while with trigeminal neuralgia, pain is noted in the zone of innervation of the branches of the trigeminal nerve. Trigeminal neuralgia trigger zones are located on the face, often around the lips, and with glossopharyngeal neuralgia they are located at the root of the tongue. The therapeutic effect in trigeminal neuralgia is achieved from the use of anticonvulsants, and in case of glossopharyngeal neuralgia, from lubricating the root of the tongue, pharynx and tonsils with local anesthetics.

The prognosis for neuralgia of the glossopharyngeal nerve is usually favorable. However, the disease requires long-term persistent treatment, for 2-3 years, and sometimes longer.

Emergency care for neuralgia and neuritis of the glossopharyngeal nerve.

To stop the painful paroxysm, the root of the tongue and throat is lubricated with a 10% solution of cocaine 3 times a day, which relieves pain for 6-7 hours. In persistent cases, novocaine is injected (2-5 ml of a 1-2% solution is injected into the root of the tongue).

Blockade with trichlorethyl or novocaine of the carotid branching area is suggested. Non-narcotic analgesics are prescribed. These activities lead to a decrease in the intensity of pain, the disappearance of the tense expectation of an attack.

Specialized help. Effective diadynamic or sinusoidal modulated currents on the zamandibular region, tonsils, larynx, for a course of 10-15 procedures. In cases where pain radiates to other areas, diadynamic currents are administered to areas of pain irradiation, in particular to the upper cervical sympathetic ganglion (modulated in short periods). Usually, diadynamic therapy is combined with medication: intramuscularly, 1000 μg of vitamin B12; 1 ml of 2.5% solution of chlorpromazine; inside 0.05 g difenin 2 times a day; finlepsin 0.2 g 2-3 times a day. A course of galvanization is recommended (8-9 procedures at a current strength of 3-5 mA; the anode is on the root of the tongue, and the cathode is on the back of the jaw).

It is also necessary etiological treatment of the underlying disease: anti-infective agents, analgesics, antipsychotics. It is believed that in case of nerve damage caused by intoxication, a 5% unithiol solution administered intramuscularly in 5-10 ml is more effective. Its action is based on the fact that the drug helps to eliminate toxic substances and products of interstitial metabolism from the body.

With an enlarged styloid process, an appropriate operation is performed.

In the absence of effect, they resort to radicotomy at the level of the posterior cranial fossa, to tractotomy, as well as mesencephalic cordotomy.

Neuralgia of the tympanic nerve (Reichert's syndrome). As you know, the tympanic nerve is a branch of the glossopharyngeal nerve, but its defeat gives a symptom complex similar in its clinical manifestations not to the neuralgia of the glossopharyngeal nerve, but to the lesion of the geniculate node. This is a rare symptom complex, the etiology and pathogenesis of which are still unclear. Suggestions are made about the role of infection and the vascular factor.

Features of clinical manifestations. Patients have sharp shooting pains in the area of ​​​​the external auditory canal, which appear paroxysmal and subside gradually. Pain occurs without apparent external causes, spontaneously. At the beginning of the disease, the frequency of attacks does not exceed five to six per day. The disease proceeds with exacerbations that last for several months, then remission may continue for several months.

In some patients, the development of the disease may be preceded by discomfort in the area of ​​​​the external auditory canal, which sometimes spread to the entire face.

When examining such patients, usually objective signs of the disease are not detected, only pain on palpation of the ear canal can be noted.

Due to the fact that the terminal branches of the tympanic nerve, together with the branches of the sympathetic plexus of the internal carotid artery, form the tympanic nerve plexus, the symptom complex that occurs when the tympanic nerve is damaged is also called the tympanic plexus syndrome.

Emergency and specialized care. Prescribe non-narcotic analgesics; synthetic derivatives of salicylic acid, pyrazolone, aniline, etc. For very severe pain, analgesics are used in combination with antihistamines (2 ml of a 50% solution of analgin with 1 ml of a 2.5% solution of diprazine intramuscularly). Electrophoresis of novocaine is carried out on the ear canal area, a course of therapy with vitamins of group B (B) and B12).

In the absence of effect, sometimes it is necessary to resort to transection of the glossopharyngeal nerve.

The most common form of damage to the glossopharyngeal nerve is glossopharyngeal neuralgia.

This is paroxysmal neuralgia with localization of pain and trigger zones in the region of innervation of the glossopharyngeal nerve.

First described by T.H.Weisenburg (1910), and later by R.Sicard and J.Robineau (1930).

The disease is quite rare. According to modern data, patients with neuralgia of the glossopharyngeal nerve range from 0.75 to 1.1% of patients with trigeminal neuralgia.

Etiology and pathogenesis

In recent years, it has been shown that in the so-called "idiopathic" glossopharyngeal neuralgia, the cause of the disease is actually compression of the nerve root by dilated vessels, usually the posterior inferior cerebellar and vertebral arteries (Jannetta P.J., 1985; Hamer G., 1986; etc.). In isolated cases, the cause may be oncological diseases of the oropharynx (cancer of the root of the tongue, tumors of the larynx).

Features of clinical manifestations

Symptoms of neuralgia of the glossopharyngeal nerve are similar to those of trigeminal neuralgia and are characterized by pain attacks and the appearance of trigger zones. The leading clinical manifestation is short-term paroxysmal pain. Their continuation may not exceed 1-2 minutes, but more often they last no more than 20 s. Patients characterize the pain as burning, shooting, resembling an electric shock. Their intensity is different - from moderate to unbearable.

Most patients, reporting the onset of the disease, note that the attacks occur suddenly in the midst of complete health. Significantly less often, precursors of the disease appear in the form of various local paresthesias, usually several weeks and even months before the development of the disease.

Most often, attacks are provoked by talking, eating, laughing, yawning, moving the head, changing the position of the body. As with trigeminal neuralgia, seizures often occur in the morning, after a night's sleep, less often at other times of the day. The number of seizures per day - from a few to countless (neuralgic status). During this period, patients can not only talk and eat, but even swallow saliva.

Forced to sit or stand with their heads tilted to the affected side, when an attack occurs, they press or rub the parotid-maxillary or posterior-maxillary region on the side of the pain syndrome with their hand. Often exhausted from hunger, in severe depression, patients with fear expect the next pain attack. An increase in the daily number of pain attacks, as well as the duration of an exacerbation, indicates the progression of the disease.

The primary localization of pain most often corresponds to the root of the tongue, pharynx, palatine tonsils, less often located on the lateral surface of the neck, around the corner of the lower jaw (in the posterior mandibular and submandibular regions or in front of the ear tragus). Often there are two centers of pain.

Trigger zones are one of the most characteristic signs of glossopharyngeal neuralgia and are found in most patients. Their location is most typical in the region of the tonsils, the root of the tongue, their combinations are not uncommon; less often they are observed in other areas, for example, in the tragus of the ear.

The appearance of the trigger zone on the skin of the chin, the mucous membrane of the lower lip, the anterior 2/3 of the tongue, i.e. outside the innervation of the 9th pair, observed in patients with a combined form of neuralgia of the glossopharyngeal and trigeminal nerves. Often there is also a change in the place of the initial localization of pain and trigger zones in different periods of the disease and during its exacerbations.

Pain irradiation zones, despite some differences, are quite definite. Most often, pains spread to the depth of the ear, pharynx, and relatively rarely to the root of the tongue, anterior to the tragus and to the lateral parts of the neck.

In the period between painful paroxysms in the course of the disease, mild aching pains appear, as well as sensations of burning, tingling, tingling, the presence of a foreign body in the pharynx, root of the tongue or palatine arch.

Pain and paresthesia, which persist for quite a long time after the end of the acute period, are aggravated by physical and emotional stress, changes in meteorological conditions, hypothermia, etc.

Diagnosis and differential diagnosis

Neuralgia of the glossopharyngeal nerve should be differentiated from neuralgia of the lingual, superior laryngeal, ear-temporal, occipital nerves, ganglionopathy of the geniculate, superior cervical sympathetic nodes, TMJ pain dysfunction, jugular foramen syndrome.

One of the most characteristic signs of neuralgia of the glossopharyngeal nerve is pain on palpation of the point behind the angle of the lower jaw. Much less often, pain is determined on palpation of the exit points of the trigeminal and large occipital nerves on the damaged side.

It should also be noted the often occurring characteristic "antalgic" posture of patients with head tilt towards pain. Unlike jugular foramen syndromes, there are no symptoms of prolapse in case of neuralgia of the glossopharyngeal nerve (bulbar disorders, disorders of taste and general types of sensitivity in the posterior third of the tongue).

An important diagnostic test confirming the styloid process syndrome in patients with glossopharyngeal neuralgia is the introduction of anesthetic solutions into the projection area of ​​the styloid process in the oral cavity. At the same time, it is possible to completely stop the pain for several hours, and sometimes for 1-2 days.

Vegetative-vascular disorders in case of neuralgia of the glossopharyngeal nerve are subtle and are presented in the form of swelling, hyperemia, less often - plaque on the root of the tongue. Salivation during painful attacks is increased, and in the period between attacks is usually normal.

Patients do not make any significant complaints about the taste disorder, but most of them experience increased pain when taking sour and salty foods; hypergesia to bitter often occurs. A number of patients have a strong laryngeal cough at the time of the pain attack and after it.

Treatment

Effective diadynamic sinusoidal modulated currents on the zamandibular region, tonsils, larynx (for a course of 10-15 procedures). Usually, diadynamic therapy is combined with medication: vitamin B12, chlorpromazine, difenin, finlepsin. A course of galvanization is recommended.

The etiological treatment of the underlying disease, anti-infective agents, analgesics, neuroleptics, and unitiol are also needed.

With an enlarged styloid process, an appropriate operation is performed. In the absence of effect, radicotomy at the level of the posterior cranial fossa, tractotomy, and mesencephalic cordotomy are used.

B.D. Troshin, B.N. Zhulev