LONG-TERM RESULTS OF SURGICAL-TREATMENT OF IDIOPATHIC NEURALGIAS OF THE GLOSSOPHARYNGEAL AND VAGAL NERVES

PHYSICIANS DISAGREE ABOUT the best surgical treatment for patients with idiopathic neuralgias of the glossopharyngeal and vagal nerves after medical treatment has failed. Some favor percutaneous thermal rhizotomy, and others prefer extracranial section of the glossopharyngeal or branches of the vagal nerve, intracranial section of the glossopharyngeal and upper vagal rootlets, or microvascular decompression. However, the results of these procedures are limited to series with follow-up periods of less than 5 years or to series with longer follow-ups that were performed before the microneurosurgical era. We reviewed the long-term results of 14 patients with vagoglossopharyngeal neuralgia treated surgically at our center between 1976 and 1987 to determine the best treatment. Sixteen procedures were performed: 2 percutaneous thermal rhizotomies; 2 extracranial sections of the superior laryngeal nerve; and 12 intracranial glossopharyngeal and upper vagal rhizotomies, 4 with and 8 without microvascular decompression. The follow-ups ranged from 4 to 17 years (mean, 10 yr). All 14 patients who underwent percutaneous or intracranial rhizotomies were pain free. Two patients who underwent percutaneous rhizotomies developed persistent dysphagia and hoarseness. Both patients who underwent extracranial nerve section experienced pain recurrence 2 and 4 years later, Of 12 patients who underwent intracranial section of the glossopharyngeal and upper vagal rootlets, 2 developed dysphagia, which resolved completely in 1 patient and persisted mildly in the other; 1 had transient hoarseness; and 2 developed frequent coughing episodes, which persisted in 1 patient and resolved completely in the other. Side effects due to motor vagal deficits may be eliminated by intraoperative monitoring. Of these 12 patients, 11 (92%) rated the procedure as excellent and 1 (8%) rated the procedure as good. We conclude that intracranial section of the glossopharyngeal and upper vagal rootlets is an effective and safe procedure in treating vagoglossopharyngeal neuralgia; microvascular decompression is a surgical adjunct for treating patients with significant compression of the lower vagal rootlets. Percutaneous thermal rhizotomy and extracranial section of the glossopharyngeal or vagal nerves should be restricted to those who cannot tolerate an open intracranial procedure.