Case Presentation:
A 63 year male with no significant cardiac history presented to our hospital due to attacks of severe right-sided throat pain for 5 weeks. The pain was described as “sharp” and “stabbing,” with each episode lasting five seconds. These attacks would come in waves, at times up to ten per hour. After these episodes the patient would experience dizziness, lightheadedness and visual “dimming.” He also felt as if he were in a state of confusion, and it would take him 20-30 seconds to reorient himself. The patient never completely lost consciousness.
In the Emergency Department, the patient was noted to have several episodes of bradycardia. During hospitalization the patient continued to have pain attacks, after which he would experience symptomatic bradycardia, with pauses on telemetry of four to eight seconds. An MRI of the brain revealed that the right PICA artery was suspected to come into contact with the cisternal portions of cranial nerves IX and X.
The pain attacks were attempted to be controlled with Diazepam and Carbamazepine, however they persisted. Ultimately the patient had a pacemaker placed due to his continued symptomatic bradycardia. Following pacemaker placement the pain attacks continued, however the patient’s visual dimming, dizziness, lightheadedness and confusion had resolved.
Discussion:
Glossopharyngeal neuralgia is a syndrome of paroxysms of intense, intermittent, unilateral pain along the areas innervated by the glossopharyngeal nerve. The pain can occur in the ear, tonsillar fossa, base of the tongue, or beneath the angle of the jaw. The pain often lasts seconds to minutes, and may be triggered by chewing, swallowing, speaking or yawning. Several dozen attacks can occur per day. These episodes tend to last for weeks to months, and then can go into remission.
Rare case reports of bradycardia/asystole resulting in hypotension and syncope have been described. This occurs presumably because input from the glossopharyngeal nerve into the tractus solitarius has an effect upon the dorsal motor nucleus of the vagus nerve. The close connection between the two nerves may favor the creation of a vagoglossopharyngeal reflex arch. Neuralgic pain, likely due to an irritative phenomenon, may activate this reflex arch, resulting in bradycardia, hypotension and syncope.
Initial treatment is pharmacologic therapy with Carbamazepine, an anticonvulsant with anticholinergic and antineuralgic properties. If medical therapy fails, surgical intervention is an option. Surgeries include intracranial sectioning of the glossopharyngeal nerve plus the upper three to four rootlets of the vagus nerve at the jugular foramen, or vascular decompression.
Conclusions:
We report a rare case of bradycardia/asystole resulting in hypotension and near-syncope in a patient suffering from glossopharyngeal neuralgia. Our patient required pacemaker insertion to treat his symptoms.