Glossopharyngeal Hyperesthesia-Related Dysphagia Post Anterior Cervical

Discectomy and Fusion Managed with Glossopharyngeal Nerve Block Vijay Raj1,*, Krishna Pokuri2,*, Alexandra Fonseca3,*, Reda Tolba4, Linda Kollenburg5, Peter van der Meer6, Fahed Alrowaily7, Alan D. Kaye8, Michael Schatman9,10, Christopher Robinson1.

Introduction

Glossopharyngeal nerve block is utilized for neuralgia, hyperesthesia, and gag reflex suppression.

This nerve, with its sensory and motor functions, is approached by carefully inserting a needle adjacent to the nerve traditionally via the intraoral route under fluoroscopy, ultrasound or landmark guidance.

Local anesthetic and steroids can be injected in order to alleviate glossopharyngeal hyperesthesia, a distressing syndrome manifesting in otic and/or oropharyngeal pain.

Figure 1. Lateral view of cervical vertebrae and mandible with styloid process seen overlying the glossopharyngeal nerve (yellow), internal jugular vein (blue) and carotid artery (red). (12)

Case Presentation

A 56-year-old man with a history of cervical radiculopathy and anterior cervical spine surgery presented with persistent dysphagia, laryngeal spasming and pain, coughing, and oxygen desaturation immediately following anterior cervical discectomy and fusion.

Related to his significant decrease in oral intake, he had lost over 80 pounds subsequent to the surgery. After extensive evaluation, the dysphagia was determined to be the source of his dyspnea.

Discussion

Dysphagia following anterior cervical spine surgery has a 5-15% incidence beyond 1-year post-surgery, often attributed to mechanical factors such as pharyngeal thickening and epiglottis inversion.

Despite normal neurological exam and EMG, nerve distortion related to stretching remains a possibility in these patients.

In our patient, a glossopharyngeal nerve block was effectively employed to manage the glossopharyngeal hyperesthesia, reducing the gag reflex and dysphagia and enhancing oral tolerance.

Multiple interventions, including staged right and left superior laryngeal nerve blocks, and medications (e.g., gabapentin, pregabalin, and amitriptyline), yielded no improvement.

An extraoral glossopharyngeal nerve block was ultimately performed under fluoroscopic guidance using 1% lidocaine and dexamethasone, which alleviated his dysphagia, reduced his dyspnea, and improved his self- reported quality of life.

Figure 2. Anteroposterior cervical radiography with

fusion hardware in place and osteophyte seen at C3-C4

Figure 3. Lateral cervical radiography with

contrast spread near the right styloid process in the vicinity of the glossopharyngeal nerve during the extraoral glossopharyngeal nerve block.

References

1.Tasiou A, Giannis T, Brotis AG, et al. Anterior cervical spine surgery-associated complications in a retrospective case-control study. Journal of Spine Surgery. 2017;3(3):444-459. doi:10.21037/jss.2017.08.03
2.Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al. Anterior Cervical Discectomy and Fusion Associated Complications. Spine (Phila Pa 1976). 2007;32(21):2310-2317. doi:10.1097/BRS.0b013e318154c57e

3.Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: a systematic review of the literature. Journal of Spine Surgery. 2020;6(1):302-322. doi:10.21037/jss.2020.01.14
4.Kowalczyk I, Ryu WHA, Rabin D, Arango M, Duggal N. Reduced Endotracheal Tube Cuff Pressure to Assess Dysphagia After Anterior Cervical Spine Surgery. J Spinal Disord Tech. 2015;28(10):E552-E558. doi:10.1097/BSD.0000000000000033
5Cancienne JM, Werner BC, Loeb AE, et al. The Effect of Local Intraoperative Steroid Administration on the Rate of Postoperative Dysphagia Following ACDF. Spine (Phila Pa 1976). 2016;41(13):1084-1088. doi:10.1097/BRS.0000000000001407

6.Caspar W, Barbier DD, Klara PM. Anterior cervical fusion and Caspar plate stabilization for cervical trauma. Neurosurgery. Published online October 1989:491. doi:10.1097/00006123-198910000-00001
7.Goel V. Glossopharyngeal Neuralgia: An Approach to Diagnosis and Management. Annals Of Headache Medicine Journal. Published online May 4, 2020. doi:10.30756/ahmj.2020.02.07
8.Debasish G, Anindita S, Aryabrata D, Arunabha S. Glossopharyngeal Nerve Block with Long Acting Local Anaesthetic Agent (Bupivacaine) and It’s Effect on Early Post- operative Period in Adult Tonsillectomy: A Prospective Study. Indian Journal of Otolaryngology and Head & Neck Surgery. 2019;71(Suppl 1):390. doi:10.1007/S12070- 018-1323-6
9.Ahmed SA, Omara AF. The Effect of Glossopharyngeal Nerve Block on Post- Tonsillectomy Pain of Children; Randomized Controlled Trial. Anesth Pain Med. 2019;In Press(In Press). doi:10.5812/aapm.90854
10.Rao S, Rao S. Glossopharyngeal Nerve Block: The Premolar Approach. Craniomaxillofac Trauma Reconstr. 2018;11(4):331-332. doi:10.1055/S-0037-1606249 11.Liu Q, Zhong Q, Tang G, He G. Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal neuralgia: a retrospective study</p>. J Pain Res. 2019;Volume 12:2503-2510. doi:10.2147/JPR.S214596
12. Shin, John H., et al. “Entrapment of the glossopharyngeal nerve in patients with EAGLE syndrome: Surgical technique and outcomes in a series of 5 patients.” Journal of Neurosurgery, vol. 111, no. 6, Dec. 2009, pp. 1226–1230, https://doi.org/10.3171/2009.1.jns08485.

1

Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA. 2Tufts Medicine, Department of Anesthesiology, Boston, MA, USA. 3Brigham and Women's Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Boston, MA, United States. 4Cleveland Clinic Abu Dhabi, Pain Management Department in the Anesthesiology Institute, Abu Dhabi, UAE. 5Radboud University Medical Center, Department of Neurosurgery, Nijmegen, The Netherlands. 6Southern New Hampshire Radiology Consultants, Bedford, NH, USA. 7Prince Mohammed Medical City, Department of Physical Medicine and Rehabilitation, Medical Affairs, and Internal Medicine, Aljouf, Sakaka City, Saudi Arabia. 8Louisiana State University Health Sciences Center Shreveport, Department of Anesthesiology, Shreveport, LA, USA. 9Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA. 10Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA. *These authors contributed equally Informed consent was obtained. Authors report no relevant conflicts of interest.