Laryngology Seminar
Hyaluronic acid in laryngology
2001-10-31
R3 周昱甫
Biochemistry
Linear polysaccharide: disaccharide unit, N-acetylglucosamine and glucuronic acid
Ubiquitously distributed, highest in loose connective tissues, lowest in blood
Molecular weight: variable, 106~107
Hydrogen bonded, stiff chain, extended, randomly coil,entangle, polymer meshwork
Biosynthesis: hyaluronan synthase on plasma memb., regulated via phosphorylation
History
1. 1910, Weisenburg, pain in distribution of glossopharyngeal n., trigeminal neuralgia,
CPA tumor at autopsy
2. 1920, Sicard & Robineau, feature of 9th neuralgia in 3 p’t, resection of 9th, 10th, sup.
cervical ganglion
3. 1921, Harris, “ glossopharyngeal neuralgia”
Etiology
1. Idiopathic
2. Secondary:
Cerebellopontine angle tumors
Metastasis in petrous bone
Exuberant choroids plexus
Trauma (surgery)
Local infection
Elongated styloid process, ossified styloid process
Parapharyngeal space lesion
Impacted wisdom tooth
Chiari type I malformation: displaced cerebellar tonsil
Multiple sclerosis:
Trigeminal neuralgia: 2% MS
1981, Rushton: 0/217 GPN
1973, Kahana: 1 GPN / 295 MS
2000, Minagar: 4 cases
Foreign body impaction after neck trauma
Vagus nerve stimulation
Vascular compression
Clinical features
1. Nature of pain:
Sharp, shooting, “like a needle”
Seconds to minutes ( may lasting for hours)
Dull-aching, burning, painful feeling, pressure feeling
Painless (tickling) but with syncope
Less severe than trigeminal neuralgia
Onset: abrupt, unpleasant sensation preceded the onset of pain
2. Age: rare before 20 y/o, peak at 6th decade, 43% < 50y/o, 57%> 50y/o
3. Localization: of 217 p’t (1981, Rushton)
Ear: 155; tonsil: 147; larynx: 69; tongue: 43
Ear + tonsil most common
Overflow of pain (15 p’t): temple, mastoid, side of nose, cheek, jaw, palate, scalp,
supraclavicular area
Left side > right: more hemodynamic stress on left VA?
Sex: equally, or female predominant( 1998, Kobata)
4. Triggers
Less definite trigger zone than trigeminal neuralgia
Triggered by: swallowing, chewing, coughing, talking, quick movement of head,
raising the arm, touching EEC, neck, mastoid, preauricular area
Spontaneous occurrence
5. Accompanying symptoms: cough, stridor, hoarseness, after pain, lacrimation
6. Syncope: 4%: cardiac asystole
Mechanism: unknown
1. Spillover of impulse from glossopharyngeal nerve---tractus solitarius---dorsal
motor nucleus of vagus nerve
2. Carotid sinus nerve ( of Hering): “ Cross- talk” with somatosensory fibers of
9th nerve
7. Cocaine test: 10% solution, aid in diagnosis
8. Geniculate neuralgia ?, tympanic plexus neuralgia, Cocaine test maybe (+)
9. Incidence: GPN/TN : 0.2~1.3%
10. Weight loss
Medical treatment
1. Carbamazepine:
Postsynaptically, slowing recovery of Na+ channel---depress high frequency
firing
100~200 mg, bid-tid, increase 200 mg/ every other day
Aplastic anemia
2. Phenytoin:
Similar mechanism of carbamazepine
Adjunctive medication
3. Baclofen:
Presynaptic:decrease the release of excitatory amino acid
Synergistic with carbamazepine or phenytoin
4. Oxcarbazepine: less serious side effect
*Glossopharyngeal neuralgia with syncope
Temporay or permanent pacemaker:
Syncope although pacemaker used:
Hypotension:mediated by carotid baroreceptor, vasodilatation
.Prevetion: Atropine, isoproterenol, and/or pacemaker
Percutaneous radiofrequency thermocoagulation
In pars nervosa of jugular foramen
Cardiac arrhythmia or arrest
Vocal cord paralysis
Glossopharyngeal nerve block:
5% phenol in glycerin, tonsillar & lingual br.
Indication for surgery
repeated injection
Surgery
Extracranial
1. Cervical
Doyle ,1923; Adson, 1924; Morrison, 1948: Skull base approach
Usadel, 1929: 9th nerve “below and over the styloglossus”
Shaheen, 1963: lat. surface of stylopharyngeus, or embeded in the muscle
2. Oropharyngeal approach:
Wilson, 1946: unilateral tonsillectomy--- incision on sup. constrictor 1cm from
post. pillar, lateral-posterior portion of lower tonsillar fossa
Ishii, 1976: 7 cases via pharyngeal approach, 1/7 recurrence---cervical approach,
No recurrence
Pathology:large myelinated fibers: loss, disorganization, & thickening of
myelin structures, rare axonal degeneration
Intracranial
Dandy procedure, 1928: resection of the 9th nerve
Karnosh, 1947: resection of upper rootlets of vagus n.
Jannetta, 1977: microvascular decompression
Microvascular decompression
1. Root entry/ exit zone theory: Jannetta, 1977
Junctional area between central and peripheral myelin
Microvascular compression only occurred in this zone
Pulsatile or cross compression: art. Or vein
Trigeminal neuralgia, hemifacial spasm, 9th neuralgia, spasmodic torticollis, 8th n
disorder, essential HTN
2. Causative arteries:
TN: Superior cerebellar a.
Hemifacial spasm: AICA, PICA, VA
Glossopharyngeal neuralgia: PICA
3. Hemodynamic stress ---art. elongation, tortuosity
Associated with aging, hypertension, atherosclerosis
4. Indication for op
Failure medical treatment
Angiography
Endovascular provocative test: Matsushima, 1999
MRA, 3D-CISS & 3D-FISP, Schmitz, 1999: describe finer features
5. . Critics:
1. difficulty to identify causative vessels
2. 60% vascular compression at cadaver without neuralgia
3. Symptom relief maybe related to trauma of nerve during op.
Combination of trigeminal neuralgia and glossopharyngeal neuralgia
75 cases reported
0.3-0.5% of TN cases
10~47% of GPN cases: Rushton, 1981: 25/217
Older age, higher rate of HTN, higher female predominance
Post. fossa crowding
Conclusion
1. Rare disease
2. Medication firstly
3. Cervical approach or pharyngeal approach for ENT doctors
Referrences
1.
Ishii T: Glossopharyngeal neuralgia: surgical treatment and electron microscopic fidings. Laryngoscope 1976;86;577-583
2.
Kobata H, Kondo A, Iwasaki K, Nishioka T:Combined hyperactive vascular syndrome of the cranial nerves.Neurosurgery
1998;43;1351-1362
3.
Rushton JG, Stevens JC, Miller RH: Glossopharyngeal neuralgia, a study of 217 cases.Arch neurol 1981;38;201-205
4.
Maris AP, F.R.C.S., Stewart TJ: Surgical treatment of glossopharyngeal neuralgia via the pharyngeal approach. J laryngol
otol 1990;104;12-16
5.
Shaheen OH, F.R.C.S.: A surgical technique for the relief of glossopharyngeal neuralgia. Ann otol rhinol laryngol
1963;72;873-884
6.
Adams CBT, Chir M, F.R.C.S.:Microvascular compression: an alternative view and hypothesis.J neurosurg 1989;70;1-12
7.
Matsushima T,Goto Y,Ishioka H,Mihara F,Fukui M: Possible role of an endovascular provocative test in the diagnosis od
glossopharyngeal neuralgia as a vascular compression syndrome.Acta neurochir 1999;141;1229-1232