Clinical Reasoning: A 50-year-old woman with deep stabbing ear pain

DeLange, Justin M.; Garza, Ivan; Robertson, Carrie E.

doi:10.1212/wnl.0000000000000893

Cited by 6 publications

(18 citation statements)

References 12 publications

(11 reference statements)

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“…Occasionally, the actual neurovascular conflict identified was not the nervus intermedius, despite predominant deep ear pain on presentation; rather, some cases involved the trigeminal or even vagal nerve. 8,9 TA B L E 1 Review of characteristics of 127 nervus intermedius neuralgia cases reported in the literature 2,6,…”

Section: Patient and Diagnostic Characteristics Of Ninmentioning

confidence: 99%

“…Primary ear conditions can cause otalgia, but because of overlapping innervation of the ear, there are also many causes of referred otalgia. 2,3 Secondary causes of otalgia include neuralgia, Bell palsy, Ramsay Hunt syndrome, carotidynia, cervical causes, dental and temporomandibular disorders, mass lesions, and myofascial pain, to name only a few. 3 Neuralgia affecting the ear can be associated with a number of possible nerves, including the trigeminal, glossopharyngeal, nervus intermedius (geniculate), auriculotemporal, lesser occipital, greater auricular, and vagal nerves.…”

Section: Introductionmentioning

confidence: 99%

“…3 Neuralgia affecting the ear can be associated with a number of possible nerves, including the trigeminal, glossopharyngeal, nervus intermedius (geniculate), auriculotemporal, lesser occipital, greater auricular, and vagal nerves. 2,3 Further complicating the diagnosis, NIN Additional points noted by ICHD-3 are that the pain can be localized to the auditory canal and/or auricle in addition to pain being referred to the mastoid process, soft palate, and even the temple or angle of the jaw. The ICHD-3 also notes that complex and overlapping innervations may make localization to one nerve difficult.…”

Section: Introductionmentioning

confidence: 99%

“…1 Although a patient may meet ICHD-3 criteria, it is difficult to make a definitive diagnosis because of the multiple innervations of the external ear, and because some conditions, like glossopharyngeal neuralgia, can refer to the ear. 2,3 NIN is described in the surgical literature but is lacking in the neurology and headache literature. This manuscript describes two cases to demonstrate the spectrum of NIN presentation and treatment response.…”

Section: Introductionmentioning

confidence: 99%

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A pain in the ear: Two case reports of nervus intermedius neuralgia and narrative review

Robblee

2021

Headache

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Objective: Present two cases of nervus intermedius neuralgia (NIN) in which patients described unilateral deep ear pain as their primary complaint and present a summary of NIN cases reported in the literature. Background: The nervus intermedius is a tiny branch of the facial nerve that, with neuralgia, can present as a deep ear pain (NIN). The International Classification of Headache Disorders, 3rd edition, (ICHD-3) criteria for an NIN diagnosis include a unilateral deep ear pain with possible radiation that occurs in paroxysms with sharp pain and a tactile trigger. Methods: A PubMed search was conducted for NIN and geniculate neuralgia. Two patients recently diagnosed with NIN at a single clinic were selected for case reports to highlight the variability of symptom presentation. Results: The two cases reported here and the 127 cases reported in the literature show a wider range of presentations than included in the ICHD-3 criteria, including variable pain radiation sometimes diagnosed as concurrent trigeminal, glossopharyngeal, or occipital neuralgia. Pain was reported as constant or paroxysmal, as well as dull, sharp, or neuralgiform with inconsistent presence of triggers. While ICHD-3 does mention reported taste change, lacrimation, and salivation, the literature reports a much wider range of potential features associated with NIN. Optimal medical treatment is unclear given the predominance of surgical reporting of positive response to microvascular decompression, nerve sectioning, or other procedures. The two cases described here were successfully managed medically. Conclusion: NIN can present as described in the ICHD-3, but a more variable presentation may be possible. More studies are needed to clarify presentation, optimal medical treatment, and surgical indications for patients with NIN, especially when patients have no clear neurovascular conflict on neuroimaging. K E Y W O R D S ear pain, geniculate, nervus intermedius, neuralgia, otalgia | 415 HEADACHE How to cite this article: Robblee J. A pain in the ear: Two case reports of nervus intermedius neuralgia and narrative review.

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Section: Patient and Diagnostic Characteristics Of Ninmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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A pain in the ear: Two case reports of nervus intermedius neuralgia and narrative review

Robblee

2021

Headache

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show abstract

“…The sensory innervation of the ear is complex and includes contributions from branches of the trigeminal nerve (CN V), nervus intermedius (CN VII), glossopharyngeal nerve (CN IX), vagus nerve (CN X), and the greater auricular and lesser occipital nerves (C2, C3) . This case demonstrates a previously undescribed etiology for neuralgic otalgia, localizing to a lesion within the spinal cord at C1.…”

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confidence: 94%