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Rapid response to:

Clinical Review

Neurocardiogenic syncope

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7461.336 (Published 05 August 2004) Cite this as: BMJ 2004;329:336

Rapid Response:

Surgical treatment for syncope caused by glossopharyngeal neuralgia

EDITOR – the excellent review of neurocardiogenic syncope describes
the commoner causes; vasovagal syncope, carotid sinus syncope, and
situational syncope. Glossopharyngeal neuralgia (GN) syncope was also
mentioned but no treatment was described. Approximately 10% of patients
with GN experience sudden excessive vagal outflow during an attack which
can result in bradycardia, hypotension, syncope, or even a seizure or
cardiac arrest1. For this reason use of the term vago-glossopharyngeal
neuralgia has been proposed2.

Microneurosurgery is effective in curing not only the pain but also
the syncope in these cases. Via a keyhole craniotomy behind the mastoid,
the glossopharyngeal and vagal rootlets can be easily approached. In many
cases the syndrome is caused by vascular compression which can be
corrected with a technique known as microvascular decompression in which
the offending vessel is repositioned3. In the absence of vascular
compression equally effective result is achieved by dividing the
glossopharyngeal nerve and also the uppermost two vagal rootlets4.

Because the condition is rare it is often not considered in the
differential diagnosis of cardiogenic syncope. We have studied two cases
of vago-glossopharyngeal neuralgia both of which were thought to be
from two unrelated conditions, a heart problem and facial pain.
“The penny did not drop” until a neurosurgical opinion was requested. The
first case has been cured by nerve root section, which surprisingly causes
no neurological deficit in the majority of cases.

Any patient with paroxysmal facial pain and syncope should be
considered for this benign neurosurgical procedure which can be successful
in up to 98% of cases5.

1 Thomson JL. Glossopharyngeal neuralgia accompanied by
unconsciousness.
J Neurosurg 1954 11: 511-515.

2 White J, Sweet WH. A 40 year experience: Pain and the
neurosurgeon.

Springfield IL, Charles C Thomas, 1969, pp 265-302.

3 Resnick DK, Jannetta PJ, Bissonnette D et al. Microvascular
decompression for glossopharyngeal neuralgia. Neurosurgery 1995 36: 64-
69.

4 Taha JM, Tew JM. Long term results of surgical treatment of
idiopathic neuralgias of the glossopharyngeal and vagal nerves.
Neurosurgery 1995 36: 926-931.

5 Sampson JH, Grossi PM, Asaoka K, Fukushima T. Microvascular
decompression for glossopharyngeal neuralgia: Long term effectiveness and
complication avoidance. Neurosurgery 2004 54: 884-890.

Hugh B Coakham Professor

Alex Davies Medical Student

Department of Neurological Surgery,
Institute of Clinical Neuroscience,
Frenchay Hospital,
Bristol
BS16 1LE


Hcoakham@aol.com

Competing interests:
None declared

Competing interests: No competing interests

23 August 2004
Hugh B Coakham
Consultant
Alex Davies, Medical Student
Department of Neurosurgery