Glossopharyngeal and Vagoglossopharyngeal neuralgia

Ross Hauser, MD

In this article, we will discuss diagnosis, symptoms, and possible treatments for Glossopharyngeal and Vagoglossopharyngeal neuralgia. In describing the possible symptoms of this disorder, we find it helpful to share some of the experiences of people who have reached out to us. Below are some of their emails. The emails have been edited for clarity.

Glossopharyngeal neuralgia is a nerve causing pain in the mouth, tongue, tonsils, throat, and ear. The origin of this pain is thought to be damage, irritation, or compression of the cranial nerve IX and cranial nerve X, the vagus nerve. The vagus nerve is mostly tied to the glossopharyngeal nerve. They travel together down the carotid sheath and innverate the pharynx (the area behind the nose and the mouth) and esophagus. The vagus nerve and glossopharyngeal nerve are so tied together that when a person has horrific lancinating or lightning-like pharyngeal pain, which can make it hard to swallow and have associated nausea and vomiting, the condition is called vago-glossopharyngeal neuralgia. As mentioned, the attacks of pain are brought on by swallowing, talking, coughing, sneezing, touching the tragus of the ear, turning the head towards the side of the pain, and rolling towards the side of the pain. It is important to remember, that the vagus nerve has sensory functions (it senses pain) and everywhere the vagus nerve goes can cause pain. Here are two examples of people’s stories.

Pain and voice change after a virus

I’ve been diagnosed with Postviral vagal neuropathy, Glossopharyngeal Neuralgia, and muscle tension dysphonia (A change in the sound of voice caused by tension on the vocal cords, voice box, and muscles of the larynx). I’ve seen probably 50 specialists and nobody can really give me a proper diagnosis or tell me where the pain is stemming from. I’ve had so many tests done and they’re all non-conclusive.

Difficulty swallowing

I began to develop a decreased appetite and difficulty swallowing. Then I woke up one morning with nausea and violent vomiting of stomach acid and bile. During the dry heaving and coughing, I felt a sharp electric shock run up my throat and the nape of my neck. In that moment, it also felt like part of the automatic function had turned off. My swallowing muscles now feel weakened and my gag reflex is diminished.

So far, all of the bloodwork and diagnostic imaging for physical abnormalities have come back as normal. I think there could be an emotional/mental component too. I was under a lot of stress and anxiety when this developed. I had a decreased appetite and trouble swallowing. Then there was the vomiting episode, which came a few days after a triggering event. Maybe this was just my body’s way of reacting to these emotional stressors. It’s like my sympathetic nervous system (fight-or-flight) became overly engaged, to the point where it felt like I physically lost some sensation of these automatic functions (swallowing, gagging, yawning). And now my body has memorized that “feeling”. The muscles in my throat feel both tense and weak when I swallow, not fluid and effortless like before. The muscles in the back of my throat don’t relax when I yawn.

Article outline:

Part 1:

  • Understanding the medical view of  Glossopharyngeal and Vagoglossopharyngeal neuralgia.

Part 2:

  • Conservative Care Treatments.

Part 3:

  • Cardiac-like and Autonomic symptoms leading to surgeries.

Part 4:

  • Surgical treatments options

Part 5:

  • How upper cervical instability can affect the brain stem and the glossopharyngeal and vagus nerve

Understanding the medical view of  Glossopharyngeal and Vagoglossopharyngeal neuralgia

In the February 2023 update of STAT PEARLS, (1) Stat Pearls is a publication of the National Center for Biotechnology Information, U.S. National Library of Medicine, Glossopharyngeal neuralgia is described as “a rare and pain syndrome in the sensory distribution of the ninth cranial nerve, also known as the glossopharyngeal nerve. . . glossopharyngeal neuralgia is a disorder characterized by a brief episodic unilateral pain, with sharp and stabbing in character, with abrupt onset and cessation, in the glossopharyngeal nerve distribution (angle of the jaw, ear, tonsillar fossa and the tongue base). It also involves the pharyngeal and auricular branches of CN X (the Vagus Nerve – this makes the “Vago” part of the Vago-glossopharyngeal). Pain is commonly triggered by coughing, talking, and swallowing. Pain in glossopharyngeal neuralgia follows a relapsing and remitting pattern, (it resolves and returns).

In our two stories above, symptoms are described which can lead to a suspicion of Vagoglossopharyngeal neuralgia.

The caption of the image below reads: The closeness of the Glossopharyngeal Cranial Nerve IX, the Vagus Cranial Nerve X, and the spinal accessory Cranial Nerve XI.

The Glossopharyngeal Cranial Nerve IX, the Vagus Cranial Nerve X, and the spinal accessory Cranial Nerve XI run together just in front of the C1 and C2 vertebrae. They can be easily damaged by the excessive motions of these vertebrae caused by upper cervical instability.

The closeness of the Glossopharyngeal Cranial Nerve IX, the Vagus Cranial Nerve X, and the spinal accessory Cranial Nerve XI


Conservative Care Treatments


A September 2022 paper (2) writes about the medications that may be prescribed and their usefulness. Here is a summary:

Carbamazepine is recommended at an initial dose of 100 to 200 mg twice daily as the first-line treatment with gradual increases in doses as needed. In most cases, doses of 300 to 400 mg twice daily are effective, and in some cases, a maximum dose of 1200 mg per day is required. In cases of carbamazepine intolerances, oxcarbazepine may be tried. . . . Despite the insufficient number of adequate clinical studies, in practice, pregabalin 300 to 600 mg and gabapentin 900 to 1800 mg have shown good results in some patients.  . . .In some patients, tricyclic antidepressants or serotonin and norepinephrine reuptake inhibitors (SNRIs, duloxetine, and venlafaxine) may be helpful.

A February 2023 case study in the Journal of Anesthesia Clinical Reports (3) describes a woman in her 70s with a chief complaint of neck pain. She reported the neck pain had bothered her for the past five years. She had a history of carbamazepine-induced interstitial pneumonia. The doctors in this case prescribed oral levetiracetam 1000 mg daily in addition to mirogabalin, which was previously prescribed. This effectively reduced the numerical rating pain scale from 9 to 1 with no adverse effects. Finally, she underwent microvascular decompression, and her symptoms were resolved.

A July 2022 case study presented by doctors at the Department of Neurology, University of Wisconsin-Madison (4) presented the case of a 76-year-old woman with glossopharyngeal neuralgia who developed bradycardia and syncope after reducing her carbamazepine doses because of worsening renal function. With the addition of gabapentin to carbamazepine, her glossopharyngeal neuralgia pain as well as bradycardia resolved. A pacemaker was placed to prevent bradycardia and syncope.


Part 3: Cardiac-like and Autonomic symptoms leading to surgery


When Glossopharyngeal neuralgia is suspected and the patient also presents cardiac-like and autonomic manifestations – vago-glossopharyngeal neuralgia is used as a diagnosis.

First, let’s look at autonomic manifestations. In my article Neurologic, digestive, cardiac, and bladder disorders: Some of the symptoms of Autonomic nervous system dysfunction and treatment options, I explain some of these symptom manifestations. I will briefly review them here.

Autonomic manifestations are among the same symptoms described above but perhaps caused by other problems. Some people will have a diagnosis of dysautonomia because of symptoms of blood pressure and heart rate (See my article Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems? Some will have a concurrent diagnosis of Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders. Some will also have Lyme Disease and/or thyroid problems. Others will tell us that they pass out for no reason or that their heart starts beating uncontrollably. Food gets stuck in their throat. The list of symptoms some people display seemingly goes on and on. Burning mouth syndromedigestive disordersChronic Fatigue Syndromeheadaches, and migraines.

Vagoglossopharyngeal neuralgia, convulsions, seizures and neck pain

In 2016, doctors in Thailand started making a connection between Vagoglossopharyngeal neuralgia, convulsions, seizures, and neck pain. In their paper, (5) the doctors suggested that they were presenting the first case history in the medical literature of Vagoglossopharyngeal neuralgia with ipsilateral (other side of the face) hemifacial spasm and versive seizure-like movement (the eyes and head involuntarily turn to one side) to the same side of facial pain.

In this case, a 71-year-old man had multiple episodes of intermittent sharp shooting pain in the right middle neck, followed by a hemifacial spasm on his right face. He also had episodes of syncope (lightheaded to the point of fainting) while his head and gaze turned to the same side of the painful neck. Electrocardiography showed sinus arrest (sinus arrhythmia).  This patient initially responded to pregabalin for two weeks, then the symptoms became worse. Microvascular decompression surgery and carbamazepine (for nerve pain and seizures) resulted in the complete remission of all symptoms after six months of follow-up. The researchers could not explain the pathophysiology of unilateral versive seizure-like movement.

A case history presented of choroid plexus compression

What are choroid plexus?

In the July 2023 update of the medical publication STATPearls – Neuroanatomy, Choroid Plexus (6) the vital roles of the choroid plexus are given. The choroid plexus is a network of blood vessels called capillaries. One of the primary functions is to produce cerebrospinal fluid (CSF). Among problems reported with a deficiency of cerebrospinal fluid production are the symptoms of sleep disturbance, head buzzing or noise, tinnitus, nausea or vomiting, dizziness, anxiety or depression, vertigo, and others. The challenges of diagnosis are seen in the many overlapping symptoms that can be caused by compression caused by cervical spine instability. For a detailed discussion, please see my article: Symptoms and Conditions of Craniocervical and Cervical Instability.

Vascular compression as a cause of Vagoglossopharyngeal neuralgia

We are going to look at a case history presented in the Asian Journal of Neurosurgery (7). The doctors here offer an introduction to understanding the problem created by vascular compression.

“Vascular compression has been reported to be the most common reason for Vagoglossopharyngeal neuralgia. The treatment may include medications, ganglion blockade with radiofrequency ablation, and microvascular decompression. A review of the literature reveals that Vagoglossopharyngeal neuralgia may develop due to choroid plexus compression, and the number of reported cases is very limited. Secondary reasons could include neoplasms, vascular malformations, demyelinating diseases (multiple sclerosis), infection, trauma, Chiari malformation, Eagle’s syndrome, and choroid plexus overgrowth.”

“A 64-year-old female patient had been diagnosed with left Vagoglossopharyngeal neuralgia four years before her admission to (the study) clinic and had been treated with carbamazepine, and gabapentin, which are effective on neuropathic pain. Ganglion blockade with radiofrequency ablation (RFA) had been used twice; as a result, the patient benefited from these procedures for a short time. However, on her admission, she had an electricity-shock-like intolerable pain beginning from the left ear and extending to the larynx. She stated that talking and chewing triggered the pain.”

A point the researchers stressed was that “no other characteristics of pain caused by choroid plexus compression were described by (the) patient compared to typical pain described by Vagoglossopharyngeal patients.” In other words, there was no clue that choroid plexus compression should be considered the primary diagnosis. Finally, her cranial magnetic resonance imaging (MRI) revealed a suspected compression. The patient underwent a microvascular decompression operation and her pain was relieved in the postoperative period.”

Let’s stop here for a moment to discuss the carotid sheath. The carotid sheath is a tube that contains vital arteries, veins, and nerves.

The caption of this image reads: Kinking of the carotid sheath at the craniocervical junction. The carotid sheath contents include the internal carotid artery, internal jugular vein, as well as the vagus, glossopharyngeal, and spinal accessory nerves. They can be compressed as they make a sharp turn up to 90 degrees, a right angle around the C1 (atlas) transverse process (the white arrow at the center of the screen) into the brain through the jugular and carotid foramen. This leads to increased intracranial pressure, localized cerebrospinal fluid accumulation, resultant cerebral atrophy, and increased eye pressure (double arrows). (Your brain shrinks, your eyes are under pressure).

The glossopharyngeal and vagus nerve component of digestive symptoms

French physicians published a case history (8) to demonstrate the glossopharyngeal and vagus nerve components of digestive symptoms in vagoglossopharyngeal neuralgia. They write:

“Vagoglossopharyngeal neuralgia is a rare pathology whose atypical forms, dominated by syncopal (fainting and passing out) manifestations, are still rarer. Although the territory of the vagus nerve involves, beyond the cardiovascular system, the respiratory and the digestive systems, there is no report in the literature of atypical forms other than syncopal. (The cardiovascular aspect).”

What can be implied here is that IF Vagoglossopharyngeal neuralgia can be suspected from cardiovascular-like problems, why then don’t digestive problems lead to the same conclusion? Why is this connection not made?

In this case history, the doctors reported the case of a patient whose vagoglossopharyngeal neuralgia was predominantly revealed by digestive symptoms.

A 58-year-old patient presented with stereotypical severe digestive disturbances including nausea, vomiting, and diarrhea. High-definition cranial MRI showed a neurovascular conflict (compression) between the posterior inferior cerebellar artery the glossopharyngeal nerve and the vagus nerve, on the right side. A microsurgical decompression was carried out which confirmed the vascular compression and successful transposition (moving) of the artery (from the nerves) One year after the surgery, the patient was free from all painful and digestive symptoms. . . The hypothesis was that the revealing digestive symptoms are linked to a similar parasympathetic mechanism, implying the compression of the vagus nerve.


Part 4: Surgical treatment options


A February 2023 paper in the Neurosurgical review (9) assessed surgical outcomes for glossopharyngeal neuralgia when pharmacological treatment fails. “Pharmacological treatment with anticonvulsants is the first line of treatment; however, about 25% of patients remain symptomatic and require surgical intervention, which is usually done via microvascular decompression (MVD) with or without rhizotomy. More recently, the use of stereotactic radiosurgery (SRS) has been utilized as an alternative treatment method to relieve patient symptoms by causing nerve ablation.” In this paper, researchers conducted a systematic review to analyze whether microvascular decompression (MVD) without rhizotomy is an equally effective treatment for Glossopharyngeal neuralgia as microvascular decompression (MVD) with the use of concurrent rhizotomy.

Study points:

  • Microvascular decompression (MVD) alone was successful in achieving pain relief immediately postoperatively in about 85% of patients, and also long-term in 65-90% of patients.
  • The most common complication found on MVD surgery was found to be transient hoarseness and transient dysphagia.
  • Rhizotomy alone shows instant pain relief in 85-100% of the patients, but the rate of long-term pain relief was lower compared to microvascular decompression (MVD).
  • The most common adverse effects observed after a rhizotomy were dysphagia and dysesthesia along the distribution of the glossopharyngeal nerve.

Microvascular decompression in Glossopharyngeal and vagoglossopharyngeal neuralgia

A July 2023 paper published in the journal Surgical Neurology International (10) assessed 20 patients for their long-term surgical results of microvascular decompression in Glossopharyngeal and vagoglossopharyngeal neuralgia.

These patients’ symptoms developed on average around the age of 51 years old. Sixty percent were women. “The posterior inferior cerebellar artery was the main offending vessel (75%).”

The immediate microvascular decompression success rate was 100%, but during follow-up, two patients (10%) were diagnosed with vagoglossopharyngeal neuralgia with pain recurrence. Overall the doctors found in this group: “Microvascular decompression is an effective and safe treatment for long-term pain relief of glossopharyngeal and vagoglossopharyngeal neuralgia. Vagoglossopharyngeal neuralgia and a prolonged hospital stay were associated with poor outcomes. More studies are required to confirm these findings.

In December 2020, (11) doctors at the Department of Neurosurgery, University of Pennsylvania, and the Department of Neurosurgery, Rowan School of Osteopathic Medicine presented two case histories of surgical relief of vagoglossopharyngeal neuralgia symptoms.

The doctors in this article present surgical two cases.

Case 1 demonstrates a 53-year-old male with right-sided Glossopharyngeal neuralgia symptoms who began to experience fainting or passing out episodes 10 years after the initial presentation.

Case 2 presents a 61-year-old female with a history of Ehlers-Danlos syndrome, and the malignant vasovagal syndrome that became associated with painful, shooting left anterior neck spasms consistent with Glossopharyngeal neuralgia.

Both patients underwent endoscopic microvascular decompression, leading to complete relief of neuralgia and cardiac symptoms.

A June 2023 paper in the journal Surgical Neurology International (12) presented the case of a 73 year-old-man with Vagoglossopharyngeal neuralgia misdiagnosed as trigeminal neuralgia. The patient was diagnosed with sick sinus syndrome (a heart rhythm disorder), and a pacemaker was put in. However, the patient’s syncope returned. Magnetic resonance imaging revealed a branch of the right posterior inferior cerebellar artery compressing the right glossopharyngeal and vagus nerves. We diagnosed Glossopharyngeal and Vagoglossopharyngeal due to neurovascular compression and performed microvascular decompression (MVD). The symptoms disappeared postoperatively.

Long-term complications occurred much more frequently following vagoglossopharyngeal rhizotomy

A December 2020 report in the journal Neurosurgery (13) compared surgical techniques for glossopharyngeal neuralgia. They note that Microvascular decompression and vagoglossopharyngeal rhizotomy are effective treatments for glossopharyngeal neuralgia. However, “surgical choice is controversial due to the need to maximize pain relief and reduce complications.”

In this study:

  • Of 87 patients with glossopharyngeal neuralgia, 63 underwent Microvascular decompression alone, 20 underwent vagoglossopharyngeal rhizotomy alone, and 4 underwent vagoglossopharyngeal rhizotomy following a failed Microvascular decompression. The long-term rate of pain relief was slightly, but not significantly, lower following Microvascular decompression than vagoglossopharyngeal rhizotomy. However, long-term complications occurred much more frequently following vagoglossopharyngeal rhizotomy. The  Brief Pain Inventory-Facial (BPI-Facial) questionnaire, which evaluates pain and complications, showed that Microvascular decompression had better postoperative quality of life than vagoglossopharyngeal rhizotomy. However, 91.7% of patients who underwent vagoglossopharyngeal rhizotomy experienced no or mild complications. There was no significant difference in the overall satisfaction rates between the groups (83.3% vs 83.6%).

“I was diagnosed with burning mouth syndrome. I had surgery to cut the glossopharyngeal nerve and put a sponge next to the vagus nerve. Not only is the burning bad but I keep tasting whatever it was I last ate. This happens after anything I eat. I get a horribly sour taste that won’t go away. Can’t get any of the doctors to listen. They just look at me like I have three heads.”

In this video, Ross Hauser MD discusses how upper cervical instability can affect the brain stem.

(Video at 1:35 ) The lower part of the brainstem is called the medulla oblongata and is where the Cranial Nerve X or the Vagus Nerve, Cranial Nerve IX or the glossopharyngeal nerve, Cranial Nerve XI or the spinal accessory nerve, and Cranial Nerve XII or the hypoglossal nerve all originate.

Upper cervical instability, by causing a decrease in neurologic function of the lower part of the brainstem can affect the nerves.

(Video at 2:23 ) A connection to constant nausea

  • Interestingly too, the nausea center is right in the lower part of the brainstem.  It is amazing how many people feel nauseated all the time and nobody can tell what’s causing it. These patients have a history of seeing gastroenterologists and various gastrointestinal doctors and they would have no idea that the cause of this chronic nausea can be upper cervical instability.

(Video at 2:45 ) Heart palpitations and arrhythmias

  • The lower part of the brainstem is what controls heart rate and blood pressure.

(Video at 3:35) Respiratory rate

  • The lower part of the brainstem also affects the respiratory rate. There are a lot of people who all of a sudden feel panicky, and on the verge of panic attacks.  They start breathing really hard or they have shortness of breath and they don’t know why. It could be that upper cervical instability is decreasing the function of the brainstem.

The Curve of the Cervical Spine

(Video at 4:05) The cervical curve

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

  • The cervical instability from ligament injury causes the cervical spine curve to change, from a normal “C” curve to the opposite, a reversal of the curve. See the progression illustration below.
  • This curve reversal causes stretching on the spinal cord, the cervical spine, with its now unnatural curve, is yanking and pulling on the brain stem and the whole brain. That traction, or pull on the brain stem, can also affect the brainstem as well have cranial nerve function.
  • To get the brainstem and all the nerves working correctly one has to address and tighten the ligaments in the back of the neck as well as get the cervical curve back to its normal lordotic configuration.

Please see our article on treatments for Atlas displacement c1 forward misalignment.


"S" cervical curve. Cervical spine instability from cervical ligaments can cause hypermobility of the cervical vertabrae. This leads to a loss of the natural curve or lordosis and eventual cervical kyphosis and an "S" curve.

“S” cervical curve. Cervical spine instability from cervical ligaments can cause hypermobility of the cervical vertebrae. This leads to a loss of the natural curve or lordosis and eventual cervical kyphosis and an “S” curve.

Treatment Prolotherapy

The clinical signs of upper cervical instability can vary from no symptoms or relatively diffuse complaints to signs and symptoms of extreme importance or seriousness. When clinical symptoms are present, assessing the degree of instability by objective means including digital motion x-rays helps in determining the treatment course. Destabilization of C0-C1 or C1-C2 joints can lead to extremes of instability with severe life-threatening neurologic sequelae that necessitate surgical consultation.

We have published dozens of papers on Prolotherapy injections as a treatment for difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. For more information please see my article Ross Hauser, MD Reviews Cervical Spine Instability and Potential Effects on Brain Physiology.

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your symptoms.

Please visit the Hauser Neck Center Patient Candidate Form

References

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