Management of Recurrent Glossopharyngeal Neuralgia Following Microvascular Decompression Surgery

Background: Glossopharyngeal neuralgia (GPN) is a rare condition, commonly misdiagnosed as trigeminal neuralgia. Microvascular decompression (MVD) is considered the first line of treatment in medically refractive idiopathic GPN, and the recurrence rate is reported to be 7.1%. We present our first case report on the surgical management of a patient with recurrent GPN and analyze the possible causes for recurrence after MVD. Case Description: A 73-year-old gentleman was referred to us with a diagnosis of recurrent left GPN. He was diagnosed 6 years ago with left mandibular branch trigeminal neuralgia for the complaint of left-side tongue pain. He received left mandibular nerve block twice earlier and Gamma Knife radiotherapy 2 years ago without relief. A year ago he was diagnosed with GPN by a neurosurgeon, and MVD was performed. The posterior inferior cerebellar artery and vertebral artery were the offending vessels and were interposed with Teflon. After a temporary pain relief, the patient had a recurrence. Redo-MVD with transposition of the vertebral artery and further interposition of posterior inferior cerebellar artery did not help. After referral to us, we operated on the patient again and found 2 small arteries at the root entry zone (REZ). Interposition with Teflon and splitting of the rootlets relieved the pain. Conclusions: MVD is considered the first line of treatment in drug-resistant idiopathic GPN. Thorough exploration of REZ for small arteries and veins is mandatory to prevent recurrence. Vascular compression can occur at the cisternal portion or at the REZ. In recurrent cases, splitting of the glossopharyngeal nerve rootlets adds to the good outcome.