Auriculotemporal Research Articles

Prevalence of tinnitus in temporomandibular joints disorder patients

BackgroundDisorders affecting the temporomandibular joint (TMJ), related structures, and the masticatory muscles are called temporomandibular disorders (TMD). The two most typical symptoms are mouth opening restriction and pain. Costen noted the connection between TMD and tinnitus in 1934. These conditions are brought about by the shared structures that connect the TMJ and the auditory apparatus (bones and muscles) through a shared innervation source and specific ligaments. Wright addresses Costen ideas, which suggest that otological symptoms of TMD could be caused by auriculotemporal nerve damage, Eustachian tube restriction, or other factors causing an incorrect intratympanic pressure adjustment.MethodsCross-sectional observation was regulated at Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Cairo University. The following are the inclusion criteria: patients with a TMD diagnosis and those older than 16 years old. The following conditions are excluded: neurological or oncological disorders, ear infection, and a history of face trauma.ResultsThe total number was 196 patients, 63.8% females and 36.2% males. A total of 76.5% had bilateral joint pain, and 21.9% had unilateral joint pain. While 70.4% had bilateral muscle pain, 18.9% had unilateral muscle pain. A total of 91.8% had mild tinnitus, while 8.2% had moderate tinnitus.ConclusionIn this study, 8.2% of patients complaining of tinnitus had severe tinnitus, while 91.8% had mild tinnitus.

The Superficial Cervical Plexus Block with the Auriculotemporal Nerve Block for Breaking the Refractory Pain Cycle of Malignant Otitis Externa and Skull Base Meningitis

Abstract Pain can be a severe and distressing symptom in conditions such as malignant otitis externa (MOE) with the associated skull base meningitis and even more following the debridement surgeries done for the same. It can be refractory to conventional therapies, including weak opioids, nonsteroidal anti-inflammatory drugs, and antineuropathic medications. Breaking this cycle of pain is very important in such cases to achieve good pain control and treat the psychological distress of the patient. Since there is a lack of literature for achieving satisfactory pain control in such cases, we successfully adopted a novel approach to break the pain cycle by employing the superficial cervical plexus block and auriculotemporal nerve (ATN) nerve block as the area of pain was in the distribution of these two nerves.

A rare variation of the infraorbital nerve, entrapping the infraorbital artery.

Anatomical variations are a common feature of the human anatomy. Variation can explain some pathological conditions and is important to keep them in mind during surgical procedures. The relations between nerves and their adjacent arteries have been proposed to play a role in the generation of peripheral trigger migraines. Close opposition between nerves and arteries can lead to vascular compression of the nerve that triggers episodes of pain. We did a routine dissection of the infratemporal fossa and orbital floor by opening the maxillary sinus. Here we report a case where the infraorbital nerves form a nervous loop entrapping the infraorbital artery in the infraorbital channel. Similar cases of close nervous and arterial apposition are described for the auriculotemporal and occipital nerves. We think that accumulating knowledge of these rare variations could expand our understanding of rare conditions such as primary infraorbital neuralgia.

ANATOMICAL VARIABILITY OF THE SEGMENTS OF THE INFERIOR ALVEOLAR NERVE IN THE PEOPLE OF SECOND PERIOD OF MATURE AND OLDER AGE

To avoid complications of bicortical implantation, great importance is attached to the study of individual morphological features of the mandible and its structures, in particular, the anatomical variability of the inferior alveolar nerve (IAN) and mandibular canal. The purpose of the study was to fi nd out the peculiarities of the structure, topography and individual anatomical variability of the IAN in persons of the second period of maturity and older age. Cone-beam computer tomography of 54 people of both sexes aged 45-65 years with three- dimensional reconstruction, morphometry and statistical analysis was studied. On the basis of our own research on the topographical and anatomical features of the IAN and its syntopy with the mandible, in particular, with the mandibular canal, we propose to distinguish 4 of its divisions: extra- canal – from the place of formation to the entrance to the mandibular canal; intracanal – from the mandibular foramen to the mental foramen; mental – after exiting the mandibular canal; incisive – after the departure of the mental branch. The topographical and anatomical features and anatomical variability of the IAN were studied. In people of the second period of mature and elderly age, anatomical variability of the macroscopic structure and topography of the IAN was established, which manifested itself in high (4.0-11.0 mm) and low (22.0-33.0 mm) levels, relative to the foramen ovale its beginning and form (one or two trunks) of departure from the mandibular nerve. The largest number of nerve connections with other branches of the mandibular nerve is formed by the extracanal section of the IAN: with the auriculo-t emporal nerve (29 cases – 53.7 %), with the lingual nerve (5 cases – 9.26 %), with the nerve of the medial pterygoid muscle (3 observations – 5.56 %) and with the nerve of the lateral pterygoid muscle (2 specimens – 3.7 %). A diff erent level of departure of the nerve to mylohyoid from the extracanal section of the IAN was established: high (5.0-7.0 mm) and low (27.0-31.0 mm). Anatomical variability of the intracanal part of the IAN was manifested by structural variants: a single trunk (43 cases, 79.6 %), rarely – two trunks (11 observations, 20.4 %) and very rarely – the lower dental plexus (6 specimens, 11,11 %). The proximity of the roots of the 7th and 8th teeth to the IAN can be the cause of severe pain in the pathology of these teeth and cause nerve damage during their removal. Nerve connections occur between the right and left incisive nerves, the knowledge of which is an important practical value for performing anesthesia of the front row of teeth. The number of branches to the teeth, interalveolar septa and gingiva from the IAN signifi cantly decreases with age and with a violation of the integrity of the dentition.

The relationship between the auriculotemporal nerve and middle meningeal artery in a sample of the South African population.

The interaction between the auriculotemporal nerve and the middle meningeal artery within the infratemporal fossa is vital in the spread of perineural tumours. Knowledge of their morphological and morphometric variations is critical to surgeons approaching the infratemporal fossa. There is a paucity of literature on the relationship between the auriculotemporal nerve and middle meningeal artery in a South African population. Hence, the aim of this study was to document the morphology and morphometry of the auriculotemporal nerve and its relationship to the middle meningeal artery within a South African cohort. The infratemporal fossae of 32 cadaveric specimens were dissected and the auriculotemporal nerves and middle meningeal arteries were analysed, together with their variations. Nine out of 32 specimens displayed one-root, 14/32 two-root, 7/32 three-root, and 2/32 four-root auriculotemporal nerves. Eighteen auriculotemporal nerves originated from the mandibular nerve, while the rest had at least one communication to the inferior alveolar nerve. The mean distance between the first and second roots of the auriculotemporal nerve was 4.69 mm. There were V-shaped formations found in 23 auriculotemporal nerves. However, the middle meningeal artery only passed through 13/23 V-shapes. The maxillary artery was of a deep course in relation to the lateral pterygoid muscle in 19/32 and superficial in 13/32 of the sample. There were 15 accessory middle meningeal arteries present in 14/32 specimens. The accessory middle meningeal arteries often arose from the middle meningeal artery (46.67%). The results of this study show a high possibility of variations of the auriculotemporal nerve and middle meningeal artery in the South African population. The variations and interactions should be considered during surgical procedures.

AURICULOTEMPORAL NERVE AND FREY'S SYNDROME

Background: The auriculotemporal nerve is one of the main branches of the mandibular nerve. It provides sensory innervation to the auricle, the scalp in the temporal region, the temporomandibular joint and part of the dura mater, the parasympathetic innervation of the parotid salivary gland, as well as the external surface of the tympanic membrane, and the sympathetic innervation of the sweat glands and of the blood vessels passing through the parotid gland. Its interruption during surgical interventions or trauma can results in its most common disease - Frey's syndrome. This article is an overview and is based on 23 foreign scientific works - articles published in refereed and renowned scientific publications and anatomy atlases by world-renowned and proven specialists in their field. Review Results: The auriculotemporal nerve is a sensory nerve which includes secretory parasympathetic vasomotor sympathetic fibers coming from the otic ganglion. It is a branch of the mandibular nerve (V3). Its five terminal nerve branches are front auricular branches, branches for the external auditory canal, branches for the temporomandibular joint, branches for the parotid gland and superficial temporal branches. Frey's syndrome occurs when the auriculotemporal nerve is cut or injured proximal to the site of separation of the branches for the parotid gland or are severed themselves. The clinical picture characteristic of Frey's syndrome includes redness, sweating, warmth and itching in the area of innervation of the nerve and less often pain. Conclusion: Knowledge of the anatomy of the auriculotemporal nerve and Frey's syndrome are essential for understanding its nature and stand on the basis of its prevention.

Minimally invasive nerve and artery sparing surgical approach for temporal migraines

Temporal migraines (TM) present with throbbing, pulsating headaches in the temporal area. Different surgical techniques ranging from resecting the auriculotemporal nerve (ATN) and or ligating the superficial temporal artery (STA) have shown similar good results to decrease TM symptoms. No conclusive data supports a specific disease of the STA in TM patients. A minimally invasive technique is proposed to preserve both vascular and nerve structures. Patients with drug resistant TM were selected and treated with two techniques: nerve sparing and nerve and artery sparing. The study included 57 patients with TM, with an average age of 47.5 years. TM improvement was quantified after at least one year of follow up time. STA biopsies were sent for histological analysis. Forty-two patients underwent nerve-sparing decompression, with a therapeutic success rate of 78.6%, corresponding to 22.1 days with migraine per month decreasing to 6.2. Histological analysis of the STA showed varying degrees of endofibrosis in 75% of the samples. Histological results do not correlate with the intensity of symptoms before or after surgery. Fifteen patients underwent nerve and artery sparing arteriolysis, with an overall therapeutic success rate of 86.6% of which 80% had >90% improvement. The average migraine days dropped from 24 to 2.5 days per month in this group. Minimally invasive nerve sparing approaches are an effective and safe treatment to improve drug resistant TM symptoms. Endofibrosis of the STA was present in 75% of the cases, but it was found to be unrelated to pre-operative symptoms and outcome. Results are promising, but the limited numbers of patients treated with artery and nerve sparing technique needs further investigations.

Anatomic Anomalies of the Nerves Treated during Headache Surgery.

Headache surgery is a well-established, viable option for patients with chronic head pain/migraines refractory to conventional treatment modalities. These operations involve any number of seven primary nerves. In the occipital region, the surgical targets are the greater, lesser, and third occipital nerves. In the temporal region, they are the auriculotemporal and zygomaticotemporal nerves. In the forehead, the supraorbital and supratrochlear are targeted. The typical anatomic courses of these nerves are well established and documented in clinical and cadaveric studies. However, variations of this "typical" anatomy are quite common and relatively poorly understood. Headache surgeons should be aware of these common anomalies, as they may alter treatment in several meaningful ways. In this article, we describe the experience of five established headache surgeons encompassing over 4000 cases with respect to the most common anomalies of the nerves typically addressed during headache surgery. Descriptions of anomalous nerve courses and suggestions for management are offered. Anomalies of all seven nerves addressed during headache operations occur with a frequency ranging from 2% to 50%, depending on anomaly type and nerve location. Variations of the temporal and occipital nerves are most common, whereas anomalies of the frontal nerves are relatively less common. Management includes broader dissection and/or transection of accessory injured nerves combined with strategies to reduce neuroma formation such as targeted reinnervation or regenerative peripheral nerve interfaces. Understanding these myriad nerve anomalies is essential to any headache surgeon. Implications are relevant to preoperative planning, intraoperative dissection, and postoperative management.

Evaluation of facial nerve perineural spread from cutaneous squamous cell carcinoma using 3T MR neurography.

Perineural spread (PNS) is a rare but potentially fatal consequence of cutaneous squamous cell carcinoma (cSCC) of the head and neck. We aimed to evaluate the accuracy of 3T MR neurography in detecting and defining the extent of facial nerve (VII) PNS from cSCC, and highlight characteristic radiological features in peripheral branches to improve early diagnosis. Single-institution retrospective review of 38 patients with clinical, radiological, and/or histopathological findings consistent with VII PNS from cSCC who underwent pre-operative 3T MR neurography. Compared to histopathology (gold standard), 3T MR neurography had a sensitivity of 89% and positive predictive value of 97%. In true-positive cases (n = 33), zonal extent was correctly identified in 100%. Seventy-nine% had simultaneous trigeminal nerve (V) PNS, mostly involving the auriculotemporal branch of the mandibular nerve (64%). When the causative lesion was absent (n = 23), the extra-temporal VII demonstrated asymmetrical enhancement alone (n = 6), bulky expansion (n = 8), or extra-neural spread (n = 9). Peripheral VII branch involvement, particularly the buccal and zygomatic, was readily identified using known anatomical landmarks. 3T MR neurography is highly accurate in evaluating VII PNS from cSCC, and thus should be specifically requested by physicians if suspicious for disease. Coexistent V PNS was common, highlighting the need to examine V branches to allow complete treatment planning. The unique radiological patterns identified showcases disease progression. As early detection improves patient outcomes, the radiologist must look for peripheral VII involvement inspecific anatomical areas, which is within the capabilities of 3T MR neurography.

The Auriculotemporal Nerve and TMJ region: anatomy and function

The studies on the auriculotemporal nerve in humans are limited. However, we considered crucial to investigate the topographic relation between the auriculotemporal nerve and the TMJ region that can explain some of the symptoms in TMDs. The results derived from our experience in the anatomic dissection on 16 adult cadaveric heads were compared with what literature describes from 1971 to 2023. The results confirm the existence of a particular anatomic position of the ATN within the infratemporal fossa in direct contact with the lateral pterygoid muscle and the TMJ capsular region. Therefore, there is evidence of a potential entrapment mechanism involving the ATN caused by an internal derangement of TMJ or a spastic condition of the lateral pterygoid muscle. Through a detailed anatomical description of the ATN the present study aims to offer an explanation to the main sensory and otological symptoms that patients with TMJ disorders often complaint, from facial pain and paresthesias to external ear pruritus.

Evaluation of Clinical Efficacy of Scalp Block with 0.25% Injection Bupivacaine and 0.25% Injection Levobupivacaine to Blunt the Hemodynamic Response to Skull Pin Insertion during Supratentorial Craniotomies - A Prospective Study

BACKGROUND
 Head fixation is necessary to maintain the desired head position. Application of skull pins in neurosurgery leads to hemodynamic changes and this sudden change can be prevented by combining general anaesthesia with scalp block which blocks supraorbital nerve, supratrochlear nerve, zygomaticotemporal nerve, auriculotemporal nerve, lesser occipital nerve and greater occipital nerve which are present in superficial and deep layers of the scalp. Several studies have been done to study the efficacy of Injection levobupivacaine and injection bupivacaine in 0.5 % concentrations for scalp block. However, the comparative efficacy of 0.25% injection levobupivacaine and injection bupivacaine for scalp block has not been determined by any study previously. We wanted to compare the efficacy of 0.25% injection levobupivacaine and 0.25% injection bupivacaine in scalp block on the haemodynamic response to head pinning, incision and during craniotomy.
 METHODS
 This prospective randomised study included 60 patients of ASA status I or II between age 18–60 years and of either sex who underwent supratentorial craniotomy under general anaesthesia followed by scalp block. Patients were randomly allocated into two groups of 30 each and before application of the Mayfield skull pin head holder, scalp block was given as per group distribution (Group A: 20 ml 0.25% injection bupivacaine and Group B: 20 ml of 0.25% injection levobupivacaine). The hemodynamic responses were recorded at baseline, during scalp block and after head pin insertion, incision and at craniotomy. The total analgesic requirement during intraoperative and post operative period was noted.
 RESULTS
 There were no clinically and statistically significant differences in values of heart rate and blood pressure after head pin insertion, skin incision and craniotomy in both the groups.
 CONCLUSIONS
 The study revealed that 0.25% injection levobupivacaine when used for scalp block was as efficacious as 0.25% injection bupivacaine. Both the drugs in low concentration of 0.25% were effective in minimizing pressor response to skull pin insertion, incision and craniotomy with less incidence of complication and reduced intraoperative requirement of analgesia.

PA13 Unilateral facial flushing in a 3-year-old girl

Abstract A 3-year-old girl presented with an 18-month history of left-sided facial erythema involving her left cheek. This occurred within seconds to minutes after eating food and lasted between 5 and 20 min before complete spontaneous resolution without any associated symptoms. The flushing was not confined to a particular food type. She was born at 37 weeks via forceps-assisted delivery, which had resulted in a small laceration to her left upper cheek. She had no significant past medical history and was not on any medications. Her twin sister did not suffer from the same phenomenon. Examination revealed no abnormalities to her facial skin. Ingestion of a chocolate bar provoked immediate subtle erythema extending from her left preauricular skin to her left mid-cheek. Overlying skin texture and temperature was unchanged, and there was no associated hyperhidrosis. Examination of the cranial nerves was unremarkable at baseline and after provocation. The erythema completely resolved after 5 min. This little girl had Frey syndrome (FS) secondary to traumatic forceps-assisted delivery at birth. Frey syndrome typically consists of gustatory hyperhidrosis and flushing in response to chewing or the smell, taste or thought of food in the auriculotemporal distribution. It is due to aberrant regeneration of parasympathetic fibres instead of sympathetic fibres along the auricolotemporal branch of the mandibular nerve following trauma or infection to the parotid gland (O’Neill JP. Lucja Frey—historical relevance and syndrome review. Surgeon 2008; 6:178–81). Instead of causing the production of saliva in response to food, the aberrant fibres cause flushing and hyperhidrosis. In adults, FS is associated with previous surgery to the parotid gland. There are case reports of it arising as a consequence of forceps-assisted delivery in infants. One study reported eight cases of FS in infants in response to a food stimulus. Six of the cases had a history of forceps-assisted delivery. None of the infants experienced any associated hyperhidrosis. It was concluded that FS arose from trauma to the parotid gland following forceps-assisted delivery at birth. All cases resolved spontaneously without treatment (Dizon MV. Localized facial flushing in infancy. Auriculotemporal nerve (Frey) syndrome. Arch Dermatol 1997; 133:1143–5). The FS is often erroneously attributed to a food allergy. A thorough history for previous trauma to the parotid region or forceps-assisted delivery is recommended in infants with unilateral facial flushing. As FS runs a benign, self-limiting course in children, our patient was reassured and discharged without treatment.

Moderní terapeutické možnosti syndromu Freyové – analýza pěti případů

Introduction: Frey‘s syndrome (SF), auriculotemporal syndrome, is an often neglected complication occurring in 6–96% of patients after parotid gland surgery according to recent studies. It arises on the basis of aberrant ingrowth of parasympathetic fi bers into the sheaths of denervated sweat glands after auriculotemporal nerve damage. The syndrome is characterized by a triad of symptoms: sweating, redness and burning or even pain in connection with food intake. Diagnosing these problems is not a time-consuming process and there are a number of therapeutic options. However, the vast majority of approaches, whether surgical or non-surgical, have only a short-term effect and carry a number of complications. The application of botulinum toxin A (BTXA) represents a relatively simple, effective and safe treatment option consisting of intradermal application of the solution according to a predetermined Frey syndrome activation map. Objectives: Presentation and evaluation of pilot results of therapeutic application of BTXA in patients dia gnosed with Frey‘s syndrome. Material and methods: Retrospective analysis of a group of 5 patients who underwent parotid gland surgery of various extents at the Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital at St. Anny in Brno between 2006 and 2019, in whom there was a signifi cant manifestation of SF symptoms on the basis of which BTXA was therapeutically applied. Results: Evaluating the subjective manifestations of SF in all patients in our cohort, after the application of BTXA, showed that the problems signifi cantly decreased from “annoying and reducing their quality of life” to “never” or “almost never” occurring. Objective results of the Minor test interpreted by SketchAndCalc showed a decrease in SF activation of 91.6% on average. Only two patients required re-administration of BTXA at 6 and 19 months intervals. No adverse reactions to BTXA were reported or observed with any of the patients. Conclusion: BTXA is an eff ective and safe way to treat patients with Frey‘s syndrome. Keywords: parotidectomy – Frey syndrome – auriculotemporal syndrome – gustatory sweating – botulinum A toxin

Combined Greater Occipital, Lesser Occipital, and Auriculotemporal Nerve (GLOAT) Block to Reduce Pain After Scalp Degloving Trauma

Combined Greater Occipital, Lesser Occipital, and Auriculotemporal Nerve (GLOAT) Block to Reduce Pain After Scalp Degloving Trauma

Literature Review: Pericranial Nerve Blocks for Chronic Migraines.

Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB). PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches. In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

Surgical therapy of migraine: a 12-year single-center experience

BackgroundIn recent years, surgical therapy has taken on an increasingly decisive role in the therapeutic armamentarium of migraine. All surgical techniques are aimed at the complete neurolysis of some extra-cranial nerves, of which the most involved (in our experience) are the greater and lesser occipital, auriculotemporal, supraorbital, and supratrochlear nerves. This paper describes our surgical approaches for the treatment of occipital, temporal, and frontal trigger sites. MethodsA single-center, retrospective study was conducted on all patients who underwent surgical treatment of migraine between 2011 and 2022. Patients were asked to fill out a headache diary and complete a migraine questionnaire assessing parameters before surgery, after 3 months, and 1 year after surgery. Data regarding age, sex, age at onset, migraines per month (in days), associated symptoms, severity (on a scale from 1 to 10), inability to work per month (in days), health status, history of neck trauma, and family history were collected. The Migraine Disability Assessment Scale (MIDAS) score was also used to evaluate the degree of disability for each patient.ResultsWe have operated on 612 patients: n.266 occipital, n.248 temporal, n.98 frontal. The surgical procedure elicited a positive response in 90% of the patients (69% complete recovery). Complications were mild and temporary: mainly, hypoesthesia and numbness of the undermined areas, lasting from 3 weeks to 6 months. We observed the onset of secondary trigger sites in 257 (42%) patients.DiscussionThe described procedure is minimally invasive and highly reproducible and allows to obtain a high degree of success with a negligible rate of complications. Nevertheless, given the high percentage of occurrence of secondary trigger points, it is particularly important to warn the patient of this possibility in pre-operative visits.Level of evidence:Level III, Therapeutic

Botulinum Toxin Type A for the Treatment of Auriculotemporal Neuralgia—A Case Series

Auriculotemporal neuralgia is a rare pain disorder in which anesthetic nerve blockade is usually effective but not always resolutive. Botulinum toxin type A has proven to be effective in treating neuropathic pain, and patients with auriculotemporal neuralgia could also benefit from this treatment. We described nine patients with auriculotemporal neuralgia treated with botulinum toxin type A in the territory of auriculotemporal nerve innervation. We compared the basal NRS and Penn facial pain scale scores with those obtained 1 month after BoNT/A injections. Both Penn facial pain scale (96.67 ± 24.61 vs. 45.11 ± 36.70, p 0.004; mean reduction 52.57 ± 36.50) and NRS scores (8.11 ± 1.27 vs. 4.22 ± 2.95, p 0.009; mean reduction 3.89 ± 2.52) improved significantly at one month after treatment. The mean duration of the effect of BoNT/A on pain was 95.00 ± 53.03 days and no adverse effects were reported.

The effectiveness and safety of cranial nerve block in migraine: a critical review

Cranial nerve blocks (CNBs) have been used for the acute and preventive treatment of a variety of headaches, including migraine. The effectiveness of CNBs in migraine is usually observed beyond the duration of the nerve block, possibly due to central pain modulation. The most used target is the greater occipital nerve. Other commonly targeted nerves are the lesser occipital nerve and various branches of the trigeminal nerve, including the supratrochlear, supraorbital, and auriculotemporal nerves. CNBs are generally safe and well-tolerated procedures that can be performed in either emergency or outpatient settings. There is currently no guideline standardizing CNBs in migraine. In clinical practice, as well as the few published studies, the results are encouraging, justifying further studies in the area. In the present study we critically review the literature about the safety and efficacy of CNBs in the treatment of migraine attacks and in the preventive treatment of migraine.

Pain Relief With Peripheral Nerve Stimulation of Superficial Cervical Plexus: A Case Report and Literature Review

BACKGROUND: Neuropathic head and facial pain are relatively common and difficult to treat pain syndromes encountered in pain clinics throughout the world. Atypical syndromes with overlapping nerve distributions can be particularly frustrating for patients and providers. In recent years, as providers search for alternatives to medications, advances in neuromodulation technology, including spinal cord stimulation and peripheral nerve stimulation (PNS), have shown promise in treating neuropathic pain confined to specific nerve distributions, such as the greater and lesser occipital nerves. However, there is limited literature describing the use of PNS for atypical facial pain. We report the first known case of PNS to the superficial cervical plexus in a 45-year-old woman with bilateral ear and postauricular pain. CASE REPORT: A 45-year-old woman presented with over 6 years of bilateral ear and periauricular pain in the auriculotemporal and lesser occipital nerve distribution. Conservative management, including neuropathic pain agents, ketamine infusions, nasal sprays, opioids, nonsteroidal anti-inflammatory medications, ice, heat, and transcutaneous neurostimulation, provided limited relief. She had excellent pain control with a series of nerve blocks to the superficial cervical plexus; however, relief was short term. In an attempt for a more long-term solution, she underwent implantation of the SPRINT PNS (MicroLead, SPR Therapeutics, Cleveland, OH), which resulted in 100% pain relief, improved function at work, and improved sleep tolerance throughout the 60-day treatment. Unfortunately, her symptoms returned shortly after treatment course completion. CONCLUSIONS: To our knowledge, this is the first case utilizing PNS of the superficial cervical plexus to treat atypical facial pain. The 60-day trial resulted in 100% pain relief of previously debilitating and functionally limiting pain symptoms during the treatment phase suggesting that the superficial cervical plexus may be a reasonable target for permanent PNS implants. KEY WORDS: Peripheral nerve stimulator, peripheral nerve stimulation, superficial cervical plexus, atypical facial pain, anesthetic blockade, pain relief, neuropathic pain, neuromodulation, SPRINT

Transoral Endoscopic-Assisted Reduction and Internal Fixation of Mandibular Condylar Fractures in Children

Extraoral approaches for open reduction and fixation of condylar fractures in children are associated with serious risks of complications, including facial nerve injury, facial scarring, parotid fistula, and auriculotemporal nerve injury. The purpose of this study was to retrospectively evaluate the outcomes of transoral endoscopic-assisted open reduction and internal fixation of condylar fractures and hardware removal in pediatric patients. This study was designed as a retrospective case series. The study included pediatric patients admitted with condylar fractures that were indicated for treatment with open reduction and internal fixation. The patients were clinically and radiographically evaluated with regard to occlusion, mouth opening, lateral and protrusive movement of the mandible, pain, chewing and speech difficulties, and bone healing at the fracture site. CT images were used to assess the reduction of the fractured segment, the stability of fixation and progress of healing of the condylar fracture at follow-up visits. The same surgical treatment approach was applied to all patients. The data from the study were analyzed for a single group without any comparison to other groups. The technique was used for the treatment of 14 subcondylar fractures in 12 patients between the ages of 3 to 11years. A total of 28 transoral endoscopic-assisted approach to the condylar region either for reduction and internal fixation or hardware removal were applied. The mean operating time was 53.1 (±11.3) minutes for the fracture repair and 20 (±2.6) minutes for hardware removal, respectively. The mean follow-up time of the patients was 17.8 (±2.7) months (median: 18) months. All patients regained stable occlusion, satisfactory mandibular motion, stable fixation, and complete bone healing at the fracture site at the end of their follow-up period. There was no transient of permanent facial nerve or trigeminal nerve injury in any of the patients. Endoscopically assisted transoral approach is a reliable technique for reduction and internal fixation of condylar fracture and hardware removal in pediatric patients. The serious risks of extraoral approaches including facial nerve injury, facial scar, and parotid fistula can be eliminated by using this technique.