Nervus Intermedius Research Articles

The surgical management of chronic cluster headache.

Chronic cluster headache occurs in less than 10% of cluster headache sufferers, but remains an intractable medical problem. Surgical treatments have also been limited in their effectiveness. The authors describe their experience with attempted surgical amelioration of chronic cluster headache. Twenty-eight patients, including two with bilateral cluster headache, underwent 39 operations for microvascular decompression of the trigeminal nerve, alone or in combination with section and/or microvascular decompression of the nervus intermedius. Follow-up averaged 5.3 years. Initial postoperative success described as 50% relief or greater was achieved in 22 (73.3%) of 30 first-time procedures and greater than 90% relief in half (15 of 30) of these. Long-term follow-up saw this success rate (excellent or good) drop to 46.6%. Repeat procedures have little success, with 7 of 8 failing at long-term follow-up. Morbidity and neurological deficit from the operations was minimal. Chronic cluster headache remains a debilitating and poorly controlled syndrome. Although various surgical treatments have had limited success, microvascular decompression of the trigeminal nerve with section of the nervus intermedius compares very favorably to other destructive techniques without the accompanying neurologic deficits. It is, therefore, our recommendation as the first-line operative treatment of chronic cluster headache.

Continuous Intracisternal and High Cervical Intrathecal Bupivacaine Analgesia in Refractory Head and Neck Pain

Background : The upper cervical component of the spinomesencephalic tract and cranial nerves V, VII (nervus intermedius), IX, and X are involved in mechanisms of acute and chronic pain from head and neck structures. To date there is no reliable method for relief of refractory pain (i.e., pain that cannot be relieved by conventional pharmacologic therapies) from these structures. Therefore, we explored continuous intracisternal infusion of bupivacaine for the treatment of refractory pain of the head and neck. Methods : Intracisternal catheters were inserted in 13 adults with refractory nonmalignant (n = 4) and malignant (n = 9) pain from the head, face, mouth, neck, and upper extremities ; 0.5% plain bupivacaine was infused continuously at rates of 1-7 (median 1.5) mg/h with optional bolus doses of 0.5-2.0 mg 4-2 times/h. The efficacy was assessed from pain relief (daily VAS max , VAS min , and VAS mean scores 0-10), daily doses of intracisternal bupivacaine and total opioid (expressed as mg parenteral morphine-eq), amount of nocturnal sleep, and rates of adverse effects. Results :The 13 patients were treated for 3-182 days (median 37, total 712 days), 3 patients being treated at home for 10-112 days (median 88, total 210 days). In one patient, the efficacy of the treatment could not be estimated because of advanced senility. Eleven of the remaining 12 patients obtained acceptable pain relief with daily doses of intracisternal bupivacaine ranging from 20 to 118 mg (median 37 mg) : VAS mean scores decreased from 7 to 2, mean pain relief increased from 30% to 80%, total opioid daily dose decreased from 53 to 36 mg parenteral morphine-eq, and nocturnal sleep increased from 2 to >6 h (all figures are median values). Speech, eating, walking, and natural functions were generally not affected. Side effects such as tiredness and malaise, somnolence and sleep, feeling of coldness in the neck and skull base, transient post-spinal puncture headache, paresthesias, hoarseness, dysphagia, transient paresis of the upper/lower extremities, episodic miosis and conjunctival hyperemia, and transient orthostatic arterial hypotension were each observed in one or two patients. No patient presented clinical evidence of phrenic nerve paralysis. There was no nausea or vomiting. No persistent neurologic deficit or death could be attributed to the intracisternal pain treatment. Conclusions : Continuous intracisternal infusion of bupivacaine may be a useful method in exceptional, well selected patients with refractory pain from the head and neck structures. Further studies are necessary to establish the indications and the safety of the method.

The effect of unilateral transection of the nervus intermedius on fungiform papillae and taste buds in the human following excision of an acoustic tumor

Otolaryngology–Head and Neck SurgeryVolume 115, Issue 2 p. P134-P134 Tuesday, October 1, 1996 Poster 35: The Effect of Unilateral Transection of the Nervus Intermedius on Fungiform Papillae and Taste Buds in the Human Following Excision of an Acoustic Tumor Randall C. Latorre MD, Randall C. Latorre MD New Haven, Conn.Search for more papers by this authorLinda M. Bartoshuk PhD, Linda M. Bartoshuk PhD New Haven, Conn.Search for more papers by this authorJohn F. Kveton MD, John F. Kveton MD New Haven, Conn.Search for more papers by this author Randall C. Latorre MD, Randall C. Latorre MD New Haven, Conn.Search for more papers by this authorLinda M. Bartoshuk PhD, Linda M. Bartoshuk PhD New Haven, Conn.Search for more papers by this authorJohn F. Kveton MD, John F. Kveton MD New Haven, Conn.Search for more papers by this author First published: August 1996 https://doi.org/10.1016/S0194-5998(96)80789-3Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume115, Issue2August 1996Pages P134-P134 RelatedInformation

Continuous intracisternal and high cervical intrathecal bupivacaine analgesia in refractory head and neck pain.

The upper cervical component of the spinomesencephalic tract and cranial nerves V, VII (nervus intermedius), IX, and X are involved in mechanisms of acute and chronic pain from head and neck structures. To date there is no reliable method for relief of refractory pain (i.e., pain that cannot be relieved by conventional pharmacologic therapies) from these structures. Therefore, we explored continuous intracisternal infusion of bupivacaine for the treatment of refractory pain of the head and neck. Intracisternal catheters were inserted in 13 adults with refractory nonmalignant (n = 4) and malignant (n = 9) pain from the head, face, mouth, neck, and upper extremities; 0.5% plain bupivacaine was infused continuously at rates of 1-7 (median 1.5) mg/h with optional bolus doses of 0.5-2.0 mg 4-2 times/h. The efficacy was assessed from pain relief (daily VAS(max), VAS(min), and VAS(mean) scores 0-10), daily doses of intracisternal bupivacaine and total opioid (expressed as mg parenteral morphine-eq), amount of nocturnal sleep, and rates of adverse effects. The 13 patients were treated for 3-182 days (median 37, total 712 days), 3 patients being treated at home for 10-112 days (median 88, total 210 days). In one patient, the efficacy of the treatment could not be estimated because of advanced senility. Eleven of the remaining 12 patients obtained acceptable pain relief with daily doses of intracisternal bupivacaine ranging from 20 to 118 mg (median 37 mg): VAS(mean) scores decreased from 7 to 2, mean pain relief increased for 30% to 80%, total opioid daily dose decreased from 53 to 36 mg parenteral morphine-eq, and nocturnal sleep increased from 2 to >6h (all figures are median values). Speech, eating, walking, and natural functions were generally not affected. Side effects such as tiredness and malaise, somnolence and sleep, feeling of coldness in the neck and skull base, transient post-spinal puncture headache, paresthesias, hoarseness, dysphagia, transient paresis of the upper/lower extremities, episodic miosis and conjunctival hyperemia, and transient orthostatic arterial hypotension were each observed in one or two patients. No patient presented clinical evidence of phrenic nerve paralysis. There was no nausea or vomiting. No persistent neurologic deficit or death could be attributed to the intracisternal pain treatment. Continuous intracisternal infusion of bupivacaine may be a useful method in exceptional, well selected patients with refractory pain from the head and neck structures. Further studies are necessary to establish the indications and the safety of the method.

Nervus intermedius function after vestibular schwannoma removal: clinical features and pathophysiological mechanisms.

The results of facial nerve outcome following vestibular schwannoma removal have generally ignored the sensory component of the nerve. This lack of reporting occurs partly because the distress relating to these functions is less obvious to the surgeon, and partly because the facial nerve grading systems currently used do not include the functions of the nervus intermedius. We have estimated the frequency and nature of abnormalities of nervus intermedius function following vestibular schwannoma removal using a retrospective questionnaire. Questionnaires were mailed to 257 patients and correctly completed and returned by 224 (87%) of the patients. Prior to surgery 5 (2%) of the patients complained of crocodile tears, 9 (4%) noted dryness of the eye, and 15 (6%) complained of an abnormality of taste. Postoperative crocodile tears occurred in 98 (44%), an absence or significant reduction in the production of tears was noted in 162 (72%), and a taste abnormality, either a significant reduction or an alteration in character, was noted in 107 (48%). The onset of crocodile tears approximated to a bimodal distribution, and the recovery of nervus intermedius functions was variable. This study has demonstrated that nervus intermedius abnormalities are common following vestibular schwannoma removal. It also documents their natural history and discusses the underlying pathophysiological mechanisms. We suggest that appropriate preoperative counseling be given to all patients undergoing surgery and that the functions of the nervus intermedius be included in the surgical reporting of facial nerve results in cerebellopontine angle surgery.

Preservation of facial, cochlear, and other nerve functions in acoustic neuroma treatment

Between March 1966 and September 1992, 1400 acoustic neuromas were treated in Paris, France, by surgical excision. The findings over the last 7 years are presented. The translabyrinthine approach has been used in more than 85% of cases. Where hearing preservation is attempted, the middle fossa approach has been adapted for intracanilicular tumors and the retrosigmoid approach for small tumors extending into the cerebellopontine angle, in which the fundus of the internal meatus is free of tumor. The main goal is to achieve a grade I or II result in facial function within 1 month of surgery. Results improved during 1991 after the introduction of continuous facial nerve monitoring and the use of the Beaver mini-blade for dissection of tumor from nerve. With these techniques, facial function of grade I or II at 1 month improved from 20% to 52% for large tumors (larger than 3 cm), from 42% to 81% for medium tumors (2 to 3 cm). and from 70% to 92% for small tumors (up to and including 2 cm extracanalicular). The facial nerve was at greater risk using the retrosigmoid or middle fossa approaches than by the translabyrinthine route. Since 1985, success in hearing preservation has changed little, with useful hearing being preserved in 38.2% of cases operated on by means of the retrosigmoid route and a 36.4% of cases after the middle fossa approach. In older patients with good hearing and small tumors, observation with periodic MRI scanning is recommended. Despite earlier diagnosis, the number of patients suitable for hearing preservation surgery remains very limited and careful selection is required. Trigeminal nerve signs were present in 20% of cases preoperatively, in 10% postoperatively, and recovered spontaneously. Palsies of the other cranial nerves after surgery were much rarer and were as follows: sixth nerve (abducens), 0.5%; ninth nerve (glossopharyngeal), 1.4%; and tenth nerve (vagus), 0.7%. The importance of preservation of function of the nervus intermedius of Wrisberg is stressed. These results emphasize the advantages of the translabyrinthine approach, offering greater security to the facial nerve and lower morbidity.

Geniculate neuralgia: the surgical management of primary otalgia

Intractable, unexplained deep-ear pain presents a rare, albeit significant problem in otolaryngological and neurosurgical practice. The authors review their experience with 18 cases of primary otalgia during the past 15 years. A total of 31 surgical procedures were performed. Seventeen patients had sequential rhizotomies and one patient had microvascular decompression alone. Based on the clinical diagnosis, the nerves sectioned were singly or in combination: the nervus intermedius (14 patients), geniculate ganglion (10 patients), ninth nerve (14 patients), 10th nerve (11 patients), tympanic nerve (four patients), and chorda tympani nerve (one patient). Microvascular decompression of the involved nerves was undertaken in nine patients, in whom vascular loops were discovered. Adhesions (six patients), thickened arachnoid (three patients), and benign osteoma (one patient) were other intraoperative abnormalities noted. The overall success of these procedures in providing pain relief was 72.2%, and the mean follow-up period was 3.3 years (range 1 month to 14.5 years). There was no surgical mortality. Expected side effects were: decreased lacrimation, salivation, and taste related to nervus intermedius nerve section, and transient hoarseness and diminished gag related to ninth and 10th nerve section. Four patients developed sequelae consisting of sensorineural hearing loss, vertigo, and transient facial nerve paresis. One patient had a cerebrospinal fluid leak and another developed aseptic meningitis as postoperative complications. Except when primary glossopharyngeal neuralgia is the working diagnosis, a combined posterior cranial fossa-middle cranial fossa approach is recommended for adequate exploration and/or section of the fifth, ninth, and 10th cranial nerves as well as the geniculate ganglion and nervus intermedius.

Surgical treatment of cluster headache

Cluster headache is ordinarily managed medically, but may become refractory to such medical management. In this setting, surgical treatment has occasionally been performed, based on evidence that pertinent pain pathways and parasympathetic pathways may be interrupted at the main sensory root of the trigeminal nerve and at the nervus intermedius. Between 1976 and 1987, 13 patients underwent surgery for treatment of cluster headache that was refractory to medical therapy (15 procedures). Partial sectioning of the main sensory root and sectioning of the nervus intermedius were performed in nine patients; only partial sectioning of the main sensory root in one; only sectioning of the nervus intermedius in one; and nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve in two. The average postoperative period for the 13 patients was 37 months (range 2 to 135 months). All patients had return of their headaches postoperatively except for one patient who obtained relief after a repeat procedure. Headache began to return between 2 days and 2 years postoperatively. Three patients are currently free of headache, including both patients who had nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve. Together with recurrence of headache, cluster-associated autonomic disturbances recurred after 14 of the 15 operations but are currently absent in the three headache-free patients. Partial sectioning of the main sensory root and sectioning of the nervus intermedius, as performed in these patients, seem to have limited value in the treatment of cluster headache.

Chronic Cluster Headache Managed by Nervus Intermedius Section

Cluster headache sufferers who become candidates for surgical treatment are those relatively rare patients who are refractory to all attempts at pharmacological relief. Ablative surgical procedures have been directed against either the trigeminal nerve or the nervus intermedius/greater superficial petrosal (NI/GSP) pathway. Both carry nociceptive impulses from the head and face, and the NI also carries parasympathetic fibres which appear to be responsible for the autonomic concomitants of cluster headache. Trigeminal operative procedures are not consistently helpful in chronic cluster headache, while NI section has been shown to give potentially long lasting relief but carries the potential risks of cerebellopontine angle surgery. In eight selected cases of chronic cluster headache we have demonstrated a high early success rate for pain relief, with few complications, in the performance of NI section, combined, when indicated, with microvascular decompression of the trigeminal main sensory root. We believe that cochlear nerve monitoring helps prevent postoperative hearing impairment. An intimate relationship between the NI and arterial loops of the anterior inferior cerebellar artery (AICA) or the internal auditory artery has been frequently observed in our chronic cluster headache patients.

The human brain at stage 16, including the initial evagination of the neurohypophysis.

Thirty-nine sectioned embryos of stage 16 were studied. Up to this stage the amygdaloid body is derived entirely from the medial eminence, which was purely diencephalic in stage 14, but now extends also to the telencephalon. The area of the future olfactory bulb is indicated by the presence of olfactory fibres entering the brain wall; the future olfactory tubercle is characterized by cellular islands. The presence of the hippocampal thickening and various histological features make it possible to outline the main, future cortical areas already at this early stage: archi-, paleo-, and neopallium. Hippocampus and area dentata correspond to the areas identified by Hines (1922) and Bartelmez and Dekaban (1962) but not to those identified by Humphrey (1966). The interventricular foramen is wide. The cerebral hemispheres grow rostrally and dorsally, thereby forming the beginning of the longitudinal fissure. Apart from the commissure of the superior colliculi, which began to appear in advanced embryos of stage 14, fibres of the posterior commissure are now present in some specimens. The neurohypophysis is apparent in fewer than half of the embryos. The marginal ridge (zona limitans intrathalamica) separates the dorsal from the ventral thalamus. Cranial nerve 3 emerges from M2. M1 has become shorter. Important pathways are beginning: the olfactory route by the olfactory fibres and the medial forebrain bundle; the vestibular by vestibulocerebellar and vestibulospinal fibres; gustatory by chorda tympani, nervus intermedius, and tractus solitarius. Fibres of the cochlear nerve are noted. The first parasympathetic ganglia, submandibular and ciliary, are identifiable. Asymmetry of the cerebral hemispheres was noted in one specimen.

Neurovascular decompression for cranial rhizopathies.

For some cranial rhizopathies, such as hemifacial spasm and glossopharyngeal neuralgia, treatment has been unsatisfactory. Neurovascular decompression now offers a cure in almost 90% of these cases. In spite of the availability of alternative minor surgical procedures for trigeminal neuralgia, neurovascular decompression, being non-destructive, is a superior method of treatment. Vascular compression may also play a role in atypical facial pain and decompression may offer relief in this intractable condition. Vascular compression was not observed on exploration for nervus intermedius neuralgia, spasmodic torticollis and Meniere's disease. However, microsurgical techniques for selective section of nerves have been beneficial in Meniere's disease and nervus intermedius neuralgia. Neurovascular decompression is a relatively major procedure and is associated with a complication rate of 15%, deafness being most significant. Surgical expertise, a familiar operating team and possibly intraoperative monitoring facilities can reduce these complications.

Cluster headache and the nervus intermedius.

SYNOPSISThe nervus intermedius (NI) appears to be the main conduit of cluster headache (CH). Parasympatheticimpulses via the NI account for the associated symptoms of ipsilateral tearing and redness of the eye,congestion of the nose and rhinorrhea. Vasodilatory stimuli to the internal carotid artery may result inpartial Horner's syndrome and set off a cascade of events causing pain, similar to the changes in theexternal carotid arterial tree during migraine. The pain of CH may also be carried by afferent impulsesaccompanying motor fibers of the deep facial muscles.The central nervous system (CNS) mechanisms responsible for the circannual recurrence of CH may beexcitatory with parasympathetic impulses channeled through the NI. Conversely, inhibitory CNSmechanisms may be invoked to explain long remissions, if CH were to be due to hypersensitivity of the NIas caused by the subtle injury of a cross compressing blood vessel.

Surgical treatment of glossopharyngeal neuralgia and pain from cancer of the nasopharynx. A 20-year experience.

The outcome is summarized for 14 cases operated on for glossopharyngeal neuralgia, with both open and percutaneous rhizotomy techniques, between 1960 and 1984. Four patients, all with primary neuralgia, underwent open surgery. Pain disappeared, leaving only a ninth nerve deficit in all but one patient; in that patient, paroxysms of pain recurred after 3 years, mediated by the nervus intermedius. Five other patients with idiopathic neuralgia and five patients with pain secondary to carcinoma underwent percutaneous procedures. Seven patients who had retrogasserian percutaneous rhizotomy for associated trigeminal neuralgia were also pain-free. No mortality or morbidity resulted from either type of procedure.

Surgical treatment directed to the nervus inter-medius for chronic cluster headache

Surgical treatment directed to the nervus inter-medius for chronic cluster headache

Blinking and Blepharospasm-Reply

In Reply.— We thank Dr Lamberts for his thoughtful comments. In our article, Blinking and Blepharospasm, we concentrated on the mechanisms, diagnosis, and treatment of common neurological and ophthalmologic conditions that cause increased blinking and blepharospasm. Defective tearing is certainly one of the most important ocular disorders, causing eye irritation, increased blinking, and even blepharospasm. We agree with Dr Lamberts that the protective value of proper lacrimation in the normal maintenance of corneal epithelium cannot be overemphasized. Normal reflex tearing may be disturbed by local corneal disease (eg, herpes zoster keratitis), by a lesion in the pontine tegmentum, where the preganglionic sympathetic fibers arise, in the sensory root (nervus intermedius) of the facial nerve, in the greater superficial petrosal nerve or in the deep petrosal nerve, in the sphenopalatine ganglion (eg, nasopharyngeal tumors), and in the ophthalmic or maxillary branches of the trigeminal nerve. An interruption of the afferent or

Genioglossus muscle responses to upper airway pressure changes: afferent pathways.

The afferent pathway of an upper airway reflex in which genioglossus muscle electromyographic (GG EMG) activity is influenced by pharyngeal pressure changes was investigated in 20 anesthetized rabbits. We took advantage of the fact that the upper airway was separated into two compartments by pharyngeal closure occurring when the animals breathe through a tracheostomy. This allowed pressure to be delivered selectively either to the nose and nasopharynx or to the larynx and hypopharynx. Midcervical vagotomy did not eliminate the GG EMG response to pressure stimuli. On the other hand high cervical vagotomy or superior laryngeal nerve section eliminated the response in the laryngeal compartment, but not in the nasopharyngeal compartment. Topical anesthesia of the mucosa of the nose, pharynx, and larynx abolished the response in both compartments. Therefore we conclude that more than one afferent pathway exists for this upper airway pressure reflex; the primary afferent pathway from the laryngeal compartment is the superior laryngeal branch of the vagus nerve, whereas the primary afferent pathway for the nasopharynx is nonvagal. Trigeminal nerve, glossopharyngeal nerve, and/or nervus intermedius carry nonvagal afferents from the nasopharynx and nose. The topical anesthetic and nerve section studies suggest that superficial receptors mediate this response. The occurrence of swallowing in response to upper airway pressure changes and its elimination by topical anesthesia or superior mechanoreceptors may mediate both genioglossus respiratory responses and swallowing responses.

Temporal bone findings in hemifacial microsomia.

The temporal bone findings in a case of hemifacial microsomia are described with photographs. The right facial hypoplasia was associated with anophthalmia and microtia on the same side. The right petrous bone was hypoplastic and showed total superior dehiscence of the internal acoustic meatus. Th otic capsule was deformed with an underdeveloped cochlear modiolus grossly deficient in spiral ganglion population. The spiralling cochlear shell showed partial deficiency of the interscalar septum between the middle and apical coils. The cochlear duct was shorter than that on the normal side; the organ of Corti however was normal. The vestibular system did not show any structural abnormality except for the degeneration and reduction of the Scarpa's ganglion cells and nerve fibers. An additional interesting fact was that the facial nerve was totally absent in the temporal bone except for its nervus intermedius component.

Medical modification of sensation

Pain: June 1977 - Volume 3 - Issue 3 - p 285-286 doi: 10.1016/0304-3959(77)90019-7

Intermedius nerve involvement and testing in acoustic neuromas.

The clinical findings in 125 patients with surgically confirmed acoustic neuromas are presented, with special regard to the involvement of the intermedius nerve in the diagnosis. In assessing the function of the intermedius nerve the examination of the nasolacrimal reflex and the sensation of taste on the anterior two-thirds of the tongue are used. The methods of investigation are described in detail. The material consisted of 20 medium-sized and 105 large tumours; no intracanalicular tumor was found. Hearing loss was the initial symptom in 85% of the patients, 10% had tinitus and 4% vertigo as the first symptom. Apart from the VIII cranial nerve symptoms, a defective nasolacrimal reflex was the most significant evidence of cerebellopontine angle pathology. The test was positive in 65% of the medium-sized tumours, in the entire material, 85%. The figures are higher than the incidence of trigeminal nerve symptoms. This in contrast to the reports of most authors. The tests described are simple and quick to perform, and it is emphasized that they should be applied to all patients with unilateral hearing loss of unknown origin.

The cisternal segment of the nevus intermedius of Wrisberg: an anatomical study under the operating microscope.

Section of the nervus intermedius in the cerebellopontine angle, which can cure some cases of facial neuralgia, is made difficult by the anatomical variability of the nerve, by its intimate relationships with the 7th and 8th cranial nerves and by the connections that the nervus intermedius develops with this nerves.