Tommy Flannagan: A 47-Year-Old Male With Severe Episodic Throat and Ear Pain

Learning Objectives

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Learn the common causes of facial pain.
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Develop an understanding of the unique anatomy of the glossopharyngeal nerve.
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Develop an understanding of the sensory innervation of the hypopharynx.
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Develop an understanding of the causes of ear pain.
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Develop an understanding of the differential diagnosis of throat and ear pain.
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Learn the clinical presentation of glossopharyngeal neuralgia.
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Learn testing options to diagnose glossopharyngeal neuralgia.
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Learn how to use physical examination to diagnose glossopharyngeal neuralgia.
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Develop an understanding of the treatment options for the various types of facial pain.

Tommy Flannagan

Tommy Flannagan is a 47-year-old male electrician with the chief complaint of, “I’m getting sharp pains in my throat and ear every time I swallow.” Tommy stated that over the last 3 weeks, he had been having electric shocks that started in the back of his throat and then shot up into his ear. Tommy said that the pain would come out of nowhere and then go away as quick as it came. He said that it seemed like when he coughed or cleared his throat, it would trigger the pain, as did swallowing and sometimes chewing meat. “Tommy, is the pain on both sides or just on one side?” He replied, “It’s always on the left, Doc. It’s never on the right.” Tommy went on to say that he had tried a heating pad and Tylenol, but the pain continued to get worse. I asked Tommy if had ever had anything like this before, and he shook his head no. I asked what made it better, and he said he had been “living off Campbell’s tomato soup” to avoid triggering the pain, but that nothing really worked. I asked how he was sleeping, and he said he had taken to sleeping in his recliner because every time he rolled over onto his right side in bed, it triggered the pain that woke him. Tommy denied any fever or chills.

On physical examination, Tommy was afebrile. His respirations were 16 and his pulse was 68 and regular. His blood pressure was 118/72. His fundoscopic examination was normal. It took some convincing to get Tommy to open his mouth to let me examine his hypopharynx. I noted that Tommy still had his tonsils, but his dentition looked fine, and there was no obvious tumor or mass. When I touched the area just below the left tonsil with the tongue depressor, Tommy immediately cried out in pain and jerked away from me. I was glad that my fingers weren’t in his mouth or he may have bitten them off. “Doc, warn me when you are going to do that again! It’s really bad, and I need to have hold of something.”

When I told him I wanted to take a look at his ears, he went nuts. “Doc, can you put me out before you look? I just don’t know how much more of this pain I can take! It’s horrible, worse than anything you can imagine. I did not know that anything could hurt this bad!” I said, “Let’s start with the right ear and go from there. How about that?” Tommy was reluctant, but said, “Do what you have to do, Doc. I have to get better or I am done for. I am afraid this will hit when I am up on a ladder at work. What did I do to deserve this?” His right ear exam was normal, and with much convincing, I got a quick look at his left ear, which appeared completely normal. His cardiopulmonary examination and thyroid were normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable.

I asked Tommy to point with one finger to show me where it “hurts the most” and with great care to avoid touching his submandibular area, he pointed to a point just below the mandible near the trachea on the left. “Doc, the pain starts way down deep in here—way at the back of my throat here—and it shoots up into my ear. Kinda ironic, isn’t it? Here I am an electrician, and my own body is shocking me.” A careful neurologic examination of the upper extremities revealed that there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. There were no pathologic reflexes. “One more question, Tommy. When you get the pain, do you ever get lightheaded or feel like you are going to pass out?” Tommy shook his head no and said, “Doc, never anything like that, but when it’s really bad, I think about blowing my brains out. I guess it’s a good thing that I don’t have any guns.” I told Tommy that I was pretty sure I knew what was going on and that we had a lot of treatment options to get on top of this pain. Tommy replied, “From your mouth to God’s ears.”

Key Clinical Points—What’s Important and What’s Not

The History

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No history of previous facial pain
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No fever or chills
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Recent onset of unilateral throat and ear pain characterized by electric shocklike pain centered at the back of the throat on the left and radiating into the ipsilateral ear
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Onset to peak of seconds to 1 minute
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Pain is episodic with pain-free periods
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Pain triggered by swallowing, clearing of the throat, and chewing
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Trigger areas in the hypopharynx in the tonsillar area on the left
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Sleep disturbance
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High degree of anxiety regarding pain with suicidal ideation

The Physical Examination

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Patient is afebrile
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Trigger areas in the hypopharynx on the left
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No obvious tumor or mass in the hypopharynx
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Normal ear examination bilaterally
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Normal neurologic examination
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Normal fundoscopic examination
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No fever

Other Findings Of Note

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Normal cardiovascular examination, specifically no bradycardia or asystole
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal neurologic examination, motor and sensory examination
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No pathologic reflexes

What Tests Would You Like to Order?

The following tests were ordered:

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Magnetic resonance imaging (MRI) of the brain with special attention to the brainstem
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Magnetic resonance angiography (MRA) of the cerebral circulation
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Electrocardiogram (ECG) with rhythm strip taken when patient triggers the pain
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Erythrocyte sedimentation rate

Test Results

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MRI of the brain with special attention to the brainstem revealed compression by the posterior inferior cerebellar artery as it crossed the glossopharyngeal nerve on the right ( Fig. 14.1 ).

Fig. 14.1

(A) Magnetic resonance imaging (MRI) axial three-dimensional (3D) T2 SPACE. The arrow points to the posterior inferior cerebellar artery that crosses the glossopharyngeal nerve closely. (B) MRI axial 3D time of flight. The hyperintense line next to the brainstem is the thick posterior inferior cerebellar artery. T2 SPACE , Sampling perfection with application optimized contrasts using different flip angle evolution.

From den Hartog AW, Jansen E, Kal JE, et al. Recurrent syncope due to glossopharyngeal neuralgia. Hear Case Rep . 2017;3(1):73–77.
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MRA confirmed the path of the inferior cerebellar artery as it crossed the glossopharyngeal nerve on the right.
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ECG with rhythm strip was within normal limits.
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The ESR is within normal limits.

Clinical Correlation—Putting It All Together

What is the diagnosis?

Glossopharyngeal neuralgia

The Science Behind the Diagnosis

Anatomy Of The Glossopharyngeal Nerve

The glossopharyngeal nerve exits from the jugular foramen in proximity to the vagus and accessory nerves and the internal jugular vein and passes just inferior to the styloid process ( Fig. 14.2 ). All three nerves lie in the groove between the internal jugular vein and internal carotid artery. The glossopharyngeal nerve (cranial nerve IX) contains both motor and sensory fibers. The motor fibers innervate the stylopharyngeus muscle. The sensory portion of the nerve innervates the posterior third of the tongue, palatine tonsil, and the mucous membranes of the mouth and pharynx. Special visceral afferent sensory fibers transmit information from the taste buds of the posterior third of the tongue. The carotid sinus nerve, which is a branch of the glossopharyngeal nerve, carries information from the carotid sinus and body to help control blood pressure, pulse, and respiration. Parasympathetic fibers pass via the glossopharyngeal nerve to the otic ganglion. Postganglionic fibers from the ganglion carry secretory information to the parotid gland. The glossopharyngeal nerve lies in proximity to the vagus nerve as well as the spinal accessory nerve, which has significant clinical implications both in terms of cardiac arrythmias and compression by vascular structures ( Figs. 14.3 and 14.4 ).