NERVUS INTERMEDIUS

NEURALGIA

Presented by
SYED.KHAJA ALIUDDIN
M.Sc.D-- ENDO
THE sensory compartment of the facial nerve that
innervates the ,

External auditory meatus,

Parts of the external auditory meatus,

Parts of pinna of the ear.

A small zone of the skin beneath and behind the lobe of

the ear, is called the NERVUS INTERMEDIUS.
When a paroxysmal neuralgia affects this nerve it is
called nervus intermedius neuralgia.

This conditions is also referred to as GENICULATE

OR SEVENTH NERVE NEURALGIA.
 CLINICAL FEATURES
PAIN is felt
Tympanic memberane.
Walls of the auditory canals.
The external auditory meatus.
External structure of the ear.

OCCASIONALY pain is felt,

In the tongue,palate,deeply in facial structure.
IN a neuralgic process,one part of the afferent
distribution may be involved without implication of
the whole nerve,and the site of the painvaries
accordingly.

Since fibers of the facial nerve innervates the anterior

two third of the tongue and part of the soft palate,the
actual propensity for numerous sites of the painand
triggering is great indeed.
THE COMMON DIFFERNTIAL DIAGNOSIS
Nervus intermedius may sometimes clinically
confused with migraine.
Following guidelines may be helpful in differentiating.
Neuro vascular pain has characteristics of deep
somatic pain, usually with a component of throbbing.
THE pain distribution often follows the vascular
arborization. Neuralgia is neuropathic and has a wide
spread distribution that makes anatomic sense to a
knowledgeable examiner.
Neurovascular pain is often accompanied by central
excitatory effects not evident with neuralgia.
If a surgical approach is comtemplated and positive
identification of the affected nerve is required,this can
be done by a neurosurgical suboccipital exposure
under local anesthesia for direct stimulation of the
nerve intermedius.
This condition may be associated with a herpes zoster
infection of the geniculate neuralgia.
 Case Report
History and Examination.
This 52-year-old woman presented with a 6-year
history of paroxysmal pain of the right auditory canal,
pinna, and adjacent retromastoid area.

She also described experiencing ipsilateral tinnitus,

right-sided hearing loss, and continuous unsteadiness,
which was complicated by vertiginous spells that
resembled bouts of motion intolerance and that were
precipitated by head movement.
She was treated with carbamazepine administration in
high doses, but this proved ineffective.
 Her previous medical history was remarkable for
arterial hypertension during medication
administration and for bilateral carpal tunnel
syndrome.
Pure tone audiometry of the patient showed complete
sensorineural right-sided hearing loss. Hearing in the
left ear was normal.
This thorough neuroimaging sequence showed that
the (AICA) anterior inferior cerebellar was extensively
curved, had entered into the IAC, internal auditory
canal and was clearly compressing the seventh and
eighth cranial nerves.

Operation and Postoperative Course.

The patient underwent a right retromastoid

craniotomy. After minimal retraction of the
cerebellum, the seventh and eighth cranial nerves
were identified.
 The sensory branch of the seventh cranial nerve was
identified as a separate branch from the rest of the
nerve that was being compressed by the arterial loop

Intraoperative views of the patient through the microscope under magnification. Left:
The loop of the AICA is shown running between the facial (upper) and
cochleovestibular (lower) nerves.

Right: View after the placement of the Teflon band between the AICA and the facial
nerve.
The artery was mobilized, and a Teflon narrow band
was placed between the artery and the seventh and
eighth cranial nerves to separate the artery from the
nerves.

The postoperative course was uneventful, apart from

mild peripheral facial nerve palsy. The paresis resolved
completely during the next 3 months. The intensity
and frequency of the otalgia (the paroxysmal pain of
the right auditory canal and the adjacent area)
decreased markedly.
The pain resolved completely during the next 6
months. In addition, the patient experienced a gradual
relief from the vertigo and tinnitus.
A postoperative audiogram demonstrated an
improvement of hearing in the right ear. Importantly,
neither sectioning of the intermediate nerve nor
excision of the GG was necessary to achieve this
excellent outcome.
 Discussion
Vascular branches in close anatomical relationship to
a cranial nerve (neurovascular proximity) may cause
compression and dysfunction of the nerve.
The pulsating artery or compression-induced
demyelination, chronic inflammatory response, and
increased excitability.
Neurovascular proximity may be present at birth,
although it may not become clinically evident until the
development of atherosclerosis and ectatic distortion
of vascular loops that compress the adjacent nerves
Geniculate neuralgia is a rare, insufficiently
understood ear canal pain. The term geniculate
neuralgia has been applied rather loosely to describe
various chronic ear or facial aches of various causes.

Geniculate neuralgia remains a diagnostic challenge

because it can be either idiopathic or secondary to
diseases of the ear or structures remote from the ear.
Intermediate nerve neuralgia was originally reported
in 1991 and also remains insufficiently understood.
The few reported patients with this condition include
cases related to herpetic infection.

In the past, without the use of preoperative imaging,

surgeons used exploratory craniotomies and MVDs,
sectioning of cranial nerves innervating the ear area
(fifth, seventh, ninth, and 10th), or excision of the GG
to treat ear canal pain.
The selection of surgical treatment seems to have
been based on the surgeon’s personal experience and
interpretation of the intraoperative findings rather
than on a firm preoperative diagnosis.
The treatment approaches for the presumed GN have even
been targeted to nerves with no known connections to the
GG.
The intermediate nerve and the GG should be excised to offer
an effective treatment for intractable INN. (intermediate
nerve neuralgia)

The present case does show that the problem of paroxysmal

otalgia can be restricted only to the intermediate nerve; in this
sense, this case represents a well-documented, distinct clinical
entity. When paroxysmal otalgia is proven to be caused by
intermediate nerve compression using combined MR
angiography and intraoperative findings, the chronic pain
should be considered a variant of GN,
Our data suggest that the wider clinical entity of GN and
atypical facial pain syndromes should be revisited using
modern sophisticated neuroimaging. This reassessment
may prove necessary because, currently, neuromodulatory
treatments of severe cephalalgias may gradually become a
serious alternative to the conventional microneuro
surgical approaches; therefore, it is expected that, in the
future, MVD(microvascular decompression) procedures
may need to be reserved for those particular cases in
which the relevant vessel is sufficiently visualized by
advanced digitized neuroimaging techniques.
Thank you all