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Tey were given either loraz- vetiracetam for (mostly) short-term seizure prophylaxis following epam (0 generic viagra 50mg otc. In two randomized controlled trials and four (20 mg/kg infused in 15 min) in an open-label fashion [95] order viagra from india. If sei- observational studies buy viagra without a prescription, there was no superiority of either agent with zures continued 10 min afer completion of the infusion cheap viagra 100mg line, the other respect to early or late seizures, but the quality of the evidence was medication was administered. At 24 hours, seizure-freedom did not difer quality of life in adults with epilepsy signifcantly, with a slight trend favouring levetiracetam over loraz- Results from a double-blind, placebo-controlled efcacy study of epam (79. Despite this, levetiracetam is frequently used well-being, overall quality of life, energy/fatigue, seizure worry of-label and outside of protocols because of its relatively low rate and medication efects) [105,106]. Specifcally, a benefcial impact of cardiorespiratory depression and lack of drug–drug interactions, of levetiracetam over placebo was seen for seizure worry, cogni- which can be important in medically complex patients. However, a recent Improvements observed in levetiracetam starters (n = 66) were neurocritical care guideline supported the use of 20–60 mg/kg sustained long term (mean follow-up 4. In the study in patients with genetic (idio- er adverse efects included dizziness and nervousness. A summary pathic) generalized epilepsy with generalized tonic–clonic seizures of adverse events recorded in placebo-controlled trials is given in [81], treatment with levetiracetam resulted in greater improve- Table 39. In a study where no titration was used, the incidence ments in quality of life from the start of study than with placebo of somnolence, nausea and dizziness was greater during initiation (38. In that study, which sufered from controlled-release carbamazepine in newly diagnosed patients with considerable methodological limitations, levetiracetam (1000 mg/ focal epilepsy [77], discontinuation of treatment because of adverse day) was found to be better than placebo in reducing headache fre- events occurred in fewer patients on levetiracetam (14. A Cochrane review identifed six studies of levetiracetam in 344 Overall, there was no substantial diference in reported adverse adults with six pain syndromes [110]. However, depression of these conditions, and more subjects had adverse efects and more and insomnia were reported signifcantly more ofen with leveti- stopped taking levetiracetam than placebo. More patients gained weight (≥7% the use of leveitiracetam in the treatment of bipolar depression of baseline) on carbamazepine than on levetiracetam; 37 out of 276 [110,111]. Levetiracetam is generally considered not to impact negatively on cognition function. In a study of monotherapy initiation in 55 Adverse effects drug-naïve patients with epilepsy, verbal and visual attention, psy- The adverse efect profle of levetiracetam has been well charac- chomotor speed, mental fexibility, executive function, verbal fuen- terized during phase 1, 2 and 3 clinical trials as well as post-mar- cy and word generation signifcantly improved [114], but lack of a keting experience. Early safety data from 3347 subjects receiving control group makes interpretation of the results difcult. In a small levetiracetam during trials, including 1422 adults and children with open-label study in patients with epilepsy and Alzheimer disease epilepsy, 1558 subjects evaluated in studies for other indications [115], levetiracetam (n = 38) was associated with improved atten- (cognitive disorders, anxiety and deep vein thrombosis) and 367 tion level and oral fuency, but lamotrigine (n = 29) had a better subjects in clinical pharmacology studies, indicated that leveti- efect on mood. Safety data from several double-blinded persistent negative cognitive side-efects. In the adjunctive-therapy controlled trial performed in children with focal seizures, the most common treatment-emergent adverse Safety and tolerability profle from clinical trials in adults events that occurred in at least 10% of levetiracetam-treated patients An analysis of withdrawal rates for adverse events has been and more frequently than in placebo-treated patients were somno- performed on the four double-blind, placebo-controlled, lence, accidental injury, vomiting, anorexia, rhinitis, hostility, in- adjunctive-therapy studies listed in Table 39. In the four double-blind stud- majority of these events were rated as mild to moderate in severity. As the confdence and placebo groups, was consistent with the expected incidence for interval encompassed unity, withdrawal rates did not difer signif- school-age children. Psychiatric and behavioural treatment-emer- cantly between the levetiracetam groups and the placebo groups. In gent adverse events occurring in more than 5% of patients were, the selected prospective, open-label, long-term studies, 14. Incidence (% of patients) Levetiracetam Levetiracetam Levetiracetam Levetiracetam Adverse events Placebo 1000 mg/day 2000 mg/day 3000 mg/day 4000 mg/day Betts et al. A randomized, double-blind, placebo-controlled, Behavioural fndings were consistent with the overall safety profle adjunctive-therapy study using a non-inferiority design assessed the of levetiracetam. Only A Cochrane review of 11 adult and paediatric randomized, events with an incidence >5% in the levetiracetam group and greater double-blind, controlled trials of adjunctive levetiracetam use for with levetiracetam than with placebo are reported. In a pooled analysis of adult and paediatric data, only somnolence occurred statistically more commonly than place- Body as a whole 58. With adults analysed separately, infection was also statistically signifcantly associated with leveti- Respiratory 30. Reproduced with permission from Wolters A systematic review of 13 trials in children found hostility, nerv- Kluwer Health. In the Cochrane review summarized earlier [70], behavioural side-efects, which were signifcantly elevated with levetiracetam use versus placebo in many individual studies, showed broad conf- dence intervals for many of the sub-categories. When these adverse several potential biases, 106 neonates received only phenobarbi- efects were grouped and analysed by age, 22. The lack of behavioural side-efects in adults scores, which were worse with increased cumulative exposure, with in the meta-analysis was considered surprising, given anecdotal re- a decrease of 8 points in the Bayley Scales of Infant Development ports from the clinic and prior published systematic reviews. For levetiracetam, the wors- al side-efects, because patients on antidepressants and other psy- ening in scores was 2. Levetiracetam is generally considered low risk, but more general populations, neurobehavioural side-efects, including should not be considered zero risk, as indicated by a case report of irritability, agitation, anger, and aggressive behaviour, may occur non-fatal anaphylaxis [118]. In placebo-controlled epilepsy trials, hypersensitiv- mained on levetiracetam for over 2 years, negative psychotropic ef- ity reactions led to dose reduction or discontinuation in one pa- fects outweighed positive, with more risk of adverse efects in those tient in the levetiracetam groups, and in six in the placebo groups. The authors acknowledged the signifcant Tere were no reports of Stevens–Johnson syndrome in the clinical bias due to the study design which included only patients who were trials, but two cases were reported in the literature along with one still taking the medication, but shows both positive and negative diagnosed with toxic epidermal necrolysis and one with erythema psychotropic efects resulting from an activating and stimulating multiforme [128]. In at least three of the four pivotal placebo-controlled, double-blind No clinically signifcant adverse efects were observed with any studies of levetiracetam in focal epilepsy, exacerbation of seizures dosage of levetiracetam on blood chemistry tests, or vital signs. Five out of 460 epilepsy Tolerability and safety of the intravenous formulation patients who received levetiracetam in these studies were reported to Two studies have been performed to assess the safety profle of the have had severe seizures [58,59,61]. A prospective but uncontrolled intravenous formulation in adults, one in 48 healthy subjects who study of 78 adults and 44 children with intractable epilepsy com- received a single infusion either at high doses or at high infusion pared seizure frequency at baseline with 8 months on levetiracetam. This included status epilepticus in three adults and tions of administration [131]. This tended to occur in those with learning disabili- The randomized, single-blind, placebo-controlled study in 48 ties at high doses. However, pooling data from three randomized, healthy subjects evaluated the safety, tolerability and pharmacoki- placebo-controlled clinical trials in focal epilepsy[59,60,61], seizure netics of single doses of levetiracetam administered intravenously at exacerbations occurred more frequently in the placebo groups than higher doses (2000, 3000 or 4000 mg over 15 min) or faster infusion in the levetiracetam-treated groups when analysing increases in sei- rates (1500, 2000 or 2500 mg over 5 min) than currently recom- zure frequency by any percentage (44. Among the 25 patients with epilepsy who received levetiracetam Tolerance as an intravenous infusion over a 4-day period [131], a total of 11 Tere has been interest in the question of whether levetiracetam (44%) experienced at least one treatment-emergent adverse event. An analysis of patients continuing on levetiracetam afer the mild or moderate, and those most frequently reported were head- completion of controlled trials indicated that many maintained ache and fatigue. Afer the 4-day twice daily treatment, results of benefts from levetiracetam therapy for up to 5 years [125]. Tirteen clinical examination and laboratory parameters remained stable, no per cent of treated patients were seizure-free for at least 6 months. The results of trials examined seizure-free days over the frst 3 months of treat- these studies suggest a broad tolerability margin of intravenous le- ment and found that seizure-free days were highest in the frst week vetiracetam. However, afer the The good tolerability and safety of intravenous levetiracetam was frst week, efcacy was maintained over time and was always great- confrmed in studies that included paediatric patients. In an interesting case study, a lar, there has been one study in 45 children, adolescents and young patient with severe epilepsy and multiple seizures per day became adults with only one withdrawal due to side-efects [132] and an- initially seizure-free with levetiracetam therapy, but the efect was other study with 30 children, as young as 6 months of age, who tol- completely lost afer the frst few weeks of treatment. Teratogenicity Levetiracetam is currently classifed as a pregnancy category C Cardiac effects drug. Major congen- As of September 2014, over 8 million patient-years of market ital malformations occurred in two from this group (0. Moreover, levetiracetam is generally well tolerated, and can 6 be initiated at a therapeutic dose, with rapid onset of action. Levetiracetam demonstrated non-inferior efca- registry 1st trimester Pregnancy Pregnancy cy to carbamazepine in newly diagnosed patients with focal seizures exposures (2014) Register (2013) Register (2013) [77] and is approved for use as initial monotherapy for adults with fo- n = 648 n = 304 n = 367 cal seizures in Europe. The introduction of an intravenous formulation has increased the use of levetiracetam in hospitalized patients. Tere was no signifcant diference in travenous formulation has regulatory approval only as replacement the levetiracetam dosages between monotherapy and polythera- therapy for patients unable to take oral medication, there have been py groups. Rates of major congenital malformations were higher reports suggesting that levetiracetam can be efective in status ep- when levetiracetam was used in combination with valproic acid ilepticus [94], and its use in patients with highly refractory status (6. In the polytherapy group, higher rates of spon- drug interactions, and low risk of idiosyncratic, haematologic, met- taneous abortions were observed with higher mean levetiracetam abolic and cardiac adverse efects. The most frequently reported ad- doses than pregnancies ending in live births or stillbirths (2306 mg/ verse efects in adults with epilepsy are somnolence, asthenia, nerv- day versus 1801 and 1000 mg/day, respectively; P = 0.

Infusing potent anti- Other potential uses in dermatology include oxidants and amino acids by mesotherapy into the 1 order cheap viagra on-line. Psoriasis Dalia Industrial Estate buy discount viagra 25 mg on line, Off New Link Road discount viagra 100 mg with amex, Andheri (W ) purchase viagra in united states online, M umbai 400058, India 9. Bharia the benefts of mesotherapy include skin rejuvena- M esotherapy is useful for: tion, skin tightening, enhanced blood fow and lymphatic Nutrition: polyvitamins, hyaluronic acid, micro drainage, and the breakdown of sclerotic tissue. M esotherapy protocols for rejuvenation require the Fat dissolution: phosphatidylcholine and/or injection of a combination of drugs that have different deoxycholate. Indications for mesotherapy for rejuvenation include Vitamin A acts on the fexibility of the skin by regu- dull skin, irregular skin texture, and uneven skin tone. By acting on the keratinization process, it favors cicatrization and partially corrects the thinning of the dermis due 23. Vitamin E is an antioxidant due to its major anti- the various drugs used have multiple benefts that radical properties. It maintains the integrity of tissue include the following properties: by fghting the formation of toxic peroxides. Antipigmention – decrease tyrosinase activity Vitamin D is required for the homeostasis of calcium. There are a number of mesotherapy drugs and com- Vitamin K plays a major role in the regulation of the pounds that are used worldwide; these drugs are used microcirculation. The amino acids allow better protein construction, the following substances can be used: minerals guarantee the ionic balance of the medium, 1. L-carnitrans – L carnitine (amino acid) Purascorbol – ascorbic acid¨Taurinox-taurine 13. Biovita-H – biotin¨botulinum toxin Puretinol – retinoic acid¨Pyrustim – sodium 16. Glycolic acid For psoriasis and atopic dermatitis, replenish vita- Drugs for cellulite treatment min C concentration. Centellasial – ivy/sea weed extracts Inhibition of melanogenesis – antityrosinase, anti- M elirutol – coumarin oxidant indications: glow and pigmentation, antiag- L-carnitrans – L carnitine (amino acid) ing, melasma, psoriasis, atopic dermatitis, hair loss, Pyrustim – sodium pyruvate skin healing enhancement. Also of Action used in mixtures for tensing face and body (arms, legs, abdomen) skin. Indications: Antiaging, wound healing, area and on curvatures but is mild and subsides in a alopecia, lypolysis. Liver toxicity, vasovagal attack, and demyelination Taurine which is a semi-essential sulfur containing of nerves have been reported with large doses of beta amino acid found in all tissues. Following mesotherapy there have been Involved in keratinocyte volume hemostasis and reports of atypical mycobacterial infections at sites of hydration in the dermis. This is a newer technique which delivers the mesother- Vasoprotective – prevents progression of athero- apy products by using ultrasound and/or iontophoresis. Indications: antiaging, smokers skin, skin Although it is less traumatic and painless, the effcacy rejuvenation toxicity: it is a non-toxic endogenous of this treatment does not compare to traditional meso- antioxidant. Dermoelectroporation, electroporation, or electropermeabilization causes signifcant increase 23. It is usually used in molecular biology as a way medicine in the right place, using one of the following of introducing some substance into a cell, such as load- techniques. It is formed when the voltage across a plasma membrane simple, painless, and there is no bleeding. If the strength of the technique is useful for patients with low pain thresh- applied electrical feld and/or duration of exposure to it old and is ideal for facial rejuvenation. It is useful for the extracellular compounds have a chance to enter into treatment of wrinkles and alopecia. It is used mainly on purposes and can be used as an alternative to injec- scalp and in the treatment of cellulite. Dermoelectroporation® technology utilizes the Point by point – This is a precise single injection into skin’s water-based “channels” to allow ionic drug solu- the deep dermis. W hen combined These pulses increase the skin permeability and allow with microdermabrasion it allows for a very effcient transdermal delivery of drugs as occurs in traditional transdermal delivery of products. M icrodermabrasion iontophoresis, even if the average current value on the enables a standardization of the skin characteristics, so patient is zero. This was one of macromolecules (greater than 800 Kdalton in size, such the drawbacks with the classical iontophoresis. This as hyaluronic acid, vitamins, amino acids, and heparin) new technique is used to provide the following: are safely delivered into the body without either modi- 1. Skin biorevitalization treatments fcation of the ionic drug solutions pH or electrolysis 2. Needles free mesotherapy applications with traditional iontophoresis systems before both pos- 4. Botox for axillary hyperhidrosis Mesotherapy Solutions for Inducing 24 Lipolysis and Treating Cellulite Benje Gutierrez and Frank L. The way that mesotherapy is practiced is a result of the M esotherapy has become popular in the United way in which it came into being, so a review of the his- States as a treatment for cellulite and to reduce local tory is appropriate. M esotherapy can be divided into injected a man suffering from asthma with procaine dur- two general types. The man’s asthma did not improve, but phosphatidylcholine and deoxycholate to destroy the his deafness improved temporarily. Thus, mesotherapy fat cells, and the second is based on increasing lipoly- was born and was given that name by Dr. The injection of deoxycholate or phosphati- increasingly popular in France, and the injection of pro- dylcholine with deoxycholate results in immediate caine was used for a variety of diseases. Pistor devel- burning, erythema, transient urticaria, and variable oped a syringe with multiple needles to assist in speeding amounts of itching. Biopsies taken one and two weeks the injection process, and mesotherapy has even been following the procedure demonstrate a panniculitis taught in French medical schools. The A smooth appearance to the skin is felt to be beauti- macrophages consist of foam cells and multinucleated ful, but the structure of the subcutaneous adipose tissue fat-containing giant cells. The infammation was asso- in women includes fbrous connective tissue septae that ciated with serious atrophy and microcyst formation surround fat cells and attach to the underside of the skin. Complications of this form of therapy have been As fat cells increase in size, the septa are stretched and reported, including benign neuromas, permanent scar- pull down on the underside of the skin making dimples. Although the the term “cellulite” by Ronsard in her popular book injection of phosphatidylcholine and deoxycholate has been considered mesotherapy, the rest of this chapter will consider nonablative treatments for cellulite and B. The differentiated human adipocytes in tionally been included in mesotherapy injections to 96-well plates generate glycerol into the media in pro- stimulate lipolysis. The results of the used to stimulate lipolysis and reduce cellulite are assay are a comparison of the fold induction of glyc- known to stimulate lipolysis, they are often used in erol induced by the compound being tested compared combination on the presumption that they will work to the buffer. Since these lipolytic combinations and glycerol was measured by adding a glycerol reagent some of the homeopathic remedies have not been that could be read in a colorimetric assay using a spec- tested for their potential to stimulate lipolysis we trophotometer at 540 nm and compared to a standard attempted to fll that knowledge gap. The concentration of the mesotherapy solutions tested was chosen through consultation with the physician mesotherapist who gave us the concentra- 24. The authors discussed mesotherapy lipolytic solu- As expected, isoproterenol, aminophylline, and tions with a physician who practices mesotherapy. M elilotus was shown to stimulate lipoly- compounds that have been demonstrated to stimu- sis signifcantly compared to control, and lipolysis late lipolysis. They were tested alone and in combi- was further stimulated to a signifcant degree over nation to determine whether combining them gives melilotus alone with the addition of aminophylline superior lipolysis. Isoproterenol stimulated lipolysis sig- ver, was chosen to test as an example of a compound nifcantly compared to control, and the addition of that has been used empirically to stimulate lipolysis. W hen that local anesthetics can inhibit lipolysis, we also lidocaine was added to isoproterenol and aminophyl- tested the effect of including lidocaine in the lipoly- line, lipolysis was inhibited to a level no different tic mixture [5]. The combination of 24 Mesotherapy Solutions for Inducing Lipolysis and Treating Cellulite 257 Fig. M elilotus was shown to stimu- aminophylline, and yohimbine, the fold induction late lipolysis and aminophylline was shown to give dropped to less than 1. As lation was still statistically different from control at suggested by prior studies showing the lipolytic inhibi- p < 0. First, it is important to confrm that the Beta products used to stimulate lipolysis in the mesotherapy V Adenosine Alpha 2 practice actually do stimulate lipolysis. Products like V Gs Gs lidocaine which are now routinely included in meso- V therapy solutions and inhibit lipolysis should be elimi- G Adenylate Cyclase G 1 1 nated from mesotherapy solutions in the future.

Computed tomographic images showing a tumor entering the sinus by eroding the lateral wall sphenoid sinus purchase viagra in united states online, eroding the lateral wall of the carotid canal best viagra 75mg, extending to the pterygoideus lateralis purchase viagra 25mg without a prescription, expanding and distorting the temporomandibular joint while eroding the bone on the temporal surface purchase 25mg viagra with visa, causing sclerosis in the mandibular condyle, and eroding the greater wing of the left sphenoid bone. Computed tomography scans of patient with unilateral post-traumatic temporomandibular joint ankylosis. Note the asymmetry secondary to fibrous ankylosis on the left condyle different left and right mandibular ramus lengths. Early treatment of unilateral temporomandibular joint ankylosis: a multidisciplinary approach. The temporal styloid process extends from the temporal bone in a caudad and ventral direction and serves as the cephalad attachment of the stylohyoid ligament (Fig. Patients suffering from Eagle syndrome have either an abnormally elongated styloid process or a calcified stylohyoid ligament which in certain positions of the head and neck have the potential to compress the internal carotid artery, the internal jugular vein, branches of the glossopharyngeal nerve, and surrounding structures (Fig. The glossopharyngeal nerve exits from the jugular foramen in proximity to the vagus and accessory nerve and the internal jugular vein and passes just inferior to the styloid process (Fig. All three nerves lie in the groove between the internal jugular vein and internal carotid artery. Compression of these nerves can result in a variety of symptoms including glossopharyngeal neuralgia, otalgia, dysphagia, and cardiac bradyarrhythmia. The anatomy of the styloid process and stylohyoid ligament and their surrounding anatomic structures. The elongated styloid process and/or calcified and thickened stylohyoid ligament can impinge on the internal carotid artery causing carotidynia. A,B: the glossopharyngeal nerve exits from the jugular foramen in proximity to the vagus and accessory nerve and the internal jugular vein and passes just inferior to the styloid process. Eagle syndrome is caused by an abnormally elongated styloid process or a calcified and thickened stylohyoid ligament (Fig. Named after Watt Weems Eagle, an American otolaryngologist who described the syndrome in 1937, Eagle syndrome is characterized by a constellation of symptoms which include a sharp stabbing cervical and craniofacial pain that occurs with turning of the neck or mandible. The pain starts below the angle of the mandible and radiates into the tonsillar fossa, temporomandibular joint, and the base of the tongue. A trigger point may be present in the tonsillar fossa in a manner analogous to glossopharyngeal neuralgia. Patients suffering from Eagle syndrome may also complain of otalgia, dysphagia, a foreign body sensation, tongue pain, and tinnitus. The elongated styloid process and/or thickened and calcified stylohyoid ligament can also impinge on the internal carotid artery and internal jugular vein (Figs. Eagle syndrome is a syndrome of the third to fifth decade although the syndrome can occur at any age. The ultrasound-guided injection technique for Eagle syndrome serves as both a diagnostic and therapeutic maneuver. Ultimately, surgical resection of the elongated styloid process and/or calcified stylohyoid ligament may be required to cure the syndrome. Diagnosis of Eagle syndrome with 3- dimensional angiography and near-infrared spectroscopy: case report. An imaginary line is drawn from the mastoid process to the angle of the mandible (Fig. A linear ultrasound transducer is then placed over the previously identified approximate location of the styloid process in the transverse plane (Fig. Color Doppler can be used to help confirm location of the vessels and their relationship to the styloid process (Figs. Care is taken to identify any abnormal mass or cyst that may be impinging on nerves or vessels. To identify the location of the styloid process, an imaginary line is drawn from the mastoid process to the angle of the mandible. Proper placement of the linear ultrasound transducer over the previously identified styloid process. Transverse ultrasound image demonstrating the relationship of the carotid artery, jugular vein, glossopharyngeal nerve, and vagus nerve to the mastoid bone. Transverse ultrasound image demonstrating the styloid process and stylohyoid ligament. Color Doppler image of the relationship of the carotid artery and stylohyoid ligament. Because both glossopharyngeal neuralgia and Eagle syndrome can be associated with serious cardiac bradyarrhythmias and syncope, the clinician must distinguish between the two syndromes as the ultimate curative treatments for these syndromes are very different. Given the low incidence of Eagle syndrome relative to other causes of pain in this anatomic region including pain secondary to malignancy, Eagle syndrome must be considered a diagnosis of exclusion. The clinician should always evaluate the patient who suffers from pain in this anatomic region for occult tumors including tumors the larynx, hypopharynx, and anterior triangle of the neck as these tumors may present with clinical symptoms that may mimic Eagle syndrome (Fig. The tumor had grown through the clearly widened left jugular foramen, extending paraspinally along the sternocleidomastoid muscle to the level of D2. A: the mass in the left cerebellopontine angle displaced the brainstem medially and compressed the fourth ventricle. B: Enlarged jugular foramen with tumor mass inside expanding to the parapharyngeal space. D: the intracranial mass had grown through the jugular foramen to the paraspinal region. E: the mass in the left cerebellopontine angle displaced the brain stem medially and compressed the fourth ventricle. Giant dumbbell-shaped intra- and extracranial nerve schwannoma in a child presenting with glossopharyngeal neuralgia syncope syndrome: a case report and review of the literature. In: Comprehensive Atlas of Ultrasound-Guided Pain Management Injection Techniques. The glossopharyngeal nerve exits from the jugular foramen in proximity to the vagus and accessory nerve and the internal jugular vein and passes just inferior to the styloid process (Fig. All three nerves lie in the groove between the internal jugular vein and internal carotid artery (Fig. 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. Information from the carotid sinus and body that helps control blood pressure, pulse, and respiration is carried via the carotid sinus nerve, which is a branch of the glossopharyngeal nerve. Postganglionic fibers from the ganglion carry secretory information to the parotid gland. The anatomy of the glossopharyngeal nerve and its relationship to the carotid artery and jugular vein. Compromise of the glossopharyngeal nerve by an elongated styloid process and/or a thickened and calcified stylohyoid ligament secondary can cause Eagle syndrome (see Chapter 12). Glossopharyngeal neuralgia is a rare condition characterized by paroxysms of pain in the sensory division of the ninth cranial nerve. It is thought to be due to compression of the glossopharyngeal nerve at the cerebellopontine angle (Fig. Although the pain of glossopharyngeal neuralgia is similar to that of trigeminal neuralgia, it occurs 100 times less frequently. The pain is unilateral in most patients, but can occur bilaterally 2% of the time. Rarely, the pain of glossopharyngeal neuralgia is associated with bradyarrhythmias; in some patients, it is associated with syncope (Fig. These cardiac symptoms are thought to be due to overflow of neural impulses from the glossopharyngeal nerve to the vagus nerve. Although rare, this unusual combination of pain and cardiac arrhythmia can be lethal. With the increased use of headphones, clinical reports of compressive neuralgia of the extracranial branches of the glossopharyngeal nerve are becoming more common. This syndrome is triggered by tactile stimulation of the external ear and is termed headphone neuralgia. A,B: In a patient with familial paragangliomas, a right vagal glomus tumor causing otalgia (A) and asymptomatic bilateral carotid body tumors (B) are seen (arrows). C: the contrast-enhanced T1-weighted image shows the enhancing mass between the anterior and medially displaced carotid (c) and posterior and laterally displaced jugular vein (j).