Cases in which I'm stumped...

[aggernodi]

OK... So I thought I would start a new thread to bring up cases in which we've been stumped by. I have two that is kicking my butt in how to treat/what to do. Hopefully, somebody will have a bright idea that I've not thought of.

Case #1:

56F w/o any medical history or medications, presents with 6 month history of shooting pain in the left ear (not around, but down in the middle ear region). The pain is described as lasting no more than one second, but it would knock her off her feet it hurts so bad. It happens about only 3-4 times per day. Physical exam is totally normal including fiberoptic exam. BOT and tonsil palpation totally normal. CT neck & t-bone w/ contrast normal. Audio, tympanogram normal. Myringotomy (as a shot in the dark) did not resolve either.

I tried her on steroid nasal sprays, astelin, prednisone burst and taper, PPI, magic mouthwash, and even antibiotics out of desperation (even though I never saw anything that looked like infection)...nothing improved it even a little. Eventually I sent to tertiary care center, and even the prof there just told her to see a GI doc due to reflux etiology...even though I've had her on PPI bid for at least 3 months.

Also, of note, no precipitating movements. She does yoga and twists her head and body in all wierd directions, any nothing can trigger it. It just comes and goes at random times.

Any ideas? I'm totally stumped...

Case #2:

23M w/o any medical history or meds presents with a 1 year history of burning lump sensation in the base of tongue region. Just like case #1, physical exam, fiberoptic exam, as well as CT neck all normal. For this patient, I even tested for food and inhalant allergy which all came back negative as well. Palpation of BOT was WNL, but patient reported that was the precise location where he feels the discomfort. He also failed to improve on 3 month trial of PPI, 6 week course of antibiotics, prednisone burst and taper, magic mouthwash, etc.

I took to OR and did an extensive BOT biopsy that all came back showing the dreaded "inflammation" but no evidence of neoplasia. Also sent to academic center where they just said it was due to reflux and refer to GI... Of course, nothing helped from reflux treatment as I had already tried all that.

Any ideas?

BTW, has anyone ever performed lingual tonsillectomy for lingual tonsil hypertrophy? I've read reports of people using laser, coblation, or suction cautery. I've never done it before, but am curious about it.

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[resxn]

Case #1
Have you already considered a neurosurgery consult for trigeminal neuralgia? Perhaps an MRI/MRA/MRV can help determine whether there is a vessel in proximity. I know the pain typically is described as pre-auricular, but with the short duration and severity it sounds very suspicious for tic deloroux [sp?].

Case #2
In the absence of all positive findings in your extensive work-up, I'd be sure to treat for up to 6 months with BID PPI before ruling out reflux (and/or let GI do some dual probes). A couple of things that I'd do in addition, if you haven't already is get a modified barium swallow (speech therapist present) and perform a functional endoscopic evaluation of swallowing with sensory testing (FEESST for the students on this board). I think that these are likely to be negative, but may help detect a motility disorder. My best guesses are cricopharyngeal spasm (consider an empiric Botox injection for both diagnostic and therapeutic reasons) or reflux.

I've done a few lingual tonsillectomies, not for globus, but usually for OSA. I use the Coblator and am pretty impressed with the lack of pain. I hate using the Coblator for tonsillectomies but will use it there when requested. However, I love using it for base of tongue reductions as well as lingual tonsillectomies. It works great and the recovery is much faster than I would have previously expected.

I had a similar lady with globus and the absence of any other findings with a similar work-up and 5 months of PPI's. The only thing she's got is a 3mm vallecular cyst which is unchanged. I've scheduled her for MDL and marsupialization, but couldn't find anything in the literature to support treatment of globus by removal of small, simple lingual tonsillar or vallecular cysts. Anyone have any experience with this?

 

[srabiei]

Case #1:
I agree with (resxn )
But you must consider the Referral pain from Dental origin, because the 57% of earache related to this kind of pathology
Any infection in root of tooth lead to pain that more often is referral to Ear.

Case #2:
The history is positive for Globus so Sedative and Fluxetin 10mg at morning may be sufficient.

 

[aggernodi]

Thanks for the replies... Regarding case #1, trigeminal neuralgia is an interesting thought. I always thought it to be a more diffuse facial pain, but it's definitely possible! I've already ruled out dental pain and TMJ with an oral surgeon.

For case #2, I'm pretty sure it is NOT globus as the burning lump is at the level of the hyoid bone. Also, when I palpate the BOT region, patient reports that's exactly the region where he is feeling the discomfort. I had someone mention metal allergy as a possibility. I'm going to send out some tests on this last point.

 

[neutropeniaboy]

Case #1
I've done a few lingual tonsillectomies, not for globus, but usually for OSA. I use the Coblator and am pretty impressed with the lack of pain. I hate using the Coblator for tonsillectomies but will use it there when requested. However, I love using it for base of tongue reductions as well as lingual tonsillectomies. It works great and the recovery is much faster than I would have previously expected.

I just have to throw in an aside on this topic of lingual tonsillectomies.

I've done a few with the coblator as well. (As another aside, I don't mind the Coblator II for palatine tonsillectomies. It's slower than electrocautery [my preferred] or intracap, but it's not so bad.) When I was a PGY-2, I did a lingual tonsillectomy for chronic lingual tonsillitis via a suprahyoid pharyngotomy. No joke. He was an older attending...

 

[neutropeniaboy]

On the subject, your case sounds more like glossopharyngeal neuralgia than trigeminal neuralgia. You might do a trial of Tegretol or Neurontin. There's actually a website. I've referred a couple of patients to it before: http://www.ninds.nih.gov/disorders/glossopharyngeal_neuralgia/glossopharyngeal_neuralgia.htm

 

[aggernodi]

On the subject, your case sounds more like glossopharyngeal neuralgia than trigeminal neuralgia. You might do a trial of Tegretol or Neurontin. There's actually a website. I've referred a couple of patients to it before: http://www.ninds.nih.gov/disorders/glossopharyngeal_neuralgia/glossopharyngeal_neuralgia.htm

Say, that sounds awfully like what my case #1 has... Thanks! I've actually never really been exposed to this entity before, but definitely worth a try with neurontin.