Discomfort swallowing and neck pain not getting better.

[pastafan]

47 y.o. athletic veterinarian had abrupt onset of right sided neck pain and dysphagia when he suddenly turned his head while bicycling to look behind him. He was seen by ENT, GI and had EGD/imaging/barium swallow all normal, no Eagle syndrome. Neurologist did EMG, diagnosed dystonia and wanted to do botox. Pt. Felt near pushed botox for everything and refused. Failed PT, muscle relaxants, TPI, NSAIDs and topical meds prior to seeing me.

He had shoulder/neck pain along with ℅ scapular pain. MBB set C5,6,7 provided 90-100% pain relief so RFA performed but he did not get relief from RFA. On subsequent visit he complained of a different shoulder pain and liftoff test positive. Injected shoulder with relief of that pain and improved ROM. Sent to PT for shoulder.

Now still has “tightness” when he swallows on right side of throat along with right neck pain. I’m looking for suggestions on what to do next and thoughts on the cause of his pain.

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[SommeRiver]

...have you tried just a regular ol CESI?

Also, when was this? Like 3 months ago?

 

[DODOCSS]

47 y.o. athletic veterinarian had abrupt onset of right sided neck pain and dysphagia when he suddenly turned his head while bicycling to look behind him. He was seen by ENT, GI and had EGD/imaging/barium swallow all normal, no Eagle syndrome. Neurologist did EMG, diagnosed dystonia and wanted to do botox. Pt. Felt near pushed botox for everything and refused. Failed PT, muscle relaxants, TPI, NSAIDs and topical meds prior to seeing me.

He had shoulder/neck pain along with ℅ scapular pain. MBB set C5,6,7 provided 90-100% pain relief so RFA performed but he did not get relief from RFA. On subsequent visit he complained of a different shoulder pain and liftoff test positive. Injected shoulder with relief of that pain and improved ROM. Sent to PT for shoulder.

Now still has “tightness” when he swallows on right side of throat along with right neck pain. I’m looking for suggestions on what to do next and thoughts on the cause of his pain.

CT CS soft tissue w/

 

[SSdoc33]

What'd MRI show?

You don't diagnose dystonia with an EMG

 

[pastafan]

Onset April 18, 2017. He told me that eagle syndrome had been ruled out but now I see CT neck with contrast read as normal although rt styloid 4.2 cm and left 3.8 cm but ENT thought this was ok. Glossopharyngeal nerve block?

 

[Orin]

I'm not sure though of the descriptors of pain being c/w a glossopharyngeal neuralgia but if that seems like your diagnosis, TCAs/SNRIs/anticonvulsants seem to be have been skipped over.

I like the idea of the block, but in my hands, it generally spills over to a few other nerves even with low volumes due to the small spaces. What approach would you use? Is your plan recurrent injections or to use that as a diagnostic to recommend surgery?

How do you explain the false positive from the C5/C6/C7 MBNBs or the shoulder pain with glossopharyngeal neuralgia?

If he has a pain sensitization issue, the oral meds make sense. I might even try a higher stellate to see how he does with a sympathectomy.

 

[pastafan]

I'm not sure though of the descriptors of pain being c/w a glossopharyngeal neuralgia but if that seems like your diagnosis, TCAs/SNRIs/anticonvulsants seem to be have been skipped over.

I like the idea of the block, but in my hands, it generally spills over to a few other nerves even with low volumes due to the small spaces. What approach would you use? Is your plan recurrent injections or to use that as a diagnostic to recommend surgery?

How do you explain the false positive from the C5/C6/C7 MBNBs or the shoulder pain with glossopharyngeal neuralgia?

If he has a pain sensitization issue, the oral meds make sense. I might even try a higher stellate to see how he does with a sympathectomy.

1. He has been on gabapentin and I believe TCA/SNRI prior to seeing me. I need to check what meds.

2. Benumof taught me his technique decades ago. The nerve is visible at the base of the tongue. Use a tongue blade to push tongue to the side and inject an ml of local through the mucosa on the nerve. I have used this as part of awake intubation strategy along with superior laryngeal nerve blocks. The question is whether this would be too distal on the nerve? May miss tympanic branch of nerve. I was planning on using this diagnostically although if he got significant, long lasting improvement then I may repeat block.

3. Can't explain shoulder pain as part of the neuralgia. I think that he also had a partial rotator cuff tear as demonstrated by liftoff test, decreased ROM, and improvement with injection/PT. MBB false positive not related to neuralgia.

These are reasons why I have posted case here. I appreciate the input.