facial pain/styloid mastoid pain

[PinchandBurn]

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I've got this lady with chronic left side facial pain. Point of max tenderness is over the styloid mastoid process. Pain then goes to facial nerve distribution.

She's tried conservative measures. Opioids, anti-inflam,etc. No benefit. I was goint to do this injection using Waldman's technique, I've done it a few times in fellowship.

How do you all code for this? It cant just be 64450 is it? Seems a bit invasive and somewhat more tedious.

Is there a code for "cranial nerve injection". Technically one is blocking the vagus, accessory, and glossopharygneal nerves.

 

[101N]

Just out of curiosity: how old is she?

 

[PinchandBurn]

Just out of curiosity: how old is she?

80s.

I know there's something called Eagles Syndrome. Her Styloid process isnt 'elongated' however. Additionally, she has been seen by TMJ specialists and had injections/et by DDS without benefit. Looking at the literature, often times the pain is referred from the styloid process.

 

[drf]

I've done it with fluoro walking off the styloid and stimming as well as with US and actually finding the nerve. It's a bit tricky.

I had one genuine Eagles. Skull X-ray based on exam with elongated styloid and cured by mu ENT.

 

[101N]

She's old enough to have isolated C1/2 arthropathy. Pain from this will be focal, Lt suboccipital and occasionally radiating up the occiput to vertex (C2 root). Make sure you take a look at a dens view to ensure you're not dealing with a funny referral pattern from the C1/2 the Lt jnt. This would be a more common occurance.

Also, why not trigeminal neuralgia? Also more common.

 

[PinchandBurn]

She's old enough to have isolated C1/2 arthropathy. Pain from this will be focal, Lt suboccipital and occasionally radiating up the occiput to vertex (C2 root). Make sure you take a look at a dens view to ensure you're not dealing with a funny referral pattern from the C1/2 the Lt jnt. This would be a more common occurance.

Also, why not trigeminal neuralgia? Also more common.

doesnt appear like TN. This is very localized over teh styloid process.

also....many of the textbooks, including Waldman's, suggest using DEPOMEDROL. Given proximity to carotid and jugular vein, are you guys clinically doing this? could place dexamethasone, but it's not 'depot'....the only other option would be to do just local anesthetic, see if pain resolves, then do a pRF of the structure.

 

[PMR 4 MSK]

80s.

I know there's something called Eagles Syndrome.

Is that the one diagnosed by some guy in a Hotel named California?

I hear the treatment for this is you need to Take it Easy, and try not to Take It to the Limit, except for an occasional Tequila Sunrise...

 

[NOSfan]

I know there's something called Eagles Syndrome.

Bingo...can be a calcified ligament as well as an elongated styloid process . Get some plain skull x-rays and let the radiologist know what you are looking for.

You can inject using fluro or without (see note below). CPT 64450

In the prone position, the angle of the right/left mandible and mastoid process were identified. At a point midline in a line between these landmarks, and after sterile prep, a 25-guague 1.5" needle was slowly advanced until contact with the styloid process. After contact, the needle was redirected posterior and advanced just slightly off the styloid process. Next, after negative aspiration to ensure non-vascular placement, a solution of 3 cc 0.25% PF Marcaine and 40 mg of Depo-Medrol was slowly instilled in incremental fashion without complication. The needle was withdrawn and the patient tolerated the procedure well. The patient's neck was re-inspected without evidence of hematoma. The patient's pulse, blood pressure, and respiration remained stable throughout. The patient was followed for 30 minutes and discharged under their own power in stable condition

 

[PinchandBurn]

Bingo...can be a calcified ligament as well as an elongated styloid process . Get some plain skull x-rays and let the radiologist know what you are looking for.

You can inject using fluro or without (see note below). CPT 64450

In the prone position, the angle of the right/left mandible and mastoid process were identified. At a point midline in a line between these landmarks, and after sterile prep, a 25-guague 1.5” needle was slowly advanced until contact with the styloid process. After contact, the needle was redirected posterior and advanced just slightly off the styloid process. Next, after negative aspiration to ensure non-vascular placement, a solution of 3 cc 0.25% PF Marcaine and 40 mg of Depo-Medrol was slowly instilled in incremental fashion without complication. The needle was withdrawn and the patient tolerated the procedure well. The patient’s neck was re-inspected without evidence of hematoma. The patient’s pulse, blood pressure, and respiration remained stable throughout. The patient was followed for 30 minutes and discharged under their own power in stable condition

pt has all s/s of Eagle Syndrome, but w/o the elongated process.

Did the injection today under fluro. Wow, was that a scary one given teh vessels that are close by!!