Correspondence

More on Headphone Neuralgia

N Engl J Med 1996; 334:1480-1481May 30, 1996

Article

To the Editor:

Skelton and Fried recently coined the phrase “headphone neuralgia” (Dec. 28 issue).1 The external ear, unlike its middle and internal counterparts, is a major neurologic crossroads. Its canal and the outer surface of the tympanic membrane are supplied by general somatic afferent fibers (for pain, temperature, and touch) from three cranial nerves: the trigeminal, facial, and vagus nerves (cranial nerves V, VII, and X, respectively). In turn, the skin of the auricle and retroauricular area are supplied by the cervical plexus, with a small contribution from cranial nerves VII and X.2 However, most modern neuroanatomists and clinicians specializing in the ear agree that the glossopharyngeus (cranial nerve IX), the nerve of the third branchial arch, does not have any cutaneous representation. To attribute the patient's syndrome exclusively to cranial nerve IX represents a misunderstanding of the embryologic, anatomical, and clinical complexity of the external ear.

The patient probably had a craniofacial polyneuralgia, possibly of viral origin,3 involving cranial nerves V and VII (“the pain radiated from the external auditory meatus to the ipsilateral parietal area of the head”), cranial nerves IX and X (pain on the side of the neck and pharynx), and cranial nerve XI and the cervical plexus (“over a period of several hours, it spread to the left shoulder”). Such polyneuralgia would also explain why “yawning, eructation, swallowing, and raising the left arm while driving all triggered the pain,” whereas glossopharyngeal neuralgia would not. In fact, the shoulder is anatomically and clinically unrelated to the third branchial arch; therefore, it can never be a “trigger zone” for glossopharyngeal neuralgia.

Because the patient was a 37-year-old woman, she was at high risk for vagoglossopharyngeal neuralgia.3 “Paroxysmal, lancinating pain in the left ear” with a pattern of radiation consistent with an idiopathic craniofacial polyneuralgia calls for careful ear, nose, and throat and neurologic evaluation,4 for the headphone hypothesis advanced by the authors is a bit far-fetched.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Osvaldo Bustos, M.D.
Office of the U.S. Army Surgeon General, Falls Church, VA 22041

4 References

1. 1

   Skelton AK, Fried RA. Headphone neuralgia. N Engl J Med 1995;333:1786-1787
   Full Text | Web of Science | Medline

2. 2

   Head and neck. In: Mathers LH Jr, Chase RA, Dolph J, Glasgow EF, Gosling JA. Clinical anatomy principles. St. Louis: Mosby, 1996:133-305.
   

3. 3

   Mandel S. Facial pain: “Why does my face hurt, doctor?“ Postgrad Med 1990;87:77-80
   Web of Science | Medline

4. 4

   Trauma. In: Rowland LP, ed. Merritt's textbook of neurology. 9th ed. Baltimore: Williams & Wilkins, 1995:417-95.
   

Author/Editor Response

Dr. Skelton replies:

To the Editor: Dr. Bustos correctly points out the complex innervation of the ear. He does not mention the tympanic branch of the glossopharyngeal nerve (Jacobson's nerve), which may overlap the vagal territory in the external auditory meatus.1

Glossopharyngeal neuralgia is a well-defined syndrome with characteristic pain, radiation of pain, and triggers. Our patient's symptoms were entirely consistent with glossopharyngeal neuralgia as described in modern textbooks.2

To postulate that a viral craniofacial polyneuralgia involving five cranial nerves caused the patient's symptoms is more “far-fetched” than the theory that the immediately preceding trauma to the external auditory meatus caused unilateral symptoms all attributable to the glossopharyngeal nerve. Although glossopharyngeal neuralgia of this origin had not been described previously, I maintain that we presented the most likely explanation for the symptoms.

Further neurologic evaluation was not warranted because the diagnosis was clear, and the symptoms resolved once the cause was removed. To date, two years later, there has been no recurrence of glossopharyngeal neuralgia or any other craniofacial pain.

Ann K. Skelton, M.D.
Maine Medical Center, Portland, Maine 04102

2 References

1. 1

   Diseases of the cranial nerves. In: Adams RD, Victor M, eds. Principles of neurology. 5th ed. New York: McGraw-Hill, 1993:1170-83.
   

2. 2

   Victor M, Martin JB. Disorders of the cranial nerve. In: Wilson JD, Braunwald E, Isselbacher KJ, et al., eds. Harrison's principles of internal medicine. 12th ed. Vol. 2. New York: McGraw-Hill, 1991:2076-81.