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Objective: Neurophysiological intraoperative monitoring of the glossopharyngeal nerve has been performed only with needle electrodes inserted into the pharyngeal muscles or soft palate. We describe a noninvasive method of monitoring this cranial nerve., Methods: A 30-year-old man who presented with headache, as well as speech and swallowing difficulty, underwent surgical resection of a right vagus nerve schwannoma. Neurophysiological intraoperative monitoring of multiple lower cranial nerves, including the glossopharyngeal and vagus nerves, was performed., Results: The glossopharyngeal nerve was monitored with an adhesive surface electrode mounted on the cuff of a laryngeal mask airway, and the vagus nerve was monitored with a similar electrode mounted on the endotracheal tube. Successful monitoring allowed separation of the glossopharyngeal nerve from the tumor, and there was no postoperative swallowing deficit., Conclusion: Monitoring of the glossopharyngeal nerve with surface electrodes is possible and reliable, but it must be combined with vagus nerve monitoring.

Intracranial section of the glossopharyngeal and upper vagal rootlets for the treatment of vagoglossopharyngeal neuralgia may cause dysphagia or vocal cord paralysis from injury to the motor vagal rootlets in 10% to 20% of cases. To minimize this complication, we recently applied a technique of intraoperative monitoring of the vagus nerve (previously described by Lipton and McCaffery to monitor the recurrent laryngeal nerve during thyroid surgery) in a patient undergoing intracranial rhizotomy for vagoglossopharyngeal neuralgia. By inserting an electrode in the ipsilateral false vocal cord and stimulating the rostral vagal rootlets intraoperatively under general anesthesia, we could differentiate the rostral vagal motor rootlets from the sensory rootlets. In this patient, the technique allowed us to preserve a rostral vagal rootlet, which if sectioned, could have caused dysphagia or vocal cord paralysis. We conclude that intraoperative monitoring of the rostral vagal rootlets is an important technique to minimize complications of upper vagal rhizotomy.

Glossopharyngeal neuralgia is an uncommon craniofacial pain syndrome. An association with syncope is even less common. We report a case illustrating that the glossopharyngeal neuralgia-syncope syndrome can occur without pain in the sensory distribution of the glossopharyngeal nerve and that it can have similar consequences. We suggest that permanent cardiac pacing alone may be a viable option in the initial management of such cases.