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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 36  |  Issue : 3  |  Page : 156-158

A rare event of vestibular complication following percutaneous trigeminal radiofrequency ablation


Epione – Center for Pain Relief, Hyderabad, Telangana, India

Date of Submission14-May-2021
Date of Decision02-Sep-2021
Date of Acceptance06-Oct-2021
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Vinoth Kumar Elumalai
No 3/77 Selai Kandigai, Selai Post, Thiruvallur Taluk and District, Chennai - 631 203, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_46_21

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  Abstract 


We report here to draw attention to an uncommon complication that could arise from routinely performed procedure in pain practice such as percutaneous trigeminal radiofrequency ablation (RFA). We report a case of a 53-year-old female who underwent trigeminal nerve RFA for trigeminal neuralgia. RFA after adequate assessment with sensory and motor stimulation is performed as a routine procedure followed by 0.2 ml 1% lignocaine for dense sensory block at the target, following which the patient developed giddiness, nausea, vomiting, and nystagmus. After 2 h of rest and gaze fixation, her symptoms improved, with a decline in the severity of nystagmus. Symptoms gradually resolved over a period of 3 h. Proximity of the membranous part of the auditory tube to the foramen ovale might lead to such mishaps. Direct administration of 1% lignocaine into the middle ear via the auditory tube might be the most likely reason for her condition.

Keywords: Auditory tube, middle ear pressure, nystagmus, radiofrequency ablation, trigeminal neuralgia, vertigo


How to cite this article:
Dara S, Elumalai VK, Chandra M. A rare event of vestibular complication following percutaneous trigeminal radiofrequency ablation. Indian J Pain 2022;36:156-8

How to cite this URL:
Dara S, Elumalai VK, Chandra M. A rare event of vestibular complication following percutaneous trigeminal radiofrequency ablation. Indian J Pain [serial online] 2022 [cited 2022 Dec 7];36:156-8. Available from: https://www.indianjpain.org/text.asp?2022/36/3/156/361625




  Background Top


Trigeminal neuralgia (TN), also known as tic douloureux, is considered to be one of the most physically and psychologically painful conditions a human being might suffer. Based on etiology, TN may be classical TN or secondary TN (STN). In the classical variety, there is a neurovascular conflict leading to compression of the trigeminal nerve or an underlying condition that affects this nerve in case of STN. TN affects males and females of all ages. TN has a prevalence of 0.1–0.2 per 1000 and an incidence ranging from 4 to 20 cases per 100,000 people per year.[1] According to a study by Bangash, right-sided involvement along with mandibular division was the most commonly affected.[2] Radiofrequency ablation (RFA) of the trigeminal nerve is an established treatment modality for TN, particularly in the elderly and patients with comorbidities with an immediate pain relief in 98% of patients.[3] However, complications include diminished corneal reflex, masseter weakness and paralysis, dysesthesia, anesthesia dolorosa, keratitis, and transient paralysis. Accidental injury to the auditory canal followed by administration of local anesthetic may cause a sudden increase in middle ear pressure, leading to vestibular complications such as vertigo, dizziness, and nausea. One such incidence was reported following mandibular nerve block; however, the incidence is negligible in RFA of the trigeminal nerve.


  Case Presentation Top


A 53-year-old female with complaints of left-sided facial pain corresponding to a NRS score of 9/10 extending from the cheek, nose, lips upto the tongue for the past 4–5 years, which is associated with headache visited the pain clinic unable to speak, swallow food and drink water. The pain mimics an electric shock and comes in paroxysms. She was prescribed tablet carbamazepine 800 mg/day and tablet baclofen 10 mg/day, despite which the pain was intolerable. She did not have any other comorbidity, did not on any other medications, and had never undergone any neurosurgical oromaxillary facial surgeries in the past. She gave a history of multiple episodes of fall following giddiness 4 years back. Routine blood investigations were carried out along with magnetic resonance imaging in the Fiesta view that revealed a vascular loop formed by the anterior inferior cerebellar artery around the trigeminal nerve, indicating a Type 1 Trigeminal neuralgia (classical variety). Trigeminal nerve V2, V3 rhizotomy was planned, and after proper counseling and obtaining informed written consent, after securing a 20G intravenous (IV) cannula, and under prophylactic antibiotic coverage, the patient was shifted to operation theater. She was positioned in the neck extended position with standard monitoring (SpO2, NIBP, HR, and 5-lead ECG) and oxygen via nasal prongs at 2 l/min. Midazolam 1mg IV was administered after locating the foramen ovale under Fluoroscopy, an opening in the greater wing of the sphenoid bone which is usually located anteromedial to the external auditory. Following 2 ml local anesthesia infiltration with 2% lignocaine at the site of entry, a 5 mm active curved tip radiofrequency needle was introduced and advanced into the foramen oval in the submental vertex view, and the electrode is advanced ~2 mm further through the canal of the foramen ovale such that the tip of the electrode reaches the junction of the petrous ridge of the temporal bone and the clivus. The stylet is then removed from the cannula, and aspiration is performed to ensure that there is no cerebrospinal fluid (CSF) or blood, and end point was confirmed in the lateral view as seen in [Figure 1] and [Figure 2].
Figure 1: End point in anteroposterior view

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Figure 2: End point in lateral view

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Sensory and motor stimulations were confirmed with 50 Hz and 2 Hz, respectively, after a positive masseter twitch, before RFA 0.2 ml of 1% lignocaine was administered to achieve a dense sensory block.[3] First lesion was done with 60°C for 1 min followed by second lesioning with 70°C for 1 min without repeating injection midazolam. The sensation over the cheek, corneal reflex, masseter twitch, and deviation of the angle of mouth were assessed. The needle was rotated and reinserted further toward the V2 division of the trigeminal ganglion and checked for sensory stimulation over the cheek which was negative/corresponding to ~ 4–5 mm within the foramen; once 0.2 ml of 1% lignocaine was administered patient complained of giddiness, nausea immediately associated with nystagmus, and further procedure was abandoned. She complained of nausea for which 4 mg injection ondansetron was administered, and after 20 min, she was shifted to the trolly after which she had an episode of vomiting associated with severe vertigo. She was shifted to the recovery room and observed for 2 h; giddiness and nystagmus settled gradually. The intensity of vertigo had reduced from Vertigo Severity Scoring 10–4; however, she had nystagmus on change in posture. At the end of 3 h, she complained of headache which was managed with injection paracetamol 1 gm, and her symptoms drastically subsided, after which she was discharged in the evening after an ophthalmologist opinion, counseling, and medications.


  Discussion Top


TN RFA is a safe and effective method for the treatment of TN. The mortality risk is extremely low with this modality, making it very appealing for elderly, frail patients, or the ones where other comorbidities enhance the risk of open neurosurgical therapy.[4] In the absence of a microvascular decompression (MVD), glycerol rhizotomy may provide relief of pain.[5] Radiofrequency rhizotomy is the procedure of choice for most patients planned for initial surgical management, whereas MVD is recommended for young and healthy patients who have isolated pain in the first ophthalmic trigeminal division or in all three trigeminal divisions and patients who desire no sensory deficit.[5] In a study by Kanpolat et al., out of 1600 people undergoing 2138 rhizotomies, complications included diminished corneal reflex in 91 patients (5.7%), masseter weakness and paralysis in 66 (4.1%), dysesthesia in 16 (1%), anesthesia dolorosa in 12 (0.8%), keratitis in 10 (0.6%), and transient paralysis. Permanent cranial nerve VI palsy was observed in two patients, CSF leakage in two, carotid-cavernous fistula in one, and aseptic meningitis in one.[6]

The proximity of foramen ovale to the cartilaginous part of the auditory canal puts it into risk of accidental injury. Rhinorrhea or CSF fistula in the nasopharyngeal cavity after Radiofrequency Trigeminal Rhizotomy (RF-TR) may be unanticipated initially. The tuba auditive (Eustachian tube) lies between the middle ear and the pharynx and regulates the pressure in the middle ear. The membranous part is very close to the foramen ovale. During penetration into the foramen ovale, the Eustachian tube can be punctured easily. If CSF is observed at this stage, a fistula between Meckel's cave and the Eustachian tube may occur. CSF then flows from the auditory canal to the nasopharynx and then through the choanae to the nose.[7] Vestibular nystagmus may result from dysfunction of the labyrinth as well as the vestibular nerve. Peripheral vestibular nystagmus results from asymmetric sensory cochlear complex input. Increased pressure in the middle ear following inadvertent local anesthetic administration stimulates the vestibulo-labyrinthine complex. Complete unilateral loss of labyrinth function produces a mixed horizontal–torsional nystagmus that may be suppressed by visual fixation.[8] Pathologies affecting the vestibular labyrinth or nerve cause a jerk nystagmus with a linear or constant slow phase velocity. Typically, the nystagmus increases when the eyes are turned in the direction of the fast phase and it is suppressed by visual fixation. The direction of the nystagmus is opposite to the side of the lesion. A change in head position may exacerbate this nystagmus.[9] Other rare but unanticipated events such as sudden bradycardia due to trigeminocardiac reflex and sudden irreversible blindness have been reported.[10],[11]


  Conclusion Top


Since TN is a condition which takes a toll on the quality of life, minimally invasive procedures such as percutaneous rhizotomy should be brought to light. Nevertheless, such modalities of treatments do not come without complication may it be because of anatomical variations, practitioner expertise, and inadequate facilities. With precision and image guidance, inadvertent injury to Eustachian tube, cavernous sinus and the middle meningeal artery may be avoided. Due to the lack of awareness regarding these procedures, a miniscule portion of the patients actually approach pain physicians. The numbers are expected to rise in the near future so are the complications, and with a meticulous approach and attention, to detail such catastrophic events may be avoided.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kataria S, Ahmed Z, Ali U, Ahmad S, Awais A. Trigeminal neuralgia induced headache: A case report and literature review. Cureus 2020;12:e9226.  Back to cited text no. 1
    
2.
Bangash TH. Trigeminal neuralgia: Frequency of occurrence in different nerve branches. Anesth Pain Med 2011;1:70-2.  Back to cited text no. 2
    
3.
Doshi P, Parikh N. Radio-frequency ablation of trigeminal ganglion for refractory pain of bilateral trigeminal neuralgia in a patient with multiple sclerosis. Indian J Pain 2018;32:113.  Back to cited text no. 3
  [Full text]  
4.
Golby AJ, Norbash A, Silverberg GD. Trigeminal neuralgia resulting from infarction of the root entry zone of the trigeminal nerve: Case report. Neurosurgery 1998;43:620-2.  Back to cited text no. 4
    
5.
Comparison of Surgical Treatments for Trigeminal Neuralgia: Reevaluation of Radiofrequency Rhizotomy | Neurosurgery | Oxford Academic. Avaialble from: https://academic.oup.com/neurosurgery/article-abstract/38/5/865/2812508?redirectedFrom=fulltext. [Last accessed on 2021 Mar 28].  Back to cited text no. 5
    
6.
Kanpolat Y, Savas A, Bekar A, Berk C. Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients. Neurosurgery 2001;48:524-32.  Back to cited text no. 6
    
7.
Ugur HC, Savas A, Elhan A, Kanpolat Y. Unanticipated complication of percutaneous radiofrequency trigeminal rhizotomy: Rhinorrhea: Report of three cases and a cadaver study. Neurosurgery 2004;54:1522-4.  Back to cited text no. 7
    
8.
Vestibular Nystagmus – An Overview | Science Direct Topics. Available from: https://www.sciencedirect.com/topics/medicine-and-dentistry/vestibular-nystagmus. [Last acessed on 2021 Mar 28].  Back to cited text no. 8
    
9.
J Chrisanthus, S George, Nystagmus. Nystagmus. Int J Otorhinolaryngol Clin 2012;4:93-9.  Back to cited text no. 9
    
10.
Meuwly C, Golanov E, Chowdhury T, Erne P, Schaller B. Trigeminal cardiac reflex: New thinking model about the definition based on a literature review. Medicine (Baltimore) 2015;94:e484.  Back to cited text no. 10
    
11.
Agazzi S, Chang S, Drucker MD, Youssef AS, Van Loveren HR. Sudden blindness as a complication of percutaneous trigeminal procedures: Mechanism analysis and prevention. J Neurosurg 2009;110:638-41.  Back to cited text no. 11
    


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