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The Microsurgical Anatomy of the Glossopharyngeal Nerve with Respect to the Jugular Foramen Lesions

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The Microsurgical Anatomy of the Glossopharyngeal Nerve with Respect to the Jugular Foramen Lesions Neurosurg Focus 17 (2):E3, 2004, Click here to return to Table of Contents The microsurgical anatomy of the glossopharyngeal nerve with respect to the jugular foramen lesions MEHMET FAIK ÖZVEREN, M.D., AND UG˘UR TÜRE, M.D. Department of Neurosurgery, Firat University School of Medicine, Elazig; and Ondokuz Mayis University School of Medicine, Samsun, Turkey Removal of lesions involving the jugular foramen region requires detailed knowledge of the anatomy and anatom- ical landmarks of the related area, especially the lower cranial nerves. The glossopharyngeal nerve courses along the uppermost part of the jugular foramen and is well hidden in the deep layers of the neck, making this nerve is the most difficult one to identify during surgery. It may be involved in various pathological entities along its course. The glos- sopharyngeal nerve can also be compromised iatrogenically during the surgical treatment of such lesions. The authors define landmarks that can help identify this nerve during surgery and discuss the types of lesions that may involve each portion of the glossopharyngeal nerve. KEY WORDS • glossopharyngeal nerve • jugular foramen • lower cranial nerve • microsurgical anatomy GLOSSOPHARYNGEAL NERVE ANATOMY ized by dysphagia, loss of the gag reflex, or fullness in the pharynx.8,27,30 They may also have a role in essential hy- The glossopharyngeal nerve can be divided into three 29,33 13,42 portions: cisternal, jugular foramen, and extracranial. pertension and syncope attacks. Exuberant choroid plexus tissue may become large enough to cause glos- sopharyngeal neuralgia.38 The vessel that most common- Cisternal Portion ly causes glossopharyngeal neuralgia seems to be the PICA,43 but the anterior inferior cerebellar artery can also The rootlets of the glossopharyngeal nerve originate compress the nerve.13,30,31,42 In some cases, vascular cross- from the upper part of the postolivary sulcus of the medul- compression by adhesions between the PICA or the VA la oblongata. These rootlets then usually form one root and rootlets of the glossopharyngeal nerve was a factor in that courses forward and laterally on the anterior side of essential hypertension and syncope attacks either with or the flocculus and choroid plexus (Fig. 1). Its entrance por- without glossopharyngeal neuralgia.13,29,33,42 us is separated from the entrance of the vagus and acces- Glossopharyngeal neuralgia is characterized by attacks sory nerves by a dural crest in the jugular foramen (Fig. of pain originating from the tonsil, tongue, or pharynx and 2). The mean length of the cisternal portion of the glos- 7 40 radiating to the ear or the mandibular angle. The par- sopharyngeal nerve is 15 mm. The VA is located below oxysms are usually provoked by swallowing, especially and behind the jugular foramen. The PICA runs very close of cold liquids, but coughing, sneezing, and touching the to the four lower cranial nerves, loops around the hypo- external meatus or ear lobe can also trigger pain. The pain glossal nerve, and then courses along the fibers of the ac- may also begin in the ear and spread to the pharynx, which cessory nerve (Figs. 1 and 3). has led to a clinical distinction between the pharyn- The first landmarks of the glossopharyngeal nerve in geal and tympanic types of glossopharyngeal neuralgia. the subarachnoid space are the flocculus and the chor- 40 Some investigators have described a cardiovascular type oid plexus of the lateral recess of the fourth ventricle. in which the neuralgia is accompanied by bradycardia The glossopharyngeal nerve may be compromised in this and arterial hypotension that causes syncope and con- space by a vascular loop, a tortuous and ectatic basilar vulsions.7,13 Glossopharyngeal neuralgia is classically artery, an inflammatory process, a Chiari malformation, divided into primary and secondary groups. No cause can a neurenteric cyst, an exuberant choroid plexus, or a tu- be demonstrated in the primary type, but it is believed that mor.7,8,16,21,22,25,29,31,33,38,48 These pathological processes may 7,25,31,38 trauma, elongation of the styloid process, inflammation, cause glossopharyngeal neuralgia, paresis character- tumors, and vascular deformities may cause the second- ary type. Abbreviations used in this paper: CCA = common carotid artery; The glossopharyngeal nerve generally is easily recog- ECA = external CA; ICA = internal CA; IJV = internal jugular vein; nized within the lateral cerebellomedullary cistern in both OA = occipital artery; PICA = posterior inferior cerebellar artery; normal anatomical conditions and cases of vascular com- SCM = sternocleidomastoid; VA = vertebral artery. pression. If the subarachnoid space is filled with tumor tis- Neurosurg. Focus / Volume 17 / August, 2004 12 Unauthenticated | Downloaded 09/24/21 08:38 PM UTC M. F. Özveren and U. Türe mately 45˚ from where it courses upward from its entrance porus. The nerve then travels through the jugular foramen in a channel leading from the pyramidal fossa below the opening of the cochlear aqueduct. Continuing on the me- dial side of the intrajugular ridge, this channel sometimes extends medially and surrounds the nerve to form a tun- nel. The glossopharyngeal nerve courses through this tun- nel on the medial aspect of the jugular bulb. The passage of the glossopharyngeal nerve in the jugular foramen is separated from the vagus and accessory nerves by a bone canal (Fig. 3A) or generally by a thick, fibrous band.40 The glossopharyngeal nerve encounters the superior and infe- rior ganglia in its course inside the jugular foramen (Fig. 3B). The superior glossopharyngeal ganglion is located just below the opening of the cochlear aqueduct within the jugular foramen. The tympanic nerve (nerve of Jacobson) originates from the inferior ganglion and enters the inferi- or tympanic canaliculus, ascending in the canal on the medial wall of the middle ear, usually on the cochlear promontory (Figs. 3B and 4).17,40 The tympanic and supe- rior and inferior caroticotympanic nerves form the tym- panic plexus.57 This plexus supplies the mucous mem- brane of the tympanic cavity, the mastoid cells, and the auditory tube; parasympathetic fibers also pass through the tympanic plexus via the lesser petrosal nerve to the otic ganglion to supply the parotid gland.3,7,44,57 A branch from the tympanic plexus goes through an opening in front of the fenestra vestibuli and joins the greater petros- al nerve.57 The nerve of Arnold is the auricular branch of the superior ganglion of the vagus nerve (Fig. 4). It reach- es the descending canal of the facial nerve through the mastoid canaliculus and supplies the back of the pinna and the external acoustic meatus.3 The nerve of Arnold also Fig. 1. Anterior view of the left cerebellopontine angle showing receives branches from the glossopharyngeal nerve, the origin of the glossopharyngeal nerve (IX) at the postolivary sul- which exits the jugular foramen posteromedial to the sty- cus of the medulla oblongata. AICA = anteroinferior cerebellar loid process and styloid muscles. The mean length of the artery; BA = basilar artery; CP = choroid plexus; FLC = flocculus; 40 O = olive. Roman numerals denote cranial nerves. Reprinted with jugular portion of the glossopharyngeal nerve is 10 mm. permission from Lippincott, Williams and Wilkins. Ozveren MF, The intrajugular processes of the temporal and occipital et al: Anatomic landmarks of the glossopharyngeal nerve: a micro- bones divide the anterior and posterior edges of the jugu- surgical anatomic study. Neurosurgery 52:1400–1410, 2003. lar foramen into sigmoid and petrosal parts.10,26,44 Occa- sionally, a deep groove is present along the medial exten- sion of the intrajugular process of the temporal bone. This groove forms a canal that surrounds the glossopharyngeal sue, however, the flocculus and choroid plexus may be 26,44 distorted or may change their anatomical positions, and nerve as it passes through the jugular foramen. The the glossopharyngeal nerve is not so easily recognized. genu is located at the external opening of the cochlear Therefore, defining a constant landmark becomes critical. aqueduct. The bone canal of the glossopharyngeal nerve appears in fewer cases than the fibrous tissue separation.4, The glossopharyngeal nerve and the vagus and accessory 9,26,44,54 nerve complex are consistently separated by a dural sep- Thus, the course of the glossopharyngeal nerve is tum that forms two meatus on the intracranial side of the separate from that of the vagus and accessory nerve com- jugular foramen; these have been named the glossopha- plex inside the jugular foramen. ryngeal meatus and the vagal meatus.44 The dural septum The glossopharyngeal, vagus, and accessory nerves are that separates the glossopharyngeal nerve from the fas- well protected in the bone structure of the jugular fora- men. Nerve function lost by trauma indicates that the de- cicles of the vagus and accessory nerves at the dural 37,56 entrance of the glossopharyngeal nerve into the jugular gree of trauma is very severe. If the lesion is a tumor, foramen is a consistent structure.49 This is the second land- loss of nerve function indicates the highly invasive nature mark of this nerve in the subarachnoid space.40 of the tumor. In addition to trauma, glomus jugulare tu- mors, chordomas, meningiomas, schwannomas, rhabdo- myosarcomas, metastatic tumor invasion, infection, and Jugular Foramen Portion cholesterol granulomas can also involve the glosso- The cochlear aqueduct drains vertically into the en- pharyngeal nerve at the jugular foramen.1,2,10,24,27,37,48,56 Be- trance porus of the glossopharyngeal nerve (Figs. 2B and cause the glossopharyngeal, vagus, and accessory nerves 3B). The nerve itself forms a genu inferiorly, approxi- course together in the jugular foramen, lesions involving 13 Neurosurg. Focus / Volume 17 / August, 2004 Unauthenticated | Downloaded 09/24/21 08:38 PM UTC Glossopharyngeal nerve anatomy Fig.
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