Geniculate Neuralgia

Geniculate neuralgia, also known as nervus intermedius neuralgia, is a rare facial pain disorder that involves attacks of severe, electric-shock or stabbing pain in the ear. It is a cousin to more common facial pain disorders including trigeminal neuralgia and glossopharyngeal neuralgia.

The pain attacks are usually brief but intense; some patients describe that it feels like an ice pick is stabbing into the ear. Attacks can be triggered by touching the ear, yawning, swallowing, chewing, talking, hot showers, or other innocuous activities. Many patients are pain-free between attacks, but the anxiety of not knowing when one might occur can be debilitating.

Geniculate neuralgia is thought to be due to irritation of the nervus intermedius, a small branch of the facial nerve that supplies sensation to part of the ear canal (see below). The cause is often compression of the nerve by a nearby blood vessel, akin to other neurovascular compression syndromes: trigeminal neuralgia, glossopharyngeal neuralgia, and hemifacial spasm.

Medications for geniculate neuralgia are the same as those for trigeminal neuralgia, namely carbamazepine (Tegretol) and oxcarbazepine (Trileptal), lamotrigine (Lamictal), and others. The diagnosis of geniculate neuralgia is clinical, meaning it is based on your symptoms and physical examination. I will order an MRI of your brain, but this is mostly for treatment planning and to exclude other problems.

If a patient has persistent symptoms despite medications, the preferred treatment for geniculate neuralgia is a microvascular decompression. In this procedure, the nervus intermedius is identified, decompressed, and sometimes sectioned (cut). There can be considerable overlap between the symptoms of geniculate neuralgia, trigeminal neuralgia, and glossopharyngeal neuralgia; for that reason, I will also inspect and decompress the trigeminal and glossopharyngeal nerves, as needed.

Microvascular decompression is effective for geniculate neuralgia, but I choose patients very carefully for this procedure. True geniculate neuralgia is very rare; most patients referred to me for geniculate neuralgia actually have trigeminal neuralgia or glossopharyngeal neuralgia. If you think you may have geniculate neuralgia or a related facial pain disorder, please consider meeting me in consultation to learn more.