Resolution of Glossopharyngeal Neuralgia & Spastic Dystonia
Following Chiropractic Care to Reduce Upper Cervical Vertebral
Subluxation: A Case Study
Michael Burcon B.Ph., D.C.1 & Jennifer Pero D.C. 2

Resolution of Glossopharyngeal Neuralgia & Spastic Dystonia
Following Chiropractic Care to Reduce Upper Cervical Vertebral
Subluxation: A Case Study
Michael Burcon B.Ph., D.C.1 & Jennifer Pero D.C. 2
ABSTRACT
Objective: This case study reports the improvement in quality of life experienced by a patient with Glossopharyngeal
neuralgia undergoing upper cervical specific care as an alternative to medication or surgery.
Clinical Features: An 82 year old female presented with right-sided Glossopharyngeal neuralgia of ten years duration.
Pain was helped by medication and exacerbated by talking, swallowing, coughing, quick head movements and air
conditioning. Daily prescriptions included Gabapentin, 5700 mg.
Patient had a case history of falling on her head in a snow skiing trauma at age sixteen followed by possible whiplash
injuries when falling on ice that same year and a vehicular accident in 1984. Patient had constant stabbing pain with
tremor in right temple, face, tongue and throat. She could only manage to whisper a few words at a time. Posture
analysis, leg length equality, modified Prill tests, thermography, and cervical x-rays supported evidence of vertebral
subluxation at atlas, axis, C4, C5 and C6.
Intervention and Outcomes: Immediately after specific adjustments to C5, C2 and C1, pain diminished from 10 to 1.
Tremor was eliminated. Head tilt, eye clarity and facial color returned to normal. She could talk normally. Two days later
pain was zero. Under her neurologist’s supervision, she started reducing her Gabapentin. Six weeks later, patient
presented with straight thermograph, balanced legs, and was pain-free without medication.
Conclusion: This case demonstrates the effectiveness of upper cervical specific care as an alternative to medication or
surgery for the control of pain associated with Glossopharyngeal neuralgia.
Key Words: Glossopharyngeal neuralgia, upper cervical subluxation complex, specific chiropractic adjustments, whiplash,
Gabapentin (Neurontin)
Introduction
Amongst the lower six cranial nerves, the glossopharyngeal
nerve (CN IX) is the smallest in terms of nerve diameter,
importance and clinical significance.1 Additionally, when
compared with the facial, vestibulococchlear (CN VIII), vagus
(CN X), accessory (CN XI), and hypoglossal (CN XII) nerves,
CASE STUDY
1. Private Practice of Chiropractic, Great Rapids, MI
2. Private Practice of Chiropractic, Summerville, SC
J. Upper Cervical Chiropractic Research Glossopharyngeal neuralgia – January 6, 2014 7
the glossopharyngeal nerve appears dwarfed in comparison.
Otolaryngologists and other clinicians are consciously aware
of the presence of the facial, vagus, accessory and hypoglossal
nerves, for these nerves are commonly encountered in neck
surgery. Inadvertent surgical injury to these nerves result in
clinically obvious problems like facial palsy, vocal cord palsy,
shoulder dysfunction from denervation of the trapezius
muscle, and speech problems arising from tongue deviation.
The glossopharyngeal nerve lies deep within the neck, and
surgeons often do not encounter the nerve even with deep
dissections. The nerve is not commonly identified or
visualized even when performing a major neck operation, for
example, a radical neck dissection.1
Cranial nerves (CN) IX through XI all leave the skull together
through the jugular foramen.2,3 Cranial nerves IX and X are
closely related, and often difficult to separate in clinical
situations. For example, testing this nerve would include the
gag reflex, but this would be testing both CN IX and X. The
glossopharyngeal nerve has sensory, parasympathetic and
motor components. The sensory division receives general
sensory fibers from the tonsils, pharynx, middle ear and
posterior one third of the tongue.
The sensory division of the nerve projects to the solitary
nucleus, which perceives information about taste.
Parasympathetic visceral fibers to the glossopharyngeal nerve
arise in the carotid bodies of the neck. It contributes to the
carotid sinus nerve (of Hering) which supplies the carotid
body and sinus. The glossopharyngeal nerve also supplies
parasympathetic innervation to the parotid gland via the otic
ganglion.2,3 The parotid gland is the largest salivary gland in
the body. The motor supply of the glossopharyngeal nerve
innervates the stylopharyngeus muscle. This muscle controls
the larynx and pulls it forward to swallow.2
The reported incidence of glossopharyngeal neuralgia is .2
to.8 cases per 100,000 people a year.3,4 The frequency of
glossopharyngeal neuralgia is underestimated due to
difficulties in clinical diagnosis, unawareness of the disease,
and differentiation from trigeminal neuralgia.4
The glossopharyngeal nerve supplies important structures in
the head and neck region in the company of the vagus nerve.1
Being that the glossopharyngeal and vagus nerves are
somewhat intertwined, it is no surprise that there is a grouped
disorder called vagoglossopharyngeal neuralgia. It is
described as paroxysmal electric shock like pain that is located
in the areas that are innervated by the glossopharyngeal nerve
and the pharyngeal branch of the vagus nerve.5 Additionally,
this article states that Microvascular Decompression and
Rhizotomies have become the standard surgical treatment for
cranial nerve syndromes, in spite of the lack of knowledge on
the etiology.
Glossopharyngeal neuralgia can be extremely disabling and
life-threatening. Patients that experience dysphagia can suffer
from weight loss and malnutrition due to fear of pain while
swallowing.1 In addition, depression from debilitating pain
may become so severe that there have been cases of neuralgic
patients who have attempted suicide. In 1921, Harris reported
that glossopharyngeal neuralgia can be associated with cardiac
dysrhythmia and instability. This relationship is well accepted,
having been documented by many authors. Intense irritability
and hyper-stimulation of the glossopharyngeal nerve
stimulates feedback onto the vasomotor center in the
brainstem, giving rise to a heightened vagal response.1
Furthermore, a heightened vagal response can result in cardiac
dysrhythmia, bradycardia, hypotension, and even asystole and
subsequent syncope. This effect is similar to that seen in
carotid sinus massage for the treatment of supraventricular
tachycardias. Massaging the carotid sinus causes a hyperstimulation
of the glossopharyngeal afferent pathway,
resulting in an exaggerated parasympathetic vagal efferent
response. In the case of glossopharyngeal neuralgia, the hyperstimulation
is induced by either an intrinsic irritability of the
nerve or compression of the nerve by blood vessels or styloid
process.1
Diagnosis is clinical. Treatment is the same as that for
trigeminal neuralgia. The first line of treatment is normally
anticonvulsive drugs such as carbamazepine or gabapentin. If
oral drugs are ineffective, topical cocaine applied to the
pharynx may provide temporary relief, and surgery to
decompress the nerve from a pulsating artery may be
necessary. If pain is restricted to the pharynx, surgery can be
restricted to the extracranial part of the nerve; if the pain is
widespread, surgery must include the intracranial part of the
nerve.6
Case Report
An 82 year old female presented with right sided
Glossopharyngeal neuralgia of ten years duration. Pain was
helped by medication and exacerbated by talking, swallowing,
coughing, quick head movements and air conditioning.
Secondary complaints included unsteady gait, dizziness,
spastic dysphonia, chronic cervicalgia, tremor, ankle edema,
hiatal hernia, high blood pressure, sleep apnea, ulcerative
colitis, reflux, migraine, hoarseness, hypothyroidism, mitral
valve prolapse, arthritis and possible transient ischemic attack.
Daily prescriptions include Gabapentin 5700 mg (3600 mg
maximum prescribed by manufacturer, less for geriatric
patients), Lipitor 20 mg, Hydrochlorothiazide 25 mg, Inderal
60 mg, Aleve, 220 mg, aspirin 81 mg, Omeprazole 20 mg,
Diazepam 15 mg, Advil 800 mg, Hydrocodone 20 mg,
Benadryl/Lidocaine 40 ml and multiple herbal and vitamin
supplements. Prior surgeries included hip replacement,
tonsillectomy, hysterectomy and bilateral stapectomies, seven
months apart at ages 30 and 31. She is widowed with six
children. She does not drink or smoke and has significant
family history of cancer.
Past History
A past history of traumas revealed that the patient sustained
two falls involving significant head impacts at age sixteen, one
snow skiing followed by another while ice-skating. Fifteen
years later, she woke up deaf in one ear. Seven months later,
she woke up deaf in the other ear. Hearing in both ears was
successfully corrected by stapedectomy surgery.
The patient suffered a minor vehicular whiplash injury in
8 J. Upper Cervical Chiropractic Res. – January 6, 2014 Glossopharyngeal neuralgia
1984. Patient stated she did have a past history of migraines.
She reported throat problems since 2001 and had been
coughing chronically since 2003. In 2005, the patient saw an
otolaryngologist with the sensation of a foreign body being
caught in her throat. In 2009, an upper GI study showed
previous Barrett’s esophagus. In 2010, she awoke with
intense throbbing pain on the right side of her neck. The
subject stated she was diagnosed with cysts on her vocal cords
in 2008 or 2009.
Cervical x-rays showed marked degenerative spondylosis of
the spine. In June of 2010, cervical CT examination showed
possible unilateral Warthin’s tumor, a benign tumor located in
the salivary glands. She was experiencing chronic right neck
pain, spastic dystonia involving the right true vocal cord and
tingling in right arm and her fourth and fifth fingers at this
time.
In December of 2010, she experienced a transient ischemic
attack, producing jumbled speech. In 2011, she was having
significant difficulty speaking, cervicalgia and painful
swallowing. Physical therapy did not help the cervicalgia.
This suggested that the problem might be neurological in
nature.
The patient was evaluated multiple times by multiple
specialists, none of which had found a cause of right-sided
throat pain. She had multiple procedures in multiple states.
The medical doctors concluded it may be from a pinched
nerve in her neck and recommended MRI, but she was not
able to have one.
In May 2011, she had “dreadful” pain in her anterior aspect of
the right sternocleidomastoid muscle when asked to extend her
neck. She could not speak. The patient took a double dose of
Neurontin and, although it made her sleepy and gave her a bit
of unsteady gait, she felt better, so the dosage was increased.
Given the patient’s age and the fact that she was taking twice
the maximum dose of Neurotonin, she became too dizzy to
live on her own. Her family decided that they would try upper
cervical chiropractic and if it did not help, they would take her
to the Mayo Clinic. The patient got under cervical specific
chiropractic care on June 8, 2011, brought in by her daughter.
Exam
The patient’s daughter explained that the subject had given up
speaking two years prior because whispering two or three
words would send electrical shock pains through her right
throat, tongue, cheek and temple. The patient was sleeping
most of the day. Most of her time awake was spent trying to
swallow one cup of water. On the first visit, her pain scale was
10 out of 10.
The patient had severe right head tilt. The thermographic
Delta T line graph (Figure 1) broke to the right 0.81 degrees
Celsius with left line breaking left, indicating a cold area over
the upper cervical spine. Her right leg presented with a one
inch short relative to left, with one-inch bilateral cervical
syndrome. A positive modified Prill tests for atlas (C1), axis
(C2) and C5 was found. X-ray analysis listed atlas posterior
and inferior on left, axis total segment right and C5 posterior
and inferior with spinous left. These three segments were
adjusted and patient rested for fifteen minutes.
Figure 1. Thermographic Scan
Intervention
The technique utilized is based on the work of BJ Palmer DC,
as developed at his Research Clinic at Palmer Chiropractic
College in Davenport, IA, from the early 1930s until his death
in 1961.7 Techniques also include the vertebral subluxation
pattern work of his clinic director, Lyle Sherman DC, for
whom Sherman College of Straight Chiropractic, Spartanburg,
SC is named.8 A detailed case history was taken on the first
visit, followed by a spinal examination. A report of findings
was given, recommending a minimum set of three cervical xrays
because evidence of an upper cervical subluxation was
discovered. X-rays and analysis of the upper cervical vertebrae
based on the work of William G Blair DC was used to
determine chiropractic listings of subluxation.
Lateral cervical, A-P open mouth and Nasium x-rays were
taken. (Figures 2-4) Blair began to develop his distinctive
method for the analysis and correction of subluxations of the
cervical spine soon after graduating from the Palmer School of
Chiropractic. Trained in the classical upper cervical specific
“Hole In One” (HIO) method, he soon became concerned with
the potential effects of osseous asymmetry or malformation on
the accuracy of the traditional spinographic analysis in
producing a valid adjustive listing. His observations of skeletal
specimens also led him to conclude that the prevailing view of
misalignment of atlas in relation to the occiput was
inaccurate.9
Detailed leg checks were performed on each visit, utilizing the
work of J Clay Thompson DC and Clarence Prill DC.10
Thompson, with the help of Romer Derifield DC, popularized
the cervical syndrome check for the upper cervical subluxation
complex in the 1940’s. Since then, no one has come up with a
reason relative leg length would change when a patient gently
turns their head from side to side, while either prone or supine,
thus not under the effects of gravity, except upper cervical
subluxation.11
J. Upper Cervical Chiropractic Research Glossopharyngeal neuralgia – January 6, 2014 9
It is unknown definitively what causes one leg to appear
shorter than the other; or why the relative lengths change
when the head is turned while the patient is lying down. One
hypothesis proposes that the mechanism of subluxation
involves impingement of the atlanto-occipital intra-articular
fat pad causing reflexive guarding contraction of the
suboccipital muscles. Stimulation of the spindles in these
muscles are thought to be involved in the initiation of tonic
neck reflexes that alter global extensor muscle tone to achieve
proper body balance in response to head movement.12
A conservative approach in determining evidence of
subluxation was used. That is, when in doubt, no adjustment
was given. The leg checks were the main criterion used to
decide when to adjust or not. Many upper cervical
chiropractors rely heavily on bilateral leg length comparisons
for analysis and post-adjustment assessments. Derifield and
upper cervical leg length checks are performed prone and
supine, respectively.13
To determine whether the major subluxation was at the level
of atlas or axis, Prill modified leg length tests were utilized.
With the patient prone, she was instructed to gently and
steadily raise their feet toward the ceiling, while the doctor
resisted such movement with his hands. The peripheral nerves
were being tested, those that innervate the postural muscles
holding one upright in gravity, so it was imperative that the
patient only lift their legs slightly and maintain this pressure
for at least two seconds.
This test was for atlas, the top cervical vertebra. Instructing
patients to rotate their feet while the doctor provided
resistance and checking relative leg length was used to test
axis. Some clinicians prefer to have the toes rotate outward.
This doctor had the patient pull their feet together. This
corresponds to the rotation of the head on the neck, 50% of
which occurs at the level of C2.
Although many chiropractors that utilize the Blair technique
do not adjust the lower cervicals, the doctor did on this patient.
Blair died before getting below C4 in his analysis and
adjusting technique protocol. The author agrees with Dr. Blair
in that until the upper cervical spine is cleared of subluxation,
adjusting the lower cervicals will not hold. Although research
may not support this, in the doctor’s experience, he found that
when there is a significant “kink” in the lower cervicals
caused by a whiplash injury, a specific lower cervical
adjustment can help the upper cervical adjustments hold
significantly longer.
This is why he developed Prill type tests for the lower
cervicals; C5, C6 and C7.14 This chiropractor uses the
technique Pierce Results to analyze and adjust lower cervical
segments. The Pierce “Results System” is a result of
combining a few techniques such as: 5th Cervical Key, Logan
Basic, HIO, Thompson, Nimmo and Pierce’s personal way of
adjusting. The main focus of Pierce centered chiropractors is
subluxation correction by way of focusing on restoring proper
structure and motion of the spine.15
Thermographs of the cervical spine were utilized using a
Tytron C-300 instrument. The instrument was used to develop
a pattern of subluxation in order to determine when to adjust.
The thermal differential of skin temperature is a demonstration
of both symmetry and pattern. A graph reading that is static
and persistent over time is considered to be the patient's
pattern. A break is defined as a heat deflection to the left or
right of the graph centerline. Advocates of the “break”
analysis or system, often consider this to be an indicator for
vertebral subluxation.16 Vertebral subluxations often cause
thermal asymmetries and/or pattern. A patient with a vertebral
subluxation that appears “in pattern” no longer displays the
normal adaptability of the autonomic nervous system to
display a continuously adapting temperature reading.17
When it was determined that the patient was in a pattern of
subluxation, some combination of Blair toggle recoil and
Pierce Results adjustments were performed. A Thuli
chiropractic table, using the cervical drop piece was utilized.
For Blair side posture adjustments, the headpiece was set to
drop straight down. In prone adjustments, it was set to drop
down and forward. The patient was then rested for fifteen
minutes and rechecked, to make sure that the pattern had been
broken.
Outcomes
The patient got up and started talking normally with a pain
level of one and went home with her daughter. Two days
later, the pain was entirely gone. The doctor checked her for
nervous system interference and found subluxation using leg
checks. This visit he chose to use an instrument to adjust.
The patient is still pain-free to this day and receiving
maintenance care.
She began reducing, and eventually, eliminating Neurontin
regimen under the supervision of her neurologist. The
neurologist encouraged the patient to stay under chiropractic
care. The doctor checked the patient a final time and she
showed balanced legs and her thermograph was not in pattern.
She was seen twelve times over six weeks, at which time she
was free of pain and medication and holding her adjustment.
Discussion
This case is an example of rare nervous system issues being
resolved outside the current medical model of surgery and
medications. The patient had experienced a variety of
symptoms for 10 years and was evaluated by several
physicians, none of whom could find the cause of the
glossopharyngeal neuralgia. This was this author’s first case
of glossopharyngeal neuralgia.
He has been treating and tracking the results of cervical
specific chiropractic with three hundred Meniere’s disease
(MD) patients for a minimum of three years, up to eleven
years. The doctor used the same protocol in this case.18 All
300 consecutive MD cases had suffered a whiplash type of
cervical trauma an average of fifteen years prior to the onset of
symptoms. Ninety percent of these patients had an atlas
subluxation, with a listing posterior and inferior on the
opposite side of the involved ear.
The doctor relates his success to his analysis of finding
subluxations. There are many terms and definitions used for
subluxation. D. D. Palmer and B. J.Palmer defined
10 J. Upper Cervical Chiropractic Res. – January 6, 2014 Glossopharyngeal neuralgia
subluxation as: “A (sub)luxation of a joint, to a Chiropractor,
means pressure on nerves, abnormal functions creating a
lesion in some portion of the body, either in its action, or
makeup.” Since then, many models have been produced trying
to explain subluxation. The vertebral subluxation complex
model has been expanded to include all essential components
of a subluxation, which currently has nine components. These
components include detailed anatomic, physiologic, and
biochemical alterations inherent in subluxation. In any
definition of subluxation, most chiropractors agree that when
you correct a subluxation through an adjustment, the
functional integrity of the nervous system, general health, and
quality of life are indicators of improvement.19
Much of the research related to this topic has been done on
trigeminal (CN V) neuralgia because as discussed previously,
the incidence of glossopharyngeal neuralgia is rare. As shown
by this case, most people with these conditions see
chiropractic care as a “last resort” effort.
Glossopharyngeal neuralgia shares several characteristics with
trigeminal neuralgia. Trigeminal neuralgia (TN) is much more
common, yet still rare, ranging at incidences between 4.17-
7.1/100,000 for both sexes. Similar characteristics between
CN V and IX neuralgias include: spastic attacks of electric
shock-like stabbing pain, trigger mechanisms (such as
speaking, swallowing, eating, breathing, cold air and slight
touch of the mouth and pharyngeal region), initial good
response to anticonvulsant drugs and association with
neurovascular compression.4
Chiropractors encounter these neuralgias very infrequently,
but may play a role in the management through recognition,
diagnosis, referral if necessary and symptom management.20
Patients with these neuralgias often live with these symptoms
for long periods of time before seeking chiropractic care.
This author has adjusted a patient with trigeminal neuralgia
using the same protocol as he did in this case to remove
vertebral subluxations. Much like this case study, the patient
is able to be pain free again and completely eliminate
Gabapentin from their life.21
Other cases with trigeminal neuralgia reported on in the
chiropractic literature show similar results. One patient had
been experiencing TN pain for 7.5 years that was gradually
worsening after a surgical resection of a brain tumor. She
sought care from a chiropractor as a last resort effort because
she could no longer stand the pain. She could not find long
term relief from the pain through acupuncture, physiotherapy
or medications. The chiropractor’s treatment consisted of
ultrasound, massage, and mobilization through adjustments
and traction. The patient received relief after the first
adjustment and is still receiving chiropractic treatments as
needed without medication.20
A case reported on in the chiropractic literature on trigeminal
neuralgia combined various modalities, diversified and cranial
adjustments to relieve TN symptoms. This patient had
experienced pain on and off for six years, when it seemed to
be caused by a tooth. After chiropractic care was initiated the
patient’s pain was reduced and she began to reduce her intake
of Carbamazepine. When followed up with three months later
she had no further trigeminal symptoms, but at her eighteen
month follow-up she had experienced the pain again. The
author was retired by this time and she visited a medical
practitioner for laser therapy instead, which was successful in
reducing her pain again.22 Furthermore, there is another TN
patient that had pain along the mandibular distribution of the
TN for five years. The patient was taking Carbamazepine
daily to manage the pain associated with his TN. After
receiving three Atlas Orthogonal upper cervical adjustments
over one month, the patient was pain free and no longer taking
Carbamazepine.23
In order to propose a mechanism by which these
improvements occurred, it is important to study the pain
generators in the cervical spine. Sources of upper cervical
pain include the occipital-atlanto-axial joint, zygapophyseal
joints through C3-C4, the vertebral artery, C2-C3
intervertebral disc, dura mater, pre- and post-vertebral skeletal
muscle.23
In the medical literature, when viewing cranial nerves under
advanced imaging, neurovascular compression is a common
finding. Many of the idiopathic cranial neuralgias are
attributed to a neurovascular nerve compression at the root
entry zone of the respective cranial nerve.4 When viewing the
brainstem, accompanied by the vessels and cranial nerves
under MRI and 3D, it was found that two arteries were the
main source of compression on the glossopharyngeal nerve
(CN IX).
The vertebral artery and posterior inferior cerebellar artery
tend to compress the CN IX on the ipsilateral side of pain.
Additionally, other neurovascular compressions including
both the trigeminal nerve and the vagus nerve were found as
well.4 Leading research indicates the superior cerebellar
artery may be the main source of compression on the
trigeminal nerve.21 Furthermore, such a compression can
cause injury to the nerves’ protective myelin sheath and cause
irregular and hyperactive function of the nerves.
The Dentate Ligament-Cord Distortion hypothesis may be
able to provide explanation as to why the correction of upper
cervical subluxations relieves trigeminal neuralgia, and
possibly other cranial nerve neuralgias.24 Additionally, the
paroxysmal nature of pain suggests that it arises as a sudden
discharge of neurons, as a result of irritation of the nerve or
it’s corresponding ganglion. Anatomical abnormalities of the
cervical spine have been the leading finding in patients with
Meniere’s syndrome, trigeminal neuralgia, Bell’s palsy,
multiple sclerosis and Parkinson’s disease.18,20-23,25 By
changing the structure of the cervical spine through specific
adjustments, it is removing the irritation to the nerve, thereby
reducing symptoms.
Conclusion
Although a case study is limited to provide conclusions, it
does offer insight that chiropractic offers a noninvasive
method to improve these patients’ quality of life. This author
continues to use the same protocol for Meniere’s syndrome,
trigeminal neuralgia, Bell’s palsy, multiple sclerosis and
Parkinson’s disease.18, 21, 25 This patient’s quality of life
rapidly changed after one adjustment. This patient suffered
ten years without knowledge of chiropractic care results. She
J. Upper Cervical Chiropractic Research Glossopharyngeal neuralgia – January 6, 2014 11
had been ingesting large amounts of medication without any
improvement. Medical doctors should consider referring
patients to cervical specific chiropractic care when they
suspect a upper cervical vertebral subluxation.
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