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mise à jour du
29 janvier 2006
Headache
1982;22:6-9
 Superior laryngeal neuralgia: carotidynia
or just another pain in the neck?
O'Neill B, Aronson A, Pearson B, Nauss L
Departments of Neurology, Otorhinolaryngology , Anesthesiology,
Mayo Clinic and Mayo Foundation, Rochester, Minnesota.

Chat-logomini

A clinical pain syndrome similar to "carotidynia" developed in a patient several years after undergoing carotid endarterectomy. The pain was reversed by superior laryngeal nerve block, followed by supenor lamygeal neurectomy. A diagnosis of superior laryngeal neuralgia was suggested by several characteristic features: (1) pain along the anterior cervical triangle, with extension to the ipsilateral ear and eye, (2) hoarseness, and (3) paralysis of the ipsilateral cricothyroid muscle on laryngoscopy. Carotidynia usually refers to neck pain arising from the carotid artery in the neck and is often viewed as a migraine variant. Our observations suggest that carotidynia may not be a migraine variant and that "carotidynia" may not be an accurate term for all pains in the anterior cervical triangle. We suggest that evaluation of neck pain include speech pathology and otolaryngologic consultations (including laryngoscopy) if any voice disorder is reported or noted. Since the superior laryngeal nerve is the neural structure most contiguous to the bifurcation of the carotid artery, the superior laryngeal nerve may have become entrapped in a fibrotic process that developed after carotid endarterectomy. Such pain may be a rare complication of carotid endarterectomy. When other causes have been excluded and pain continues, a superior laryngeal nerve block should be considered.
 
INTRODUCTION
 
Carotidynia usually refers to neck pain arising from the carotid artery in the anterior cervical triangle. The pain is often an episodic, throbbing neck pain, frequently associated with carotid artery tenderness and adjacent swelling. As described, the pain usually is considered to be a migraine variant. However, any abnomiahty of the wall of the carotid artery may cause pain about the head, face, and neck, as evidenced by reports of similar pain with carotid artery aneurysms, carotid arteritis, and dissection of the carotid artery.
 
Recently, we evaluated a 60-year-old man whose description of pain resembled carotidynia. Careful voice analysis and laryngoscopy indicated a lesion of the superior laryngeal nerve on the symptomatic side. Pain was relieved after successful block of the nerve and superior laryngeal neurectomy.
 
REPORT OF A CASE
 
A 60-year-old man was first seen in July 1979 with a complaint of right anterior neck pain. He reported a 6-to 12-month history of episodic then constant "burning" in the right anterior aspect of his neck. The pain began as a muscle "cramping" initiated by opening his mouth, yawning, or turning his head. The pain, initially located in the anterior cervical triangle, would extend to the right shoulder, cheek, maxilla, and retroauricular and retro-orbital regions. Except fur occasional tearing with intense pain, no vasomotor or neurologic signs were apparent. He became aware of tenderness from palpation or pressure and resorted to sleeping on his left side so that he would avoid compressing the right side of his neck during sleep. Prolonged talking or singing would intensify the pain as much as turning his neck. His voice became lower-pitched, rough, and easily fatigued. He eventually abandoned singing.
 
Pertinent past medical history included bilateral carotid endarterectomies done 9 (right side) and 7 (left side) years before evaluation. Soon after the operations, he began to notice occasional cramping discomfort across his neck.
 
When the patient was first seen, he had moderate tenderness along the course of the right carotid artery in the neck. A right carotid angiogram revealed only slight deformity of the right internal carotid artery at its point of origin from the common carotid artery. At speech pathology consultation, a low-pitched hoarseness was noted during contextual speech and a tremorlike voice unsteadiness was noted toward the end of vowel prolongation.
 
indomethacin, amitriptyline, propranalol, carbamazepine, methysergide, and diazepam (at maximal recommended dosages) produced no change in symptoms. The patient returned 4 months after initial evaluation, with intense pain that would extend to his forehead. Pain could be triggered by pressure over the right carotid artery near the tip of the hyoid bone and at the angle of the mandible. No further change in his speech was noted. Otorhinolaryngologic consultation demonstrated an oblique larynx with the posterior commissure deviated to the left, consistent with contracture of the right cricothyroid muscle. A computed tomographic (CT) study of the neck demonstrated the relationships in the anterior cervical triangles. Appropriate distortion of the laryngeal image, on section through the level of the arytenoid cartilages, was consistent with the laryngoscopic impression.
 
Complete block of the superior laryngeal nerve was achieved by injection of a 0.25% solution of bupivacaine HCI, followed by instillation of a 5% phenol-water solution near the tip of the right hyoid bone. Pain returned approximately 2 months after injection. Similar blocks produced pain relief of successively shorter duration. Superior laryngeal neurectomy was then performed, with nearly complete resolution of the pain. A small region of "burr-like" discomfort remained at the tip of the hyoid bone.
 
DISCUSSION
 
The earliest descriptions of carotidynia by Fay suggested that sensitivity of the carotid artery may be a cause of facial and neck pain. Some of his patients were improved by denervation of the artery and interruption of the cervical sympathetic fibers. Electrical stimulation of the wall of the carotid artery near its bifurcation caused pain in the teeth, gums, eye, nose, cheek, and jaw, depending on the precise area of the artery stimulated. He noted that digital pressure over the carotid arteries near their bifurcation elicited a similar pain and was a helpful diagnostic feature.
 
Subsequent literature suggests two basic categories of carotidynia: one a migrainous disorder and the other a structural disease of the carotid artery.
 
Raskin and Prusiner described an episodic, throbbing pain with tenderness and swelling of the carotid artery which sometimes was associated with vascular headache, nausea, and vasomotor phenomena. Eight patients responded to antimigrainous drugs. They further noted that nearly 40% of patients with frequent migraine had tender carotid arteries, which almost invariably were ipsilateral to the hemicranial headache.
 
The carotid arteries were nontender in 100 controls. Similar experience has been cited by Lovshin in a review of 100 cases. Others,6 however, have remarked on the resistance of carotidynia to parenterally administered ergotamine. Whether this responsiveness is itself an indicator of functional (that is, migraine) versus structural disease of the carotid artery is unknown.
 
Pain in the carotid artery may be caused by various pathologic processes, such as arteritis, dissection of the carotid artery, thrombosis, aneurysm, or direct trauma to the artery. These causes probably constitute a category of carotid artery pain less common than migrainous carotidynia. Nevertheless, such pain is a valuable indicator that significant disease may be present in the neck. The pain in these disorders is less often episodic or accompanied by a typical hemicrania. The pain is usually a stabbing or pulling type and is characteristically aggravated by head and neck movements; swallowing, chewing, yawning, and sneezing may be poorly tolerated. A benign, self-limited form, occasionally bilateral, has been considered to represent a viral cause.
 
The clinical findings in our case resembled those associated with this second type of carotidynia. Our patient lacked the prior migraine history, the coexistent hemicrania, and the episodic, throbbing neck pain with interictal normalcy, and he had no response to antimigrainous drugs. A structural lesion was suggested. The observation of coexistent voice change led to the consideration that the larynx was participating in the pathologic process. Speech evaluation by a speech pathologist and an otorhinolaryngologist confirmed chronic paralysis of the ipsilateral cricothyroid muscle, thus suggesting a lesion of the superior laryngeal nerve.
 
The cricothyroid muscle is the only intrinsic muscle of the larynx supplied by the superior laryngeal nerve; all other muscles are supplied by the recurrent laryngeal nerve. The cricothyroid muscle approximates the thyroid and cricoid cartilages. It lengthens, stretches, and tenses the vocal cord - actions that are essential to the production of sounds of higher pitch. It also functions as an adductor of the vocal cord. Acute paralysis of one of the cricothyroid muscles produces a unilateral failure of tensing and adducting of the cord. The voice will be weak, rough, and easily fatigued. Pitch will be lowered, and most high tones will be lost, as will the singing voice. The intact cricothyroid muscle rotates the cricoid, producing an oblique deviation of the glottis toward the unaffected side. Thus, in acute palsy of the right superior laryngeal nerve, the posterior commissure is rotated to the right. In chronic palsy, contracture of the ipsilateral cricothyroid probably rotates the posterior larynx to the left. The internal branch of the superior laryngeal nerve also is the sensory supply to the larynx above the glottis. Hence, the superior laryngeal nerve functions as a mixed nerve.
 
The superior laryngeal nerve is the neural structure most contiguous to the carotid bifurcation and must be carefully protected during carotid endarterectomy. Typically, the bifurcation of the superior laryngeal nerve lies medial to the crotch formed by the internal and external carotid arteries. Hoarseness, typically without pain, may develop after carotid endarterectomy, probably by damage to the external branch of the superior laryngeal nerve. The strain involved in using a voice that tires easily and requires effort to maintain pitch, however, may cause considerable annoyance. If the sensory branch is also involved, minor problems of swallowing and coughing may be transient phenomena. The exact frequency of injury to the superior laryngeal nerve during carotid artery surgery is unknown, but probably occurs more frequently than is recognized (Piepgras DG: Personal communication). Similar injury to the superior laryngeal nerve has been described during neck dissection for carcinoma and during thyroid surgery.1° Face pain, neck tenderness, and pain on swallowing were described in a patient 6 years after carotid endarterectomy. Other than this report, we are unaware of carotidynia after carotid artery surgery.
 
Observations on our patient may be unrelated to his prior carotid artery surgery and may represent superior laryngeal neuralgia. An earlier publication from our institution described two patients with pain cured by resection of the superior laryngeal nerve. Echols and Maxwell first described surgical cure of this neuralgia after the injection of procaine HCI gave transient relief. These reports, as well as other, differentiated superior laryngeal neuralgia from the more common glossopharyngeal neuralgia by the latter's tendency to extend to the ear from the tonsillar region, which is the trigger zone. None of these reports utilized speech pathologic analysis of voice and laryngoscopic examination. The superior laryngeal neuralgia was inferred by a trigger spot above and lateral to the thyroid cartilege, the radiation of pain, and the response to blocks or resection of the superior laryngeal nerve.
 
In summary, a clinical pain syndrome similar to "carotidynia" developed in our patient several years after carotid endarterectomy. The pain was reversed initially by block of the superior laryngeal nerve and by resection of the nerve. A diagnosis of superior laryngeal neuralgia was suggested by several characteristic features: pain along the anterior cervical triangle, with extension to the ipsilateral ear and eye, hoarseness, and paralysis of the ipsilateral cricothyroid muscle on laryngoscopy. We suggest that evaluation of neck pain include speech pathology and otolaryngologic consultations if any speech disorder is reported or noted.
 
 
Superior laryngeal neuralgia: carotidynia or just another pain in the neck?
O'Neill B, Aronson A, Pearson B, Nauss L
Headache
1982;22:6-9
 
The myth of carotidynia
Biousse V, Bousser M.
Neurology
1994;44:993-995
 
Carotidynia: a pain syndrome
Hill LM, Hastings G
J Fam Pract
1994;39:71 -75
 
Fay T. Atypical facial neuralgia. Arch Neurol Psychiat.1927;18:309-315
Fay T. Atypical facial neuralgia, a syndrome of vascular pain. Ann Otol Rhinol Laryngol 1932; 41; 1030-1062
Buetow MP, Delano MC. Carotidynia. AJR Am J Roentgenol. 2001;177(4):947
Burton BS, Syms MJ, Petermann GW, Burgess LPA. MR imaging of patients with carotidynia. AJNR 2000;21:766 -769
Arning C. Ultrasonography of Carotidynia. Am. J. Neuroradiol. 2005; 26(1): 201 - 202.