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The glossopharyngeal neuralgia patient
Operating room nurse Barbara Howe answers Mrs M's questions during the preoperative interview. Photographs b y Doris C MacClelland. The AORN Journal thanks the staff at Green Hospital of Scripps Clinic, La Jolla, Calif, for their assistance in preparing this article.
Doris C MacClelland, RN
The glossopharyngeal neuralgia patient Mrs M, a 42-year-old homemaker and ophthalmology assistant in Mesa, Ariz, experienced her first painful episode of glossopharyngeal neuralgia in August 1975. Since then, she has endured three more periods of severe neuralgia lasting as long as two weeks at a time. Pain medications were ineffective, and Mrs M began to feel desperation and hopelessness.
The excruciating pain of glossopharyngeal neuralgia is transitory and paroxysmal, attacking a t any time without warning. Although much rarer than trigeminal neuralgia, it is just as devastating. Incidence is only about 1% that of trigeminal neuralgia, of which about 5,000 to 15,000 cases are reported annually. The uncertainty of when an attack might occur becomes a mental
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and physical barrier. Patients find themselves planning their activities by thinking, “What if the pain occurs?” The pain of glossopharyngeal neuralgia is described as jabbing, burning, cutting, laminating, and like an electric shock. Following the ninth cranial nerve, it can be experienced in the oropharynx, tonsillar fossa, base of the tongue, and deep in the ear. Because of its proximity, the tenth nerve is frequently involved, with an associated vagal neuralgia. Sometimes pain radiates to the distribution of the trigeminal nerve, neck, or shoulder, which is considered an overflow phenomenon.’ Vascular compression of the rootlets of the ninth and tenth cranial nerves is now recognized as the most frequent cause of glossopharyngeal neuralgia, although trauma, local infection, elongated styloid process, ossified stylohyoid ligament, vascular abnormalities, and tumors can be etiological factors.2 Glossopharyngeal neuralgia due to vascular compression is more common in midlife and later years, because of the normal loss of elasticity in the vessel walls. This may cause arteries to droop, allowing the vessels to rest on the
Doris C MacClelland, RN, MS, is a retired US Navy commander and operating room supervisor. A diploma graduate of Emanuel Hospital School of Nursing, Portland, Ore, she received a BA from San Francisco State University and an MS from Indiana University, Bloomington.
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nerves. The pulsations seem to act as irritating stimuli, producing the attacks of neuralgia. Diagnostic procedures are of little help. Most angiographic, radiographic, and electroencephalographic studies are usually within normal limits. Vascular anomalies may sometimes be visualized, but vascular compression of the nerve may not be visible preoperatively. Diagnosis is usually based on the patient’s history and the lack of clinical manifestations of other pathology. Current treatment of glossopharyngeal neuralgia is surgical, although some patients are managed medically with varying degrees of relief. Drugs such as carbamazepine (Tegretol) and/or phenytoin sodium (Dilantin) may provide temporary relief of symptoms, but surgical intervention has the most encouraging long-range results, both in controlling pain and eliminating untoward side effects. Past surgical techniques usually involved sectioning the nerve or nerves at some selected point. Since cutting the nerve creates sensory and/or motor deficit that can be permanent, it is more desirable to leave the nerves intact if possible. A procedure to decompress the nerve, which eliminates the need for sectioning, is becoming more widely used. Approximately ten years ago, Peter J Jannetta, MD, University of Pittsburgh School of Medicine, developed and described a procedure for the relief of trigeminal neuralgia, which is now being adapted €or other cranial nerve neuralgias3 In the hands of a capable neurosurgeon, this procedure is relatively simple and has virtually no undesirable postoperative sequelae. A posterior craniotomy (retromastoid craniectomy) approach is used. With an operating microscope, the cranial nerves in question are identified at the root entry zone and the vascular struc-
AORN Journal, March 1980, V o l 3 1 N o 4
(L
t has put me
I i n a very nervous state of emotions.”
tures observed. In most instances, the vertebral artery or the posterior inferior cerebellar artery (PICA)will be found to be compressing the nerve at this point. A tiny piece of silastic sponge or polyvinylchloride sponge (Ivalon) is then placed between the vessel and the nerve, relieving the pulsating pressure to the nerve. In some cases, a tissue sling may be created to lift the vessel from the nerve, but this technique has been used more often in the treatment of trigeminal neuralgia. If there is no evidence of vascular compression or other pathology, the nerve or nerves may be sectioned. After surgery, transitory hypertension may occur. This predisposes the patient to intracerebral hematoma, a condition thought to be related to disturbance on the ninth cranial nerve. Other possible postoperative complications are the same as those normally expected from any major neurological procedure done under general anesthesia. *If surgery is done with the patient in sitting position, there is an increased risk of air embolism, so some surgeons place the patient in the prone position. The success of the procedure in relieving pain is directly related to the adequacy of the procedure. Results from this operation have generally been good. Based on its success in treating trigeminal neuralgia, patients with glossopharyngeal neuralgia can expect the same favorable results.*
After she had been scheduled for surgery Sept 24, 1979, at the Green Hospital of Scripps Clinic, La Jolla, Calif, I contacted Mrs M at home to see if she would share her experience with the AORN Journal. Since she knew her condition was uncommon and the proposed operation was relatively new, she agreed. This was the second time her surgery had been scheduled. It was initially scheduled for April 18, but had to be cancelled when her husband was hospitalized with what was first thought to be an acute myocardial infarction. The diagnosis was later changed, and he was released from the hospital in about a week with no further difficulty. I first met Mrs M and her husband in the lobby of the motel in La Jolla where he would be staying throughout her hospitalization. Her surgery was scheduled for the next morning. I found them to be warm, friendly, and optimistic. My immediate reaction was admiration, since I recognized how easily they could have become dejected and negative because the neuralgia had disrupted their lives. The more we talked, the more evident it became that both were willing to make the best of a difficult situation. It also was evident that they enjoyed a loving, supportive relationship. After telling me briefly about the history of her pain, Mrs M said the episodes of neuralgia were characterized by the
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onset of a background pain-a numb, tingling, burning, aching sensation. She later experienced a severe stabbing, lancinating pain in the same area. Felt primarily deep under the left ear, the pain would be triggered by movement of the mouth or throat. Most distressing was the accompanying sensation of choking even though she did not actually choke. Usually the pain disappeared during sleep, probably because the triggering mechanisms were at rest. She also had experienced a slight ptosis of the left eyelid during several of the acute pain episodes. Although paroxysms of pain could be initiated by certain movements such as chewing, talking, swallowing, or yawning, onset of an episode could not be related to any identifiable physical or emotional factor. “It’s just there,” Mrs M sighed. “I can be relaxed and enjoying myself when all of a sudden it happens. And I know then it will be with me at least several hours.” Mrs M’s statement that attacks were
not related t o emotional stress had been validated when her husband was admitted to the hospital. Her own anxieties about surgery plus this stress situation did not precipitate an episode of neuralgia as might have been expected. When the pain first occurred in 1975, the physician who treated her believed she had an infection and prescribed a n antibiotic with propoxyphene napsylate (Darvon) for pain. Obtaining no relief, she began searching for help. A dental check revealed no pathologic condition, and an examination by a n otolaryngologist was normal. A neurologist diagnosed glossopharyngeal neuralgia. Phenytoin sodium (Dilantin) was prescribed, but within several days Mrs M developed a severe rash, and the medication was discontinued. Fortunately, the pain simultaneously disappeared. The second episode occurred in April 1976 and was characterized by a sharp, pulsating pain. This time, the neurologist prescribed carbamazepine (Tegretol) 100 mg 3 times a day. Since Teg-
The patient was turned to a prone position and the head immobilized in a stereotaxic head holder. Then the lower part of the scalp was shaved. At right, the assistantsurgeon is injecting the head with anesthetic.
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retol is toxic to the hemopoietic system, it became necessary to stop the drug within four days because of evidence of bone marrow depression. Again, the pain disappeared after the drug was discontinued. In September 1978, just three weeks after the family had moved from the midwest to Arizona, the next episode occurred. Mrs M located another neurologist, who also prescribed Tegretol. The drug was stopped five days later, and again the pain disappeared. When the current episode began in July 1979, the neurologist doubled the dose of Tegretol, stating the blood changes were reversible. Mrs M wondered what would happen. After several days, she said, “the Tegretol made me a n absolute basket case as far as my nerves went. I felt I was going into a real mental depression. I became extremely tired. On top of that, the pain was still there, too.” Because she could no longer cope with the severe emotional side effects of the
medication, she stopped taking it. At this point, she could no longer work and was experiencing a feeling of panic and desperation. Mrs M heard about Scripps Medical Institutions and called for consultation. When she first visited the clinic as a n outpatient, on Sept 6, 1979, she was interviewed and thoroughly evaluated by Thomas A Waltz, MD, a neurosurgeon. He found Mrs M to be a cooperative woman with intact speech and hearing. There were normal sensations to her face, corneal reflexes were normal, and her face, tongue, and palate moved symmetrically. Her gait was normal, and she demonstrated symmetrical reflexes with normal sensation to touch, pin, and position. Although her history revealed previous ptosis of the left eyelid, there was no evidence of ptosis a t that time. Results of the computed tomography (CT) scan and studies for brainstem-evoked responses and visual-evoked responses were also within normal limits.
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The diagnosis of glossopharyngeal neuralgia was confirmed. Since Dr Waltz believed medical treatment options had been exhausted, he recommended that Mrs M consider surgery. The proposed operation was thoroughly explained to Mr and Mrs M. Weighing the risks against the proposed outcome, they agreed t o surgery, which was scheduled for one week later. During this period, Mr M was admitted t o the coronary care unit a t a hospital in Arizona, so Mrs M’s surgery was canceled and rescheduled after her husband’s condition improved. During our preadmission interview, I attempted to elicit Mrs M’s feelings about h e r condition and proposed treatment. Asked how she felt her life had been affected most, she responded, “It has put me in a very nervous state of emotions that I have never had because I’ve always been a very relaxed, happy-go-lucky person.” I then asked if and how this had affected her family. She answered, ‘‘I’m
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sure it has because I have been very nervous about the whole thing. In the back of my mind I always worried about the uncertainty of when the pain would happen and what I could do about it. Then thinking about surgery-well, I know it has affected them.” I then directed the same question to Mr M, and he replied, “We’ve always been a very relaxed and close family. We have three boys 20,17, and 13. We found ourselves having to be careful what we said and did so as not t o upset her. The boys would sometimes ask me what was the matter with mother because she wasn’t herself.” From their comments, it is obvious this condition had been a disruptive force in a family who had a comfortable relationship with each other. Describing h e r feelings about surgery, Mrs M said, “Well, I feel like I The operation is conducted using an operating microscope. Here the nurse views the surgical field through the microscope eye piece.
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have no real choice in the matter. If I could put it off, I probably would. But I think in all fairness, not only to myself but also to the people around me, that I must go ahead and do it. Even when the pain is tolerable, and right now it is within tolerance, I feel I should go ahead.” Mr M added, “I’m nervous about the operation, but I’m confident about what the doctor has told us. And he’s a competent doctor. He knows what he is doing. I just have faith that the operation is going to take care of it.” They emphasized their confidence in the surgeon. They said his calm, confident approach was reassuring, since most of the other physicians she had seen were not familiar with her condition nor the treatment. To assess Mrs M’s knowledge about her operation, I asked what the surgeon had told her about her surgery and the expected outcome. In her answer, she demonstrated a high degree of understanding. Although she had no specific expectations for her nursing care, she said she knew she would receive excellent care. This response was based on the reputation of the hospital and her own observations during her outpatient visit. “It was just phenomenal,” she said. “There was never any wondering what they were doing. They explained it all to me.” I emphasized that her interest was good, because patients who take an active interest in understanding their illness and treatment can play an active role in reaching the goals of their prescribed therapy. During the interview, I provided support and encouragement to Mrs M as she faced the frightening prospect of “having her head cut open.” I explained that a nurse from the operating room would come to see her before surgery and answer any specific questions she might have. I told her that I, too, would
visit her the next morning before surgery. Arriving at the hospital that afternoon, Mrs M completed the necessary forms and was shown to her room. The nursing assessment was completed, and later in the evening, preoperative studies were done. Since Mrs M was in excellent health, no special nursing measures were required. The anesthesiologist visited her and thoroughly explained the type of anesthesia planned and what Mrs M could expect before and after surgery. He discussed drugs he would be using and special positioning that would be necessary for her operation. He reassured her by telling her that he would be with her and would be monitoring her condition at all times. She later told me she was pleased with his manner and felt confident he would take good care of her. In the morning, Barbara Howes, the operating room nurse, arrived for the preoperative interview. After determining what Mrs M knew about her operation, she explained what would be happening to her after her arrival in the operating suite. Although this was Mrs M’s first surgery, her job as an ophthalmology assistant had taken her into the operating room, so she was not a complete stranger to the environment. The nurse instructed her in postoperative coughing and deep breathing and reviewed the purpose of preoperative medications. She told Mrs M she would be going to the postanesthesia recovery room and then to the surgical intensive care unit, where she would probably remain until the following day. Since Mr M was present, the OR nurse told him where he could wait and explained visiting policies for postoperative patients. When I arrived later that morning, Mrs M was in good spirits and “ready t o get this over with.” Dr Waltz came in briefly to see if she had any questions,
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and her husband had been with her since early morning. Our presence and her positive attitude seemed to help her to approach surgery with confidence, in spite of the normal expected apprehensions. On her arrival to the OR holding area, Mrs M was greeted by the OR nurse, who identified her and confirmed the site of the operation. The nurse checked for all necessary records and reviewed Mrs Ms preparation for surgery. The operating room was set up. Special items included the stereotaxic headrest and chest rolls for positioning, bipolar and monopolar electrosurgical units, a sterile air-powered drill and a full tank of nitrogen, hair clippers, the operating microscope with attached camera, and the necessary sterile instrumentation. Routine equipment and supplies were prepared and all the necessary counts recorded. In the room, Mrs M was assisted onto the OR bed in supine position. An intravenous infusion was started and the
electrocardiograph (ECG) electrodes positioned. A blood pressure cuff was placed on the arm and connected to the computerized sphygmomanometer. During this preparation, the OR nurse remained at Mrs M’s side to provide emotional support and ensure her comfort and safety. Anesthesia was begun. When the patient was relaxed, the endotracheal tube was inserted and secured. After it was determined that she was in stable condition, Mrs M was carefully turned to prone position and her head immobilized in the stereotaxic head holder. The nurse checked for good body alignment, with adequate support and padding. Mrs M’s arms were secured at her sides, with a sheet clipped over her back and the adherent grounding plate applied to her thigh. The safety strap was placed just below the buttocks. Her head was then prepared by the assistant surgeon, who clipped the lower half of the posterior hair and then shaved the scalp. The nurse applied
Dr Waltz uses the power drill to enter the skull as the nurse irrigates away bone particles. The assisting surgeon is at left.
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povidone-iodine, and the incision area was injected with lidocaine and epinephrine. Sterile drapes were applied and the sterile field readied. The procedure was to be a craniotomy with neurovascular decompression. Through an L-shaped incision from the left mastoid to the midline and down to C-2, the muscles were lifted from the occipital bone and the bone removed. The dura mater was opened and the cerebellar self-retaining retractor positioned. With the help of the dissecting microscope, the arachnoid was divided to give access to the ninth, tenth, and eleventh cranial nerves at the jugular foramen. The nerves were then traced medially to the root entry zone and the arteries identified. The ninth and tenth nerves were found to be deformed by two branches of what was probably the posterior inferior cerebellar artery (PICA). A branch underneath the tenth and eleventh nerves deflected them posteriorly and then extended forward to deflect the n i n t h nerve anteriorly. Another branch somewhat closer to the brainstem passed underneath the root entry zone of the tenth cranial nerve. The arteries were lifted off the nerves and two small pieces of Silastic sponge placed between to separate the nerves and the arteries. A small piece of absorbable gelatin sponge was then placed over the nerves. The wound was thoroughly irrigated, the dura closed with 4-0nylon, and the muscles and galea reapproximated with 2-0 silk. The scalp was closed with 3-0 polypropylene and a head dressing applied. No drains were used, and the estimated blood loss was 150 cc. Two hours after the opening incision at 2:30 pm, the operation was completed. The OR nurse was alert to the needs of the surgical team during the operation and the condition and safety of the patient. Blood loss was observed, sponges and cottonoids accounted for, and opera-
tive records completed. As she was transferred to the recovery bed, Mrs M was then covered with a warm blanket. The endotracheal tube was removed when her level of consciousness and respiratory activity permitted. Because of the late hour, she was taken directly to the surgical intensive care unit by the circulating nurse and the anesthesiologist. A joint report was given to the unit nurse, who immediately checked vital signs and began oxygen by mask to assist Mrs M in waking up. Neurologic checks were done including pupil size and reaction, hand grasps, and extremity movements so any changes in response could be detected early. Her head was elevated 30 degrees to help reduce any possible cerebral edema. Mrs M was drowsy but responding to verbal stimuli, so the unit nurse said Mr M could come in for a short time. The surgeon had already discussed the operation with him and assured him all was well. Immediate postoperative care was r o ~ t i n e The . ~ next day, Mrs M was transferred to the surgical unit where her recovery was steady and uncomplicated. The operating room nurse who had done the preoperative assessment was unable to make a follow-up evaluation, but through my visits, the objectives of the postoperative interview were accomplished. The value of preoperative teaching became evident when Mrs M told me her throat was sore but she knew it was from the endotracheal tube. She also related some of her muscular discomfort to the positioning during surgery and was able to understand the reasons for some of the nursing measures. Mr M’s concern that she was not coughing or deep breathing indicated that he recognized the importance of good lung expansion to an uncomplicated recovery. As Mrs M convalesced, we discussed her surgical experience and her re-
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actions t o it. O n e m a j o r i n f l u e n c e in h e r recovery w a s h e r p o s i t i v e m e n t a l a t t i t u d e and h e r b e l i e f each day w a s g o i n g t o b e better. If n u r s e s recognized t h e p o w e r b e h i n d t h i s concept, w e w o u l d h a v e a s i m p l e but p o w e r f u l t o o l t o aid u s in c o u n s e l i n g p a t i e n t s and in t h e f o r m ing of o u r o w n attitudes. Mr and M r s M had b e e n impressed by t h e r e l a t i o n s h i p a m o n g t h e p a t i e n t s and b e t w e e n t h e p a t i e n t s and s t a f f . I t s e e m e d i m p o r t a n t f o r p a t i e n t s and f a m i l i e s t o support o t h e r s w h o w e r e at d i f f e r e n t stages in t h e i r h o s p i t a l i z a tions. Staff m e m b e r s f r o m secretaries t o housekeeping personnel conveyed t h e i r i n t e r e s t in t h e p a t i e n t s by a s k i n g t h e m and t h e i r f a m i l i e s h o w t h e y w e r e getting a l o n g and o f f e r i n g encouragement. T h i s emphasized t h e n e e d f o r and t h e p o w e r o f g r o u p s u p p o r t int i m e s o f stress and u n c e r t a i n t y . On t h e s e v e n t h p o s t o p e r a t i v e day, M r s M’s sutures w e r e removed, and she w a s discharged in excellent condition. During o u r l a s t v i s i t , she s a i d h o w happy she had been w h e n she recogn i z e d t h e pain w a s gone, and t h e operat i o n had b e e n successful.
[I
Notes 1. Ranjit K Laha, Peter J Jannetta, “Glossopharyngeal neuralgia,” Journal of Neurosurgery 47 (September 1977) 316-320. 2. Ibid. 3. Peter J Jannetta, “Treatment of trigeminal neuralgia by suboccipital and transtentorial cranial operations, ’ Clinical Neurosurgery 24 (1976) 538549. 4. Laha, Jannetta, “Glossopharyngeal neuralgia,” 316-320. 5. Susan M Tucker et al, Patient Care Standards (St Louis: C V Mosby Co, 1975) 21-23.
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Portable computer aids in patient evaluation A portable, low-cost microcomputer that processes information needed in caring for patients in the operating room and in intensive care has been developed at Cleveland Metropolitan General Hospital. The computer can be operated by personnel who have no prior programming experience. Skills can be developed using only the supplied basic manuals. John M Schulz, of the hospital’s anesthesiology department, described the computer system to members of the American Society of Anesthesiologists at their annual meeting Oct 24. “With health care costs soaring,” he said, “the use of flexible, inexpensive microcomputer systems not requiring highly skilled manpower, yet having the capability of putting out useful patient information is fast becoming a necessity.” Schulz said the hardware for the computer was put together from commercially available subsystems and costs less than $3,000. “The system we used is only one of the many commercially available microcomputers. It is advertised as a personal computer used in the home for anything from playing TV tennis to the efficient handling of banking and checking accounts.” The software program for the system was put together by a person with minimal prior experience in programming. The program takes the input information directly from monitors, such as the electrocardiograph, electroencephalograph, and blood pressure monitors and calculates all parameters. With sufficient data, the user can obtain a complete physiological profile of the patient, including blood vessel, heart, and lung function. Bar graphs can also be obtained. Data are available on a television-like screen or in hard copy printout for inclusion in the patient’s chart.
AORN Journal, March 1980, V o l 3 1 , N o 4
Doris C MacClelland, RN
The glossopharyngeal neuralgia patient Mrs M, a 42-year-old homemaker and ophthalmology assistant in Mesa, Ariz, experienced her first painful episode of glossopharyngeal neuralgia in August 1975. Since then, she has endured three more periods of severe neuralgia lasting as long as two weeks at a time. Pain medications were ineffective, and Mrs M began to feel desperation and hopelessness.
The excruciating pain of glossopharyngeal neuralgia is transitory and paroxysmal, attacking a t any time without warning. Although much rarer than trigeminal neuralgia, it is just as devastating. Incidence is only about 1% that of trigeminal neuralgia, of which about 5,000 to 15,000 cases are reported annually. The uncertainty of when an attack might occur becomes a mental
AORN Journal, March 1980, V o l 3 1 , N o 4
589
and physical barrier. Patients find themselves planning their activities by thinking, “What if the pain occurs?” The pain of glossopharyngeal neuralgia is described as jabbing, burning, cutting, laminating, and like an electric shock. Following the ninth cranial nerve, it can be experienced in the oropharynx, tonsillar fossa, base of the tongue, and deep in the ear. Because of its proximity, the tenth nerve is frequently involved, with an associated vagal neuralgia. Sometimes pain radiates to the distribution of the trigeminal nerve, neck, or shoulder, which is considered an overflow phenomenon.’ Vascular compression of the rootlets of the ninth and tenth cranial nerves is now recognized as the most frequent cause of glossopharyngeal neuralgia, although trauma, local infection, elongated styloid process, ossified stylohyoid ligament, vascular abnormalities, and tumors can be etiological factors.2 Glossopharyngeal neuralgia due to vascular compression is more common in midlife and later years, because of the normal loss of elasticity in the vessel walls. This may cause arteries to droop, allowing the vessels to rest on the
Doris C MacClelland, RN, MS, is a retired US Navy commander and operating room supervisor. A diploma graduate of Emanuel Hospital School of Nursing, Portland, Ore, she received a BA from San Francisco State University and an MS from Indiana University, Bloomington.
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nerves. The pulsations seem to act as irritating stimuli, producing the attacks of neuralgia. Diagnostic procedures are of little help. Most angiographic, radiographic, and electroencephalographic studies are usually within normal limits. Vascular anomalies may sometimes be visualized, but vascular compression of the nerve may not be visible preoperatively. Diagnosis is usually based on the patient’s history and the lack of clinical manifestations of other pathology. Current treatment of glossopharyngeal neuralgia is surgical, although some patients are managed medically with varying degrees of relief. Drugs such as carbamazepine (Tegretol) and/or phenytoin sodium (Dilantin) may provide temporary relief of symptoms, but surgical intervention has the most encouraging long-range results, both in controlling pain and eliminating untoward side effects. Past surgical techniques usually involved sectioning the nerve or nerves at some selected point. Since cutting the nerve creates sensory and/or motor deficit that can be permanent, it is more desirable to leave the nerves intact if possible. A procedure to decompress the nerve, which eliminates the need for sectioning, is becoming more widely used. Approximately ten years ago, Peter J Jannetta, MD, University of Pittsburgh School of Medicine, developed and described a procedure for the relief of trigeminal neuralgia, which is now being adapted €or other cranial nerve neuralgias3 In the hands of a capable neurosurgeon, this procedure is relatively simple and has virtually no undesirable postoperative sequelae. A posterior craniotomy (retromastoid craniectomy) approach is used. With an operating microscope, the cranial nerves in question are identified at the root entry zone and the vascular struc-
AORN Journal, March 1980, V o l 3 1 N o 4
(L
t has put me
I i n a very nervous state of emotions.”
tures observed. In most instances, the vertebral artery or the posterior inferior cerebellar artery (PICA)will be found to be compressing the nerve at this point. A tiny piece of silastic sponge or polyvinylchloride sponge (Ivalon) is then placed between the vessel and the nerve, relieving the pulsating pressure to the nerve. In some cases, a tissue sling may be created to lift the vessel from the nerve, but this technique has been used more often in the treatment of trigeminal neuralgia. If there is no evidence of vascular compression or other pathology, the nerve or nerves may be sectioned. After surgery, transitory hypertension may occur. This predisposes the patient to intracerebral hematoma, a condition thought to be related to disturbance on the ninth cranial nerve. Other possible postoperative complications are the same as those normally expected from any major neurological procedure done under general anesthesia. *If surgery is done with the patient in sitting position, there is an increased risk of air embolism, so some surgeons place the patient in the prone position. The success of the procedure in relieving pain is directly related to the adequacy of the procedure. Results from this operation have generally been good. Based on its success in treating trigeminal neuralgia, patients with glossopharyngeal neuralgia can expect the same favorable results.*
After she had been scheduled for surgery Sept 24, 1979, at the Green Hospital of Scripps Clinic, La Jolla, Calif, I contacted Mrs M at home to see if she would share her experience with the AORN Journal. Since she knew her condition was uncommon and the proposed operation was relatively new, she agreed. This was the second time her surgery had been scheduled. It was initially scheduled for April 18, but had to be cancelled when her husband was hospitalized with what was first thought to be an acute myocardial infarction. The diagnosis was later changed, and he was released from the hospital in about a week with no further difficulty. I first met Mrs M and her husband in the lobby of the motel in La Jolla where he would be staying throughout her hospitalization. Her surgery was scheduled for the next morning. I found them to be warm, friendly, and optimistic. My immediate reaction was admiration, since I recognized how easily they could have become dejected and negative because the neuralgia had disrupted their lives. The more we talked, the more evident it became that both were willing to make the best of a difficult situation. It also was evident that they enjoyed a loving, supportive relationship. After telling me briefly about the history of her pain, Mrs M said the episodes of neuralgia were characterized by the
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onset of a background pain-a numb, tingling, burning, aching sensation. She later experienced a severe stabbing, lancinating pain in the same area. Felt primarily deep under the left ear, the pain would be triggered by movement of the mouth or throat. Most distressing was the accompanying sensation of choking even though she did not actually choke. Usually the pain disappeared during sleep, probably because the triggering mechanisms were at rest. She also had experienced a slight ptosis of the left eyelid during several of the acute pain episodes. Although paroxysms of pain could be initiated by certain movements such as chewing, talking, swallowing, or yawning, onset of an episode could not be related to any identifiable physical or emotional factor. “It’s just there,” Mrs M sighed. “I can be relaxed and enjoying myself when all of a sudden it happens. And I know then it will be with me at least several hours.” Mrs M’s statement that attacks were
not related t o emotional stress had been validated when her husband was admitted to the hospital. Her own anxieties about surgery plus this stress situation did not precipitate an episode of neuralgia as might have been expected. When the pain first occurred in 1975, the physician who treated her believed she had an infection and prescribed a n antibiotic with propoxyphene napsylate (Darvon) for pain. Obtaining no relief, she began searching for help. A dental check revealed no pathologic condition, and an examination by a n otolaryngologist was normal. A neurologist diagnosed glossopharyngeal neuralgia. Phenytoin sodium (Dilantin) was prescribed, but within several days Mrs M developed a severe rash, and the medication was discontinued. Fortunately, the pain simultaneously disappeared. The second episode occurred in April 1976 and was characterized by a sharp, pulsating pain. This time, the neurologist prescribed carbamazepine (Tegretol) 100 mg 3 times a day. Since Teg-
The patient was turned to a prone position and the head immobilized in a stereotaxic head holder. Then the lower part of the scalp was shaved. At right, the assistantsurgeon is injecting the head with anesthetic.
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retol is toxic to the hemopoietic system, it became necessary to stop the drug within four days because of evidence of bone marrow depression. Again, the pain disappeared after the drug was discontinued. In September 1978, just three weeks after the family had moved from the midwest to Arizona, the next episode occurred. Mrs M located another neurologist, who also prescribed Tegretol. The drug was stopped five days later, and again the pain disappeared. When the current episode began in July 1979, the neurologist doubled the dose of Tegretol, stating the blood changes were reversible. Mrs M wondered what would happen. After several days, she said, “the Tegretol made me a n absolute basket case as far as my nerves went. I felt I was going into a real mental depression. I became extremely tired. On top of that, the pain was still there, too.” Because she could no longer cope with the severe emotional side effects of the
medication, she stopped taking it. At this point, she could no longer work and was experiencing a feeling of panic and desperation. Mrs M heard about Scripps Medical Institutions and called for consultation. When she first visited the clinic as a n outpatient, on Sept 6, 1979, she was interviewed and thoroughly evaluated by Thomas A Waltz, MD, a neurosurgeon. He found Mrs M to be a cooperative woman with intact speech and hearing. There were normal sensations to her face, corneal reflexes were normal, and her face, tongue, and palate moved symmetrically. Her gait was normal, and she demonstrated symmetrical reflexes with normal sensation to touch, pin, and position. Although her history revealed previous ptosis of the left eyelid, there was no evidence of ptosis a t that time. Results of the computed tomography (CT) scan and studies for brainstem-evoked responses and visual-evoked responses were also within normal limits.
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The diagnosis of glossopharyngeal neuralgia was confirmed. Since Dr Waltz believed medical treatment options had been exhausted, he recommended that Mrs M consider surgery. The proposed operation was thoroughly explained to Mr and Mrs M. Weighing the risks against the proposed outcome, they agreed t o surgery, which was scheduled for one week later. During this period, Mr M was admitted t o the coronary care unit a t a hospital in Arizona, so Mrs M’s surgery was canceled and rescheduled after her husband’s condition improved. During our preadmission interview, I attempted to elicit Mrs M’s feelings about h e r condition and proposed treatment. Asked how she felt her life had been affected most, she responded, “It has put me in a very nervous state of emotions that I have never had because I’ve always been a very relaxed, happy-go-lucky person.” I then asked if and how this had affected her family. She answered, ‘‘I’m
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sure it has because I have been very nervous about the whole thing. In the back of my mind I always worried about the uncertainty of when the pain would happen and what I could do about it. Then thinking about surgery-well, I know it has affected them.” I then directed the same question to Mr M, and he replied, “We’ve always been a very relaxed and close family. We have three boys 20,17, and 13. We found ourselves having to be careful what we said and did so as not t o upset her. The boys would sometimes ask me what was the matter with mother because she wasn’t herself.” From their comments, it is obvious this condition had been a disruptive force in a family who had a comfortable relationship with each other. Describing h e r feelings about surgery, Mrs M said, “Well, I feel like I The operation is conducted using an operating microscope. Here the nurse views the surgical field through the microscope eye piece.
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have no real choice in the matter. If I could put it off, I probably would. But I think in all fairness, not only to myself but also to the people around me, that I must go ahead and do it. Even when the pain is tolerable, and right now it is within tolerance, I feel I should go ahead.” Mr M added, “I’m nervous about the operation, but I’m confident about what the doctor has told us. And he’s a competent doctor. He knows what he is doing. I just have faith that the operation is going to take care of it.” They emphasized their confidence in the surgeon. They said his calm, confident approach was reassuring, since most of the other physicians she had seen were not familiar with her condition nor the treatment. To assess Mrs M’s knowledge about her operation, I asked what the surgeon had told her about her surgery and the expected outcome. In her answer, she demonstrated a high degree of understanding. Although she had no specific expectations for her nursing care, she said she knew she would receive excellent care. This response was based on the reputation of the hospital and her own observations during her outpatient visit. “It was just phenomenal,” she said. “There was never any wondering what they were doing. They explained it all to me.” I emphasized that her interest was good, because patients who take an active interest in understanding their illness and treatment can play an active role in reaching the goals of their prescribed therapy. During the interview, I provided support and encouragement to Mrs M as she faced the frightening prospect of “having her head cut open.” I explained that a nurse from the operating room would come to see her before surgery and answer any specific questions she might have. I told her that I, too, would
visit her the next morning before surgery. Arriving at the hospital that afternoon, Mrs M completed the necessary forms and was shown to her room. The nursing assessment was completed, and later in the evening, preoperative studies were done. Since Mrs M was in excellent health, no special nursing measures were required. The anesthesiologist visited her and thoroughly explained the type of anesthesia planned and what Mrs M could expect before and after surgery. He discussed drugs he would be using and special positioning that would be necessary for her operation. He reassured her by telling her that he would be with her and would be monitoring her condition at all times. She later told me she was pleased with his manner and felt confident he would take good care of her. In the morning, Barbara Howes, the operating room nurse, arrived for the preoperative interview. After determining what Mrs M knew about her operation, she explained what would be happening to her after her arrival in the operating suite. Although this was Mrs M’s first surgery, her job as an ophthalmology assistant had taken her into the operating room, so she was not a complete stranger to the environment. The nurse instructed her in postoperative coughing and deep breathing and reviewed the purpose of preoperative medications. She told Mrs M she would be going to the postanesthesia recovery room and then to the surgical intensive care unit, where she would probably remain until the following day. Since Mr M was present, the OR nurse told him where he could wait and explained visiting policies for postoperative patients. When I arrived later that morning, Mrs M was in good spirits and “ready t o get this over with.” Dr Waltz came in briefly to see if she had any questions,
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and her husband had been with her since early morning. Our presence and her positive attitude seemed to help her to approach surgery with confidence, in spite of the normal expected apprehensions. On her arrival to the OR holding area, Mrs M was greeted by the OR nurse, who identified her and confirmed the site of the operation. The nurse checked for all necessary records and reviewed Mrs Ms preparation for surgery. The operating room was set up. Special items included the stereotaxic headrest and chest rolls for positioning, bipolar and monopolar electrosurgical units, a sterile air-powered drill and a full tank of nitrogen, hair clippers, the operating microscope with attached camera, and the necessary sterile instrumentation. Routine equipment and supplies were prepared and all the necessary counts recorded. In the room, Mrs M was assisted onto the OR bed in supine position. An intravenous infusion was started and the
electrocardiograph (ECG) electrodes positioned. A blood pressure cuff was placed on the arm and connected to the computerized sphygmomanometer. During this preparation, the OR nurse remained at Mrs M’s side to provide emotional support and ensure her comfort and safety. Anesthesia was begun. When the patient was relaxed, the endotracheal tube was inserted and secured. After it was determined that she was in stable condition, Mrs M was carefully turned to prone position and her head immobilized in the stereotaxic head holder. The nurse checked for good body alignment, with adequate support and padding. Mrs M’s arms were secured at her sides, with a sheet clipped over her back and the adherent grounding plate applied to her thigh. The safety strap was placed just below the buttocks. Her head was then prepared by the assistant surgeon, who clipped the lower half of the posterior hair and then shaved the scalp. The nurse applied
Dr Waltz uses the power drill to enter the skull as the nurse irrigates away bone particles. The assisting surgeon is at left.
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povidone-iodine, and the incision area was injected with lidocaine and epinephrine. Sterile drapes were applied and the sterile field readied. The procedure was to be a craniotomy with neurovascular decompression. Through an L-shaped incision from the left mastoid to the midline and down to C-2, the muscles were lifted from the occipital bone and the bone removed. The dura mater was opened and the cerebellar self-retaining retractor positioned. With the help of the dissecting microscope, the arachnoid was divided to give access to the ninth, tenth, and eleventh cranial nerves at the jugular foramen. The nerves were then traced medially to the root entry zone and the arteries identified. The ninth and tenth nerves were found to be deformed by two branches of what was probably the posterior inferior cerebellar artery (PICA). A branch underneath the tenth and eleventh nerves deflected them posteriorly and then extended forward to deflect the n i n t h nerve anteriorly. Another branch somewhat closer to the brainstem passed underneath the root entry zone of the tenth cranial nerve. The arteries were lifted off the nerves and two small pieces of Silastic sponge placed between to separate the nerves and the arteries. A small piece of absorbable gelatin sponge was then placed over the nerves. The wound was thoroughly irrigated, the dura closed with 4-0nylon, and the muscles and galea reapproximated with 2-0 silk. The scalp was closed with 3-0 polypropylene and a head dressing applied. No drains were used, and the estimated blood loss was 150 cc. Two hours after the opening incision at 2:30 pm, the operation was completed. The OR nurse was alert to the needs of the surgical team during the operation and the condition and safety of the patient. Blood loss was observed, sponges and cottonoids accounted for, and opera-
tive records completed. As she was transferred to the recovery bed, Mrs M was then covered with a warm blanket. The endotracheal tube was removed when her level of consciousness and respiratory activity permitted. Because of the late hour, she was taken directly to the surgical intensive care unit by the circulating nurse and the anesthesiologist. A joint report was given to the unit nurse, who immediately checked vital signs and began oxygen by mask to assist Mrs M in waking up. Neurologic checks were done including pupil size and reaction, hand grasps, and extremity movements so any changes in response could be detected early. Her head was elevated 30 degrees to help reduce any possible cerebral edema. Mrs M was drowsy but responding to verbal stimuli, so the unit nurse said Mr M could come in for a short time. The surgeon had already discussed the operation with him and assured him all was well. Immediate postoperative care was r o ~ t i n e The . ~ next day, Mrs M was transferred to the surgical unit where her recovery was steady and uncomplicated. The operating room nurse who had done the preoperative assessment was unable to make a follow-up evaluation, but through my visits, the objectives of the postoperative interview were accomplished. The value of preoperative teaching became evident when Mrs M told me her throat was sore but she knew it was from the endotracheal tube. She also related some of her muscular discomfort to the positioning during surgery and was able to understand the reasons for some of the nursing measures. Mr M’s concern that she was not coughing or deep breathing indicated that he recognized the importance of good lung expansion to an uncomplicated recovery. As Mrs M convalesced, we discussed her surgical experience and her re-
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actions t o it. O n e m a j o r i n f l u e n c e in h e r recovery w a s h e r p o s i t i v e m e n t a l a t t i t u d e and h e r b e l i e f each day w a s g o i n g t o b e better. If n u r s e s recognized t h e p o w e r b e h i n d t h i s concept, w e w o u l d h a v e a s i m p l e but p o w e r f u l t o o l t o aid u s in c o u n s e l i n g p a t i e n t s and in t h e f o r m ing of o u r o w n attitudes. Mr and M r s M had b e e n impressed by t h e r e l a t i o n s h i p a m o n g t h e p a t i e n t s and b e t w e e n t h e p a t i e n t s and s t a f f . I t s e e m e d i m p o r t a n t f o r p a t i e n t s and f a m i l i e s t o support o t h e r s w h o w e r e at d i f f e r e n t stages in t h e i r h o s p i t a l i z a tions. Staff m e m b e r s f r o m secretaries t o housekeeping personnel conveyed t h e i r i n t e r e s t in t h e p a t i e n t s by a s k i n g t h e m and t h e i r f a m i l i e s h o w t h e y w e r e getting a l o n g and o f f e r i n g encouragement. T h i s emphasized t h e n e e d f o r and t h e p o w e r o f g r o u p s u p p o r t int i m e s o f stress and u n c e r t a i n t y . On t h e s e v e n t h p o s t o p e r a t i v e day, M r s M’s sutures w e r e removed, and she w a s discharged in excellent condition. During o u r l a s t v i s i t , she s a i d h o w happy she had been w h e n she recogn i z e d t h e pain w a s gone, and t h e operat i o n had b e e n successful.
[I
Notes 1. Ranjit K Laha, Peter J Jannetta, “Glossopharyngeal neuralgia,” Journal of Neurosurgery 47 (September 1977) 316-320. 2. Ibid. 3. Peter J Jannetta, “Treatment of trigeminal neuralgia by suboccipital and transtentorial cranial operations, ’ Clinical Neurosurgery 24 (1976) 538549. 4. Laha, Jannetta, “Glossopharyngeal neuralgia,” 316-320. 5. Susan M Tucker et al, Patient Care Standards (St Louis: C V Mosby Co, 1975) 21-23.
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Portable computer aids in patient evaluation A portable, low-cost microcomputer that processes information needed in caring for patients in the operating room and in intensive care has been developed at Cleveland Metropolitan General Hospital. The computer can be operated by personnel who have no prior programming experience. Skills can be developed using only the supplied basic manuals. John M Schulz, of the hospital’s anesthesiology department, described the computer system to members of the American Society of Anesthesiologists at their annual meeting Oct 24. “With health care costs soaring,” he said, “the use of flexible, inexpensive microcomputer systems not requiring highly skilled manpower, yet having the capability of putting out useful patient information is fast becoming a necessity.” Schulz said the hardware for the computer was put together from commercially available subsystems and costs less than $3,000. “The system we used is only one of the many commercially available microcomputers. It is advertised as a personal computer used in the home for anything from playing TV tennis to the efficient handling of banking and checking accounts.” The software program for the system was put together by a person with minimal prior experience in programming. The program takes the input information directly from monitors, such as the electrocardiograph, electroencephalograph, and blood pressure monitors and calculates all parameters. With sufficient data, the user can obtain a complete physiological profile of the patient, including blood vessel, heart, and lung function. Bar graphs can also be obtained. Data are available on a television-like screen or in hard copy printout for inclusion in the patient’s chart.
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