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\begin{document}

\title{Sluder's neuralgia- A sequalae of nasogastric tube feeding}



\author[1]{Joshna Naidu}%
\author[2]{Anand Subash}%
\author[3]{Vishal Rao}%
\affil[1]{Healthcare Global Enterprises Ltd}%
\affil[2]{HealthCare Global Enterprises Ltd}%
\affil[3]{HCG}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Management of nutritional needs is of paramount importance in cancer
patients and nasogastric feeding is the most common method. Nasal cavity
being a richly innervated region, is also a hallway for the exposure of
the same to external environment. Any trauma or pressure to these nerve
endings result in unilateral headache mimicking Sluder's neuralgia.
Nasogastric tube may irritate the nasal mucosa and exert pressure on the
nasal turbinates. We believe that the persistent headache in patients
with NG tube is distinctly significant that it interferes with the
physical comfort of patient. It also influences the sleep patterns,
thereby causing repercussions in the emotional well-being. Head and neck
oncologists being the primary clinicians, it is imperative to consider
the Sluder's neuralgia in patients with nasogastric tube feeding. This
mandates a prospective study to describe the clinical features and the
treatment of `NGT neuralgia'.%
\end{abstract}%



\sloppy


\emph{Sluder's neuralgia- A sequalae of nasogastric tube feeding}

Management of nutritional needs is of paramount importance in cancer
patients. Albeit the availability of methods like PEG feeds, feeding
jejunostomy and parenteral nutrition, feeds via nasogastric tube is the
most common mode of nutrition in patients with head and neck
malignancies\textsuperscript{1}. Nasogastric feeding may irritate the
nasal mucosa and exert pressure on the nasal turbinates. This can
potentially cause unilateral headache, which is known to simulate the
Sluder's neuralgia.

Nasal cavity being a richly innervated region, is also a hallway for the
exposure of the same to external environment. Nerves supplying the nasal
cavity are sensitive to external factors because of nociceptive
receptors they bear. General sensory innervation is predominantly
contributed by the branches of Trigeminal nerve via Nasociliary nerve
(V1) and nasopalatine nerve(V2). The anterior ethmoidal nerve which is a
continuation of nasociliary nerve, runs along the cribriform plate
before passing through a slit, lateral to the crista galli to enter the
nasal cavity. Medial and lateral branches of the nerve innervate the
mucosa of the nasal septum and lateral nasal wall,
respectively\textsuperscript{2}.Any trauma or pressure to these nerve
endings result in unilateral headache mimicking Sluder's neuralgia.

Sluder (1901) described the neurogenic condition causing headache due to
contact points between different structures within the nasal cavity. In
1934, McAuliffe et al. stimulated the lower, middle and upper turbinates
mechanically with a probe or by a faradic current and reported that this
process produced referred pain with a specific distribution depending on
the area stimulated\textsuperscript{3}.Williams (1954) advocated removal
of middle turbinate in the treatment of what he described as `nasal
contact headache'\textsuperscript{4}. Further to this, Stammberger and
Wolf proposed that neuropeptides, especially substance P, are involved
in the mediation of facial pain owing to mucosal
contactpoints\textsuperscript{5}.

Sluder's neuralgia exhibits symptoms of unilateral headache due to
injury or inflammation to the sphenopalatine ganglion or its
branches\textsuperscript{3}. Often, Sluder's neuralgia is confused with
the diagnosis of Vidian neuralgia and anterior ethmoidal nerve syndrome.
A common triggering factor for the above mentioned spectrum of neuralgia
is injury, constant pressure or chemical irritation to nasal turbinates.
Presence of septal spur or deviated nasal septum abutting on the middle
turbinate are the most common predisposing factors. Surgical removal or
correction of the predisposing factor will relieve the discomfort. We
have noticed that the presence of nasogastric tube (NGT) has similar
effect and its removal has abated the unilateral headache caused by
nasogastric tube (Figure 1). Hence this condition is popularly
recognised in our institute as `\emph{NGT neuralgia'} .\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1- Nasogastric tube impingement on nasal turbinates

We believe that the persistent headache in patients with NG tube is
distinctly significant that it interferes with the physical comfort of
patient. It also influences the sleep patterns, thereby causing
repercussions in the emotional well-being. Patients usually complain of
unilateral headache in the post-operative period, corresponding to the
side of nasogastric tube. The headache as described by the patients is
constant, persistent, unilateral and sleep disrupting. The Pain is not
associated with any sensory loss, with no observed changes in the
laboratory or imaging studies. Notably, the pain typically subsides upon
the removal of nasogastric tube. Head and neck oncologists being the
primary clinicians, it is imperative to consider the Sluder's neuralgia
in patients with nasogastric tube feeding. This mandates a prospective
study to describe the clinical features and the treatment of NGT
neuralgia.

\subsection*{References}

{\label{references}}

1) Pearce CB, Duncan HD.Enteral feeding. Nasogastric, nasojejunal,
percutaneous endoscopic gastrostomy, or jejunostomy: its indications and
limitations. Postgraduate Medical Journal 2002;78:198-204

2) Navarro J.A.C., de Lima Navarro J., de Lima Navarro P. (2001)
Arteries and Nerves of the Nasal Cavity and Paranasal Sinuses. In: The
Nasal Cavity and Paranasal Sinuses. Springer, Berlin, Heidelberg. Pg no
61-70. https://doi.org/10.1007/978-3-642-56829-9\_6.

3) McAuliffe GW, Goodell H, Wolff HG. Experimental studies on headache:
Pain from the nasal and paranasal structures. Research Publication. New
York: Association for research in nervous and mental disease 1942;
23:185--208.

4) Williams HL. Somatic head pain from the standpoint of the
rhinologist, otologist and laryngologist. Lancet. 1954;74:22--26.

5) Stammberger H. \& Wolf G. (1988) Headache and sinus disease: the
endoscopic approach. Ann. Otol. Rhinol. Laryngol. (Suppl.) 134, 77.

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