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
malignancies1. 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,
respectively2.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 stimulated3.Williams (1954) advocated removal
of middle turbinate in the treatment of what he described as ‘nasal
contact headache’4. Further to this, Stammberger and
Wolf proposed that neuropeptides, especially substance P, are involved
in the mediation of facial pain owing to mucosal
contactpoints5.
Sluder’s neuralgia exhibits symptoms of unilateral headache due to
injury or inflammation to the sphenopalatine ganglion or its
branches3. 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 ‘NGT neuralgia’ .