Herpetic and postherpetic ganglioneuritis

Among the neuropathies affecting various structures of the nervous system, ganglionitis or inflammation of the sympathetic and parasympathetic ganglia is distinguished - nerve cells grouped in the form of nodes that provide communication between the peripheral and central nervous systems.

However, ganglionitis does not have an ICD-10 code: codes G50-G59 indicate diseases associated with damage to individual nerves, nerve roots and plexuses.

The pathological process in ganglionuritis affects not only the nerve nodes, but also the adjacent plexuses of sympathetic or afferent vegetative-visceral nerve fibers. When only the nerve node is inflamed, ganglionitis is diagnosed.

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Epidemiology

The clinical statistics of ganglionitis and ganglionitis are unknown, but the most common localization of these diseases is considered to be the pterygopalatine ganglion and the geniculate ganglion of the facial nerve.

There are some data regarding the annual incidence of pterygopalatine ganglionitis: in young patients with herpes zoster or as a complication of chickenpox, it is diagnosed in 0.2-0.3% of cases, and in the general population, postherpetic ganglionitis or postherpetic neuralgia of various localizations is observed, on average, in 12.5% of patients.

Causes ganglioneuritis

Inflammation of the ganglia of the peripheral nervous system, called ganglionitis by domestic neurologists, develops as a result of a locally acting infection: bacterial (most often streptococcal or staphylococcal) or viral (adenoviruses, herpes virus, etc.), which spreads from structures and tissues close to the nerve nodes.

Experts associate the key causes of ganglionitis with inflammation in tonsillitis and monocytic angina; carious destruction of teeth; influenza and diphtheria; otitis and eustachitis; tuberculosis and syphilis; with some transmissible and zoonotic infections (tick-borne borreliosis, malaria, brucellosis, etc.).

For example, inflammation of the pterygopalatine ganglion (ganglion pterygopalatinum), which has roots of the facial and trigeminal nerves – pterygopalatine ganglionitis or Sluder syndrome – can be the result of both advanced caries and chronic and acute inflammatory processes localized in the maxillary sinuses with sinusitis, ethmoiditis, frontal sinusitis or sphenoiditis (since the pterygopalatine ganglion is connected to the auricular and ciliary ganglion).

Inflammation of the ganglia of the autonomic nervous system is especially common with shingles, and also as a complication of chickenpox, caused by one pathogen – the neurotropic virus Herpes zoster (or Varicella Zoster virus). In such cases, the diagnosis can be determined as postherpetic ganglionitis.

Pelvic ganglionitis/ganglioneuritis of the pelvic plexuses in women can be a consequence of inflammation of the appendages (adnexitis or salpingo-oophoritis) or ovaries (oophoritis), and in men, sacral ganglionitis occurs with a chronic inflammatory process in the prostate gland (prostatitis).

Risk factors

Neurologists see risk factors for the development of ganglionitis in the presence of foci of chronic infection against the background of weakened protective forces of the body and decreased resistance to the oxidative action of free radicals, in hypothermia of the body (especially in people who are forced to stay in the cold for a long time and often become overcooled).

By the way, there is a risk of contracting shingles, that is, the Herpes zoster virus, although herpetic ganglionitis is not contagious in the absence of dermatological manifestations of herpes zoster. But lumbar ganglionitis can be contagious at the stage of vesicular rashes in the lumbar region. And the particular danger of Herpes zoster is that this virus, when penetrating the bloodstream, captures nerve cells and settles in the ganglia of the peripheral nervous system, but may not show its presence in the human body for a long time.

The risk of inflammation of the autonomic ganglia due to the negative impact of exogenous toxins (primarily ethanol) on them, as well as damage to the nerve nodes with nearby nerve trunks and axon plexuses during metastasis of malignant neoplasms, cannot be ruled out.

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Pathogenesis

When considering the pathogenesis of ganglionitis, it is important to keep in mind the fact that the structures of the autonomic nervous system – in particular, the sympathetic, parasympathetic and sensory ganglia – respond to infection not only by the release of proinflammatory cytokinins by their immunocompetent cells, but also by certain changes in the trophism and metabolism of neuro- and gliocytes, as well as the tissues of the fibrous membranes and stroma of the nodes.

This leads to functional disturbances in the reception of nerve signals by the ganglia, arriving via preganglionic fibers, the subsequent differentiation of these impulses and further transmission via peripheral nerve fibers, as well as via postganglionic trunks to the corresponding analyzer centers of the central nervous system (in the brain).

Due to such disturbances, there is an increase in outgoing impulses, which is associated with the symptoms of a vegetative, motor or sensory nature that arise with ganglioneuritis.

Symptoms ganglioneuritis

The way ganglionitis manifests itself depends on the localization of the inflamed ganglion, but the first signs of the pathology are neuralgic pain; in most cases, this is a bursting, pulsating pain of a burning nature (pronounced causalgia), perceived by patients as diffuse - with a subjectively difficult to determine focus.

Symptoms that indicate pterygopalatine ganglionitis/ganglioneuritis of the pterygopalatine ganglion include sudden attacks of severe pain in the face, affecting the eye area (with its redness), nose (in the bridge of the nose), jaws, temple, ears, radiating to the back of the head, neck, shoulder blades and even the upper limb. The pain appears against the background of unilateral hyperemia and swelling of the skin of the facial part of the skull, increased sweating, photophobia, sneezing and increased secretion of tears, nasal secretions and saliva. Nausea and dizziness are common.

Symptoms of ganglionitis of the otic node (ganglion oticum) also manifest as paroxysmal pains (aching or burning), which patients feel in all structures of the ear, as well as in the jaw, chin and neck. There may be unpleasant sensations of congestion or distension in the ear; the skin around the ear and on the temple turns red; the formation of saliva increases (hypersalivation).

Localization of pain in ganglionuritis of the sublingual ganglion (ganglion sublinguale) is the tongue and the area under it, and in inflammation of the submandibular ganglion (ganglion submandibularis), patients complain of pain (including when articulating sounds and eating) in the lower jaw, in the neck (side), in the temporal and occipital regions; increased salivation is characteristic.

Inflammation of the ciliary ganglion (ganglion ciliare) located in the eye socket or Oppenheim syndrome is characterized by intense paroxysmal pain in the eyeball, photophobia, hyperemia of the mucous membranes of the eye; a decrease in blood pressure is possible.

Ganglioneuritis of the trigeminal nerve, or more precisely ganglionitis of the trigeminal, trigeminal or Gasserian ganglion (ganglion trigeminale) located on the upper part of the pyramid of the temporal bone, causes causalgia (most intense at night), fever, swelling of the soft tissues of the face, and impaired skin sensitivity along the trigeminal nerve.

Hunt syndrome, ganglionitis of the geniculate ganglion of the facial nerve (ganglion geniculate in the facial canal of the temporal bone) or ganglioneuritis of the geniculate ganglion of the facial nerve is caused by the Varicella Zoster virus. Its symptoms and localization of pain are the same as with inflammation of the pterygopalatine and ciliary ganglia, but facial expression disorders are more often observed.

When cervical ganglionitis develops, it is necessary to differentiate between lower cervical, upper cervical and cervicothoracic (stellate) ganglionitis. In the first case, in addition to pain, there is cyanosis of the skin on the arm on the side of the affected caudal ganglion (ganglion cervicale inferius); decreased sensitivity of the skin on the arm and in the area of the upper ribs and decreased muscle tone; the eye slit stops closing when the cornea is irritated, and some other reflexes are impaired.

In the second case - with inflammation of the ganglion cervicale superius - cervical ganglionitis manifests itself as pain radiating to the lower jaw, and also leads to forward displacement of the eyeball (with a decrease in intraocular pressure), an increase in the palpebral fissure and dilation of the pupil; a decrease in skin sensitivity below the collarbones; increased sweating. Paresis of the muscles of the larynx and vocal cords (with the appearance of hoarseness) may develop.

In ganglioneuritis of the stellate or cervicothoracic ganglion (ganglion cervicothoracicum), pain is felt in the sternum (on the corresponding side), and the person often thinks that his heart hurts. In addition, movement of the little finger on the corresponding hand is difficult.

Pelvic, or ganglionitis of the pelvic plexuses in women causes paroxysmal burning pain in the lower abdomen and pelvis (radiating to the lumbar region, perineum, inner thighs), hypo- or hyperesthesia of the skin in the specified localization. Intimate intimacy may be accompanied by unpleasant sensations.

Lumbar ganglionitis manifests itself in diffuse debilitating pain in the back and abdomen, deterioration of the trophism of the tissues of the internal organs, negative changes in the vascular system of the lower extremities and abdominal organs with impairment of their functions. In general, specialists note a wide range of vasomotor (vasomotor) disorders and segmented innervation disorders.

With sacral ganglioneuritis, pain radiates to the lower back, peritoneum, pelvis, rectum; itching in the genital area and urination disorders appear; in women, the menstrual cycle may be disrupted.

Complications and consequences

The following consequences and complications of ganglionitis are observed:

• in case of ganglionuritis of the geniculate node of the facial nerve, a large part of this nerve can be affected with the development of facial nerve paralysis;
• inflammation of the otic ganglion is complicated by damage to the eardrum and structures of the inner ear;
• When the geniculate node of the facial nerve becomes inflamed, the secretion of tear fluid may decrease, which leads to irritation and dryness of the cornea;
• Cervical ganglionitis can lead to increased hormone-producing activity of the thyroid gland and, as a consequence, to hyperthyroidism.

Trigeminal ganglionitis that lasts for years causes chronic insomnia and psychoemotional disorders (turning a person into a neurasthenic); patients with this disease often lose their ability to work.

Diagnostics ganglioneuritis

The basis for the diagnosis of ganglioneuritis is the clinical picture of the disease, the patient's medical history and their complaints.

In addition to a general blood test, tests for HIV, tuberculosis, syphilis are required; a test for herpes is done, that is, an IFN blood test for antibodies to the Herpes zoster virus.

To determine the exact location of the inflammatory process, assess its spread to the autonomic nerve fibers and to differentiate pathology, instrumental diagnostics are used: X-ray of the spine, ECG, ultrasound, CT or MRI (of the chest and abdominal organs, pelvis, facial part of the skull), electromyography, etc.

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Differential diagnosis

Differential diagnostics are necessary, which should distinguish, for example, lumbar ganglionitis from osteoarthrosis of the spine or intervertebral disc herniation; cervical ganglionitis - from manifestations of radiculopathy (radicular pain), osteochondrosis, spondylosis and reflex myofascial syndromes; ganglionitis of the cervicothoracic node - from angina pectoris and other cardiological problems; ganglionitis of the pelvic plexuses in women - from gynecological diseases.

Treatment ganglioneuritis

Etiological treatment of ganglion vuritis involves the use of medications aimed at the cause of inflammation - infection. If the infection is microbial, antibacterial drugs are used (prescribed by an otolaryngologist, gynecologist and other specialists). For antiviral therapy, other drugs are needed, read more - Treatment of shingles

To get rid of pain, neurologists recommend analgesics of various pharmacological groups. Thus, the combined painkiller Spazmalgon (other trade names are Spazgan, Revalgin, Baralgetas) can be used for a short time (for three days) orally - 1-2 tablets no more than three times a day; as an intramuscular injection - 2-5 ml twice a day. Side effects of this drug include nausea, vomiting, abdominal pain, increased blood pressure, increased heart rate, headache, skin allergic reaction, etc. Spazmalgon is contraindicated in cases of blood disorders, severe liver or kidney failure, glaucoma, prostate adenoma, bronchial asthma, pregnancy and lactation.

A drug from the ganglionic blocker group – Hexamethonium benzosulfonate (Benzohexonium) – is taken orally (at a dosage of 0.1-0.2 g per dose, three times a day) or a 2.5% solution is administered subcutaneously (0.5 ml). This drug can cause general weakness and dizziness, tachycardia, a drop in blood pressure; it cannot be prescribed for hypotension, thrombophlebitis, severe liver and kidney diseases.

Medicines belonging to the group of peripherally acting anticholinergics are used: Gangleron, Metacil. Platyphylline hydrotartrate (Platyphylline) or Difacil (Spazmolitin, Adifenin, Trazentin).

A single dose of Gangleron in tablets is 40 m, it is recommended to take one tablet three times a day.

Metacil tablets (2 mg) can be taken one or two at the same frequency, and a 0.1% solution of the drug is injected into the muscle (0.5-2 ml). Platyphylline is used both orally (0.25-0.5 mg no more than three times a day) and parenterally (1-2 ml of a 0.2% solution subcutaneously). And Difacil is prescribed orally at 0.05-0.1 g 2-3-4 times a day (after meals). All anticholinergic drugs can cause headaches, temporary visual impairment, dry mouth and upset stomach, as well as an increase in heart rate; these drugs are prohibited for use in patients with glaucoma.

The use of NSAIDs for ganglioneuritis is not excluded, for more details see - Tablets for neuralgia

In cases of pelvic or sacral ganglionitis, rectal pain-relieving suppositories can have a positive effect.

In case of unbearable pain, novocaine blockades are performed.

It is also recommended to take B vitamins and, as prescribed by your doctor, immunostimulants.

Physiotherapy is actively used in the complex therapy of ganglionitis, details in the material - Physiotherapy for neuritis and neuralgia of peripheral nerves

Massage treatment for ganglionitis helps reduce pain intensity and improve tissue trophism.

If medications do not relieve the pain, surgical treatment is performed, which involves removing the affected nerve node using laparoscopic sympathectomy or radiofrequency destruction.

Prevention

The main prevention of inflammation of the sympathetic and parasympathetic ganglia is timely and adequate treatment of infections that lead to the development of ganglionitis.

Measures to strengthen the immune system also contribute to the body's resistance to pathogenic bacteria and viruses.

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Forecast

With a generally favorable outcome of ganglionevitis treatment, it should be borne in mind that the therapy of this disease takes time, and very often the process becomes chronic. Irreversible complications of this disease are also possible. And even radical intervention does not guarantee relapses.