Acupuncture for Severe Postoperative Occipital Neuralgia/Myofascial Pain Syndrome

Abstract

A 27-year-old woman presented with severe chronic postoperative occipital neuralgia and myofascial pain syndrome occurring after revision of the middle ear due to a cholesteatoma removal. Acupuncture began 6 months after the onset of pain and relief was obtained immediately. The patient decided not to continue acupuncture after 2 treatments and wished to pursue other therapeutic modalities. A follow-up conversation with the patient many months later found her still in pain and pursuing possibly a spinal stimulator.

Case Report

History of Present Illness

A 27-year-old woman (height, 67 in, weight, 198 lbs), an active duty airman with a history of right cholesteatoma, presented to the Acupuncture Clinic at the Malcolm Grow Medical Center, Andrews Air Force Base, Maryland. She reported severe chronic right ear pain stemming from a revision canal wall-up tympanomastoidectomy with ossicular chain reconstruction/autograft incus 6 months previously. She was routinely seen in the otolaryngology clinic at her 1-week postop appointment only reporting pruritus and mild tenderness in the operative area. At her 1-month follow-up, she reported increasing tenderness (5 on a 10-point scale) in the postauricular region, external auditory canal, and in the auricle. The tenderness worsened in the temporal area when she wore glasses. The surgeon was concerned that the moderately erythematous incision was infected, thus a 10-day course of antibiotics (cefpodoxime, 200 mg orally 2 times daily) was given. At 7 postoperative weeks, the right supra-auricular region was aspirated for a small hematoma and no pus was noted. She was referred to the orofacial pain clinic for evaluation of postauricular pain (8 on a 10-point scale) and had since been treated for neuropathic pain in that region. This patient initially underwent a right cholesteatoma removal 14 months prior to presentation, which included a right canal wall-up tympanomastoidectomy, atticotomy, canalplasty, temporalis fascia, and cartilage tympanoplasty. Her medical history included depression, anxiety, and chronic back pain. Current medications were gabapentin, escitalopram, and oxycodone/acetaminophen as needed. She reported no allergies.

Physical Examination

The patient's blood pressure was 117/80 mm Hg; heart rate, 91/min; respiratory rate, 18/min; temperature, 97.4°F; and pain level, 6 on a 10-point scale.

A right pressure equalization tube was in place and patent; incus outlined beneath an intact tympanic membrane; no evidence of infection, small amount of cerumen present in the right external auditory canal, but otherwise dry; minimal erythema was present postauricularly. Air conduction and bone conduction was performed in both ears. Tenderness to palpation and when wearing glasses was noted in the supra-auricular region, point tenderness at the exit site of the greater occipital nerve on the right as well as right tendomandibular tenderness. Her affect was also noted to be blunted.

Diagnosis

Occipital neuralgia and myofascial pain syndrome in the right auricular region pain following revision canal wall reconstruction tympanomastoidectomy with ossicular chain reconstruction/autograft incus. Her depression was worsened by chronic pain syndrome.

Conventional Treatment

The patient was treated with nonsteroidal anti-inflammatories, analgesics, antidepressants, and antibiotics. Her pain remained recalcitrant to conventional medical therapies, and thus, she was referred by her surgeon for acupuncture treatment. She presented with 6/10 pain in the right auricular region.

Methods

The patient was initially treated with the Battlefield Acupuncture technique.¹ The dominant ear was found to be the left ear after a gold ASP needle (Lhasa OMS, Inc, Weymouth, MA) placed in the right cingulate gyrus failed to produce any pain reduction. Subsequently, the patient responded to gold ASP needles placed in the left ear in the cingulate gyrus, thalamus, Omega 2, Shenmen, and Point Zero. The patient ambulated after each insertion. A piezoelectrical stimulator was used on LI 4-LI 4 for about 20 clicks to further reduce pain. Small 1-2/10 residual pain was treated with a low-level 5 mW LP-5F1 Dual Mode Laser Pen, bright red 670 nm wavelength (Lhasa OMS, Inc) in continuous mode for 5 minutes (1.5 J) on the left Omega 2.

Results

Acupuncture began at 6 months after the patient's symptoms first appeared. During the first session, she happily stated that it was the first pain-free period in the postoperative 6 months. She returned the next day with a slightly increased level of rebound pain (7/10) and was again treated as she was the day before, with complete resolution of her symptoms. Unfortunately, the patient did not return for further acupuncture and was lost to follow-up. The patient, many months later, was still in pain and pursuing a spinal cord stimulator.

Discussion

For this patient, conventional medical management was ineffective for severe postoperative occipital neuralgia and myofascial pain syndrome. Causes of occipital neuralgia include trauma, compression of the upper cervical roots by degenerative spine changes, and tumors involving the second and third cervical dorsal roots.² In this case, the pain occurred in relation to a second (revision) operation on the right ear, which was complicated by a small hematoma and persistent pain. Because depression and pain have overlapping neurobiologic mechanisms, her comprehensive treatment plan included the maintenance of serotonergic pharmacotherapy until long-term resolution of both could be reassessed at a future visit.³ Although the exact pathophysiology of her occipital neuralgia is unclear, it is possible that direct or indirect compression of the occipital nerve by hematoma, operative swelling/scarring, and connective tissue may have induced variable segmental demyelination of the nerve, with expression of sodium channels that becomes spontaneously active and pain is perceived.⁴ This mechanism has also been described for trigeminal neuralgia.⁵

Traditional Chinese Medicine (TCM), concerned with the Meridian systems, is intent on correcting the patterns of disharmony of Qi Stagnation, thus restoring function. Multimodal acupuncture was used and was highly effective in this case. Her myofascial pain stemmed from inflammation of the fascia. Myofascial pain syndrome may involve either a single muscle or a whole muscle group. As in this case, the area where a person experiences the pain may not be where the myofascial pain generator is located. The surgical procedure, the possible postoperative infection, and/or actual hematoma likely prompted the development of a trigger point that caused her referred pain.⁶ Acupuncture was effective in resolving her pain symptoms for a brief period. It is possible that the patient already diagnosed as depressive became discouraged when she experienced relapse with acupuncture after only 2 treatments.

Conclusions

Postoperative occipital neuralgia and myofascial pain syndrome is a rare complication of canal wall reconstruction tympanomastoidectomy with ossicular chain reconstruction/autograft incus. In this case, acupuncture was successful after 5 months of active conventional therapies failed to provide adequate relief. After just 1 acupuncture treatment, albeit temporary, pain resolution was obtained. This signified that this cycle of resistant pain could in fact be broken and perhaps effectively extinguished with successive sessions.

Footnotes

Disclosure Statement

No competing financial interests exist.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Air Force Medical Corps, the Air Force at large, or the Department of Defense. The authors indicate that they do not have any conflicts of interest.

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