To systematically summarise the peer-reviewed literature relating to the aetiology, clinical presentation, investigation and treatment of geniculate neuralgia.

Articles published in English between 1932 and 2012, identified using Medline, Embase and Cochrane databases.

The search terms ‘geniculate neuralgia’, ‘nervus intermedius neuralgia’, ‘facial pain’, ‘otalgia’ and ‘neuralgia’ were used to identify relevant papers.

Fewer than 150 reported cases were published in English between 1932 and 2012. The aetiology of the condition remains unknown, and clinical presentation varies. Non-neuralgic causes of otalgia should always be excluded by a thorough clinical examination, audiological assessment and radiological investigations before making a diagnosis of geniculate neuralgia. Conservative medical treatment is always the first-line therapy. Surgical treatment should be offered if medical treatment fails. The two commonest surgical options are transection of the nervus intermedius, and microvascular decompression of the nerve at the nerve root entry zone of the brainstem. However, extracranial intratemporal division of the cutaneous branches of the facial nerve may offer a safer and similarly effective treatment.

The response to medical treatment for this condition varies between individuals. The long-term outcomes of surgery remain unknown because of limited data.