A rare cause of otalgia is geniculate neuralgia. In its most typical form, it is characterized by severe paroxysmal neuralgic pain centered directly in the ear. The pain can be of a gradual onset and of a dull, persistent nature, but occasionally it is sharp and stabbing. When the pain becomes intractable, an operation to surgically excise the nervus intermedius and geniculate ganglion via the middle cranial fossa approach is indicated. The purpose of this article is to review the long-term outcomes in 64 patients who were treated in this manner. Findings indicate that excision of the nervus intermedius and geniculate ganglion can be routinely performed without causing facial paralysis and that it is an effective definitive treatment for intractable geniculate neuralgia.