Here, we present a case of a 55-year-old woman with a 10-year history of hemifacial spasm accompanied by 1-month ipsilateral paroxysmal otalgia. Magnetic resonance imaging revealed the presence of vessels around the facial nerve root. Surgical exploration via suboccipital retromastoid craniotomy showed converging compression of the facial nerve root and intermediate nerve from both sides by an anterior inferior cerebellar artery loop. The patient’s hemifacial spasm and ipsilateral otalgia were completely relieved after microvascular decompression of the facial nerve root and intermediate nerve. Intraoperative findings and the postoperative result of this case confirmed that vascular compression of the intermediate nerve was the exclusive cause of paroxysmal otalgia. The presence of ipsilateral hemifacial spasm, combined with preoperative neuroimaging studies, contributed to the diagnosis of intermediate nerve neuralgia. Microvascular decompression should be considered for the management of patients with intermediate nerve neuralgia.