Facial pain can occur due to many different disorders of the nose and paranasal sinuses, teeth and gums, eyes and orbits, temporomandibular joints, oral cavity and salivary glands, jaws, and cranial nerves.
The most common causes of Facial Pain are named below –
1) TRIGEMINAL NEURALGIA (Tic Douloureux)
2) Atypical Facial Pain
3) Glossopharyngeal Neuralgia
4) Post-herpetic Neuralgia
5) Temporomandibular (Craniomandibular) Disorders
6) Myogenic (Masticatory Muscles) Disorders
(I) TRIGEMINAL NEURALGIA (Tic Douloureux)
It is the most common type of facial pain and occurs in middle and later life.
Women are more affected than men.
CLINICAL FEATURES OF TRIGEMINAL NEURALGIA
1) Momentary episodes of a fraction of seconds or a few minutes of sudden sharp, stabbing, and shooting facial pain occur in the region of one or more divisions (ophthalmic, maxillary, and mandibular) of the trigeminal nerve.
2) Pain may radiate toward the ear, eye, mouth, or nostrils.
3) Precipitating factors include chewing, speaking, face washing, tooth-brushing, cold winds, or touching of trigger spots such as upper lip or gum.
4) Spontaneous remissions for several months or longer are not uncommon.
5) Neurological examination is normal.
DIFFERENTIAL DIAGNOSIS OF TRIGEMINAL NEURALGIA
In a young patient, MULTIPLE SCLEROSIS must be suspected.
Evoked potential testing and CSF examination may be corroborative.
CT/MRI scan is done to rule out posterior cranial fossa tumor.
TREATMENT OF TRIGEMINAL NEURALGIA
# MEDICINES FOR TRIGEMINAL NEURALGIA —
Given in 600–1200 mg/day in 3–4 divided doses.
It is usually very effective. They need monitoring of CBC and liver function tests.
It also offers good results.
Given in a dosage of 200–400 mg/day.
It is used when Carbamazepine or oxcarbazepine is not effective or not tolerated.
Given in dosage of 10–20 mg in 3 or 4 times a day.
It may be used either alone or in combination with the above molecules.
5) Gabapentine or pregabalin
Gabapentin 900–2400 mg/day in 3 divided doses or Pregabalin up to 300 mg/day.
It is used when the above medicines do not work or the patient is suffering from multiple sclerosis.
# NON-INVASIVE PROCEDURES for TREATING TRIGEMINAL NEURALGIA–
1) Radiofrequency rhizotomy
This simple procedure is preferred in elderly patients with a limited life expectancy.
2) Trigeminal root gamma radiosurgery
This non-invasive procedure is successful in 80% of patients.
# INVASIVE PROCEDURES for TREATING TRIGEMINAL NEURALGIA–
Exploration of posterior cranial fossa
Simple decompression and separation of anomalous vessels from the nerve root usually produce lasting relief.
The anomalous artery or vein impinging on the trigeminal nerve root is usually not seen on CT, MRI, or arteriograms.
It is not indicated in patients with multiple sclerosis.
(II) ATYPICAL FACIAL PAIN
CLINICAL FEATURES of ATYPICAL FACIAL PAIN
1) Diffuse, dull, persisting pain occurs in depressive young or middle-aged women.
2) It may be unilateral or bilateral.
3) Initially the burning pain has restricted distribution but soon spreads to the rest of the face.
4) In some patients pain may involve the other side, neck, or occipital region.
TREATMENT of ATYPICAL FACIAL PAIN
Patients may be given analgesics, tricyclic antidepressants, carbamazepine, oxcarbazepine, or phenytoin but the response is often not satisfactory.
(III) GLOSSOPHARYNGEAL NEURALGIA
This disorder is uncommon. Usually, no structural abnormality is found. Multiple sclerosis may be the cause in some patients.
CLINICAL FEATURES of GLOSSOPHARYNGEAL NEURALGIA
1) This neuralgic pain (similar in quality to trigeminal neuralgia) occurs usually in the TONSIL REGION (tonsillar fossa).
2) It may occur deep in the ear or at the base of the tongue.
3) The precipitating factors may be swallowing, chewing, talking, or yawning.
4) It may be accompanied by syncope.
TREATMENT of GLOSSOPHARYNGEAL NEURALGIA
Pharmacological treatment is similar to trigeminal neuralgia and should be given a trial.
Microvascular decompression of the Glossopharyngeal nerve is indicated when medical treatment fails.
(IV) POST-HERPETIC NEURALGIA
About 15% patients of with shingles (Herpes zoster) develop postherpetic neuralgia.
RISK FACTORS FOR DEVELOPING POST-HERPETIC NEURALGIA
1) Old age,
2) Severe rash (long duration, painful, and scarring),
3) Involvement of Ophthalmic division of Trigeminal Nerve, and
4) Delayed Acyclovir therapy.
CLINICAL FEATURES of POST-HERPETIC NEURALGIA
1) Dull, burning, persisting (occasionally paroxysm) pain occurs after herpetic lesions.
2) It affects the trigeminal area, especially the ophthalmic division.
3) Healed lesion with scars is associated with sensory loss.
TREATMENT of POST-HERPETIC NEURALGIA
It is essentially medical.
In addition to the medical treatment (carbamazepine, phenytoin, Gabapentin, and pregabalin) mentioned in the trigeminal neuralgia, it also includes the following:
1) Amitriptyline and perphenazine
If simple analgesics are not effective tricyclic antidepressant (amitriptyline up to 100–150 mg/day) in conjunction with phenothiazine (perphenazine 2–8 mg/day) is usually effective.
2) Gabapentin and morphine
The combination of gabapentin and morphine taken orally is more effective than taken individually.
3) Topical applications:
Capsaicin cream (0.025%) and lidocaine (5%) are worthy of trial.
Prevention of POST-HERPETIC NEURALGIA
Live-attenuated zoster vaccine for elderly patients (> 60 years) prevents the occurrence of herpes zoster and markedly reduces morbidity.
(V) Temporomandibular (Craniomandibular) Disorders
Temporomandibular disorders (TMD) consist of not only the internal derangement of the temporomandibular joint (TMJ) but also areas extrinsic to TMJ.
Temporomandibular (craniomandibular) disorders (TMD) patients present with musculoskeletal symptoms such as diffuse facial pain with jaw movements, limitation of mandibular movement, and masticatory muscle and TMJ tenderness.
Patients with internal derangement of TMJ (disc displacement, osteoarthrosis, inflammation, and congenital, developmental, traumatic, and neoplastic disorders) present with well-localized pain.
ETIOLOGY of TEMPOROMANDIBULAR DISORDERS
They occur due to the misalignment of one TMJ.
TMD may be caused by malocclusion, abnormal bite, or faulty dentures.
CLINICAL FEATURES of TEMPOROMANDIBULAR DISORDERS
Patients usually have dental loss with altered bite.
Other features are the following:
1) Aching pain occurs around the ear that is aggravated by chewing.
2) Limitation in jaw movements.
3) Deviation in mandibular motion.
4) Locking of the jaw in an open or closed position.
5) Clicking sound/crepitus within TMJ.
6) Masticatory muscles pain and tenderness.
(VI) Myogenic (Masticatory Muscles) Disorders
Temporomandibular disorder patients with myogenic pain usually have normal TMJ.
The limitation of jaw movement is due to muscle pain and stiffness.
The pain is usually due to hyperfunction.
Myogenic disorders include myofascial pain, fibrositis, muscle splinting (trismus), spasm and swelling (myositis), contracture, bruxism, hypertrophy, and dyskinesia.
There is usually no evidence (clinical and radiographic) of internal derangement of TMJ.
PREDISPOSING FACTORS for MYOGENIC (MASTICATORY MUSCLES) DISORDERS
Nocturnal or diurnal bruxism (grinding or clenching) is very common.
It is more during physical or emotional stress.
This hyperactivity results in muscle fatigue and spasm.
This strain which is due to overuse or improper use must be treated as such.
CLINICAL FEATURES for MYOGENIC (MASTICATORY MUSCLES) DISORDERS
The most common complaint of the patients is diffuse facial pain.
According to the involvement of muscles, patients with myogenic disorders may have the following symptoms —
It is most commonly involved and produces jaw pain.
This is the second most commonly involved muscle and produces headaches.
It produces odynophagia. The patient develops a sensation of a painful swollen gland just beneath the angle of the mandible.
It produces referred ear pain or retrobulbar pain.
DIFFERENTIAL DIAGNOSIS of MYOGENIC (MASTICATORY MUSCLES) DISORDERS
In jaw (masticatory) claudication, pain develops progressively with mastication. It is a feature of giant cell arteritis.
TREATMENT of MYOGENIC (MASTICATORY MUSCLES) DISORDERS
It consists of the treatment of the underlying TMJ disorder.
Most TMD patients respond to nonsurgical therapy that includes rest, and medical, physical, and splint therapies.
Surgical treatment is indicated only for internal derangement of the TMJ.
1) Restricted mouth opening and soft diet
Limitation of function reduces painful loads on the inflammatory tissues.
Non-narcotic analgesics (acetaminophen) and nonsteroidal anti-inflammatory drugs (NSAIDs) constitute the initial therapy.
When a particular NSAID is not effective then a different one should be used. Long-term or high doses of NSAIDs may cause gastrointestinal bleeding, ulcers, or nephrotoxicity.
The commonly used NSAIDs include —
1) Ibuprofen (900–2400 mg/day in divided doses),
2) Diclofenac (50 mg bd/tds),
3) Naproxen (275–550 mg/day),
4) Ketoprofen (75 mg/day),
5) Piroxicam (20 mg/day),
6) Celecoxib (100–200 mg bd
7) Valdecoxib (10 mg/day).
3) MUSCLE RELAXANTS
Centrally acting agents are usually prescribed.
They have a general sedating effect on the central nervous system (CNS).
The commonly used agents include —
1) Methocarbamol (1500–3000 mg/day in divided doses),
2) Tizanidine (2–4 mg tds),
3) Carisoprodol (100–1400 mg/day in divided doses),
4) Cyclobenzaprine (5–30 mg/day) and
5) Metaxalone (800 mg tds).
Benzodiazepines are sedatives and reduce anxiety and muscle hyperactivity.
The commonly used agents include —
1) Clonazepam (0.5–1 mg 1–4 times/day),
2) Diazepam (2–10 mg 1–4 times/day), and
3) Alprazolam (0.5 mg 1–3 times/day).
Tricyclic and serotonin-reuptake inhibitors are useful in the management of chronic pain.
The commonly used agents include —
1) Amitriptyline (10–25 mg/ day),
2) Imipramine (10–25 mg/day),
3) Fluoxetine (5 mg/day),
4) Sertraline (50 mg/day),
5) Citalopram (20 mg/day),
6) Venlafaxine (75 mg/day),
7) Nortriptyline (10–25 mg/day),
8) Bupropion (100 mg bd), and
9) Paroxetine (20 mg/day).
They are used in chronic pain patients.
Caution is required as they are habit-forming agents.
7) Bite-appliance (splint) therapy:
The splint is worn on the teeth and stabilizes the occlusion (in bruxism) and reduces the load. It relieves acute myogenic and TMJ pain.
8) Other therapies:
Physical therapy, behavioral training, and stress management are effective in many patients.
Surgical correction is indicated only when internal derangement symptomatic TMJ patients do not respond to above-mentioned modalities of treatment.
The details of surgical options include —
Arthrotomy (arthroplasty), and
Meniscal repair (plication).
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