Ch 18 - Orofacial Pain Flashcards
What are the 2 alternate names for Bell palsy?
- Idiopathic Seventh Nerve Paralysis
2. Idiopathic facial paralysis
What are the main two theories for the etiology of Bell palsy?
herpes infection (HSV or VZV)
or
cell-mediated autoimmune reaction
Bell palsy can develop at any age, but whats the most common?
young and middle-aged adults
How long does Bell palsy take to completely set in?
Hours - pts usually wake up in full paralysis, can have prodromal symptoms
It is infrequent for Bell palsy to be bilateral, what are 4 other conditions that present with this bilateral, rapid onset?
- Guillain-Barre syndrome
- uveoparotid fever (AKA acute sarcoidosis aka Heerfordt syndrome)
- if other CN deficits consider a CNS infectious disease or a basilar skull tumor
- +vertigo, +tinnitus = Ramsay Hunt syndrome (VZV)
What is the treatment for Bell palsy?
self limiting, should resolve in 3-4 months..if no recovery systemic corticosteroids (see other flashcard)
What % of Bell palsy patients may not have a complete recovery?
20-30%
So assuming that Bell palsy was not self limiting and did not recover after 3-4 months, what treatment is given? Be specific with the regimen… What is NOT recommended?
10 day taper of prednisone starting at 60mg/day + antiviral (acyclovir, famciclovir, or valacyclovir)…NOT recommended: antiviral therapy alone
Eye protection for Bell palsy patients is critical so what can we do?
topical ocular antibiotics and artificial tears may be required to prevent corneal ulcer
What are the 2 alternate terms for Frey syndrome?
- Auriculotemporal syndrome
2. Gustatory sweating and flushing
What are the characteristics of Frey syndrome?
- Facial flushing and sweating along the auriculotemporal nerve
- in response to gustatory stimulus
- caused by injury to the nerve
What % range of patients with a history of a parotidectomy will develop Frey syndrome?
40-70%
What is the objective test for Frey syndrome?
Minor starch-iodine test
What systemic condition can cause bilateral gustatory sweating, thus mimicing Frey syndrome?
1/3 of diabetics WITH neuropathy esp severe kidney damage
What are two “related” phenomena to Frey syndrome that accompany an operation or injury to the submandibular gland or the facial nerve proximal to the geniculate ganglion?
- submandibular gland = chorda tympani syndrome
2. facial nerve proximal to the geniculate ganglion = gustatory lacrimation syndrome aka “crocodile tears”
How long does it take for the effects of Frey syndrome to present following the nerve injury?
2 months to 2 years
What color will present in a positive Minor iodine-starch test for a Frey syndrome patient?
blue
What % of adult patients and infants with Frey syndrome can have complete resolution without intervention?
5% of adults, almost all infants
What treatment can be effective long term for Frey syndrome?
botox injectons
What anatomical structure makes it difficult for patients to localize the source of their head and neck pain?
the trigeminal convergence (pain fibers from the head and neck travel to the spinal nucleus caudalis of the trigemnial nerve)
What is the alternate name for trigeminal neuralgia?
Tic Douloreux (or just Tic) (translated means “painful jerking”)
What is the definition of neuralgia?
pain extending along a nerve
What is the most common facial neuralgia? Which branches of the nerve are most commonly affected?
trigeminal neuralgia…V2 or V3
Which disease has one of the highest suicide rates?
trigeminal neuralgia
What is the theory for the etiology of classical trigeminal neuralgia?
compresion of the nerve by aging blood vessels leading to demyelination
What are three etiologies for secondary trigeminal neuralgia?
- Multiple sclerosis
- tumor pushing nerve
- AV malformation
Whats the incidence of trigeminal neuralgia in the US?
4-5 cases / 100,000
What % range of patients with multiple sclerosis develop trigeminal nerualgia?
2-4%
Although trigemnial neuralgia can occur at any age, what is the characteristic range? Gender?
50 and older… Women 1.5:1
Bilateral trigeminal neuralgia is unusual, what should be suspected?
multiple sclerosis
What are two common “trigger zones” for trigeminal neuralgia?
nasolabial fold or oral cavity
How long does a trigeminal neuralgia episode typically last?
no longer than 2 minutes - with a refractory period of no pain - can be helpful to distinguish from odontogenic pain
What are some terms (total of 3) that can be used when a patient presents with some, but not all of the diagnostic criteria for trigeminal neuralgia?
- atypical trigeminal neuralgia
- persistent idiopathic facial pain
- atypical facial nerualgia
If a patient has suspected trigeminal neuralgia, but presents with objective sensory loss, what should be considered for the diagnosis?
a CNS tumor
What is the initial treatment for trigeminal neuralgia? What % of patients respond to this treatment?
carBAMazepine (anticonvulsant)…80%
What is the term for distorted sensations of the facial skin?
facial dysesthesia
What is the term for a combination of anesthesia and spontaneous pain?
anesthesia dolorosa
What is the alternate term for glossopharyngeal neuralgia?
Vagoglossopharyngeal neuralgia
Where is the pain felt in glossopharyngeal neuralgia?
the tonsil and ear (often radiating from the throat to the ear because of typmanic branch of the glossopharyngal nerve)
What is the etiology of Classical glossopharyngeal neuralgia?
unassociated with any underlying disorder and often is attributed to ARTERIAL COMPRESSION of the nerve as it courses through the subarachnoid space to the jugular foramen
What are 3 etiologies for secondary/symptomatic glossopharyngeal neuralgia?
Compression of the nerve by a specific lesion:
- intracranial or cranial base tumors / oropharyngeal tumors
- pagetic bone
- calcified stylohyoid ligament
Unlike trigeminal neuralgia, it is uncommon for glossopharyngeal neuralgia to be associated with what systemic disease?
multiple sclerosis
Age and gender for glossopharyngeal neuralgia?
middle aged and older adults, no gender predilection
What is the term for paroxysmal pain felt in the ear?
tympanic plexus nerualgia
Is glossopharyngeal neuralgia bilateral or unilateral?
unilateral - bilateral is RARE
What general region does the patient feel pain in with glossopharyngeal neuralgia?
pain radiates upward from the oropharynx to the ipselateral ear
While trigger points for glossopharyngeal neuralgia are not usually found on the skin, where is an “external” trigger point?
within the ear canal
What % of glossopharyngeal neuralgia patients will also experience vagoglossopharyngeal neuralgia? What are some of the symptoms? (5 total)
10%
- syncope
- hypotension
- seizures
- bradycardia
- cardiac arrest
What is the typical med given to the 10% of glossopharyngeal neuralgia patients with vagoglossopharyngeal neuralgia and have an increased risk for cardiac complications?
atropine
