Chapter 18: Facial pain Flashcards
Bell’s palsy (Idiopathic seventh nerve paralysis, idiopathic facial paralysis)
-‐ Unilateral facial paralysis.
-‐ Causes: herpes simples or zoster reactivation, nerve demyelination, nerve edema or ischemia, AI damage to nerve and vasospams of vessels associated with nerve
-‐ Triggers: otitis, pressure change, cold, infection, pregnancy, MRS, multiple sclerosis
-‐ Guillain-‐Barre: rapid onset of bilateral facial paralysis
Trigeminal neuralgia (tic dolourex)
-‐ Most serious and common facial neuralgia
-‐ Shock-‐like pain along trigeminal nerve (most V2/V3).
-‐ Abrupt onset (paroxysmal) and short duration (few secs), followed by pain-‐free period
-‐ Secondary TN: from brain-‐stem tumor or infarction
-‐ Gradenico syndrome: suppurative otitis media, trigeminal nerve pain, abducens nerve palsy
-‐ Atypical TN: meets only some of the diagnostic criteria for TN
-‐ Pretrigeminal neuralgia: dull, continuous pain that precedes TN
-‐ Trigger point: usually in nasolabial fold, vermillion border of lip, midfacial or periorbital skin.
-‐ Intra-‐oral trigger: alveolus
-‐ Tic douloureux: “painful jerking”, face clutching with pain attack
-‐ SUNCT: short-‐lasting unilateral neuralgiform headache with conjunctival injection and tearing
-‐ Raeder’s syndrome: V3 pain, ptosis, miosis and lack of sweating in medial aspect of forehead
-‐ Tx: carbamazepine (anticonvulsant)
-‐ Sx complications: facial dysesthesia (distorted sensations of facial skin) and anesthesia dolorosa (mix of numbness and pain)
Glossopharyngeal neuralgia (vagoglossopharyngeal neuralgia)
-‐ Affects 9th nerve (tonsil and ear). Similar to TN, except for location (tonsil irradiating to ear)
-‐ Tympanic plexus neuralgia: when pain felt in the ear (ddx TMD)
-‐ Pain below angle of MD (ddx with Eagle syndrome)
-‐ Trigger point within ear canal (no points on external skin)
Postherpetic neuralgia
-‐ Pain persisting 1-‐6 mths after onset of rash
-‐ Burning with episodic stabbing (useful to diff from TN-‐electric)
-‐ Tactile allodynia: light touch over area elicits pain
-‐ 50% pts over 50y and 75% of pts over 75 develop PHN
Atypical facial pain
-‐ Dx of exclusion
-‐ Drawing aching or pulling pain
-‐ Hot spot on bone scan: zone of increased temperature, tenderness or marrow activity
Cluster headache (Horton’s syndrome, histaminic cephalgia, migrainous neuralgia)
-‐ Pain of midface and upper face, especially around eyes. Attacks occur in temporal groups.
-‐ Vascular cause. 80% smokers. Strong familial influence.
-‐ Aka Alarm clock headache: pain often begins at same time everyday
-‐ No aura and pt hyperactive (vs has aura and pt is reclusive in migraine)
Paroxysmal hemicrania
-‐ Similar to cluster headache, but high frequency/short attacks, and responds to indomethacin
-‐ Attacks last 2-‐30 min, up to 40x day
-‐ Hemicrania continua: responds to indomethacin. Unilateral, chronic, daily ~ to cluster headache
-‐ Sjaastad syndrome (chronic paroxysmal hemicranias): congestion of conjunctival blood vessels and increased intraocular pressure
Migraine
-‐ Paroxysmal, unilateral, 4-‐72h duration. Two types: with aura and without aura
-‐ Vasoconstriction of brain arteries due to serotonin reduction, leading to ischemia and dilation
-‐ Aura: visual hallucination before pain. Seeing sparks (scintillation), partial blindness, loss of light perception (scotoma), and loss of ability to express thoughts (aphasia)
Temporal arteritis (Giant cell arteritis, cranial arteritis)
-‐ Multifocal AI vasculitis of temporal artery. Headache coinciding with patient’s hearbeat
-‐ Superficial temporal artery sensible to palpation and erythematous, swollen or tortuous
-‐ Jaw claudication (pain with mastication), pain wearing hats (pressure) and blindess
-‐ Polymyalgia rheumatica: generalized muscle aching and stiffness after headache attack
-‐ Histo: chronic inflammation of the tunica intima and media, narrowing of lumen from edema and prolif of tunica inteima, necrosis, giant cells
Myasthenia gravis
-‐ AI against acetylcholine receptors with progressive fatigue of skeletal muscle
-‐ Pts have thymus hyperplasia or thymoma and also at least 1 AI disorder
-‐ Subtle but progressive weakness most noted in head and neck
-‐ Inability to focus eye, drooping eyelid (ptosis), double vision (diplopia), dysphagia, dysarthria (slurring of words), and difficulty chewing. Jaws “hang open”.
-‐ Dx: elevated serum acetylcholine receptor antibody levels
-‐ Histo: degenerated muscle fibers, which appear smaller and lose rounded cross-‐section look
Motor neuron disease
-‐ Fatal neurodegenerative disorder with progressive weakness and wasting of muscles
-‐ (1) Progressive musclar atrophy (2) progressive bulbar palsy (3) amyotrophic lateral sclerosis
-‐ PMA: most common lethal AR disorder (SMN gene). Occurs in childhood. No facial involvement
-‐ PBP: children/young adults. Starts with dysphagia. Atrophy of facial muscles.
-‐ ALS (Lou Gehrig disease): middle age. Leg stiffness (one more affected than other-‐ dragging leg).
-‐ Fasciculation (small, synchronous muscle contractions) in ALS
-‐ Bulbar paralysis: dysfunction of muscles controlled by medulla oblongata in late ALS
Burning mouth syndrome
-‐ Common dysesthesia (distortion of taste)
-‐ Glossopyrosis, stomatopyrosis, glossodynia, stomatodynia
-‐ Scalded mouth syndrome: immune response to ACE inhibitor
Dysgeusia and hypogeusia (phantom taste, distorted taste)
-‐ Dysgeusia: abnormal taste.
-‐ Hypogeusia/ageusia: deficiency in taste
-‐ Hyponosmia/anosmia: deficiency in smell
-‐ Most due to underlying systemic disorder or RT
-‐ Trauma, tumors or peripheral nerve inflammation: Transient hypogeusia
-‐ URT infections: Temporary dysgeusia
-‐ CNS tumor: dysgeusia
-‐ Migraine, Bell’s palsy and herpes zoster: taste hallucination
-‐ Hemiageusia: ageusia of ½ tongue (seen in ischemia and infarction of brainstem)
-‐ Xerostomia: hypogeusia and ageusia
-‐ Periodontitis: salty taste due to high NaCl content of oozing crevicular fluids
-‐ Olfactory disorder must be r/o when pt complaints of dysgeusia (75% of flavor is in smell)
-‐ Parosmia: aberrant odor perception. Pts complain of foul or rancid taste.
-‐ Phantom taste: dysgeusia even in absence of food/liquid stimulus
Frey syndrome (Auriculotemporal syndrome, gustatory sweating and flushing)
-‐ Facial flushing and sweating along auriculotemporal nerve in response to gustatory stimuli.
-‐ Due to injury of nerve (parotid abscess, sx, trauma, diabetes)
-‐ Chorda tympani syndrome: sx of submd gland. Chin and submental skin sweating.
-‐ Gustatory lacrimation syndrome (crocodile tears): due to facial nerve injury. Tears when eating.
-‐ Minor’s starch iodine test: pt skin painted with iodine and starch, pt given something to eat, moisture from sweat mixes with iodine, then reacts with starch and gives blue color
Osteoarthritis (degenerative arthritis, degenerative joint disease)
-‐ Destruction of joints (inflammation), but likely an aging phenomenon
-‐ Deep ache and pain, usually in morning (stiffness), swelling, motion limitation. Most on hips.
-‐ TMJ: same signs. Musles of mastication tender (“muscle guarding” to keep joint immobile)
-‐ Xray: obliteration of joint space, exostoses/osteophytes on surface, RL subchondral cysts, and ossification within the synovial membrane (ossicles)
