Facial pain

Question 1

Probability diagnosis

Answer 1

When a pt complains of pain in the face rather than the head, consider foremost the possibilities of:

Dental disorders up to 90% of pain in and about the face

• caries
• periapical/dental abscess
• fractured tooth

Maxillary/frontal sinusitis

Herpes zoster (shingles)

temporomandibular joint (TMJ) dysfunction

eye disorders

lesions of the oropharynx or posterior third of the tongue

trigeminal neuralgia

chronic paroxysmal hemicrania.

Question 2

Serious disorders not to be missed

Answer 2

Cardiovascular:

• myocardial ischaemia
• aneurysm of cavernous sinus
• internal carotid aneurysm
• ischaemia of posterior inferior cerebellar artery
• temporal arteritis

Cancer/neoplasia:

• cancer: mouth, sinuses, posterior fossa, nasopharynx, tonsils, tongue, larynx
• metastases: orbital, base of brain, bone

Infection:

• orbital cellulitis
• erysipelas
• periapical abscess → osteomyelitis
• acute sinusitis → spreading infection

Question 3

Pitfalls (often missed)

Answer 3

TMJ dysfunction

Migraine variants:

• facial migraine
• chronic paroxysmal hemicrania

Atypical facial pain

Eye disorders:

• glaucoma
• iritis
• optic neuritis

Chronic dental neuralgia

Facial bone diesease

Parotid gland: mumps, cancer, sialectasis, abscess

Acute glaucoma (upper face)

Cranial nerve neuralgias:

• post-herpetic neuralgia
• trigeminal neuralgia
• glossopharyngeal neuralgia

Question 4

Masquerades checklist

Answer 4

Depression

Spinal dysfunction

Question 5

Is the patient trying to tell me something?

Answer 5

Quite probably.

Atypical facial pain has underlying psychogenic elements.

Question 6

Key history

Answer 6

Diagnosis of virtually all types of facial pain must be based entirely on the history.

Include the typical pain analysis, especially site and radiation.

Question 7

Key examination

Answer 7

The key to the diagnosis is the clinical examination

• because even the most sophisticated investigation may provide no additional information.

Palpate the face and neck to include the parotid glands, eyes, regional lymph nodes and skin

Inspect the TMJs and cervical spine

Carefully inspect;

• nose
• mouth (esp. each tooth)
• pharynx
• postnasal space

Inspect the sinuses with transillumination

Perform a neurological exam of the cranial nerves

Question 8

Key investigations

Answer 8

Referral may be appropriate.

The association of tumours with neuralgias may have to be investigated.

Radiological investigations to consider include:

• plain X-rays of the paranasal sinuses
• CT scans
• MRI
• orthopantomograms.

Question 9

Diagnostic tips

Answer 9

Facial pain never crosses the midline; bilateral pain means bilateral lesions.

Malignancy must be excluded in the elderly with facial pain.

Problems from the molar teeth, especially the third (wisdom) commonly presents with peri-auricular pain and pain in the posterior check.

Don’t overdiagnose sinusitis: many URTIs may produce mild facial ache (vacuum effect).

Question 10

Red flag pointers for facial pain

Answer 10

persistent pain: no obvious cause

unexplained weight loss

trigeminal neuralgia: possible serious causes

herpes zoster involving nose

person >60 years:

• consider temporal arteritis
• malignancy