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Ocular Disease 3 - Midterm > Facial Pain - Neuralgias > Flashcards

Facial Pain - Neuralgias Flashcards

1
Q

what are the 3 sensory branches of CN5?

A

ophthalmic (V1), maxillary (V2), and mandibular (V3)

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2
Q

where does V1 go through?

A

superior orbital fissure

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3
Q

where does V2 go through?

A

foramen rotundum deep in skull to pterygopalantine fossa

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4
Q

where does V3 go through?

A

foramen ovale into the infratemporal fossa (also supplies non-taste sensation to anterior 2/3 of tongue)

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5
Q

what is the CN5 motor branch?

A

axons travel with V3 to ipsilateral muscles of mastication (nucleus lies medially to sensory nucleus)

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6
Q

what are the first order neurons for CN5 and where do they converge?

A

V1, V2, V3 - converge at trigeminal ganglion (gasserian or semilunar) at apex of petrous temporal bone in a depression (meckel’s cave) lateral to cavernous sinus in middle cranial fossa

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7
Q

where do the 2 pathways for the second order neurons converge from the brainstem?

A

in the thalamus

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8
Q

what are the 2 nuclei for the second order neurons?

A

main sensory nucleus and spinal trigeminal nucleus

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9
Q

what does the main sensory nucleus do and where is it located?

A

in the mid pons

mediates fine touch, two point discrimination, joint position, vibration, and sends fibers to thalamus

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10
Q

what does the spinal trigeminal nucleus do?

A

axons cross the midline and ascend in trigeminophthalmic tract (TTT) to the ventral posteromedial (VPM) nucleus in the thalamus

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11
Q

where are the third order neurons for CN5?

A

in thalamus - they ascend carrying sensory signals to primary sensory cortex

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12
Q

what is neuralgia?

A

intense lancinating pain (cutting, piercing, burning), shooting along the nerve and is paroxysmal (sudden or brief)
cause is unknown or due to nerve irritation or damage

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13
Q

what are the 3 primary facial neuralgias (non-headache)?

A

trigeminal neuralgia, Raeder’s paratrigeminal syndrome and post-herpatic neuralgia (PHN)

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14
Q

how is trigeminal neuralgia diagnosed?

A

usually by the patient history

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15
Q

who typically gets trigeminal neuralgia?

A

onset > 50, females slightly more than males and may have a familial predilection

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16
Q

what are the key features of trigeminal neuralgia?

A

paroxysmal pain is excruciating (seconds long), triggered by hypersensitivity, hemifacial (V2 most common, V1 least common) and without significant sensory loss

17
Q

what is the etiology for trigeminal neuralgia?

A

compression, irritation, inflammation, peripheral CN5 injury, demyelination zone (MS)
often cause is unknown

18
Q

what is the prognosis for trigeminal neuralgia?

A

tends to get worse over time, temporary spontaneous remission is possible but never permanent and medical management eventually fails (25-50%)

19
Q

what is the first line of treatment for trigeminal neuralgia?

A

medical = Carbamazepine (tegretol) is the most effective

phenytoin is less effective

20
Q

what surgery for trigeminal neuralgia is typically used in younger patients?

A 
microvascular decompression (craniotomy) = isolate nerve from adjacent vessel with a sponge
long term pain relief and lowest recurrence 
most cost effective
21
Q

which treatment for trigeminal neuralgia has a delayed response?

A

the non-invasive stereotactic radiosurgery with a gamma knife = ionizing radiation targets CN5 roots
delayed 2-6 months
recurrence is common

22
Q

what treatment for trigeminal neuralgia is used for patients with MS, elderly and pain persisting after MVD?

A

percutaneous transovale procedure = needle through foramen ovale to target V3

23
Q

what is raeder’s paratrigeminal syndrome?

A

severe unilateral ocular (V1) pain, ipsilateral oculosympathetic palsy or partial horner’s (no anhydrosis) and associated with tearing, erythema and decreased IOP

24
Q

what type of pain does a patient with raeder’s paratrigeminal syndrome have?

A

single episode hours - weeks, pain exacerbates with touch, self-limiting within 2-3 months and occasionally recurrent

25
Q

who typically gets raeder’s paratrigeminal syndrome?

A

middle aged males (hx of recurrent AM headaches associated with nausea/vomiting)
very uncommon

26
Q

what are the 3 classes of raeder’s paratrigeminal syndrome?

A
  1. V1 pain + horner’s + other CN involvement (work up for mass)
  2. V1 pain + horner’s + cluster headaches (benign)
  3. V1 pain + horner’s (benign)
27
Q

what do you do if a patient has raeder’s paratrigeminal syndrome + V2 and V3 involvement?

A

assume a broader parasellar syndrome (CN3, 4,5,6 involved) = ophthalmoplegia with oculomotor nerve and oculosympathetic nerve involvement

28
Q

how do cluster headaches present?

A

pain around one eye, drooping eyelid, tearing, redness on same side as pain
may have ipsilateral horner’s, lacrimation, conjunctival injection, nasal congestion, and eyelid edema
typically males

29
Q

what is post-herpatic neuralgia (PHN)?

A

severe burning, aching, stabbing, protracted pain - accompanied by or triggered by super-sensitivity to light touch (allodynia)
distribution is usually unilateral (typically V1)

30
Q

what causes PHN?

A

typically follows HZV infection (shingles)

risk increases with age

31
Q

what are the signs and symptoms of PHN?

A

paresthesia can be present (prickly, crawling sensation or numbness), occasionally facial muscle weakness

32
Q

what can reduce the risk of PHN?

A

early intervention with HZV infection

33
Q

what is the treatment for PHN?

A

antidepressant, anticonvulsant, analgesic, electrical nerve stimulation, dorsal root surgery or acupuncture

34
Q

what is the prognosis for PHN?

A

response to treatment is variable - can be lifelong suffering but typically fades over 5 years

35
Q

what is hypesthesia?

A

reduced sensitivity

36
Q

what is anesthesia?

A

lack of sensitivity

37
Q

what are dysethesia or paresthesia?

A

tingling sensation, pin-prick, difficult to describe

Ocular Disease 3 - Midterm (7 decks)

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