Facial pain- the neuralgias Flashcards
It might be impt to ask a patient with intense facial pain about a history of:
- facial paralysis
- pain in jaw/tongue when chewing (GCA)
- numbness/tingling
- scalp tenderness
corneal sensitivity is from ____branch
nasociliary
Function of CN V includes: efferent to muscles of mastication, facial sensory affarent, facial motor efferent. It does NOT include:
sense of taste affarent; this comes from the anterior 2/3 of the tongue which CN VII is responsible .Sensory from V3 is tongue’s sensation of touch!
CN V does not innervate the angle of the ______.
jaw.
CN ___ is the largest CN. Which is the smallest root of CN V? which is the largest?
V; V1; V3
Ophthalmic nerve, nasociliary, and long ciliary carry cornea sensory info. Which nerve does not?
frontal nerve
Sensory affarents, V1, V2, V3 _____ order neurons converge at _____ ganglion at apex of petrous temporal bone at lateral wall of the cavernous sinus in middle cranial fossa and synapse in two different sensory nuclei.
first; trigeminal
_____efferents go out to the muscles of mastication and follow _____ branch and synapse in motor nucleus.
Motor; V3
Which branches of CN V pass through the cavernous sinus?
V1, V2; along with CN III, IV, and VI.
Cell bodies are located in the _______
ganglion
cranial nerve nucleus =
synapses
T/F Trigeminal pain and touch fibers travel the same central neuronal pathways
False; pain & temp follow a different pathway from touch.
The trigeminal nerve has ____ sensory nuclei and _____motor nuclei.
3; 1
When we talk about second order neurons (trigemini-thalamic) we talk about 3 sensory pathways that converge in the pons and synapse in the ______. Which are the 3 sensory pathways/nuclei?
thalamus;
- main sensory nucleus: touch and sensation as far as the face goes.
- Mesencephalic: Proprioceptive cues from muscles and tendons of mastication.
- Spinal Trigeminal nucleus: Carries pain and temperature
All of these feed into the thalamus
_____ order neurons ascend from the thalamus and carry sensory signals to primary ________ cortex.
Third; somatosensory
You would have ipsilateral fibers going from the thalamus to the _______ side and some fibers crossing. So you have some preservation of sensation if you have a lesion above the main sensory nucleus.
same
Some sensory alteration include hypesthesia which refers to reduced sensitivity which may be due to _____ or MS if nuclear or central lesion. If peripheral lesion it involves V1, V2, and V3. Things that can cause this include orbital fracture, neoplasm or aneurysm.
ischemia
______ refers to lack of sensitivity or total numbness.
Anesthesia
______ refers to odd sensation including tingling or partial numbness.
Paresthesia
_____ refers to super sensitivity; threshold for sensitivity has changed.
Hyperesthesia
Neuralgia can present with _____pain which refers to cutting, piercing, burning, or stabbing pain. Shoots along the course of affected nerve. Shooting is along the course of affected nerve. It is often ________ which refers to sudden, brief, and recurrent. The cause is unknown or due to nerve irritation or damage.
lancinating; paroxysmal
Primary facial neuralgias include:
- Trigeminal neuralgia
- Raeder’s paratrigeminal syndrome (neuralgia)
- postherpetic neuralgia
Trigeminal neuralgia (Tic Douloureux) includes extreme facial pain. People can’t touch eyelashes, eat, brush teeth, wash face etc. Usually due to vascular compression on CN V as it exits the brainstem. Artery sits on top of the nerve and pulsates causing the sharp, shooting, electric pain. It is primarily diagnosed by patient history. Onset is > ____ yrs. There is no strong inherited pathway thats been identified. First line of treatment is ______.
50; medication
Most common area of involvement in trigeminal neuralgia includes____. V1 is least common. Typically you don’t get sensory loss.
V2
If your pt presents with paroxysmal lancinating pain below the RE that has occurred numerous times in recent weeks. Which additional info supports your tentative diagnosis of TN?
episodes occur after applying make up. (you’re looking for a trigger)
in the prognosis and management of TN, what happens over long term?
- pain free intervals diminish
- pain is less responsive to medication
- some sensory loss can occur.
The most commonly accepted cause of trigeminal neuralgia is :
vascular compression ; more common in superior cerebellar artery
some inflammatory causes of TM include:
- MS
- neuritis
- Tolosa hunt syndrome
_______(Tegretol) controls 2/3 of patients initially.
Carbamazepine; anticonvulsant
Surgical interventions to treat TM include microvascular decompression (MVD) which includes isolating the superior cerebellar artery with sponge. This is preferred for younger patients (90% initial success). This has the ______term pain relief; lowest recurrence, and is the most cost effective. You get preserved facial sensation and low morbidity.
longest
A non surgical technique includes radiation technique which applies a local anesthetic and sticks a needle up the foramen ovale. What are advantages of this
- not as invasive
2. doesn’t require a craniotomy.
Another surgical method is percutaneous trans ovale, which is preferred for elderly patients, _____, or pain persisting after MVD.
MS
Percutaneous ______ trigeminal gangliosis is typically 3-4 pain free typically.
radiofrequency
Raeder’s Paratrigeminal Syndrome includes severe _______ ocular V1 pain. Typical is single episode lasting _____to weeks. Occasionally recurrent, self limiting in 2-3 months. You also get ipsilateral oculosympathetic palsy or partial horners, but you have preserved hydrosis. Middle aged male almost exclusively get this with association with cluster headaches.
unilateral; hours
What are the 3 classes of Raeder’s paratrigeminal syndrome.
- V1 pain + horner’s + other CN involvement require with mass for lesion.
- V1 pain + horners with cluster HA - benign course
- V1 pain + horners w/o cluster HA -benign course
MRI/MRA and CBC, physical exam indicated for Raeder’s to rule out:
- internal carotid artery dissection
- trauma
- vasculitis
- parasellar, maxillary sinus mass
- hypertension
How do cluster headaches present?
involves pain around one eye, along with drooping of the lid, tearing and congestion on the same side as the pain.
cluster headaches involve _____periorbital severe pain, avg of 45 mins and can last from ____min to 3 hours. Recurrences are on the same side and in clusters that range from 4- _____weeks
unilateral; 15; 12
Avoid vasodilation, or alcohol for cluster HA. Treat with oxygen, analgesics, octreotide (injectable synthetic somatostatin, triptans, ergotamine, and local anesthetics. For prevention use:
Ca++ channel blockers, corticosteroids, nerve block
Postherpetic neuralgia involves severe burning, aching, stabbing protracted pain. It is usually unilateral and involves V1. It follows a HZV infection (shingles). _______ can be present. and risk increases with age.
Paresthesia
the risk of Postherpetic neuralgia can be reduced by early intervention with HZV infection
antidepressants
RAmsay Hunt Syndrome is an HZV infection of the external _____. It involves CN VII and sometime ____. there is acute pain, ipsilateral facial paresis with loss of taste, secretory function, decreased and hypersensitive hearing, along with vertigo, and nystagmus.
ear; CN VIII
Sphenopalatine ganglion neuralgia is severe unilateral or bilateral pain around root of nose, eyes, upper teeth, gums, jaws. Residual neck tenderness following attack. Photobophobia, conjunctivitis, and lacrimation. You get stuffy, itch, watery nose and pain on swallowing, anasthesia of soft palate, itching of hard _______. Damage here causes brain freeze!
palate
