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5th Oral Disease - Facial Pain > Trigeminal Neuralgia > Flashcards

Trigeminal Neuralgia Flashcards

1
Q

What is trigeminal neuralgia?

A

A sudden, unilateral, severe, brief stabbing, recurrent pain in the distribution of one or more branches of the 5th CN

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2
Q

What is the incidence of trigeminal neuralgia?

A

3-5/ 10,000
Women> men
Often are 50+

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3
Q

What are 3 types of trigeminal neuralgia?

A

Idiopathic
Classical
Secondary

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4
Q

What is the presentation of trigeminal neuralgia?

A

Unilateral
Sharp shooting pain
Paroxysms
Describe: knife, electric shock

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5
Q

When in the day is it more common to see trigeminal neuralgia?

A

Day > night

Increased activity

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6
Q

What is the pathophysiology of trigeminal neuralgia?

A

Local demyelination of trigeminal nerve

Nerve loses myelin allows jumping of electrical signals

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7
Q

What structure is between pons (brain) and trigeminal ganglion?

A

Dorsal root

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8
Q

What artery overlies the nerve and what significance is this?

A

Inferior cerebellum artery

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9
Q

Causes of classical, secondary and idiopathic tN?

A

Classical - blood vessel
Secondary - underlying pathology
Idiopathic - unknown

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10
Q

What are secondary causes of TN?

A

Multiple sclerosis
Tumour cerebellar-pontine angle
Peripheral neuropathy
Skull base deformity

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11
Q

What would you see on MRI of pt w/ MS and TN?

A

White plaques of demyelination

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12
Q

How many pt w/ MS get TN?

A

6%

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13
Q

Example of peripheral neuropathy that can cause TN?

A

Charcot-Marie Tooth

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14
Q

Example of skull base deformity that can cause TN?

A

Pagets

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15
Q

What is management of TN?

A

Drugs - first choice (if don’t control then surgical)

Surgical

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16
Q

Example of surgical options of tx of TN?

A

Microvascular decompression
Ganglion procedures
Stereotactic radiosrugery
Cryoanalgesia

17
Q

What types of medications can be used for TN?

A

Sodium channel blockers
Gabapentin/ pregabalin
Phenytoin
Valporate

18
Q

Example of Na channel blocker?

A

Carbamazepine
Oxcarbazepine
Lamotrigine

19
Q

What is tx of choice for TN?

A

Na channel blocker and anticonvulsant

Slow release preparation 2x day

20
Q

Can dentist prescribe carbamazepine?

A

Technically yes

Not easy drug to prescribe - complex drug as induced liver enzyme altering metabolism of other drugs

21
Q

What liver enzyme does carbamazepine induce?

A

P450

Metabolises other drugs esp warfarin, OCP, Ca channel blockers

22
Q

What dosage would carbamazepine be given in?

A

2x daily

Increase dose gradually

23
Q

Side effect of carbamazepine?

A

Rash
Ataxia
Sommonlence
Dyscrasia (Rare) - affect blood marrow formation and reduce WBC/ platelet

24
Q

When can microvascular decompression be used?

A

Pt w/ classic TN - can see artery pressing on nerve

25
Q

What is microvascular decompression?

A

Major neurosurgical procedure (1 week in hospital) to move blood vessel away from nerve

26
Q

Problems w/ microvascular decompression?

A

Significant risk - CSF leak, infection (meningitis), damage to nerves (CN defect), deafness, stroke risk

27
Q

Adv of microvascular decompression?

A

> 80% complete pain relief - often life long

28
Q

What pt would be suitable for microvascular decompression?

A

Young fit pt

Wouldn’t do on elderly

29
Q

What is involved in ganglion procedures?

A

GA

Inject into ganglion - damaged nerve fibres (C/A delta fibres = pain)

30
Q

Advantage of ganglion procedures?

A

Less invasive - better for elderly pt

31
Q

Disadvantage of ganglion procedures?

A

Sensory deficit - doesn’t damage just small pain fibres

Not permanent - 2-3yrs

32
Q

How is ganglion procedure undertaken?

A

Needle inserted through frogmen ovale into ganglion

Glycerol injection/ compression balloon/ thermocoagulation

33
Q

What is cryoanalgesia?

A

Freezing of peripheral nerve

34
Q

Problems w/ cryoanalgesia?

A

Recovery and recurrence of pain
Fibrosis - only do 1-2x per pt
Sensory deficit

35
Q

When can cryoanalgesia be useful?

A

If pt has trigger e.g on lower lip (can freeze mental nerve)

36
Q

What is stereotactic radiosrugery?

A

High dose of gamma radiation

One off tx

37
Q

How many grays does trigeminal nerve receive during stereotactic surgery?

A

80 grays

38
Q

In an audit what problems where associated w/ stereotactic radiosurgery?

A

Delay in pain relief
Failure of tx - 20-30% pt get some paraesthesia
Recurrence of pain

5th Oral Disease - Facial Pain (4 decks)

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