Facial pain. II. Facial pain with dysfunction.
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Carcinoma of the parotid gland presenting as facial pain.
Facial pain is a common reason for patients seeking medical help. A patient is presented who gave a 5-month history of right-sided facial pain, which was subsequently diagnosed as carcinoma of the right parotid gland.
Adenocarcinoma↗
Intracranial tumours presenting with facial pain.
Facial pain is a common presenting symptom in oral surgery outpatient clinics. Among the large number of patients presenting in this way, a small number of patients will be found to have intracranial tumours. Three such cases are described and recommendations made regarding the selection of facial pain patients for further investigation.
Adult↗
Facial pain.
Facial pain is a debilitating disorder if left untreated. Too often patients are labelled as having psychopathology when face pain etiology is unclear. These patients are categorized as 'atypical', 'idiopathic' or 'psychogenic'. Idiopathic, when referring to a medical problem suggests that there is something unknown, and does not define the problem. The same applies to terms incorporating the word 'atypical'. It is postulated that the most commonly undiagnosed facial pain conditions include neuropathic and myofascial pains because their pathophysiologies are not well understood. Peripheral and central mechanisms associated with these disorders are used to provide an update of these frequently seen clinical conditions.
Facial Pain↗
Motor cortex stimulation for neuropathic facial pain.
Facial neuralgia is the last common pathway for a variety of pathological conditions with different etiology. Neuropathic facial pain is often refractory to routine medical or surgical treatments. We present here a long-term follow-up of two patients with unilateral facial neuropathic pain due to idiopathic trigeminal neuropathy or to surgical trauma to the glossopharyngeal nerve, respectively. These patients have been treated by other modalities for several years without obtaining satisfactory pain relief. Electrical stimulation of the motor cortex (MCS) with a quadripolar electrode contralateral to the painful area of the face was attempted in both cases for control of the facial pain, and resulted in immediate analgesia with more than 50% pain reduction. During a follow-up period of 72 months, a sufficient (> 50%) and stable analgesic effect of MCS was observed. These cases are discussed and the recent literature on MCS is reviewed in an attempt to identify indications for MCS as well as key structures in the brain for mediating the MCS effect.
Adult↗
Psychiatric problems in chronic facial pain.
Facial pain patients have been known to describe their life as "a living hell." By employing a biopsychosocial approach, the dental surgeon can often markedly reduce suffering and diminish the negative impact of chronic pain on the patient's day-to-day life, and enhance his or her capacity to deal long-term with this often complex clinical presentation.
Adult↗
Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers: facial pain other than trigeminal neuralgia.
I describe the results of retrogasserian differential lidocaine block to aid in the selection of patients for a differential thermal lesion in the trigeminal ganglion and rootlets. This procedure temporarily duplicates the state of analgesia without anesthesia one seeks to make permanent with the radiofrequency heating. The results of this heating procedure are described in the treatment of 71 patients with facial pain of cancer, postherpetic, periodic migrainous neuralgia, acromegaly, trigeminal neuropathy, central pain, post-traumatic facial neuralgia, and atypical facial neuralgia.
Electrocoagulation↗
Prevalence of nasal mucosal contact points in patients with facial pain compared with patients without facial pain.
A cohort of 973 consecutive attendants at a rhinology clinic was studied prospectively and divided into patients without facial pain (n = 566, 58 per cent) and patients with facial pain (n = 407, 42 per cent). The prevalence of nasal mucosal contact points was the same in both groups, being four per cent in patients with nasal contact points without facial pain and four per cent in patients with facial pain. A contact point is defined as when contact remains after topical decongestion. Of the 18 patients with facial pain, nine had a spur contacting the lateral nasal wall and nine had a middle turbinate contacting the septum. These 18 patients were followed up for a mean of two years and two months. In the light of their treatment and response the following diagnoses were made: five had tension-type headache, six had midfacial segment pain, one had migraine, two had cluster headache and four had purulent nasal disease. Of the four with unilateral symptoms, two had a contact point on the contralateral side. Eleven of these 18 patients responded to medical treatment for tension-type headache or midfacial segment pain, migraine and cluster headache, three patients were better after surgery for coexisting purulent nasal disease and one patient had a spur removed surgically and remained better at 2 years follow-up, whereas three patients were no better after the same procedure. The results demonstrate that the prevalence of nasal contact points in patients with facial pain is the same as in those within pain. Surgery undertaken to remove mucosal contact points for facial pain is usually unnecessary as the aetiology of this facial pain appears to be a more central processes.
Case-Control Studies↗
An electromyographic and cephalometric study on facial pains and facial morphology in children.
Twelve children, five girls and seven boys with a mean age of 12 years, exercised maximal voluntary tooth clenching until intolerable pains and total subjective exhaustion of at least the right masseter muscle forced the children to stop the isometric muscle exercise; that is, the pain tolerance, or the isometric endurance time, of at least the right masseter muscle was determined in seconds, and it amounted to an average of 100 s. Concomitantly, the electrical activity in the right masseter muscle was recorded by bipolar surface electrodes and integrated, and it showed a significant decrease of 32% during the endurance test, probably as an expression of progressive physiological muscle fatigue. A large ANB angle was associated with relatively little decline of the contractile activity and a trend not to endure pains, possibly because isometric tension was generated predominantly by muscle fibres with a high anaerobic capacity.
Cephalometry↗
The McGill Pain Questionnaire in patients with TMJ pain and with facial pain as a somatoform disorder.
The purpose of this study was to assess the discriminative capacity of the McGill Pain Questionnaire (MPQ) in patients with temporomandibular joint disorders (TMD) or with facial pain disorder as somatoform disorder (referred to as "atypical facial pain") (FP). The MPQ was administered to 57 TMD and 34 FP patients. Weighted MPQ item scores, subscale Pain Rating Indexes (PRI), and total Pain Rating Index were tested for significant differences (Student's t-test), and the frequency of descriptor choice was also analyzed. Furthermore, the data were processed through two systems based on a counter-propagation neural network: the Self-Organizing Map (SOM) system and a cluster-like analysis. In the FP group eleven MPQ item scores and five PRI scores were significantly higher than those of the TMJ group. There was a considerable difference in descriptor choice between the groups. SOM analysis and cluster-like analysis correctly discriminated 85% or more of the patients. In conclusion, the MPQ showed a consistent discriminative capacity between TMD and FP patients.
Adult↗
Pain maps from facial pain patients indicate a broad pain geography.
Two hundred consecutive female patients, who were referred to a university-based facial pain clinic, were asked to mark all painful sites on sketches showing the contours of a human body in the frontal and rear views. The drawings were analyzed with transparent templates containing 1875 (frontal view) and 1929 (rear view) square cells of equal size. The average patient scored 71.8 cells in the frontal and 99.7 cells in the rear view (corresponding to 3.8% and 5.2% of the maximum possible scores). In individual patient drawings, however, up to 42.7% and 44.9% of all cells were marked. Only 37 cases (18.5%) exhibited pain that was limited to the trigeminal system. An analysis of the pain distribution according to the arrangements of dermatomes revealed three distinct clusters of patients: (1) pain restricted to the region innervated by the trigeminal nerves (n = 37); (2) pain in the trigeminal dermatomes and any combination involving the spinal dermatomes C2, C3, and C4, but no other dermatomes (n = 32); and (3) pain sites involving dermatomes in addition to the ones listed above (n = 131). Mean ages in the three clusters were 38.7, 35.5, and 37.5 years, respectively (p = 0.62, n.s.). Widespread pain existed for longer durations (median, 48 months) than conditions involving local and regional pain (median, 24 months) (p = 0.02, s.). Our findings showed that among a great percentage of persistent facial pain patients the pain distribution is more widespread than commonly assumed, and that the persistence of pain in the regional and widespread pain presentations is significantly greater than in cases with pain limited to the trigeminal system.
Adolescent↗
Chronic, burning facial pain following cosmetic facial surgery.
Chronic, burning facial pain as a result of cosmetic facial surgery has rarely been reported. During the year of 1994, two female patients presented themselves at our Pain Relief Clinic with chronic facial pain that developed following aesthetic facial surgery. One patient underwent bilateral transpalpebral surgery for removal of intraorbital fat for the correction of the exophthalmus, and the other had classical face and anterior hairline forehead lifts. Pain in both patients was similar in that it was bilateral, symmetric, burning in quality, and aggravated by external stimuli, mainly light touch. It was resistant to multiple analgesic medications, and was associated with significant depression and disability. Diagnostic local (lidocaine) and systemic (lidocaine and phentolamine) nerve blocks failed to provide relief. Psychological evaluation revealed that the two patients had clear psychosocial factors that seemed to have further compounded their pain complaints. Tricyclic antidepressants (and biofeedback training in one patient) were modestly effective and produced only partial pain relief.
Antidepressive Agents, Tricyclic↗
Temporomandibular disorders, occlusion, and neck pain in subjects with facial pain: a case-control study.
The etiology of facial pain is multifactorial. Based on the results of a questionnaire included in the study of the 1966 Northern Finland Birth Cohort, performed in 1997-98, we found an association of facial pain with subjective symptoms of temporomandibular disorders (TMD), neck pain and with occlusal factors reported by 5,696 subjects. The aim of the present study was to examine these associations clinically. In the year 2000, a new inquiry was sent to the following subjects living in Oulu: 1. all subjects who had reported facial pain in the former questionnaire (n=162) (case group); and 2. to a randomly selected group of nonpain controls (n=200), group matched for gender. Those who reported willingness to participate were invited to a clinical examination. Finally, the total number of subjects was 104, including 52 (10 men, 42 women) cases and 52 (10 men, 42 women) controls. Anamnestic data were collected, and clinical stomatognathic and musculoskeletal examinations were performed, both the clinicians and the subjects being unaware of the case-control status. Anamnestically, stress was the most often reported provoking factor for facial pain. Facial pain associated significantly with reported TMD symptoms and allergies. Based on clinical findings, most of the cases were classified in the myogenous subgroup of TMD. The risk for facial pain was six-fold in subjects with clinically assessed TMD, defined as moderate (DiII) or severe (DiIII) by Helkimo's clinical dysfunction index, almost six-fold in subjects with protrusion interferences and approximately three-fold in subjects with clinically assessed tenderness of distinct fibromyalgia (FM) points in the neck. According to the adjusted logistic regression analyses, TMD had the strongest influence on facial pain, followed by protrusion interferences, anamnestically reported allergies and "other headaches". The present study shows that as well as being connected with TMD, facial pain is associated with pain and muscle tenderness in the neck area.
Adult↗
Trigeminal nucleus caudalis dorsal root entry zone radiofrequency thermocoagulation for invalidating facial pain.
INTRODUCTION: Facial pain syndromes occasionally result in desperate clinical settings completely unresponsive to any known therapy. Trigeminal nucleus caudalis dorsal root entry zone (DREZ) lesion is reported to be of benefit in such cases. In 1982 Nashold performed the first DREZ caudalis lesion in a patient with anaesthesia dolorosa. PATIENTS AND METHODS: From 1994 to 2002 we have performed six DREZ caudalis lesions on five patients with extremely invalidating facial pain resistant to multiple pharmacological and surgical therapies. Pain was secondary to previous craniofacial surgery in all but one case. Pain presented as anaesthesia dolorosa or atypical facial pain so severe as to interfere with personal hygiene and even to prevent patients from oral feeding. A midline suboccipital approach was used and radiofrequency lesions (at the trigeminal nucleus caudalis in the cervicomedullary junction) were made at 1-mm intervals, 75 (o)C for 15 seconds each along the ipsilateral posterolateral sulcus from the cervical DREZ up to the obex. RESULTS: Pain relief was complete and permanent in two patients. Three patients experienced significant improvement but pain recurred in two (weeks to a few months after the procedure). No patient's pain was made worse. A patient with persistent postoperative nasolabial pain was re-operated on (improving again but ultimately remaining unchanged). Air venous embolism related to the sitting position (3 patients) during surgery and bradycardia due to manipulation in medulla (2 patients) occurred during some of the procedures without any cardiovascular or neurological repercussion. Postoperative complications included mild and transient ataxia and monoparesia (3 patients). DISCUSSION: Facial pain secondary to craniofacial surgery is known to be among the least responsive to treatment and a true challenge for pain clinicians. Actual indications for this procedure, operative technical details and the results of our series compared to previous reports are reviewed. CONCLUSION: Trigeminal nucleus caudalis radiofrequency thermocoagulation is an effective neurosurgical procedure for the treatment of chronically debilitating and desperate facial pain syndromes with acceptable morbidity.
Adult↗
Neurogenic facial pain.
Neurogenic facial pain can be classified as either paroxysmal or persistent. Trigeminal neuralgia is the commonest example of the former, and postherpetic neuralgia, atypical facial pain, and tension head and facial pains are examples of the latter. The cause of many of these pains is poorly understood, the complex neuroanatomy of the head and neck being a contributory factor. Even when the aetiology is known, the mechanism whereby pain is produced is usually obscure. While treatment with drugs and surgical measures for trigeminal neuralgia are often satisfactory, and acupuncture for pain due to "muscle tension" may be beneficial, there is often little effective treatment for a considerable proportion of patients with neurogenic facial pain.
Adult↗
[Facial pain. 2: Extracranial causes of facial pain].
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Bone Diseases↗
Neurologic aspects of chronic facial pain.
Chronic facial pain can result from neuropathic changes associated with deafferentation. The pattern of deep afferent convergence on trigeminal cells may also relate to the pathophysiology of chronic facial pain disorders.
Chronic Disease↗
Peripheral trigeminal nerve surgery for patients with atypical facial pain.
Atypical facial pain (AFP) is characterized by a constant, poorly defined anatomically aching pain, lacking the paroxysmal quality, trigger point activation, and well-defined anatomical distribution of trigeminal neuralgia. This study examines a set of AFP patients with respect to their responses to external decompression (4 patients) and neurectomy (11 patients). Criteria for trigeminal nerve exploration were: failure of non-operative treatments, the ability to control pain temporarily with local anesthetic nerve blocks, and pain generally located within the anatomical distribution of the affected nerve. Decision as whether to perform an external decompression or neurectomy was based on gross anatomical findings during exploration. A retrospective interview was conducted to evaluate the effects of the chosen procedure in regard to subjective level of pain, freedom from restrictions placed on activities of daily living, and past medical history, including history of the facial pain. The neurectomy procedure (p = 0.022), medical history of autoimmune disease (p = 0.004), and preoperative pain distribution on the left side (p = 0.042), were all found to have a positive effect on outcome. History of psychiatric treatment (p = 0.055) and preoperative affected activities of daily living (p = 0.026) significantly adversely affected the outcome.
Activities of Daily Living↗