- Dull constant aching pain over the maxillary sinus
- Tenderness over underlying skin
- Postnasal drip
- Ethmoid/sphenoid a pain felt deep in the midline at the root of the nose
- Pain is worse on bending
- Pain usually lasts 1-2 weeks and is often associated with symptoms of a cold (coryza)
Other facial Pain
- Short stabbing pains – extremely painful! – can last from a few seconds to a few minutes
- Patients often wince involuntarily – hence the name tic douloureaux
- Typically only affects the distribution of one branch of the trigeminal nerve (usually mandibular or maxillary)
- In between attacks there are usually no other symptoms. Attacks are ‘clustered’, in a similar way to cluster headaches, where there may be no attacks for months or years, followed by several weeks of continued incidents.
- Typical patient is male aged over 50
- Attacks usually brought on by shaving, washing, eating, or even just touching affected area
- Most cases thought to be the result of compression of the trigeminal nerve root by blood vessels. Over time, this wears away the myelin sheath, making the nerve more excitable.
- Also associated with multiple sclerosis – in which case there is a demyelination plaque at the trigeminal root.
- Other Secondary causes can include tumours, aneurysms, meningeal irritation etc.
- Secondary disease accounts for 14% of cases
- Carbamazepine – 100mg every 6 hours. Patients can take up to 1200mg/day if necessary.
- Gabapentic, lamotrigine and phenytoin are alternatives.
- Posterior craniotomy – to remove/reroute the offending blood vessel (if this is the cause) is often very effective
- Alcohol/phenol injection – to a branch of the trigeminal nerve – a simple alternative
- Lesion of the nerve near the Gasserian ganglion – can be effective, but there is a risk that too much damage can cause anaesthesia dolorosa – a type of neurogenic pain, worse than the initial neuralgia.
Atypical Facial Pain (ATFP)
- Unilateral pain – not usually as bad as trigeminal neuralgia
- Burning / aching / cramping
- Usually in distribution of trigeminal nerve, but can extend into the neck and occipital regions
- Poorly localised
- Usually present for most of the day, or continuous, with no periods of remission
- No clinical signs
- Some patients also have features of trigeminal neuralgia
- Some speculate that it is an early form of trigeminal neuralgia
- Possibly linked to dental / mandibular trauma
- Surgical treatments – e.g. decompression of trigeminal nerve (if any is present) are usually unsuccessful
- Pain often resistant to analgesia
- Anti-convulsants and antidepressants may be useful.
- Shingles is VERY common! – about 20% of people will have it in their lifetime. Normally, the pain of shingles goes away when the rash resolves.
- Facial pain, that occurs with the resolution of herpes zoster related inflammation, and that persists for >3 months
- Burning, stabbing, gnawing type pain
- Altered sensation in affected area (can be either hypersensitive or feelings of numbness)
- Rarely – muscular involvement (tremor, weakness) of related muscles (if motor fibres are involved)
- More common in older patients – the risk of developing it increases with age
- Wearing loose fitting clothes – to prevent pain caused by hypersensitivity to touch
- Some patients find that covering the area in cling film helps, as it allows clothes to slide freely over the affected area
- Analgesia – start with the basics (such as paracetomol) and work up. Rarely codeine may be used.
- TCA antidepressants –may ease the pain straight away, but take 2-3 weeks to have maximum effect. Cause drowsyness
- Anticonvulsants –most commonly gabapentin
- Antivirals – when given at the onset of herpes-zoster can reduce the duration of shingles, and decrease the risk of developing post herpetic neuralgia.
- Lidocaine skin patches –may be useful for some patients
Other causes of facial pain
- Inflammation / lesions of the orbit
- Teeth problems
- Inflammation of the temporomandibular joint
- Subdural emphysema (rare)
- Lesions of the trigeminal nerve (rare) – these tend to cause loss of sensation rather than pain