Sinusitis

Clinical features

  • 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)
Infection disease in general account for 7% of headaches

Other facial Pain

Trigeminal Neuralgia

(aka Tic Douloureaux)
One of the most common causes of facial pain, but all neuralgias account for <1% of all headaches.

Clinical features

  • Short stabbing pains – extremely painful! – can last from a few seconds to a few minutes
    • Patients often wince involuntarily – hence the name tic douloureaux
  • Unilateral
  • 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

Pathology

  • 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 sclerosisin 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

Treatment

Pain relief:
  • Carbamazepine – 100mg every 6 hours. Patients can take up to 1200mg/day if necessary.
  • Gabapentic, lamotrigine and phenytoin are alternatives.
Surgery
  • 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)

Unknown aetiology and pathology, most likely functional. It is usually a diagnosis of elimination – if no other causes can be found for the pain, a diagnosis of ATFP may be given.

Clinical features

  • 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

Pathology

  • Some speculate that it is an early form of trigeminal neuralgia
  • Possibly linked to dental / mandibular trauma

Treatment

  • 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.

Post-herpetic neuralgia

This is pain caused by the varicella zoster virus. This is the virus that causes the acute infection chickenpox. After the acute illness, the virus lays dormant in nerve cell bodies, dorsal root ganglion, cranial nerve or autonomic nerve ganglions, and it can become active again at any time in life, resulting in the condition shingles.
  • 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.
Post-herpetic neuralgia occurs after an outbreak of shingles. The pain is typically only found in one dermatome , and is a result of damage to the nerve supplying this dermatome. The pain can occur anywhere on the body

Clinical features

  • 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

Treatment

Cases will often resolve themselves over time. About 30% of cases will still have pain after a year.
  • 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

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