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NEURALGIAS
Dr V.RAMKUMARCONSULTANT DENTAL&FACIOMAXILLARY SURGEONREG NO: 4118-TAMILNADU-INDIA(ASIA)
CLASSIFICATION OF OROFACIAL PAIN
Typical facial pain: dental, ocular, TMJ Primary neuralgias
Trigeminal neuralgia Glosso pharyngeal Geniculate Post-herpetic neuralgia
Secondary neuralgias Atypical neuralgia : Pain of vascular origin
PRIMARY NEURALGIAS
The most common paroxysmal neuralgia arises in the trigeminal nerve. Occasionally, it affects the glossopharyngeal and superior laryngeal branch of vagus nerve.
The aetiology of this pain is unclear. It may be due to viral aetiology within the
ganglion, demyelination of intracranial nerve roots due to compression by small vascular loops, by dural bands or by narrowing of foramina.
Secondary neuralgias
They arise from irritation of the trigeminal ganglion or nerves by some identifiable lesion and may either mimic exactly the primary paroxysmal pain, or present as a less specific disturbance.
Important differentiating features are the associated local sensory or motor impairment which may or may not be present when the patient first presents.
The lesion can be either extracranially or intracranially.
Secondary neuralgias :Extra cranial lesions:
1. Causalgia2. Fray’s syndroma3. Herpes zoster4. Post-herpetic neuralgia5. Nasopharyngeal carcinoma (Trotter’s
syndrome)6. Cranial base lesions
Secondary neuralgias: Intracranial lesions
1. Tumours of posterior cranial fossa
(ex: Schwannoma)
2. Tumors of middle cranial fossa
(Ex: pituitary tumors & aneurysms of
the internal carotid aretry)
3. Multiple sclerosis
TRIGEMINAL NEURALGIA
It is defined as sudden, usually unilateral, severe, brief, stabbing, lancinating, recurring pain in the distribution of one or more branches of fifth cranial nerve.
Introduction
‘Tic Doloureux’ (powerful jerking) coined by Nicholaus Andre.
Also called as Fothergill’s disease.
Etiology
Vascular factorsMechanical factorsAnomaly of superior cerebellar arteryDental etiologyInfections Multiple sclerosis
Etiology –cont….
Post-traumatic neuralgiasIntra-cranial tumorsBasilar compressionsIntra-cranial vascular abnormalitiesViral etiology
General characteristics
Incidence – 4 in 100,000 persons.Age of occurrence: late middle age or
later in life (5th to 6th decade).Sex predilection: female (58%)Affliction of sides: Right side (60%)Division of trigeminal nerve involvement:
V3 is more common than V2. V1 is rarely involved (5%)
Clinical features
It typically manifests as a sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating, shock like pain, elicited by slight touching superficial “trigger points” which radiate from that point , across the distribution of the one or more branches of the trigeminal nerve.
CONT…
Pain is usually confined to one part of the one division of TN- mandibular or maxillary, but occasionally spreads to an adjacent division or rarely involve all the three divisions.
Pain is of short duration and lasts for a few seconds, but may recur with variable frequency though there is a refractory period (complete lack of pain) between the attacks, some patients report of dull ache in between the attacks.
Clinical features
Trigger points are stimulated either by touching or chewing, smiling or speaking, brushing or shaving or even washing the face.
Presence of an intraoral or extraoral trigger points provocable by external stimuli is seen in TN.
Location of trigger points depends on the division of the 5th cranial nerve In V1 – supraorbital ridge of the affected side in V2 –skin of the upper lip, ala nasi or cheek
or on the upper gums In V3 - lower lip, teeth or gums of the lower
jaws .
Cont…
Paroxysmal Excruciating pain – stabbing, severe, burning or shocking lasting for several seconds.
Pain is associated with lacrimation, flushing and salivation
Trigger zones (V3)– most common site- mental foramen and maxillary canine region.
Cont….
Effected region is usually hyperkeratinised due to vigorous rubbing
Rarely crosses the midline. Does not occur during sleep Paroxysms occur in cycles, each cycles lasting
for weeks or months. Pain seems to become more intense and unbearable with each attack.
In extreme cases, the patient will have a motionless face – frozen or mask like face.
Diagnosis
History (classic clinical pattern) MRI scanning & CT. Response to carbamazepine is universally
accepted by many clinicians as a step in definitive diagnosis of the codition.
Diagnostic injections of a local anesthetic agent into the patients trigger zone should temporarily eliminate all the pain.
Protocol for diagnostic nerve blocks
Materials required
1cc syringe, 25 gauze needle, normal saline, LA without adrenaline.
Always begin injections at the site of pain and then move proximally.
Inject 0.5 ml of normal saline at test site. wait for 5 min, if pain is relieved then psychogenic pain is likely.
Cont….
If pain persists, the inject 0.5 ml of 2 % lignocaine without adrenaline at surface site and wait for 5 min, if pain is relieved then direct therapy at small nociceptor fibres.
If pain persists, inject little deeper and wait for 5 min, if pain is relieved then consider musculoskeletal origin of pain.
If pain is not relieved, inject more proximal portion of nerve, if pain is relieved, direct therapy at site.
Glossopharyngeal Neuralgia
Similar to trigeminal neuralgia RarePain related to sensory areas supplied
by pharyngeal and auricular branch of vagus ( vagoglossopharyngeal neuralgia)
Cause unknown
Clinical features :
Age : 15 – 85 (average 50)No sex predilectionParoxysmal pain in ear , infra auricular area,
tonsil , posterior mandible, lateral wall of pharynx.
Difficulty in locating the painEpisodic pain – unilateral , sharp,
lancinating, extremely intense.
Cont….
Abrupt onsetShort duration (30-60 secs) that repeats
for every 5 – 30 mins.Talking , chewing , swelling, yawning,will
produce painDefinite trigger zone easily identified.
Treatment
Unpredictable remissions and recurrence80% of the patient has immediate pain relief
after the application of topical LA.Drugs like carbemezipine, oxcarbazepine,
baclofen, phenytoin Ressection of glossopharyngeal nerve
Sphenopalatine neuralgia
Otherwise called as Cluster Head achePain affliction to middle face and upper
face.Occurs as temporal groups or clustersCause – vascular (vasodiation) has been
suggested related to abnormal hypothalamic function, head trauma, abnormal release of histamine.
Cont…
Head ache is initiated by alcohol , cocaine and nitroglycerine .
80% of the patients are cigarette smokers.
Clinical featuresoccurs at any age.Sex predilection Male> Female
Cont…..
Pain is unilateral and follows the distribution of ophthalmic division of trigeminal nerve.
Pain felt behind the orbit , radiating to temporal and upper cheek region.
Simulates tooth ache.Pain is abrupt in onset , burning and
lancinating without trigger zones.
Cont…..
Pain lasts for 15 mins to 3 hrs. Eight times daily or alternate days. And lasts for week.
Pain often begins at same time at given 24 hr (alarm clock headache).
Treatment
Prednisone, ergotamine, lithium carbonate, Indomethacin, verapamil.
Sumatriptan New surgical tecniques have been
proposed.
(Gamma Knife Radiosurgery)
Thank you