Facial Pain: Diagnosis and treatment Ahmed M. Raslan, MD
Assistant Professor Department of Neurological Surgery OHSU,
Portland, OR, USA
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Disclosure None
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Diagnosis of Facial Pain Clinical ! Imaging
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Classification of Facial Pain Trigeminal distribution Other
cranial Nerves Cluster Migraine TMJ
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Classification of Facial Pain TN1 TN2 Symptomatic Neuropathic
Postherpetic Deafferentation Atypical Rare syndromes Trigeminal
distribution Other cranial Nerves
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Glossopharyngeal Nervus Intermedius Ramsy-Hunt Trigeminal
distribution Other cranial Nerves Classification of Facial
Pain
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Other Cranial Neuralgia Unilateral Throat pain Syncope/
Swallow- syncope Base of tongue-tonsillar fossa- angle of mandible,
ear pai n Glossopharyngeal Nervus Intermedius Ramsy-Hunt
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Unilateral Sharp episodic pain deep in the EXTERNAL ear Other
Cranial Neuralgia Glossopharyngeal Nervus Intermedius
Ramsy-Hunt
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Sudden onset Retroauricular and facial pain Followed 2 days
later by facial palsy Vesicular eruptions ? Glossopharyngeal Nervus
Intermedius Ramsy-Hunt Other Cranial Neuralgia
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Trigeminal Neuralgia IASPIHS Sudden, usually unilateral, severe
brief stabbing recurrent pains in the distribution of one or more
branches of the Vth cranial nerve Painful unilateral affliction,
characterized by brief electric shock like pain limited to the
distribution of one or more divisions of the trigeminal nerve. Pain
is commonly evoked by trivial stimuli including washing, shaving,
smoking, talking and brushing the teeth, but may also occur
spontaneously. The pain is abrupt in onset and termination and may
remit for varying periods
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Classification of facial pain TN1TN2SymptomaticNeuropathicPost-
Herpetic De- afferentation Atypical Sharp stabbing episodic pain
for more than 50 % of the time. Constitute the typical TN Sharp
stabbing pain < 50 with predominant component of dull aching or
burning pain. Advanced from of TN Due to: 1-MS 2-Tumour 3-AVM
4-Aneurysm Etc.. Un- intentional injury 1- surgical ENT, Ophth.
Plastic. 2- traumatic Herpes Zoster out- break Severe neuro- pathy
Intentional neuro- surgical injury for treatment of TN 1-Rhizotomy
2-RF 3-Radio- surgery Somato- form Pain disorder Can not be diagnos
ed By history only Burchiel K. A new classification of facial pain.
Neurosurgery 53 (5) 2003: 1164-1176 Eller J, Raslan A, Burchiel K.
Trigeminal Neuralgia: Definition and classification. Neurosurg
Focus 18 (5) 2005: E3
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1- TN1 Represents the classic TN Severe abrupt stabbing,
electric or shock-like pains is the hallmark Dull aching or burning
pain is absent or present for less than 50 % of the time the
patient experience the pain Presence of pain free intervals
Straight forward diagnosis May progress to TN2..?
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2- TN2 Still the patient experience sharp pains, but the
hallmark is dull aching, burning pain or back ground pain that
constitute more than 50 % of the time Constant back ground pain is
the most significant attribute with the absence of any structural
abnormality
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TN2 Type A Progressed from prior TN1 Type B Started de novo a
TN2 ; ? Trigeminal ganaglion dysfunction
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3- Symptomatic TN Represents what is usually called secondary
TN There is another disease or diagnosis that causes demyelination
of the trigeminal nerve Trigeminal nerve can be still compressed
and sometimes can be treated by treatment of the cause Broggi et
al. Operative findings and outcome of microvascular decompression
for trigeminal neuralgia in 35 patients affected with multiple
sclerosis. Neurosurgery 55(4) 2004: 830-839
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4- Neuropathic TN Patients complain of pain of constant nature,
with areas of numbness as a hallmark Due to un-intentional injury
to the trigeminal nerve during surgery or trauma, could be
spontaneous *Johnson M, Burchiel K. Peripheral stimulation for
treatment of trigeminal post herpetic neuralgia and trigeminal
post-traumatic neuropathic pain: A pilot study. Neurosurgery 55(1)
2004 : 135-142
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5- Post Herpetic TN Constitutes a severe form of neuropathy to
the trigeminal nerve Easily diagnosed by history of eruptions
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6- Deafferentation facial pain Anesthesia Dolorosa Means
Painful Anesthesia Doctors induced pain syndrome Follows
destructive procedures for trigeminal neualgia Surgical rhizotomy
RF procedures, Balloon, rarely Glycerol Radiosurgery Very severe
and difficult to treat
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7- Atypical Facial Pain We use this term to describe patients
who complain of facial pain as a part of somatoform pain disorder
Can be diagnosed by Neuro-psychological evaluation Patients usually
describe the following symptoms Bilateral pain, or pain that cross
the midline Pain outside the distribution of trigeminal nerve
Multiple complaints in multiple body parts Patients often carries
diagnoses like chronic fatigue syndrome, Fibromyalgia. Surgical
treatment is contra-indicated