FACE PAIN

Ask the following questions:

1. Is the pain constant or intermittent? Intermittent pain would suggest trigeminal neuralgia, cluster headaches, or atypical migraine. Constant pain would suggest any local abnormalities in the structures underlying the face such as an abscessed sinus, an abscessed tooth, or a neoplasm in these areas.
2. Is the pain increased by chewing? Pain that is increased by chewing very often may be related to the temporomandibular joint syndrome, but it could be related to trigeminal neuralgia or dental caries.
3. Is there an associated nasal discharge? An associated bloody nasal discharge would make one think of a nasopharyngeal carcinoma, but a purulent discharge would make one think of acute or chronic sinusitis. A watery nasal discharge often accompanies cluster headaches or atypical migraine.
4. Are there abnormal neurologic findings? Face pain sometimes accompanies multiple sclerosis, acute Wallenberg's syndrome, and advanced acoustic neuromas. The pain in the trigeminal distribution associated with multiple sclerosis often is intermittent and suggests trigeminal neuralgia.

DIAGNOSTIC WORKUP

The first thing to determine is whether there is an infectious or neoplastic process in the structures underlying the face. X-rays of the sinuses and teeth and CT scans of the sinuses and brain may be necessary to further elucidate this. An x-ray of the temporomandibular joint may be helpful. An MRI of the temporomandibular joint is the procedure of choice to rule out pathology of this joint. Referral to a dentist to evaluate the patient's teeth or to an ear, nose, and throat specialist to evaluate sinusitis may be necessary.

To rule out cluster headaches or atypical migraine, a histamine test may be done. It may be wise to see the patient during an attack so that superficial temporal artery compression can be done to rule out migraine and/or a shot of sumatriptan succinate can be given, which should provide immediate results in cluster headache and atypical migraine.

A trial of carbamazepine (Tegretol®) can be given in cases of suspected trigeminal neuralgia, but referral to a neurosurgeon for an alcoholic injection of the maxillary or mandibular branches of trigeminal nerve will more likely make the diagnosis and solve the patient's problem.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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