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Probability diagnosis

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Dental pain:

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  • caries

  • periapical/dental abscess

  • fractured tooth

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Maxillary/frontal sinusitis

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Herpes zoster (shingles)

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Serious disorders not to be missed

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Cardiovascular:

++

  • myocardial ischaemia

  • aneurysm of cavernous sinus

  • internal carotid aneurysm

  • ischaemia of posterior inferior cerebellar artery

  • temporal arteritis

++

Cancer/neoplasia:

++

  • cancer: mouth, sinuses, posterior fossa, nasopharynx, tonsils, tongue, larynx

  • metastases: orbital, base of brain, bone

++

Infection:

++

  • orbital cellulitis

  • erysipelas

  • periapical abscess → osteomyelitis

  • acute sinusitis → spreading infection

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Pitfalls (often missed)

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TMJ dysfunction

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Migraine variants:

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  • facial migraine

  • chronic paroxysmal hemicrania

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Atypical facial pain

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Eye disorders:

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  • glaucoma

  • iritis

  • optic neuritis

++

Chronic dental neuralgia

++

Facial bone diesease

++

Parotid gland: mumps, cancer, sialectasis, abscess

++

Acute glaucoma (upper face)

++

Cranial nerve neuralgias:

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  • post-herpetic neuralgia

  • trigeminal neuralgia

  • glossopharyngeal neuralgia

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Masquerades checklist

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Depression

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Spinal dysfunction

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Is the patient trying to tell me something?

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Quite probably. Atypical facial pain has underlying psychogenic elements.

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Key history

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Diagnosis of virtually all types of facial pain must be based entirely on the history. Include the typical pain analysis, especially site and radiation.

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Key examination

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  • Palpate the face and neck to include the parotid glands, eyes, regional lymph nodes and skin

  • Inspect the TMJs and cervical spine

  • Carefully inspect the nose, mouth (esp. each tooth), pharynx and postnasal space

  • Inspect the sinuses with transillumination

  • Perform a neurological examination of the cranial nerves

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Key investigations

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Referral may be appropriate. The association of tumours with neuralgias may have to be investigated. Radiological investigations to consider include:

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  • plain X-rays of the paranasal sinuses

  • CT scans

  • MRI

  • orthopantomograms.

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Diagnostic tips

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  • Facial pain never crosses the midline; bilateral pain means bilateral lesions.

  • Malignancy must be excluded in the elderly with facial pain.

  • Problems from the molar teeth, especially the third (wisdom) commonly presents with peri-auricular pain and pain in the posterior check.

  • Don’t overdiagnose sinusitis: many URTIs may produce mild facial ache (vacuum effect).

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