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When a patient complains of pain in the face rather than the head the physician has to consider foremost the possibilities of dental disorders (which accounts for up to 90% of pain in and about the face), sinus disease, esp. of the maxillary sinuses, temporomandibular joint (TMJ) dysfunction, eye disorders, lesions of the oropharynx or posterior third of the tongue, trigeminal neuralgia and chronic paroxysmal hemicrania.

The key to the diagnosis is the clinical examination because even the most sophisticated investigation may provide no additional information.

Cervical spinal dysfunction

The upper cervical spine can cause facial pain from lesions of C2 or C3 via the lesser occipital or greater auricular nerves which may give pain around the ear. It is important to remember that C2 and C3 share a common pathway with the trigeminal nerve.

Dental disorders

Dental caries, impacted teeth, infected tooth sockets and dental roots can cause pain in the maxillary and mandibular regions. Impacted third molars (wisdom teeth) may be associated with surrounding soft tissue inflammation, causing pain which may be localised to the mandible or radiate via the auriculotemporal nerve to the ear.

Features of dental caries

• Pain is usually confined to the affected tooth but may be diffuse.

• Pain is almost always aggravated by thermal changes in the mouth:

  • cold—if dental pulp vital

  • hot—if dental pulp is necrotic

• Pain may be felt in more than one tooth.

• Dental pain will not cross the midline.

Treatment of dental pain

• Arrange urgent dental consultation.

• Pain relief aspirin 600 mg (o) 4–6 hrly or paracetamol 0.5–1 g (o) 4–6 hrly.

• If pain severe add codeine 30 mg (o) 4–6 hrly.

Dental infection (e.g. tooth abscess)

Dental treatment may relieve but if moderate to severe:

• amoxycillin 500 mg (o) tds for 5 d

If unresponsive: amoxycillin/clavulanate 875/125 mg (o) bd

Add:

• metronidazole 400 mg (o) 12 hrly for 5 d

If widespread (e.g. adjacent fascial infection) use parenteral antibiotics (e.g. procaine penicillin 1 g (IM) daily for 5 d).

Alveolar osteitis (dry tooth socket)

Refer for localised toileting. Usually heals naturally in 14 days. Antibiotics of no proven use.

Pain from paranasal sinuses

Infection of the paranasal sinuses may cause localised pain. Localised tenderness and pain may be apparent with frontal or maxillary sinusitis. Sphenoidal or ethmoidal sinusitis causes a constant pain behind the eye or behind the nose, often accompanied by nasal blockage.

Maxillary sinusitis

The maxillary sinus is the one most commonly infected. It is important to determine whether the sinusitis is caused by stasis following an URTI or acute rhinitis or due to dental root infection.

Clinical features of acute sinusitis

• Facial pain and tenderness

• Toothache

• Purulent postnasal drip

• Nasal discharge

• Nasal obstruction

• Rhinorrhoea

• Cough (worse at night)

• Fever

• Epistaxis

• Suspect bacterial cause if high fever and purulent nasal discharge.

Clinical features of chronic sinusitis

• Vague facial pain

• Offensive postnasal drip

• Nasal obstruction

• Toothache

• Malaise

• Halitosis

Management of maxillary sinusitis

• Analgesics

• Antibiotics (first choice) (Sinusitis):

  • amoxycillin 500 mg (o) tds for 7 d or

  • amoxycillin clavulanate 875/125 mg (o) tds for 7 d (if resistance to amoxycillin is suspected or proven or poor response to above)

• Nasal decongestants (oxymetazoline—containing nasal drops or sprays) only if congestion

• Inhalations (a very important adjunct)

Invasive methods

Surgical drainage may be necessary by atrial lavage or frontal sinus trephine.

Temporomandibular joint (TMJ) dysfunction

This condition is due to abnormal movement of the mandible, esp. during chewing. The basic cause is dental malocclusion.

Treatment of TMJ dysfunction

If organic disease, such as rheumatoid arthritis and obvious dental malocclusion is excluded, a special set of instructions or exercises can alleviate the annoying problem of TMJ arthralgia in about 3 wks.

Method 1: ‘Chewing’ a piece of soft wood

• Obtain a rod of soft wood ∼5 cm long × 1.5 cm wide. An ideal object is a large carpenter's pencil.

• Instruct the patient to position this at the back of the mouth so that the molars grasp the object with the mandible thrust forward.

• The patient then rhythmically bites on the object with a grinding movement for 2–3 mins at least 3 times/d.

Method 2: The ‘six by six’ program

This is a specific program recommended by some dental surgeons. The 6 exercises should be carried out 6 times on each occasion, 6 times a day, taking about 1–2 mins.

Injection into the TMJ

Indications: painful rheumatoid arthritis, osteoarthritis or TMJ dysfunction not responding to conservative measures.

Trigeminal neuralgia

Trigeminal neuralgia (‘tic douloureux’) is a condition of often unknown cause which typically occurs in patients >50 yrs, affecting the 2nd and 3rd divisions of the trigeminal nerve and on the same side of the face. Brief paroxysms of pain, lasting on average 1–2 mins often with associated trigger points, are a feature.

Treatment

Note: Precise diagnosis is essential.

• Patient education, reassurance and empathic support is very important in these patients.

• Medical therapy:

  • carbamazepine (from onset of attack to resolution) 50 mg (elderly patients) or 100 mg (o) bd initially, gradually ↑ dose to avoid drowsiness every 7 d to 200 mg bd (maintenance); or to a maximum of 600 mg bd

  • alternative drugs if carbamazepine not tolerated or ineffective (but question the diagnosis if lack of response):

    • gabapentin 300 mg initially then increase as necessary

    • phenytoin 300–500 mg/d

    • clonazepam, lamotrigine or sodium valproate

• Surgery: refer to a neurosurgeon if medication ineffective.

Glossopharyngeal neuralgia

This is a rare condition with similar clinical features of severe laminating pains.

Sites: Back of throat around tonsillar fossa and adjacent fauces deep in ear. May extend to external ear and neck.

Triggers: swallowing, coughing, talking

Treatment: as for trigeminal neuralgia

Facial migraine (lower half headache)

Migraine may rarely affect the face below the level of the eyes, causing pain in the area of the cheek and upper jaw. It may spread over the nostril and lower jaw. Pain is dull and throbbing and nausea and vomiting are commonly present. Treatment is as for other varieties of migraine.

Chronic paroxysmal hemicrania

In the rare condition of chronic or episodic paroxysmal hemicrania there is a unilateral facial pain that can resemble chronic cluster headache but the duration is briefer, about 15 mins, and it may recur many times a day even for years. It responds specifically, sometimes dramatically, to indomethacin.

Herpes zoster and postherpetic neuralgia

Herpes zoster may present as hyperaesthesia or a burning sensation in any division of the 5th nerve, esp. the ophthalmic division.

Atypical facial pain

This is mainly a diagnosis of exclusion whereby patients, usually middle-aged women, complain of diffuse pain in the cheek (unilateral or bilateral) without demonstrable organic disease or which does not conform to a specific nerve distribution. It is usually described as deep-seated, severe, continuous and ‘boring’.

Treatment

• Amitriptyline 10–75 mg nocte or

• Other appropriate antidepressant or carbamazepine

This is an abnormal build-up of fat in liver cells. Rarely serious.

There are 2 types:

• simple (hepatic steatosis)

• steatohepatitis (uncommon)—inflammation; potentially serious

Causes—big 3:

• alcohol excess

• obesity

• diabetes

Also:

• crash diet

• starvation/protein ↓

• high blood pressure

• drugs, e.g. steroids

Usu. asymptomatic or fatigue. May be hepatomegaly.

Treat cause, e.g. diabetes, obesity.

Facts and figures

• Fever plays an important physiological role in the defence against infection.

• Normal body temp. (measured orally) is 36–37.3°C (av. 36.8°C). There is considerable diurnal variation in temperature so that it is higher in the evening by ∼0.6°C.

• Normal average values (morning):

  • oral 36.8°C

  • axilla 36.4°C

  • rectum 37.3°C

• Fever (pyrexia):

  • morning oral >37.2°C

  • evening oral >37.8°C

• Fevers due to infections have an upper limit of 40.5–41.1°C (105–106°F).

• Hyperthermia (temp. >41.1°C) and hyperpyrexia appear to have no upper limit.

• Infection remains the most important cause of acute fever.

• Symptoms associated with fever include sweats, chills, rigors and headache.

• Drugs can cause fever (e.g. allopurinol, antihistamines, barbiturates, cephalosporins, cimetidine, methyldopa, penicillins, isoniazid, quinidine, phenolphthalein, inc. laxatives, phenytoin, procainamide, salicylates, sulphonamides).

Fever of less than 3 days duration

• Usually due to self-limiting viral URTI.

• Watch out for an infectious disease, UTI, pneumonia or other infection.

• Consider routine urine examination.

• Most can be managed conservatively.

Fever present for 4–14 days

If fever persists beyond 4–5 days a less common infection should be suspected since most common viral infections will have resolved by about 4 days (e.g. Epstein–Barr mononucleosis, PID, drug fever, zoonosis, travel acquired infection, abscess inc. dental abscess).

Fever in children

Fever is usually a response to a viral infection. Consider a fever of ≥38.5°C as significant and warranting close scrutiny. Fever itself is not harmful until it reaches 41.5°C. Temperatures >41°C are usually due to CNS infection or the result of human error, e.g.:

• shutting a child in a car on a hot day

• overwrapping a febrile child

Complications include dehydration (usually mild) and febrile convulsions.

Management

• Treatment of low-grade fevers should be discouraged.

• Treatment of high-grade fevers includes:

  • treatment of the causes of the fever (where appropriate) + adequate fluid intake

  • paracetamol (acetaminophen) is the preferred antipyretic since aspirin is potentially dangerous in young children. The usual dose of 10–15 mg/kg every 4–6 h may represent undertreatment. Use 20 mg/kg as loading dose and then 15 mg/kg maintenance.

Evidence favours tepid sponging for 30 mins + paracetamol.

• Dress the child in light clothing (stripping off is unnecessary).

• Do not overheat with too many clothes, rugs or blankets.

• Give frequent small drinks of light fluids, esp. water.

• Sponging with cool water and using fans is not effective.

Febrile convulsions

• Features

• The commonest cause is an upper respiratory infection.

• Rare <6 mths and >5 yrs.

• Commonest age range 9–20 mths.

• Recurrent in up to 50% of children.

• Consider meningitis.

• Perform lumbar puncture after first convulsion if <2 yrs or cause of fever not obvious.

• Epilepsy develops in about 2–3% of such children.

Management of the complex seizure (prolonged: >15 min)

• Undress the child to singlet and underpants to keep cool but avoid getting cold.

• Maintain the airway and prevent injury.

• Place patient chest down with head turned to one side.

• Give oxygen 8 L/min by Hudson mask.

• Give midazolam buccal 2–5 mg/dose (undiluted from vial) 0.1–0.15 mg/kg IV or 0.2 mg/kg IM or intranasal or

• Diazepam by one of two routes:

  • IV 0.2 mg/kg, undiluted or diluted (10 mg in 20 mL N saline) or

  • rectally 0.5 mg/kg (dilute with saline or in pre-prepared syringe). Can be given as a suppository or rectal gel.

• Repeat after 5 mins if necessary but watch for respiratory depression (needs ventilation).

• Check blood glucose. Give IV dextrose.

• If still fitting, admit to hospital, rapidly induce ‘coma’ with thiopentone then intubation with ventilatory support.

• Administer paracetamol once convulsion ceases, orally if conscious, rectally (15 mg/kg) if drowsy.

Fever of undetermined origin (FUO)

FUO, also referred to as pyrexia of unknown origin (PUO), has the following criteria:

• illness for at least 3 wks

• fevers >38.3°C (100.9°C)

• undiagnosed after 1 wk of intensive study

Most cases represent unusual manifestations of common diseases and not rare or exotic diseases. Examples are shown in Table F2.

Investigations

Basic investigations include:

• haemoglobin, red cell indices and blood film

• white cell count

• ESR/CRP

• chest X-ray and sinus films

• urine examination (analysis and culture)

• routine blood chemistry

• blood cultures

Other investigations are based on the clinical picture.

These benign tumours of uterine smooth muscle are oestrogen dependent and shrink with onset of menopause. Usu. asymptomatic.

Symptoms

• Menorrhagia

• Dysmenorrhoea

• Pelvic discomfort ± pain (from pressure)

• Bladder dysfunction

• Subfertility (acts like IUCD if submocosal)

Investigation

• Pelvic US

• FBE ? anaemia

• Uterine biopsy (suspected malignancy)

Management

• Consider COCP for menorrhagia (30 mcg oestrogen can reduce bleeding)

• Gn RH analogues, esp. >42 yrs (max. 6 mths)

• Surgical options:

  • myomectomy (remove fibroids only)

  • hysteroscopic resection/endometrial ablation

  • hysterectomy

Fibromyalgia appears to be a form of neural dysfunction, but without demonstrable neural deficits on clinical testing, that presents as musculoskeletal symptoms. It presents an enormous management problem. It is not to be confused with so-called fibrositis or tender trigger points.

The main diagnostic features are:

1. a history of widespread pain (neck to low back)

2. pain in 11 of 18 painful points on digital palpation

Other features

• Female:male ratio = 4:1

• Usual age 29–37: diagnosis 44–53

• Poor sleep pattern

• Fatigue (similar to chronic fatigue syndrome)

• Psychological disorders (e.g. anxiety, depression)

• Others (e.g. headache, irritable digestive tract)

Patients require considerable explanation, support and reassurance. It is difficult to treat. The best evidence to date supports the value of educational programs and regular aerobic exercise.

Treatment

• Explanation, reassurance and counselling

• Attention to sleep disorders, stress factors and physical factors

• Rehabilitation exercise program (e.g. walking, swimming or cycling)

• Paracetamol (max. dose 4 g/d) for pain (first line)

• Psychotherapy/cognitive behaviour therapy

Medication

Consider as a trial:

• antidepressants (of proven short-term value), e.g. amitriptyline (10–75 mg nocte), doxepin (25–75 mg nocte) or

• duloxetine 30 mg nocte to 60 mg in 2 wks

Note: NSAIDs are of no proven value.

Flatus arises from two main sources:

• swallowed air (aerophagia)

• bacterial fermentation of undigested carbohydrate

Exclude

• malabsorption

• irritable bowel syndrome

• anxiety → aerophagy

• drugs, esp. lipid-lowering agents

• lactose intolerance

Management

• Assess diet (e.g. high fibre, beans and legumes, cabbage, onions, grapes and raisins)

• Avoid drinking with eating, esp. with leafy vegetables

• Cook vegetables thoroughly

• Trial of a lactose-free diet

• Consider simethicone preparations (e.g. No Gas)

As a rule they are not serious.

• Floaters = normal ageing esp. >55 yrs; posterior vitreous detachments, haemorrhage or choroiditis

• Flashing lights = normal ageing esp. >55 yrs; posterior vitreous detachment or indicates traction on retina (?retinal detachment).

• Reassure patient and suggest specialist review. Appearance of a fresh onset is of concern re. retinal detachment.

A generalised acute erythematous maculopapular rash can be a manifestation of bacterial folliculitis, typically caused by S. aureus and Pseudomonas aeruginosa.

Pseudomonas folliculitis can cause confusion, the typical features being:

• rapidly spreading rash

• mainly on trunk, buttocks and thighs

• itchy

• small pustules surrounded by circular red-purple halo

• follows immersion in a hot spa bath or tub

Treatment is based on the sensitivity of the cultured organisms (e.g. ciprofloxacin).

Folliculitis: of groin

Folliculitis of the groin area is common in women who shave and tends to recur.

• Use tea-tree lotion daily for folliculitis.

• Prior to shaving apply ‘tea-tree wash’.

• If persistent, use povidone-iodine or chlorhexidine (Hibiclens) solution.

• If severe, use mupirocin 2% (Bactroban) ointment.

Folliculitis: of trunk from spa baths

Due to Pseudomonas aeruginosa or S. aureus (in poorly chlorinated water maintained at 37–40°C).

• Rx—ciprofloxacin 500 mg (o) bd for 7 d

Includes pitted keratolysis secondary to hyperhidrosis (common in teenagers).

Treatment (with options)

• Education and reassurance

• Wear cotton or woollen socks

• Aluminium chloride 20% in alcohol solution (Driclor, Hidrosol) or Neat Feat—apply nocte for 1 wk, then 1–2 times wkly as necessary

• Shoe liners (e.g. Odor Eaters; charcoal inner soles)

• Apply undiluted Burow's solution after a shower or bath

• Formalin 1–5% soaks every second night

• Iontophoresis

• The teabag treatment (if desperate):

  • Prepare 600 mL strong hot tea (from 2 teabags left in water for 15 mins).

  • Pour hot tea into a basin with 2 L cool water.

  • Soak feet in this for 20–30 mins daily for 10 d, then as often as required.

Serious disorders not to be missed

The very important serious disorders to consider include:

• vascular disease—affecting small vessels

• diabetic neuropathy

• osteoid osteoma/other tumours

• rheumatoid arthritis

• complex regional pain syndrome 1

• foreign bodies (e.g. needles, in children)

• ruptured tendons—Achilles, tibialis posterior

Vascular causes

The main problem is ischaemic pain that occurs only in the foot. The commonest cause is atheroma.

Symptoms:

• claudication (rare in isolation)

• sensory disturbances, esp. numbness at rest or on walking

• rest pain—at night, interfering with sleep, precipitated by elevation, relieved by dependency

Complex regional pain syndrome 1

Originally known as reflex sympathetic dystrophy, usually a sequel of trauma, usually lasts 2 yrs and recovery to normality usually follows.

Clinical features include sudden onset in middle-aged patients, pain worse at night, stiff joints and skin warm and red. X-rays that show patchy decalcification of bone are diagnostic.

Treatment includes reassurance, analgesics, mobility in preference to rest and physiotherapy.

Osteoid osteoma

Benign tumours of bone that typically occur in older children and adolescents. Nocturnal pain is a prominent symptom with pain relief by aspirin being a feature.

Diagnosis is dependent on clinical suspicion and then X-ray, which shows a small sclerotic lesion with a radiolucent centre. Treatment is by surgical excision.

Osteochondritis/aseptic necrosis

Three important bones to keep in mind are:

• the calcaneum—Sever's disease

• the navicular—Kohler's disease

• the head of the second metatarsal—Freiberg's disease

Sever's disease is traction osteochondritis while the other disorders are a ‘crushing’ osteochondritis with avascular necrosis.

Skin disorders

Two conditions commonly seen in teenagers are pitted keratolysis and juvenile plantar dermatosis.

Pitted keratolysis

This malodorous condition which has a pitted ‘honeycomb’ appearance is usually seen at 10–14 yrs. Known as ‘moccasin foot’, ‘stinky feet’ or ‘sneaker's feet’, it is related to sweaty feet. Treatment includes keeping the feet dry, wearing all-leather shoes, cotton or woollen socks (not synthetics), charcoal inners and using an ointment such as Whitfield's or an imidazole or sodium fusidate or benzoyl peroxide 2.5–5% to remove the responsible Corynebacterium organism.

Use a drying agent to decrease sweating. Preparations include formaldehyde soaks nocte or aluminium chloride 20% in alcohol solution (e.g. Driclor, Hidrosol, Neat Feat) applied nocte for 1 wk then 1–2 times/wk.

Juvenile plantar dermatosis

‘Sweaty sock dermatitis’ is a painful condition of weightbearing areas of the feet. The affected skin is red, shiny, smooth and often cracked. It usually starts in school years and resolves in mid-teens and is rare in adults. The treatment is to change to leather or open shoes and to cotton socks. A simple emollient cream gives excellent relief.

Arthritic conditions

Arthritis of the foot or ankle is caused by osteoarthritis (commonly), rheumatoid arthritis, gout and the spondyloarthropathies (uncommon).

Foot strain

Foot strain is probably the commonest cause of podalgia. A foot may be strained by abnormal stress or by normal stress for which it is not prepared. In foot strain the supporting ligaments become stretched, irritated and inflamed. It is commonly encountered in athletes who are relatively unfit or who have a disorder such as flat feet. The strain may be acute or chronic.

Symptoms and signs:

• aching pain in foot and calf during or after prolonged walking or standing

• initial deep tenderness felt on medial border of plantar fascia

Treatment

Acute strain is treated with rest and by reducing walking to a minimum. Try the application of cold initially and then heat. The management of chronic strain is based on an exercise program and orthotics, including arch supports, to correct any deformity.

Metatarsalgia

Refers to pain and tenderness over the plantar heads of metatarsals. Causes include foot deformities (esp. with depressions of the transverse arch), arthritis of the MTP joints, trauma, Morton's neuroma, Freiberg's disorder and entrapment neuropathy.

Treatment involves treating any known cause, advising proper footwear and perhaps a metatarsal bar.

Stress fractures

Clinical features

• Aches or pains may be slow in onset or sudden.

• A bone scan is the only way to confirm the suspected diagnosis.

• Basis of treatment is absolute rest for 6 or more wks with strong supportive footwear.

• A walking plaster is not recommended.

Stress fractures can occur in:

• the base of 5th metatarsal (an avulsion fracture)

• neck of metatarsal (usually second)—the ‘march’ fracture

• tarsal bones, esp. the navicular (mainly athletes)

Morton neuroma

Probably misdiagnosed more often than any other painful condition of the forefoot.

Clinical features

• Usually presents in adults <50

• Four times more common in women

• Bilateral in 15% of cases

• Commonest between 3rd–4th metatarsal heads (Fig. F3), then 2nd–3rd

• Severe burning pain between 2nd–3rd or 3rd–4th toes

• Worse on weight-bearing on hard surfaces (standing and walking)

• Aggravated by wearing tight shoes

Treatment

Early problems are treated conservatively by wearing loose shoes with a low heel and using a sponge rubber metatarsal pad or a special orthosis. Most eventually require surgical excision, preferably with a dorsal approach.

Foot ache

Treatment

• Avoid wearing high heels.

• Wear insoles to support the foot arch.

• Perform foot exercises.

• Soak the feet in a basin of warm water containing therapeutic salts (Epsom salts is suitable).

• Massage feet with baby oil followed by a special ribbed wooden foot massager.

Callus, corn and wart

Diagnosis of localised, tender lumps on the sole of the foot can be difficult.

Calluses

• Remove the cause.

• Proper footwear is essential, with cushion pads over callosities.

• Pare with a sterile sharp scalpel blade.

• Daily applications of 10% salicylic acid (SA) in soft paraffin with regular paring (if severe).

Corn

Hard corns:

• Remove source of friction and use wide shoes.

• Use corn pads with low-strength SA.

• Soften corn with a few daily applications of 15% SA in collodion or commercial ‘corn removers’ (salicylic acid), then pare carefully.

Soft corns (in webbing toes):

• Keep dry.

• Pare and curette hard core.

• Keep webbing apart with wool preparation or cigarette filter tips.

Plantar warts

• Pare wart with a 21 g scalpel blade.

• Apply Upton's paste (salicylic acid + trichloracetic acid) to wart each night and cover (after paring) or

• Apply salicylic acid 16% + lactic acid 16% in collodion paint daily or

• Apply paste of 70% salicylic acid in raw linseed oil after paring. Occlude for 1 wk, review, pare, apply liquid nitrogen, review or

• Apply liquid nitrogen. Repeat in 1 wk, then as necessary.

Turf toe

• A painful, swollen, stiff great toe caused by a sprain of the first MTP point from forced hyperextension (common sporting injury). X-rays unhelpful.

• Treatment is conservative, with RICE, NSAIDs and relative rest. Surgical intervention sometimes required.

Ingrowing toenails

Paronychia

• Reassure patient.

• Use a sunscreen.

• Otherwise, rather than use ‘fade cream’, use fresh lemon juice. Squeeze lemon juice (½ lemon) into small bowl and apply the juice with a cotton ball to the spots daily. Continue for 8 wks.

• Apply tretinoin 0.05% cream daily at night, if necessary.

Treatment depends on severity.

Precautions: watch for secondary infection, tetanus, gangrene

Physical treatment

• Elevate affected limb.

• Rewarm in water just above body temperature 40°C (104°F) or use body heat (e.g. in axillae).

• Avoid thawing or refreezing.

• Surgical debridement.

• Don't debride early (wait until dead tissue dried).

• Don't drink alcohol or smoke.

• For blistering, apply warm water compresses for 15 mins every 2 h.

Drug Rx: analgesics