Chapter 52: Pain in the face

When a patient complains of pain in the face rather than the head, the physician has to consider foremost the possibilities of dental disorders, sinus disease, especially 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.

A basic list of causes of facial pain is presented in TABLE 52.1.¹ The causes can vary from the simple, such as aphthous ulcers, herpes simplex and dental caries, to serious causes, such as carcinoma of the tongue, sinuses and nasopharynx or osteomyelitis of the mandible or maxilla.

A summary of the diagnostic strategy model is presented in TABLE 52.2.

Probability diagnosis

The commonest cause of facial pain is dental disorders, especially dental caries. Another common cause is sinusitis, particularly maxillary sinusitis.

TMJ dysfunction causing TMJ arthralgia is a very common problem encountered in general practice and it is important to have some simple basic strategies to give the patient.

Serious disorders not to be missed

It is important not to overlook cancer of various structures, such as the mouth, sinuses, nasopharynx, tonsils, tongue, larynx and parotid gland, which can present with atypical chronic facial pain.

It is important therefore to inspect these areas, especially in the elderly, but lesions in the relatively inaccessible nasopharynx can be easily missed. Nasopharynx cancer spreads upwards to the base of the skull early and patients can present with multiple cranial nerve palsies before either pain or bloody nasal discharge.¹

Tumours may arise in the bones of the orbit, for example, lymphoma or secondary cancer, and may cause facial pain and proptosis. Similarly, any space-occupying lesion or malignancy arising from the region of the orbit or base of the brain can cause facial pain by involvement (often destruction) of trigeminal sensory fibres. This will lead to a depressed ipsilateral corneal reflex.

Also, aneurysms developing in the cavernous sinus¹ can cause pain via pressure on any of the divisions of the trigeminal nerve, while aneurysms from the internal carotid arising from the origin of the posterior communicating artery can cause pressure on the oculomotor nerve.

Temporal arteritis typically causes pain over the temporal area but can cause ischaemic pain in the jaws when chewing.

Pitfalls

Commonly overlooked causes of facial pain include TMJ arthralgia and dental disorders, especially of the teeth, which are tender to percussion, and oral ulceration. Diagnosing the uncommon migraine variants, particularly facial migraine and chronic paroxysmal hemicrania, often presents difficulties, including differentiating between the neuralgias. Glossopharyngeal neuralgia, which is rare, causes pain in the back of the throat, around the tonsils and adjacent fauces. The lightning quality of the pain of neuralgia gives the clue to diagnosis.

Common pitfalls

• Failing to refer unusual or undiagnosed causes of facial pain

• Overlooking infective dental causes, which can cause complications

• Failing to consider the possibility of malignant disease of ‘hidden’ structures in the older patient

• Unaware that facial pain never crosses the midline

Seven masquerades checklist

Of these, depression and cervical spinal dysfunction must be considered. The upper cervical spine can cause facial pain from lesions of C2 or C3 via the lesser occipital or greater auricular (see FIG. 52.1) nerves, which may give pain around the ear. It is important to remember that the C2 and C3 nerves share a common pathway with the trigeminal nerve (see CHAPTER 62).

Depressive illness can present with a variety of painful syndromes and facial pain is no exception. The features of depression may be apparent and thus antidepressants should be prescribed. Usually the facial pain and the depression subside concomitantly.

Psychogenic considerations

Psychogenic factors have to be considered in every painful condition. They are considered to be high in patients with atypical facial pain.

History

Diagnosis of nearly all types of facial pain must be based almost entirely on the history. It is often difficult to delineate the exact nature and distribution of the pain. The history should include the typical analysis of pain, especially noting the site and radiation of the pain.

Examination

The patient’s general state and behaviour should be noted. Any sudden jabbing pain in the face causing the characteristic ‘tic’ may indicate neuralgia.

Palpate the face and neck to include the parotid glands, eyes, regional lymph nodes and the skin. Inspect the TMJs and cervical spine. Carefully inspect the nose, mouth, pharynx and postnasal space. In particular inspect the teeth, percussing each tooth if dental disorder is suspected. Bimanual palpation of the floor of the mouth is performed to detect induration or submandibular and submental lymph node enlargement.

The sinuses, especially the maxillary sinuses, should be inspected and a torch light should be placed inside the mouth to test transillumination of the maxillary sinuses. It works best when one symptomatic side can be compared with an asymptomatic side.

Perform a neurological examination on the cranial nerves with special emphasis on the trigeminal, oculomotor and glossopharyngeal nerves.

Investigations

If investigations are being contemplated referral may be appropriate. The association of multiple sclerosis and tumours with neuralgias may have to be investigated. Radiological investigations include plain X-rays of the paranasal sinuses, CT scans, MRI and orthopantomograms.

Apart from trauma, facial pain in children is almost invariably due to dental problems, rarely migraine variants and occasionally childhood infections such as mumps and gingivostomatitis. A serious problem sometimes seen in children is orbital cellulitis secondary to ethmoiditis.

Sinusitis occurs in children, especially older children, and it should be suspected with persistent bilateral mucopurulent rhinorrhoea (beyond 10 days).

Many of the causes of facial pain have an increased incidence with age, in particular trigeminal neuralgia, herpes zoster, cancer, glaucoma, TMJ dysfunction and cervical spondylosis. Glossopharyngeal neuralgia does not seem to have a particular predilection for the elderly. Xerostomia due to decreased secretions of salivary glands may cause abrasion with minor trauma. It may aggravate the pain of glossitis, which is common in the elderly.

Dental caries, impacted teeth, infected tooth sockets and dental roots can cause pain in the maxillary and mandibular regions. Caries with periapical and apical abscess formation produces pain from infection extending around the apex of the tooth into the alveolar bone. Retention of a fractured root may cause unilateral paroxysmal pain. Impacted third molars (wisdom teeth) may be associated with surrounding soft tissue inflammation (pericoronitis), causing pain that may be localised to the mandible or radiate via the auriculotemporal nerve to the ear. Candida albicans, which is an oral commensal, may colonise dentures causing hyperaemia and painful superficial ulceration of the denture-bearing mucosa. Antibiotics are of no proven use.

Features of dental caries

• Pain is usually confined to the affected tooth but it 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.

• Antibiotics are not indicated.

Treatment of dental pain

• Arrange urgent dental consultation

• Pain relief:³

  • aspirin 600 mg (o), 4–6 hourly

  • or

  • ibuprofen 400 mg (o), 4–6 hourly

  • or

  • paracetamol 0.5–1 g (o), 4–6 hourly

Tooth abscess, inflamed wisdom tooth, spreading dental infection or root canal infection⁴

Dental treatment will usually alleviate the problem; however, if severe:

• amoxycillin 500 mg (o) tds for 5 days

If unresponsive:

• amoxycillin/clavulanate 875/125 mg (o) bd (adjust to children’s dose)

• add metronidazole 400 mg (o) 12-hourly for 5 days

For patients hypersensitive to penicillin:

• clindamycin 300–450 mg (o) 8-hourly for 5 days

Gingivitis and periodontitis

Refer to CHAPTER 72

Alveolar osteitis (dry socket)

Refer urgently for specialised toileting and insertion of dressing. This usually heals naturally in 14 days. Antibiotics are of no proven use (see FIG. 52.2).^3,4

If a permanent (second) tooth is knocked out, it can be saved by immediate proper care. Likewise, a broken tooth should be saved and urgent dental attention sought.

The knocked-out tooth

• Place the tooth in its original position, preferably immediately (see FIG. 52.3); if dirty, put it in milk before replacement or, better still, place it under the tongue and ‘wash it’ in saliva. Do not use water, and do not wipe or touch the root.

• Fix the tooth by moulding strong silver foil (e.g. cooking foil) over it and the adjacent teeth.

• Refer the patient to his or her dentist or dental hospital as soon as possible.

Note: Teeth replaced within half an hour have a 90% chance of successful re-implantation.

Ludwig angina⁴

This is a rapidly swelling cellulitis occurring in both the sublingual and submaxillary spaces without abscess formation, often arising from a root canal infection. It resembles an abscess and should be treated as one. It is potentially life-threatening as it can compromise the airway.

Management

• Culture and sensitivity testing

• Specialist consultation

• Empirical treatment:

  • amoxycillin 2 g IV, 6-hourly

    plus

  • metronidazole 500 mg IV, 12-hourly

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. Chronic infection of the sinuses may be extremely difficult to detect. The commonest organisms are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.

Expanding lesions of the sinuses, such as mucocoeles and tumours, cause local swelling and displace the contents of the orbit—upwards for maxillary, laterally for the ethmoids and downwards for the frontal.

Maxillary sinusitis

The maxillary sinus is the one most commonly infected.⁵ It is important to determine whether the sinusitis is caused by stasis following a URTI or acute rhinitis, or due to dental root infection. Most episodes are of viral origin.

Clinical features (acute sinusitis)

• Facial pain and tenderness (over sinuses)

• Toothache

• Headache

• Purulent postnasal drip

• Nasal discharge

• Nasal obstruction

• Rhinorrhoea

• Cough (worse at night)

• Prolonged fever

• Epistaxis

Suspect bacterial cause if high fever and purulent nasal discharge.

Clinical features (chronic sinusitis)

• Vague facial pain

• Offensive postnasal drip

• Nasal obstruction

• Toothache

• Malaise

• Halitosis

Some simple office tests

Diagnosing sinus tenderness⁶

To differentiate sinus tenderness from non-sinus bone tenderness palpation is useful. This is best done by palpating a non-sinus area first and last (see FIG. 52.4), systematically exerting pressure over the temporal bones (T), then the frontal (F), ethmoid (E) and maxillary (M) sinuses, and finally zygomas (Z), or vice versa.

Differential tenderness both identifies and localises the main sites of infection (see FIG. 52.4).

Diagnosing unilateral sinusitis

A simple way to assess the presence or absence of fluid in the frontal sinus, and in the maxillary sinus (in particular), is the use of transillumination. It works best when one symptomatic side can be compared with an asymptomatic side.

It is necessary to have the patient in a darkened room and to use a small, narrow-beam torch. For the maxillary sinuses remove dentures (if any). Shine the light inside the mouth (with lips sealed), on either side of the hard palate, pointed at the base of the orbit. A dull glow seen below the orbit indicates that the antrum is air-filled. Diminished illumination on the symptomatic side indicates sinusitis.

A CT scan may show mucosal thickening without fluid levels. Plain films are not indicated.

Management (acute bacterial sinusitis)

• Exclude dental root infection.

• Control predisposing factors.

• Use appropriate antibiotic therapy.

• Establish drainage by stimulation of mucociliary flow and relief of obstruction.

Consider therapy for severe cases displaying at least three of the following:

• persistent mucopurulent nasal discharge (>7–10 days)

• facial pain

• poor response to decongestants

• tenderness over the sinuses especially maxillary

• tenderness on percussion of maxillary molar and premolar teeth that cannot be attributed to by a single tooth

• Analgesics

• Antibiotics:⁴

  • amoxycillin 500 mg (o) tds for 7 days

  • or (if sensitive to penicillin)

  • doxycycline 100 mg (o) bd for 7 days

  • or

  • cefaclor 500 mg (o) tds for 7 days

  • or

  • amoxycillin + clavulanate 875/125 mg (o) tds for 7–14 days if poor response to above (indicates resistant H. influenzae)

• In complicated or severe disease, use intravenous cephalosporins or flucloxacillin

• Nasal decongestants (oxymetazoline-containing nasal drops or sprays)⁵ for 5 days (only if congestion)

• Inhalations (a very important adjunct)

• Nasal saline irrigation

Antihistamines and mucolytics are of no proven value.

Invasive methods

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

Inhalations for sinusitis

The old method of towel over the head and inhalation bowl can be used, but it is better to direct the vapour at the nose. Equipment needed is a container, which can be an old disposable bowl, a wide-mouthed bottle or tin, or a plastic container.

For the inhalant, several household over-the-counter preparations are suitable such as Friar’s Balsam (5 mL), Vicks VapoRub (1 teaspoon), or menthol (5 mL).

The cover can be made from a paper bag (with its base cut out), a cone of paper or a small cardboard carton (with the corner cut away).

1. Add 5 mL or 1 teaspoon of the inhalant to 0.5 L (or 1 pint) of boiled water in the container.

2. Place the paper or carton over the container.

3. Get the patient to apply nose and mouth to the opening and breathe in the vapour deeply and slowly through the nose, and then out slowly through the mouth.

4. This should be performed for 5–10 minutes, three times a day, especially before retiring.

After inhalation, upper airway congestion can be relieved by autoinsufflation.

Chronic sinusitis

Chronic sinusitis or recurrent sinusitis may arise from chronic infection or allergy. It may be associated with nasal polyps and vasomotor rhinitis, but is frequently associated with a structural abnormality of the upper airways. Refer to CHAPTER 59.

It does not usually cause pain unless an acute infection intervenes. The acute or chronic attack is treated as for the acute attack but with 14 days of antibiotics. Those with an allergic mucous membrane may respond to intranasal corticosteroids. Surgical intervention will benefit chronic recurrence with mechanical blockage.

TMJ dysfunction

This condition is due to abnormal movement of the mandible, especially during chewing. The basic causes are dental malocclusion and masticatory muscle dysfunction. Check for bruxism. The pain is felt over the joint and tends to be localised to the region of the ear and mandibular condyle, but it may radiate forwards to the cheek and even the neck.

Examination

• Check for pain and limitation of mandibular movements, especially on opening the mouth.

• Palpate about the joint bilaterally for tenderness, which typically lies immediately in front of the external auditory meatus; palpate the temporalis and masseter muscles.

• Palpate the TMJ over the lateral aspect of the joint disc.

• Ask the patient to open the mouth fully when tenderness is maximal. The TMJ can be palpated posteriorly by inserting the little finger into the external canal.

• Check for crepitus in mandibular movement.

Management

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 weeks. Warm packs may help. Provide patient education advice and self-care.

• Obtain a rod of soft wood approximately 15 cm long and 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 minutes at least 3 times a day.

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

Instruct the patient as follows:

1. Hold the front one-third of your tongue to the roof of your mouth and take six deep breaths.

2. Hold the tongue to the roof of your mouth and open your mouth six times. Your jaw should not click.

3. Hold your chin with both hands keeping the chin still. Without letting your chin move, push up, down and to each side. Remember, do not let your chin move.

4. Hold both hands behind your neck and pull chin in.

5. Push on upper lip so as to push head straight back.

6. Pull shoulders back as if to touch shoulder blades together.

These exercises should be pain-free. If they hurt, do not push them to the limit until pain eases.

Treatments

Injection into the TMJ⁷

• Indications: painful rheumatoid arthritis, osteoarthritis or TMJ dysfunction not responding to conservative measures. Inject a 1 mL solution of local anaesthetic and corticosteroid in equal parts.

• Dental management that may be required for malfunction of the bite includes dental occlusal splinting.

• NSAIDs: A trial of NSAIDs, e.g. ibuprofen 400 mg (o) tds for 10 days, for TMJ inflammation may need consideration. Cease if no response after 10 days.

A variety of ulcerative conditions and infections of structures such as gingivae, tongue, tonsils, larynx and pharynx can cause facial pain (refer to CHAPTER 72). Gingivostomatitis, herpes labialis (cold sores) and aphthous ulceration are common examples. Lesions of the posterior third of the tongue, the oropharynx, tonsils and larynx may radiate to the region of the ear via the tympanic branch of the ninth nerve or the auricular branch of the tenth nerve.

Trigeminal neuralgia

Trigeminal neuralgia (tic douloureux) is a condition of often unknown cause that typically occurs in patients over the age of 50, affecting the second and third divisions of the trigeminal nerve and on the same side of the face. Brief paroxysms of pain, often with associated trigger points, are a feature.

Clinical features

• Site: sensory branches of the trigeminal nerve (see FIG. 52.5) almost always unilateral (often right side)

  FIGURE 52.5

  Typical cutaneous sensory distribution of the trigeminal nerve and its branches

  Graphic Jump Location

  

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• Radiation: tends to commence in the mandibular division and spreads to the maxillary division and (rarely) to the ophthalmic division

• Quality: excruciating, searing jabs of pain like a burning knife or electric shock

• Frequency: variable and no regular pattern

• Duration: seconds to 1–2 minutes (up to 15 minutes)

• Onset: spontaneous or trigger point stimulus

• Offset: spontaneous

• Precipitating factors: talking, chewing, touching trigger areas on face (e.g. washing, shaving, eating), cold weather or wind, turning onto pillow

• Aggravating factors: trigger points usually in the upper and lower lip, nasolabial fold or lower eyelid (see FIG. 52.6)

• Relieving factors: nil

• Associated features: rarely occurs at night; spontaneous remissions for months or years

• Signs: there are no signs, normal corneal reflex

Causes

• Unknown

• Local pressure on the nerve root entry zone by tortuous pulsatile dilated small vessels (probably up to 75%)

• Multiple sclerosis

• Neurosyphilis

• Tumours of the posterior fossa

Note: Precise diagnosis is essential. MRI may be helpful.

Treatment

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

• carbamazepine (from onset of the attack to resolution)⁸ 50 mg (elderly patient) or 100 mg (o) bd initially; gradually increase the dose to avoid drowsiness every 7 days to 200 mg bd (maintenance); higher dosage to maximum 600 mg bd may be necessary

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

• gabapentin 300 mg daily initially, then increase lamotrigine 400 mg (o) daily

• phenytoin 300–500 mg daily

• clonazepam

• baclofen

• sodium valproate

• Refer to a neurosurgeon if medication ineffective

• Possible procedures include:

  • – decompression of the trigeminal nerve root (e.g. gel foam packing between the nerve and blood vessels)

  • – if severe, refer for neuroablative treatment, e.g. thermocoagulation/radiofrequency neurolysis

  • – surgical division of peripheral branches

Glossopharyngeal neuralgia^8,9,10

This is an uncommon condition of the ninth cranial nerve and branches of the vagus nerve with similar clinical features of severe, lancinating pains, particularly felt in one ear, the base of the tongue or beneath the angle of the jaw. The pain usually lasts 30–60 seconds.

• Sites: back of throat around tonsillar fossa and adjacent fauces deep in ear, back of tongue

• Radiation: ear canal, neck

• Triggers: swallowing, coughing, talking, yawning, laughing

• Treatment: as for trigeminal neuralgia

As described in CHAPTER 56, the pain is unilateral and centred around the eye with associated lacrimation and stuffiness of the nose.

Facial migraine (lower half headache)⁸

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. The pain is dull and throbbing, and nausea and vomiting are commonly present. The treatment is as for other varieties of migraine with simple analgesics or ergotamine for infrequent attacks.

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 minutes, and it may recur many times a day even for years. It responds dramatically to indomethacin.¹¹

Refer to CHAPTER 121. Herpes zoster may present as hyperaesthesia or a burning sensation in any division of the fifth nerve, especially the ophthalmic division.

Atypical facial pain

This is mainly a diagnosis of exclusion whereby patients, usually middle-aged to elderly women, complain of diffuse pain in the cheek (unilateral or bilateral) without demonstrable organic disease. The pain does not usually conform to a specific nerve distribution (although in the maxillary area), varies in intensity and duration and is not lancinating as in trigeminal neuralgia. It is usually described as deep-seated and ‘boring’, severe, continuous and throbbing in nature. It is a very confusing and difficult problem to treat. These patients tend to show psychoneurotic tendencies but caution is needed in labelling them as functional.

Treatment

Trial of an antidepressant⁸, e.g.:

• amitriptyline 10–75 mg nocte (first line)

• or

• dothiepin 25–150 mg nocte

This may produce mild or severe unilateral or bilateral headache. There may be ischaemic pain in the jaws when chewing. There may be marked scalp tenderness over the affected arteries. See CHAPTER 32 for management.

Erysipelas

Classical erysipelas is a superficial form of cellulitis involving the face. It usually presents with the sudden onset of butterfly erythema with a well-defined edge (see FIG. 52.7). It often starts around the nose and there may be underlying sinus or dental infection which should be investigated. There is an associated ‘flu-like’ illness and fever. It is invariably caused by Streptococcus pyogenes. Treatment is by phenoxymethylpenicillin or di/flucloxacillin for 7–10 days.

• Severe trigeminal or glossopharyngeal neuralgia

• Unusual facial pain, especially with a suspicion of malignancy

• Continuing pain of uncertain cause

• Positive neurological signs, such as impaired corneal reflex, impaired sensation in a trigeminal dermatome, slight facial weakness, hearing loss on the side of the neuralgia

• Possible need for surgical drainage of sinusitis—indications for surgery include failure of appropriate medical treatment, anatomical deformity, polyps, uncontrolled sinus pain⁵

• Dental root infection causing maxillary sinusitis

• Other dental disorders

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Sinusitis

• Temporomandibular joint dysfunction