It’s as though the devil suddenly thrust red hot electric needles through my right cheek towards my ear.
PATIENT (ANONYMOUS), DESCRIBING ‘TIC DOULOUREUX’
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.
Table 52.1Diagnoses to consider in orofacial pain ||Download (.pdf) Table 52.1 Diagnoses to consider in orofacial pain
Positive physical signs
Cervical spinal dysfunction
Paranasal sinus disorders
Absent physical signs
Atypical facial pain
Chronic paroxysmal hemicrania
Depression-associated facial pain
Facial migraine (lower half headache)
Migrainous neuralgia (cluster headache)
Trigeminal neuralgia (tic douloureux)
Key facts and checkpoints
Dental disorders are the commonest cause of facial pain, accounting for up to 90% of pain in and about the face.2
The most common dental disorders are dental caries and periodontal diseases.
The mean age of onset of trigeminal neuralgia is 50–52 years.
There is a similarity in the ‘occult’ causes of pain in the ear and in the face (refer to FIGS 50.4 and 50.5).
Sinusitis occurs mainly as part of a generalised upper respiratory infection. Swimming is another common predisposing factor.
Dental root infection must be sought in all cases of maxillary sinusitis.
A summary of the diagnostic strategy model is presented in TABLE 52.2.
Table 52.2Pain in the face: diagnostic strategy model ||Download (.pdf) Table 52.2 Pain in the face: diagnostic strategy model
Serious disorders not to be missed
aneurysm of cavernous sinus
internal carotid aneurysm
ischaemia of posterior inferior cerebellar artery
cancer: mouth, sinuses, nasopharynx, tonsils, tongue, larynx, salivary gland
metastases: orbital, base of brain, bone
Pitfalls (often missed)