Transcutaneous Electrical Nerve Stimulation for Facial Pain

Transcutaneous electrical nerve stimulation (TENS) has been used for its analgesic effects for chronic pain, including facial pain. Here, we summarize how the electrical stimulation of branches of the trigeminal nerve via TENS has been utilized to reduce pain resulting from trigeminal neuralgia, temporomandibular joint disorder, migraine and other headache types, and ocular pain sensations. TENS has been used for both short-term (one session) and long-term (multiple sessions) pain control with little to no adverse effects reported by subjects. The results of the summarized studies suggest TENS is an effective non-invasive, non-pharmacologic means of pain control for patients with facial pain conditions.

The anatomy of the sympathetic pathway through the pterygopalatine fossa in humans

Generally, sympathetic distribution in the pterygopalatine fossa (PPF) is considered to be via the pterygopalatine ganglion (PPG) sympathetic root and branches. We hypothesized that there may be a dual sympathetic path within the PPF, through the vidian nerve and the PPG and through the periarterial plexuses. We dissected 10 human adult cadavers, fixed and unfixed; we applied antibodies for tyrosine hydroxylase (TH) to 5 human adult samples of PPF contents dissected from cadavers at autopsy. We identified TH(+) nerves and fibers distributed through the neuronal clusters of the PPG and also bundles extrinsic to these clusters, distributed along the maxillary artery. Also, TH(+) reactions were identified at the level of the neuronal capsules of the PPG. All the arteries within the PPF presented TH(+) fibers, periadventitial and intramural-the periarterial plexuses were also identified during dissections, a major one being that along the descending palatine artery, distinctive to the greater palatine nerve. Thus, concerning the sympathetic entry to the PPF, this one seems to use both the path of the external carotid artery (via the maxillary artery plexus) and the path of the internal carotid artery, via the vidian nerve supplying the PPG and reinforcing the maxillary artery plexus. The sympathetic exit of the PPF uses the neural scaffolding of the PPG branches and also the arterial scaffolding. The complex trigeminal-autonomic, anatomic content of the PPF may be involved in several distinctive facial algias and thus the pain may be relieved by routine approaches to the PPF, based on updated anatomical knowledge and a correct diagnostic.

[Functional somatic syndrome in dental practice]

Functional somatic syndromes (FSSs) are common in dental as well as medical practice. Many patients with unexplained symptoms in oro-maxillo-facial areas visit dentists, but they are not diagnosed and treated properly. Temporomandibular disorder, atypical facial pain, and glossodynia (burning mouth syndrome) are included in dental FSSs. These diseases overlap with each other and with FSSs in other organs, such as myofacial pain syndrome, tension-type headache, fibromyalgia, and chronic fatigue syndrome. They coexist with mental disorders, such as anxiety disorder, mood disorder, and somatoform disorder. Multidisciplinary and holistic approaches should be applied to dental FSSs; pharmacological therapy (antidepressants), physical therapy, and cognitive-behavioral therapy. Clinicians have to support a patient in"enjoying his/her life with symptoms". Dental specialists in "oral medicine" with psychosomatic viewpoints are now required.

An up-to-date view on persistent idiopathic facial pain

Previously called atypical facial pain, persistent idiopathic facial pain (PIFP) is a common, but poorly defined entity. The cause of PIFP is unknown, but surgery or injury in the distribution of the trigeminal nerve could be reported as early event. Treatment is often unsatisfactory and quality research relating management of this condition is missing. Psychologi-cal distress is frequently observed in patients suffering from persistent idiopathic facial pain. The present review aims at presenting the available knowledge of this elusive orofacial pain condition.

Atypical odontalgia: a case report

Diagnosis and treatment of orofacial pain is not uncommon; however, reaching a definitive diagnosis in these cases can be a complex challenge. Dentists are most likely to face this situation, because persistent and chronic pain is more common in the head and neck region than in any other part of the body. However, the complexities and diagnostic challenges mean that misdiagnosing neuropathic pain is common. This article presents a case of atypical odontalgia and illustrates the complexities involved when diagnosing the condition.

Atypical odontalgia--a form of neuropathic pain that emulates dental pain

In order for the neuropathic pain associated with AO to occur in the oral or facial area, a deafferentation process must be initiated as previously explained. Deafferentation happens when there is a trauma to tissues including, but not limited to, endodontic therapy, a surgical extraction or even a simple one, a deep scaling, an injurious dental injection, and even the placement of a crown. Thankfully, most patients heal uneventfully. Apparently a small percentage of patients have a genetic predisposition to deafferentation pain. In reviewing articles on this subject, there is often material about the inadvertent dental treatment of patients with AO. Many patients often have undergone numerous invasive procedures in an effort to ameliorate pain. It is not possible to read a research paper about AO without reading about the recurrent theme of either overtreatment or unnecessary treatment. Caution should be exercised when performing endodontic therapy solely for the relief of pain without objective need for such therapy. It is common for the AO patient to undergo many other irreversible dental treatments with no resolution of pain symptoms. When the dentist encounters a patient in pain for which there is no dental connection, he or she should strongly consider referring the patient to a facility or practitioner who has expertise in dealing with the non-dental source of dental pain.

Differences and similarities between atypical facial pain and trigeminal neuropathic pain

OBJECTIVE

To investigate contribution of neuropathic mechanisms to clinically diagnosed atypical facial pain (AFP) using neurophysiologic and thermal quantitative sensory testing (QST) and comparing findings in AFP with those in definite trigeminal neuropathic pain (TNP).

METHODS

Twenty patients with AFP and 12 patients with TNP participated after thorough clinical diagnostic workup. All patients underwent blink reflex (BR) recordings, habituation of the BR, and (except one patient with TNP) thermal QST. The results were compared with the reference values of our laboratory for normality.

RESULTS

Of the patients with AFP, 75% showed abnormal findings. The BR responses were abnormal in three (15%) AFP patients (in two patients, the findings were compatible with a peripheral neuropathy and in one with a brainstem lesion), and in seven (58%) TNP patients. Seven (35%) patients with AFP and four (33%) with TNP showed increased excitability of the BR in the form of deficient habituation. Thermal QST indicated abnormal small fiber function in 11 (55%) patients with AFP and in all patients with TNP tested. QST showed thermal hypoesthesia in 45% and warm allodynia in 10% of patients with AFP. In TNP, all findings indicated thermal hypoesthesia. Abnormalities in BR and thermal QST were less frequent in AFP than TNP, but when present, type and pattern of findings were similar in both conditions.

CONCLUSIONS

Clinical diagnosis of atypical facial pain represents a heterogeneous entity and seems to form a continuum regarding the level and extent of neuropathic involvement. Without detailed neurophysiologic and quantitative sensory examinations, neuropathic cause of chronic orofacial pain may be overlooked.

[Trigeminalgia caused by neurovascular compression in 12 years old girl]

Trigeminalgia is one of the most frequent clinical problems, common in adults but also found in children. In this paper we described a case of 12 years old girl with symptomatic trigeminalgia caused by neurovascular compression, hospitalized in the Department of Pediatric Neurology Jagiellonian University in Kraków. It creates a very difficult diagnostic problem. The girl was first unsuccessfully treated with carbamazepine and afterwards the surgery of neurovascular decompression was performed. We emphasis the crucial role of MR and MRA in cases refractory to classic pharmacotherapy.

[Cenesthesia as a rare differential diagnosis of persistent idiopathic facial pain]

Cenesthesia is portrayed as a rare differential diagnosis to persistent idiopathic facial pain, including the resulting therapy with antipsychotics. In this case report a female patient developed persistent facial pain 2 years after manifestation of a depressive disorder. The symptoms appeared as a bizarre pain phenomenon closely resembling the psychotic phenomenon of cenesthesia (body hallucinations). Treatment with imipramine and doxepin or a combination of venlafaxin, carbamazepine, and tilidine N had not been successful. Based on diagnostic classification of the complaint as cenesthesia in the context of a depressive disorder, add-on therapy of the atypical antipsychotic ziprasidone was administered. This led to clear improvements in mood and pain symptoms after 4 weeks of treatment.

[Spontaneous pain attacks: neuralgic pain]

Paroxysmal orofacial pains can cause diagnostic problems, especially when different clinical pictures occur simultaneously. Pain due to pulpitis, for example, may show the same characteristics as pain due to trigeminal neuralgia would. Moreover, the trigger point of trigeminal neuralgia can either be located in a healthy tooth or in the temporomandibular joint. Neuralgic pain is distinguished into trigeminal neuralgia, glossopharyngeal neuralgia, Horton's neuralgia, cluster headache and paroxysmal hemicrania. In 2 cases trigeminal neuralgia is successfully managed with a neurosurgical microvascular decompression procedure according to Jannetta. Characteristic pain attacks resembling neuralgic pain result from well understood pathophysiological mechanisms. Consequently, adequate therapy, such as a Janetta procedure and specific pharmacological therapy, is available.

[Neurovascular conflicts]

Neuro-vascular conflict is a pathophysiologic phenomenon which is implicated in several cranial neuropathies. The most common are trigeminal neuralgia and hemifacial spasm. Spasmodic torticolis, glosopharyngeal neuralgia, disabling positional vertigo may be due to neural compression as well, but other pathologies such as neurogenic hypertension and limited cases of tinnitus, although rare, highly susceptible to the neurovascular conflict, should be taken into considerration. Current diagnostic approach comprises clinical and radiological evaluation. Along with thorough otoneurological examination, MRI scans are essential to diagnose the conflict. This provides information about the presence of neuro-vascular conflict and involved structures. The microvascular decompression (MVD) is a treatment of choice, based on the separation of offending vessel from the nerve. Those procedures are safe, with high rate success according to the literature ranging from 70-90%. Additionaly, in early 90. a new minimally invasive approach with use of rigid endoscopes were proposed. Those gave the possibility to reduce morbidity and improve results by providing wider insight into the operating field with smaller intraoperative injury. Authors present 9 patients diagnosed with neuro-vascular conflict in the ENT department in Poznań. Clinical findings comprised 5 cases of hemifacial spasm, 3 with unilateral tinnitus and 1 with trigeminal neuralgia. Due to variety of symptoms, it is proposed that specialized centers should be formed to diagnose and treat cranial nerves neuropathies. Team approach composed of neurologist, neurosurgeon, radiologist and otologist is essential in terms of good treatment results. Authors describe symptomatology, diagnosis and treatment options of neuro-vascular conflicts.

A pilot study of nitric oxide blood levels in patients with chronic orofacial pain

BACKGROUND

Control of pain is the major goal in the management of chronic orofacial pain (COP) patients. The pathogenesis of COP is currently not well understood. Consequently, the treatment of COP may be suboptimal or even harmful. Based on independent observations, we propose that local elevated levels of nitric oxide (NO) may have a central role in the pathogenesis of COP.

HYPOTHESIS

NO level in the orofacial region of COP patients is elevated. A regional increased level of NO causes excessive vasodilatation. This hyperperfusion is manifested by hyperthermia of the overlying skin, while NO enhances nociception, aggravating orofacial pain. An alternative mechanism involving NO as a neurotransmitter at the CNS level may contribute to orofacial pain, but seems not to account for all the known clinical observations.

METHODS

Two groups of subjects were studied: 5 patients with COP and 59 control subjects. For each subject we collected blood samples for analysis of nitrite\nitrate (or NOx).

RESULTS

(1) NOx blood levels for 5 patients diagnosed with COP was 65.9 microM (SD of 10.4) verses 42.7 microM (SD of 24.2) for 59 control subjects, the difference being statistically significant, t-statistic = -2.12 (P > .05). (2) No statistical difference was found for NOx blood levels for 59 control subjects divided by gender (male vs female), with 23 female controls having NOx blood levels of 42.6 microM (SD of 25.2) and male controls having NOx blood levels of 42.8 microM (SD of 24.0), t-statistic = -0.03, P = .98.

CONCLUSION

This pilot study suggests that NO blood levels may have an association with COP. A better understanding of the mechanism of chronic orofacial pain is expected to lead to more precise diagnostic staging and management of this disorder.

Otolaryngic myofascial pain syndromes

It has been long recognized in the otolaryngic community that despite great effort dedicated to the physiology and pathology of the ear, nose, throat/head and neck, there are a number of symptoms, including pain in various locations about the head and neck, which cannot be explained by traditional otolaryngic principles. The tenets of myofascial dysfunction, however, as elucidated by Dr. Janet Travell, explain most of these previously unexplained symptoms; furthermore, treatment based on Dr. Travell's teachings is effective in relieving these symptoms.

Painful sweating

OBJECTIVE

The authors report a case of spontaneous and gustatory facial pain and sweating.

METHODS

The patient had frequent episodes of pain, sweating, and flushing bilaterally in the hairless skin of the ophthalmic and maxillary distributions of the trigeminal nerve. Gustatory stimuli (e.g., orange juice, pickled onions) reliably evoked episodes, but episodes also frequently came on spontaneously. The problem had begun during adolescence, about the time of topical treatment and then electrocauteries for facial warts. The patient reported benefit from tricyclic antidepressants, guanethidine, and trospium chloride (an anti-cholinergic quaternary amine used in Europe for urinary urgency). There was no pain or excessive sweating in other body areas, nor pain with exercise.

RESULTS

Administration of edrophonium IV evoked pain and sweating, and ganglion blockade by IV trimethaphan eliminated pain and sweating and markedly attenuated responses to edrophonium. Trospium chloride also prevented edrophonium-induced pain and sweating. Bicycle exercise produced the same increment in forehead humidity as in a spontaneous episode but did not evoke pain. Tyramine infusion did not bring on pain or sweating, whereas iontophoretic acetylcholine administration to one cheek evoked pain and sweating bilaterally. Topical glycopyrrolate cream eliminated spontaneous, gustatory, and edrophonium-induced episodes.

CONCLUSIONS

The findings indicate that facial pain and sweating can result from occupation of muscarinic cholinergic receptors after acetylcholine release from local nerves. The authors propose that after destruction of cutaneous nerves, aberrant regenerant sprouting innervates sweat glands, producing gustatory sweating as in auriculotemporal syndrome (Frey syndrome), and innervates nociceptors, producing pain.

[The expression of PPTA and c-fos mRNA in dog caudal spinal trigeminal nucleus induced by traumatic occlusion]

OBJECTIVE

PPTA and c-fos mRNA expression were detected in dog caudalis subnucleus of trigeminal spinal tract nucleus (VC) induced by trauma occlusion in order to investigate orofacial pain mechanism.

METHODS

The occlusal surface of the first and second maxillary right molars in 15 dogs were unilaterally raised 1.5 mm with casting Ni-Cr inlay which were fixed in Class I hole. On days 3, 7, 14, 30 and 60 after teeth operation, the VC of right and left sides were removed. PPTA and c-fos mRNAs were detected in experimental and control groups with reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

(1) The basal levels of PPTA and c-fos mRNAs were extremely low and poorly detectable in VC in control animals. (2) The expression of PPTA mRNA in VC of traumatic side was up regulated from 3 days after inlay was fixed in molar and reached peak level during 14 to 30 days and then down-regulated gradually and no significant difference was noted between 60 days group and control group. (3) c-fos mRNA expression was more intense during 3 to 7 days compared with the control group but undetectable in the other experimental period. (4) Both PPTA and c-fos mRNAs expression in VC of trauma occlusal side were more intense than that in the contralateral side.

CONCLUSIONS

The present results show that both PPTA and c-fos mRNA expression are elevated in dog's VC induced by traumatic occlusion. The primary afferent terminal of orofacial area is sensitized, which suggest one kind of mechanism of orofacial pain in the condition of traumatic occlusion.

[Improvement of chronic pain syndrome by free tissue transfer. Report of two cases]

We report on two patients with chronic pain syndrome of a lower limb due to chronic constriction after radiation therapy in one case and to popliteal entrapment in the other. The patients had been in pain therapy for years and had achieved insufficient analgesia in one case and satisfactory analgesia in another case with high doses of morphine sulphate and other medication. Surgery was indicated for limb salvage in one patient, and for pain relief in the other patient. It consisted of decompression and defect reconstruction by free latissimus dorsi flaps. In both cases, after an uncomplicated follow-up, quick and complete weaning from the analgesics was possible. One of the patients is completely free of pain.

Midfacial segment pain: implications for rhinitis and sinusitis

During the past decade, studies on facial pain have shown that there is a distinct group of patients who have a form of facial neuralgia that has all the characteristics of tension-type headache, except that it affects the midface; it is called midfacial segment pain. The pain is described as a feeling of pressure, although some patients might feel that their nose is blocked when they have no nasal airway obstruction. Midfacial segment pain is symmetric, and it might involve areas of the nasion (the root of the nose), under the bridge of the nose, on either side of the nose, the peri- or retro-orbital regions, or across the cheeks. There might be hyperesthesia of the skin and soft tissues over the affected area. Nasal endoscopy and CT scans are typically normal. Most patients with this condition respond to low-dose amitriptyline, but noticeable improvement might require up to 6 weeks.

[Case of painful tic convulsif: discussion of the underlying mechanisms and review of the literature]

The combination of trigeminal neuralgia and ipsilateral hemifacial spasm, known as painful tic convulsif (PTC), is a relatively rare entity in neurovascular compression syndrome. A case of PTC attributable to different offending arteries is described, the mechanisms and characteristics of PTC are discussed, and a review of the literature is presented. This 80-year-old woman had a 10-year history of left trigeminal neuralgia and ipsilateral hemifacial spasm. She presented with intermittent left facial twitching and pain, especially upon swallowing. MRI revealed compression of the left trigeminal nerve by the left anterior inferior cerebellar artery and of the ipsilateral facial nerve by the posterior inferior cerebellar artery. Microvascular decompression of the lesions via left lateral suboccipital craniotomy resulted in immediate and complete symptom improvement. Our case demonstrates that different arteries can affect the trigeminal and facial nerve at a stage that precedes compression by a tortuous vertebrobasilar artery. We suggest that the presence of PTC should be considered in patients with a tortuous vertebrobasilar artery, irrespective of the offending arteries.

Occipital neuralgia and twelfth nerve palsy from a chondromyxoid fibroma

The purpose of this case report is to record the unusual combination of occipital neuralgia and hypoglossal nerve palsy causing dysarthria, dysphagia, and unilateral weakness of tongue protrusion, with no other neurological findings. The cause was a discrete tumor in the clivus and the right occipital condyle. Following surgical resection of the tumor, dysarthria and dysphagia persisted. These improved with therapy by a speech therapist, but deviation of the tongue persisted on protrusion. No similar case reports were found in the literature. In addition, the tumor was an unusual one, a chondromyxoid fibroma (CMF); these tumors uncommonly involve the skull base.

SUNCT syndrome in association with persistent Horner syndrome in a Chinese patient

This is the first case report of a chinese patient with SUNCT (shortlasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing) presenting with persistent Horner's syndrome. She had episodic, brief, right periorbital pain in association with ipsilateral eye injection, lacrimation and rhinorrhea as well as persistent ipsilateral miosis and ptosis. She had partial response to a combination of indomethacin and carbamazepine therapy.

Headache and facial pain in children and adolescents

Headaches commonly affect children and adolescents. Proper diagnosis and management is dependent on thorough history taking and a comprehensive physical and neurological examination. Additional diagnostic testing is indicated in some cases. The second edition of the headache classification system by the International Headache Society has recently become available. The classification system is primarily based on adults, but we discussed the subtle distinctions made regarding children. In addition to the primary headache types of migraine, tension-type, and cluster headaches, we discussed selected symptomatic headaches. Emphasis was placed on migraine and tension-type headaches because these are the most common pediatric headache types. We briefly discussed genetic aspects of headaches. Genetic factors have been hypothesized for chronic tension headache and other forms of migraine, but genetic linkage has only been established for familial hemiplegic migraine. We reviewed the nonpharmacologic and pharmacologic therapies, including abortive and prophylactic medications for various age groups. Unlike headaches, facial neuralgias are rare in otherwise healthy children. Facial pain may be neurological, vascular, or dental in origin. We focused on trigeminal neuralgia, glossopharyngeal neuralgia, occipital neuralgia, and Bell's palsy as neurological causes of facial pain in children.

Neurogenic pain relief by repetitive transcranial magnetic cortical stimulation depends on the origin and the site of pain

OBJECTIVE

Drug resistant neurogenic pain can be relieved by repetitive transcranial magnetic stimulation (rTMS) of the motor cortex. This study was designed to assess the influence of pain origin, pain site, and sensory loss on rTMS efficacy.

PATIENTS AND METHODS

Sixty right handed patients were included, suffering from intractable pain secondary to one of the following types of lesion: thalamic stroke, brainstem stroke, spinal cord lesion, brachial plexus lesion, or trigeminal nerve lesion. The pain predominated unilaterally in the face, the upper limb, or the lower limb. The thermal sensory thresholds were measured within the painful zone and were found to be highly or moderately elevated. Finally, the pain level was scored on a visual analogue scale before and after a 20 minute session of "real" or "sham" 10 Hz rTMS over the side of the motor cortex corresponding to the hand on the painful side, even if the pain was not experienced in the hand itself.

RESULTS

and discussion: The percentage pain reduction was significantly greater following real than sham rTMS (-22.9% v -7.8%, p = 0.0002), confirming that motor cortex rTMS was able to induce antalgic effects. These effects were significantly influenced by the origin and the site of pain. For pain origin, results were worse in patients with brainstem stroke, whatever the site of pain. This was consistent with a descending modulation within the brainstem, triggered by the motor corticothalamic output. For pain site, better results were obtained for facial pain, although stimulation was targeted on the hand cortical area. Thus, in contrast to implanted stimulation, the target for rTMS procedure in pain control may not be the area corresponding to the painful zone but an adjacent one. Across representation plasticity of cortical areas resulting from deafferentation could explain this discrepancy. Finally, the degree of sensory loss did not interfere with pain origin or pain site regarding rTMS effects.

CONCLUSION

Motor cortex rTMS was found to result in a significant but transient relief of chronic pain, influenced by pain origin and pain site. These parameters should be taken into account in any further study of rTMS application in chronic pain control.

Management issues of neuropathic trigeminal pain from a medical perspective

The purpose of this article is to review the pharmacological treatment of neuropathic trigeminal pain by means of a systematic review. A number of randomized controlled trials and important historical and uncontrolled studies in trigeminal neuralgia and postherpetic neuralgia were identified. Trigeminal neuralgia is a unique neuropathic pain disorder with a specific therapy. It does not respond to the usual drugs used for other neuropathic pains. The drug therapy of trigeminal postherpetic neuralgia is similar to that of other neuropathic trigeminal pain conditions.

Peripheral glycerol injection for the relief of facial neuralgia in children

OBJECTIVE

In order to evaluate the therapeutic value of peripheral glycerol injection (PGI) in children with trigeminal neuralgia (TN).

METHODS

A total of 18 sick chlordane with TN have been treated by PGI with a follow-up period ranging from 2.5 to 3.6 years.

RESULTS

It is shown that the result is excellent in 72.2%, good in 11.1%, poor in 11.1%, and 22.2% had a recurrence. Of them, 16 of the original patients experienced a satisfactory control of pain following PGI, which produced no changes of the facial sensibility.

CONCLUSION

This report indicates that it is a less formidable procedure, simple to perform and easily repeated so remains the choice for the majority of sick children with intractable TN, along with the additional benefit of no risks of facial sensory loss when compared to that of classic neuroectomy.

Neuropathic pain in the orofacial region: clinical and research challenges

Neuropathic pain in the orofacial region poses a difficult challenge to the treating physician. In some cases diagnosis is far from easy. Common causes of orofacial neuropathic pain are reviewed here, with a focus on the 2 most common: postherpetic neuralgia and posttraumatic painful peripheral neuropathy. In addition, the discussion includes idiopathic trigeminal neuralgia (tic douloureux), a neuropathic pain syndrome that is nearly unique to the trigeminal distribution (very rarely, it has also been reported in the glossopharyngeal region). Brief summaries of major research problems and successes are also provided.

Classification of headache and facial pain

It is important for us as otolaryngologists to identify our critical role in diagnosing and treating the subset of patients that suffers from headaches. It is equally important for the layperson and the medical community to recognize the importance of a multidisciplinary team approach in the management of headache and facial pain. Despite its limitations, classification provides us with a starting point from which scientists, clinicians, and patients can begin to determine the success of diagnostic and therapeutic strategies. It also indicates future directions for research.

Sinonasal facial pain

Evaluation of the paranasal sinuses and nasal cavity in patients with headache and or facial pain must include a thorough medical and social history, with close attention to the pattern and character of the pain, a thorough physical examination that includes a palpation and nasal endoscopy, and imaging studies such as CT scans and Magnetic Resonance Imaging. The physician must remember that every pain in the face is not caused by sinusitis.

Pain from the oral cavity

The head, face, mouth, and throat collectively is the most frequent site of pain in humans. Facial pain is a particularly distressing problem because identification and effective treatment of the underlying cause is often challenging and sometimes elusive. This article focuses on the more common causes of facial pain that originate in the oral cavity and associated structures and outlines a general approach to diagnosis and management of these problems.

[Trigeminal neuralgia presenting as a deep recurrent desmoplastic neurotropic melanoma of a lentigo maligna]

INTRODUCTION

Neurotropic melanoma is a particular anatomopathological form corresponding to dermal proliferation of desmoplastic cells of neuroid differentiation. We report a new case of neurotropic melanoma revealed by facial neuralgia.

CASE REPORT

A 64 year-old man presented in 1996 with a lentigo maligna on the right cheek treated by complete excision. After 2 years of medical supervision, a pigmented lesion recurred leading to new surgical treatment. The histological examination of the total lesion showed intra-epidermal atypical melanocyte proliferation without dermal invasion. In 1999, right trigeminal neuralgia occurred without associated cutaneous change. Cranial MRI revealed an infiltration of the right trigeminal nerve. Endo-buccal surgery disclosed a black swelling of the trigeminal nerve. Histological examination and immunohistochemistry revealed a desmoplastic melanoma.

DISCUSSION

Neurotropic melanoma with nerve invasion by malignant cells presenting as a trigeminal neuralgia is rare. Our case report underlined the depth of the neurotropic melanoma and the initial existence of a lentigo maligna without associated "neurotropic" melanoma.

Versorgung von Patienten mit chronischem orofazialem Schmerz

OBJECTIVE

The aim of this study was to evaluate the significance attributed by dental and maxillofacial surgeons to the ambulatory management of chronic orofacial pain syndromes.

MATERIALS AND METHODS

All the dentists and oral and maxillofacial surgeons working in ambulatory capacities within a county of the German Rhine Area were asked to answer a questionnaire on demographic data, diagnostic and therapeutic principles, and the use of analogue scales, surgical, minimal-invasive or pharmacological procedures.

RESULTS AND DISCUSSION

Seventy-two ambulatory institutions reported 985 patients suffering from temporomandibular disorders (40.2%), headache-syndromes associated with facial pain (18.2%), and atypical odontalgia respectively phantom tooth pain (17.0%). Patients were characterized by prior dental treatment or trauma (41.9%), female gender (66.8%), middle age (81.1%, 20-60 years), very frequent change of therapists (54.6%) and long-term perseverance of pain (61.1% >6 months). Only 7% of therapists used visual or numerical analogue scales to assess pain intensity. Therapeutic procedures consisted of analgesics (15.7%) and further surgical procedures (47.7%). Pain therapists were rarely involved (12.5%).

CONCLUSION

Dental and maxillofacial surgeons should apply an interdisciplinary and multimodal approach to diagnostics and therapy at an earlier stage in order to optimize the pain management of patients with chronic orofacial pain.

Contributing factors to chronic myofascial pain: a case-control study

This case-control study was designed to investigate the contributing factors for chronic masticatory myofascial pain (MFP). Eighty-three patients with MFP, selected from the dental clinics of the Jewish General and Montreal General Hospitals, Montreal, Canada, and 100 concurrent controls selected only at the first clinic, participated in this study. The association with MFP was evaluated for bruxism, head-neck trauma, psychological factors (symptom check list 90 revised questionnaire, SCL-90R) and sociodemographic characteristics by using unconditional logistic regression. Clenching-grinding was associated with chronic MFP in multiple models including anxiety (OR=8.48; 95% CI: 2.85; 25.25) and depression (OR=8.13; 95% CI: 2.76; 23.97). This association also remained for MFP, excluding all other temporomandibular disorders (TMD). Clenching-only (OR=2.54; 95% CI: 1.10; 5.87) and trauma (OR=2.10; 95% CI: 1.0; 4.50) were found to be associated with the chronic MFP, when the level of anxiety was adjusted in the model. No significant change was noted when the effects of clenching-only (2.76; 95% CI: 1.20; 6.35) and trauma (OR=2.08; 95% CI: 1.03; 4.40) were adjusted for depression. Clenching-only and clenching-grinding remained related to MFP regardless of patients being informed about these habits. A higher score of anxiety (OR=5.12; 95% CI: 1.36; 19.41) and depression (OR=3.51; 95% CI: 1.07; 11.54) were associated with MFP, as well as other psychological symptoms. In addition, female gender had almost three times the risk of chronic MFP than males when the model was also adjusted for psychological symptoms. Grinding-only, age, household income and education were not related with chronic MFP. Tooth clenching, trauma and female gender may contribute to MFP even when other psychological symptoms are similar between subjects.

[Differential and common characteristics of patients with atypical facial pain and craniomandibular dysfunction]

BACKGROUND

Craniomandibular disorders (CMD) and atypical facial pain (AFP) represent a clinical challenge. Whereas CMD patients respond to somatic approaches, somatization should be strictly avoided in AFP. The aim of this study was to establish prognostic criteria to identify an aggravated risk of a chronic course in CMD and AFP.

METHOD

A total of 124 consecutive patients with CMD ( n=108) or AFP ( n=16) were examined by two interdisciplinary academic pain centers. Psychometric evaluation was conducted with standardized questionnaires (SCL-90R, STAXI, modified SBAS-IV). All patients were clinically assessed by a maxillofacial surgeon or specialized dentist.

RESULTS

The following variables proved to be significant: age (risk for AFP vs CMD increased by 6% p.a.), decreased dysfunction index (13% higher risk for AFP vs CMD), and low scores concerning outwardly directed anger (12% higher risk for AFP vs CMD). There was no correlation between initial pain intensity and somatic parameters of disease as assessed by the standardized clinical examination. Low educational status proved to be the best predictor ( p<0.001) for patients presenting high initial pain with a marked discrepancy between somatic findings and subjective status.

CONCLUSIONS

CMD patients differ from AFP patients regarding age, psychosocial isolation, outwardly directed anger, and a decreased dysfunction index. Additionally, initial pain intensity in patients presenting indistinct CMD/AFP can be considered as a valid predictor for a chronic course in pain.

Chronic varicella-zoster virus ganglionitis--a possible cause of postherpetic neuralgia

Postherpetic neuralgia (PHN) is dermatomal distribution pain that persists for months to years after the resolution of herpes zoster rash. The cause of PHN is unknown. Herein, we report clinical, molecular virological, and immunological findings over an 11-year period in an immunocompetent elderly woman with PHN. Initially, blood mononuclear cells (MNCs) contained varicella-zoster virus (VZV) DNA on two consecutive occasions. Random testing after treatment with famciclovir to relieve pain did not detect VZV DNA. However, the patient was reluctant to continue famciclovir indefinitely and voluntarily stopped drug treatment five times. Pain always recurred within 1 week, and blood MNCs contained many, but not all, regions of the VZV genome on all five occasions. Immunological analysis revealed increased cell-mediated immunity to VZV. Chronic VZV ganglionitis-induced PHN best explains the recurrence of VZV DNA in MNCs whenever famciclovir was discontinued; the detection of only some regions of the viral genome in MNCs, compared to the detection of all regions of the VZV genome in latently infected ganglia; the increased cell-mediated immunity to VZV; and a gratifying clinical response to famciclovir. The presence of fragments of VZV DNA in MNCs likely represents partial degradation of viral DNA in MNCs that trafficked through ganglia during productive infection.

[Myoarthropathy of the temporomandibular joint and masticatory muscles. Pain therapy management and relaxation instead of aggressive surgery]

Temporomandibular pain is often characterized by a mismatch between symptoms and findings. The dentist's well-established therapeutic strategies for the management of acute pain are therefore frequently not effective in patients with painful temporomandibular disorders (TMD). Instead, dentists should apply the tried and tested principles that are applied in general medicine to the diagnosis and treatment of musculoskeletal pain (e.g. arthritic pain or fibromyalgia). When consulted by patients with rheumatic diseases, physicians should routinely enquire whether they also experience temporomandibular pain.

[Determining the diagnosis from the pain pattern. Brief and stabbing or chronic and dull?]

For the neurological differential diagnosis of facial pain, symptomatic pain must be differentiated from the so-called primary pain syndromes. Trigeminal neuralgia is usually readily diagnosed on the basis of the typical history. The treatment of choice is carbamazepine. If this fails, invasive options are available. Atypical facial pain should be diagnosed only when all known primary and secondary pain syndromes have been excluded. Treatment is difficult and comprises the administration of tricyclic antidepressants. Cluster headache and chronic paroxysmal hemicrania each has an unmistakable temporal course. Although the etiology remains unknown, specific therapeutic options are available. The Tolosa-Hunt syndrome is presumably caused by a granuloma in the cavernous sinus, and treatment is effected with corticosteroids. Painful craniomandibular dysfunction (CMD) is often misinterpreted as atypical facial pain.

[Acute and chronic facial pain due to injured neural plexus of the upper teeth]

The general causes of upper dental plexus injury are tooth disturbances and the periodontal tissues diseases, the pathology of maxillary sinus, various traumatically manipulations in the area of tooth and maxilla as well. The main symptom of upper tooth neural plexus injury is acute and chronic pain in the alveolar sprout of maxilla, gums or in the area of singly tooth, which rarely spreads into neighboring maxillofacial areas. The authors recommend that the acute pain syndrome would be called the inflammation of upper tooth plexus, and the chronic pain syndrome--plexopathia of upper tooth. Study presents the differential diagnosis according to character of facial pain syndrome and the data of sensority disorders research and investigation of pain thresholds as well. The recommendations for treatment tactic and methods of analyzed indispositions are suggested.

[Eagle syndrome: diagnostic imaging and therapy]

In the case of clinical symptoms such as dysphagia, foreign-body sensation and chronic neck or facial pain close to the ear, an Eagle syndrome should be considered in the differential diagnosis. Rational diagnostics and therapy are elucidated on the basis of four case reports. Four patients presented in the outpatients clinic with chronic complaints on chewing and a foreign-body sensation in the tonsil region. Upon specific palpation below the mandibular angle, pain radiating into the ear region intensified. In all patients, local anaesthesia with lidocaine only led to a temporary remission of symptoms. Imaging diagnostics then performed initially included cranial survey radiograms according to Clementschitsch as well as in the lateral ray path and an OPTG. An axial spiral-CT was then performed using the thin-layer technique with subsequent 3-D reconstruction. Therapy consisted of elective resection with a lateral external incision from the retromandibular. From a symptomatic point of view, the cranial survey radiograms and the OPTG revealed hypertrophic styloid processes. The geometrically corrected addition of the axial CT images produced an absolute length of 51-58 mm. The 3-D reconstruction made it possible to visualise the exact spatial orientation of the styloid processes. An ossification of the stylohyoid ligament could definitely be ruled out on the basis of the imaging procedures. After resection of the megastyloid, the patients were completely free of symptoms. Spiral-CT with subsequent 3-D reconstruction is the method of choice for exact determination of the localisation and size of a megastyloid, while cranial survey radiograms according to Clementschitsch and in the lateral ray path or an OPTG can provide initial information. The therapy of choice is considered to be resection of the megastyloid, whereby an external lateral incision has proved effective.

Neurotological complications after radiosurgery versus conservative management in acoustic neuromas: a systematic review-based study

OBJECTIVE

Treatment modalities for acoustic neuroma (AN) include surgery, observation and gamma-knife surgery. The aim of this study was to compare neurotological complications resulting from two treatment alternatives to microsurgery: radiosurgery and observation.

MATERIAL AND METHODS

We conducted a systematic review of the literature dealing with radiosurgery for AN and compared the rate of neurotological complications in this population with that in a cohort of patients managed conservatively.

RESULTS

We found that neurotological complications, namely facial hypoesthesia (p = 0.002), hearing loss (p < 0.05) and hydrocephalus (p = 0.02), were more frequently encountered after radiosurgery than with conservative management. In contrast, we found that the risk of growth of AN is significantly higher with conservative management and that the rate of stability of the tumor did not differ significantly between the two treatments.

CONCLUSION

We prefer a conservative management regimen for patients who cannot be operated on for their AN. However, there are some difficulties inherent in this conservative management policy, namely non-compliance and difficulties in establishing the evolution of the tumor.

Infraorbital nerve palsy: a complication of laser in situ keratomileusis

PURPOSE

To report infraorbital nerve dysfunction after laser in situ keratomileusis.

DESIGN

Observational case report.

METHODS

Neuro-ophthalmologic examination with brain and orbital magnetic resonance imaging (MRI) and orbital computed tomography (CT).

RESULTS

During laser in situ keratomileusis, two healthy women, aged 42 and 46 years, experienced acute onset of sharp ipsilateral cheek pain. Both cases occurred during manipulation of the eyelid speculum. Postoperatively, ipsilateral numbness and tingling or pain of the upper cheek was reported, and examination showed decreased sensation in the distribution of the infraorbital nerve. In both cases, brain and orbit MRI and orbit CT were normal. Both patients were managed medically. In one patient, mild symptoms persisted 1 year postoperatively, and in the second patient, moderate discomfort persisted 8 months postoperatively.

CONCLUSION

Infraorbital nerve palsy is a potential complication of laser in situ keratomileusis. Symptoms improve but may persist.

Chronic facial pain: a multidisciplinary problem

Atypical facial pain is an unrecognised and unhelpful diagnosis but one which describes chronic pains that do not fit the present classification system. Due to the site of the pain, patients may seek and, indeed, receive treatment from dental practitioners and specialists, but the pain is often unresponsive and may have more in common with unexplained medical symptoms affecting other areas of the body, than with other dental symptoms. This review suggests a need for a diagnostic category of "chronic facial pain", which demands a multidisciplinary approach to diagnosis and management.

[Idiopathic SUNCT (short lasting unilateral neuralgiform headache attacks with conjunctival injection, tearing, sweating and rhinorrhea) syndrome: 2 new cases]

The syndrome of short-lasting unilateral, neuralgiform attacks of pain in the peri orbital area associated with conjunctival injection and tearing (SUNCT) is a rare disorder affecting mainly males. We report two French patients (1 male and 1 female) with SUNCT syndrome, 27 and 28 years of age respectively. Both patients had short (30 sec), frequent (30-100/day) excruciating pain located at the peri orbital area, associated with conjunctival injection, tearing, rhinorrhea, ptosis and others vasomotor symptoms. Clinical examination and imaging were normal. Most drugs used in the treatment of migraine, cluster headache, trigeminal neuralgia, and other short-lasting headaches were not successful.

Stylalgia: an Indian perspective

OBJECTIVE

The main objective was to study the stylalgia profile in Indians and the outcome of styloidectomy in such cases.

DESIGN

This prospective study was carried out by random selection of patients with stylalgia using periodic random numbers.

SETTING

This was a hospital-based study.

METHODS

Surgical excision of the symptomatic enlarged styloid process was performed by the transtonsillar route using a dilation and curettage (D and C) curette.

MAIN OUTCOME MEASURES

The patients were followed postoperatively for their pain relief.

RESULTS

Of 40 patients operated on, 31 (77.5%) became symptom free, 5 (12.5%) had considerable improvement in their symptoms, and 4 (10%) had no relief.

CONCLUSIONS

The incidence of an enlarged styloid process was found to be higher in an Indian rural population with female preponderance owing to their carrying of heavy weight on head. Styloidectomy was very rewarding. The D and C curette was found to be a very effective instrument for styloidectomy.

[Interrelation between physical disease and chronic pain--importance of understanding myofascial pain syndrome]

Myofascial pain syndrome(MPS) is characterized by its unique pathology on developing the intramuscular trigger points. The author performed the psychological tests(Cornell Medical Index, Tokyo University Egogram, Minnesota Multiphasic Personality Inventory) on 46 MPS patients to clarify the psychological background. Results revealed that the MPS patients had remarkable hypochondriacal tendency with irrational way of thinking. The author concluded that it is necessary to be hypochondriacal and irrational for the formation of apparent MPS with outstanding TPs. This fact suggests that TPs in MPS are the result of deteriorated central pain control mechanism that should actually suppress the mechanical constriction of damaged muscles.

A spectrum of exertional headaches

Headaches that have an explosive onset with exercise, including sexual activity, generally are benign in origin. A subarachnoid hemorrhage, a mass lesion in the brain, or an anomaly of the posterior fossa must be considered, however. The mechanisms that produce sexually induced or cough headaches of abrupt onset are unknown. It is known, however, that a rapid increase in intrathoracic pressure suddenly reduces right atrial pressure and presumably decreases venous sinus drainage from the brain. This situation results in a transient increase in intracranial pressure. Jaw pain that occurs with chewing often is considered to be TMJ dysfunction when arthritic in quality and if subluxations of the jaw can be shown on the physical examination. Giant cell arteritis and common or external carotid artery occlusive disease should be considered when the pain is ischemic in quality. An anginal equivalent is another possibility. Headaches that worsen with vigorous exercise are commonly migrainous. When their onset is apoplectic with exertion (particularly exertion against a closed glottis), the most likely diagnoses are increased intracranial pressure, a posterior fossa abnormality, or benign exertional headaches. Most cardiac induced headaches, but not all, are of a more gradual onset. If there are significant risk factors for coronary artery disease, an exercise stress test is appropriate. A therapeutic trial of nitroglycerin may help to establish a diagnosis if it improves the headache. Using antimigraine drugs as a diagnostic test is inappropriate because triptans and ergots are contraindicated in the presence of coronary artery disease, and a positive response is not diagnostic of migraine.