18. Facial pain

Question 1

Index conditions

Answer 1

Sinusitis
Atypical facial pain
TGN
TMJ dysfunction
Dental causes (e.g. abscess)
Eye-related (e.g. glaucoma)
Temporal arteritis

Question 2

Facial pain: history

a) HPC - SOCRATES
b) Ass Sx
c) PMHx
d) DHx
e) FHx
f) SHx

Answer 2

a) - Site: unilateral/bilateral, nerve distribution (?TGN), sinus distribution (?sinusitis)
- Onset: traumatic?, sudden/gradual
- Character: electric shock (?TGN), dull ache (?tooth, ear or sinus infection)
- Radiation: ?
- Timing: intermittent or constant
- E/R factors: touch (?TGN, sinusitis), medications, bending forward (?sinusitis), chewing (?GCA, dental, TMJ disorder, parotitis)

b) - Scalp tenderness, headache, vision loss, proximal muscle weakness (?GCA)
- Nasal discharge, loss of smell, recent URTI (?sinusitis)
- Vesicles on nose, hearing loss (?shingles - Ramsay Hunt)
- Malignant symptoms - weight loss, anorexia, unexplained bleeding/anaemia, fever/night sweats

c) - Recent dental surgery
- Previous sinusitis

d) ? allergies
e) ?

f) - Smoking, alcohol
- Travel history

Question 3

Facial pain: examination

a) Examination of face
b) Systems

Answer 3

a) - Unilateral erythema and vesicles in the distribution of the trigeminal nerve: herpes zoster infection (may not be present in the early stages of the disease).
- Scalp tenderness (?GCA)
- Sinus palpation (?sinusitis)
- Jaw movement - limitation (TMJ dysfunction) or pain

b) - ENT examination
- Intraoral inspection may reveal any obvious pathology but may require dental expertise.
- CN examination
- Regional LNs

Question 4

Facial palsy - DDx

Answer 4

• Herpes Zoster - Ramsay Hunt

- Parotid tumour

Question 5

Facial pain: investigations

Answer 5

• FBC: raised white cell count in infection or malignancy.
• ESR, CRP: increase in infection, malignancy, temporal arteritis.
• X-rays: dental x-rays
• CT head/sinuses
• USS/sialography - salivary gland pathology.
• Fine-needle aspiration: parotid tumours.

Question 6

Intermittent post-prandial unilateral facial pain - DDx?

Answer 6

• Sialadenitis (eg. parotitis) - often secondary to salivary gland stone
• GCA
• Dental (eg. abscess)