Facial pain- the neuralgias

Question 1

It might be impt to ask a patient with intense facial pain about a history of:

Answer 1

1. facial paralysis
2. pain in jaw/tongue when chewing (GCA)
3. numbness/tingling
4. scalp tenderness

Question 2

corneal sensitivity is from ____branch

Answer 2

nasociliary

Question 3

Function of CN V includes: efferent to muscles of mastication, facial sensory affarent, facial motor efferent. It does NOT include:

Answer 3

sense of taste affarent; this comes from the anterior 2/3 of the tongue which CN VII is responsible .Sensory from V3 is tongue’s sensation of touch!

Question 4

CN V does not innervate the angle of the ______.

Answer 4

jaw.

Question 5

CN ___ is the largest CN. Which is the smallest root of CN V? which is the largest?

Answer 5

V; V1; V3

Question 6

Ophthalmic nerve, nasociliary, and long ciliary carry cornea sensory info. Which nerve does not?

Answer 6

frontal nerve

Question 7

Sensory affarents, V1, V2, V3 _____ order neurons converge at _____ ganglion at apex of petrous temporal bone at lateral wall of the cavernous sinus in middle cranial fossa and synapse in two different sensory nuclei.

Answer 7

first; trigeminal

Question 8

_____efferents go out to the muscles of mastication and follow _____ branch and synapse in motor nucleus.

Answer 8

Motor; V3

Question 9

Which branches of CN V pass through the cavernous sinus?

Answer 9

V1, V2; along with CN III, IV, and VI.

Question 10

Cell bodies are located in the _______

Answer 10

ganglion

Question 11

cranial nerve nucleus =

Answer 11

synapses

Question 12

T/F Trigeminal pain and touch fibers travel the same central neuronal pathways

Answer 12

False; pain & temp follow a different pathway from touch.

Question 13

The trigeminal nerve has ____ sensory nuclei and _____motor nuclei.

Answer 13

3; 1

Question 14

When we talk about second order neurons (trigemini-thalamic) we talk about 3 sensory pathways that converge in the pons and synapse in the ______. Which are the 3 sensory pathways/nuclei?

Answer 14

thalamus;

1. main sensory nucleus: touch and sensation as far as the face goes.
2. Mesencephalic: Proprioceptive cues from muscles and tendons of mastication.
3. Spinal Trigeminal nucleus: Carries pain and temperature

All of these feed into the thalamus

Question 15

_____ order neurons ascend from the thalamus and carry sensory signals to primary ________ cortex.

Answer 15

Third; somatosensory

Question 16

You would have ipsilateral fibers going from the thalamus to the _______ side and some fibers crossing. So you have some preservation of sensation if you have a lesion above the main sensory nucleus.

Answer 16

same

Question 17

Some sensory alteration include hypesthesia which refers to reduced sensitivity which may be due to _____ or MS if nuclear or central lesion. If peripheral lesion it involves V1, V2, and V3. Things that can cause this include orbital fracture, neoplasm or aneurysm.

Answer 17

ischemia

Question 18

______ refers to lack of sensitivity or total numbness.

Answer 18

Anesthesia

Question 19

______ refers to odd sensation including tingling or partial numbness.

Answer 19

Paresthesia

Question 20

_____ refers to super sensitivity; threshold for sensitivity has changed.

Answer 20

Hyperesthesia

Question 21

Neuralgia can present with _____pain which refers to cutting, piercing, burning, or stabbing pain. Shoots along the course of affected nerve. Shooting is along the course of affected nerve. It is often ________ which refers to sudden, brief, and recurrent. The cause is unknown or due to nerve irritation or damage.

Answer 21

lancinating; paroxysmal

Question 22

Primary facial neuralgias include:

Answer 22

1. Trigeminal neuralgia
2. Raeder’s paratrigeminal syndrome (neuralgia)
3. postherpetic neuralgia

Question 23

Trigeminal neuralgia (Tic Douloureux) includes extreme facial pain. People can’t touch eyelashes, eat, brush teeth, wash face etc. Usually due to vascular compression on CN V as it exits the brainstem. Artery sits on top of the nerve and pulsates causing the sharp, shooting, electric pain. It is primarily diagnosed by patient history. Onset is > ____ yrs. There is no strong inherited pathway thats been identified. First line of treatment is ______.

Answer 23

50; medication

Question 24

Most common area of involvement in trigeminal neuralgia includes____. V1 is least common. Typically you don’t get sensory loss.

Answer 24

V2

Question 25

If your pt presents with paroxysmal lancinating pain below the RE that has occurred numerous times in recent weeks. Which additional info supports your tentative diagnosis of TN?

Answer 25

episodes occur after applying make up. (you’re looking for a trigger)

Question 26

in the prognosis and management of TN, what happens over long term?

Answer 26

1. pain free intervals diminish
2. pain is less responsive to medication
3. some sensory loss can occur.

Question 27

The most commonly accepted cause of trigeminal neuralgia is :

Answer 27

vascular compression ; more common in superior cerebellar artery

Question 28

some inflammatory causes of TM include:

Answer 28

1. MS
2. neuritis
3. Tolosa hunt syndrome

Question 29

_______(Tegretol) controls 2/3 of patients initially.

Answer 29

Carbamazepine; anticonvulsant

Question 30

Surgical interventions to treat TM include microvascular decompression (MVD) which includes isolating the superior cerebellar artery with sponge. This is preferred for younger patients (90% initial success). This has the ______term pain relief; lowest recurrence, and is the most cost effective. You get preserved facial sensation and low morbidity.

Answer 30

longest

Question 31

A non surgical technique includes radiation technique which applies a local anesthetic and sticks a needle up the foramen ovale. What are advantages of this

Answer 31

1. not as invasive

2. doesn’t require a craniotomy.

Question 32

Another surgical method is percutaneous trans ovale, which is preferred for elderly patients, _____, or pain persisting after MVD.

Answer 32

MS

Question 33

Percutaneous ______ trigeminal gangliosis is typically 3-4 pain free typically.

Answer 33

radiofrequency

Question 34

Raeder’s Paratrigeminal Syndrome includes severe _______ ocular V1 pain. Typical is single episode lasting _____to weeks. Occasionally recurrent, self limiting in 2-3 months. You also get ipsilateral oculosympathetic palsy or partial horners, but you have preserved hydrosis. Middle aged male almost exclusively get this with association with cluster headaches.

Answer 34

unilateral; hours

Question 35

What are the 3 classes of Raeder’s paratrigeminal syndrome.

Answer 35

1. V1 pain + horner’s + other CN involvement require with mass for lesion.
2. V1 pain + horners with cluster HA - benign course
3. V1 pain + horners w/o cluster HA -benign course

Question 36

MRI/MRA and CBC, physical exam indicated for Raeder’s to rule out:

Answer 36

1. internal carotid artery dissection
2. trauma
3. vasculitis
4. parasellar, maxillary sinus mass
5. hypertension

Question 37

How do cluster headaches present?

Answer 37

involves pain around one eye, along with drooping of the lid, tearing and congestion on the same side as the pain.

Question 38

cluster headaches involve _____periorbital severe pain, avg of 45 mins and can last from ____min to 3 hours. Recurrences are on the same side and in clusters that range from 4- _____weeks

Answer 38

unilateral; 15; 12

Question 39

Avoid vasodilation, or alcohol for cluster HA. Treat with oxygen, analgesics, octreotide (injectable synthetic somatostatin, triptans, ergotamine, and local anesthetics. For prevention use:

Answer 39

Ca++ channel blockers, corticosteroids, nerve block

Question 40

Postherpetic neuralgia involves severe burning, aching, stabbing protracted pain. It is usually unilateral and involves V1. It follows a HZV infection (shingles). _______ can be present. and risk increases with age.

Answer 40

Paresthesia

Question 41

the risk of Postherpetic neuralgia can be reduced by early intervention with HZV infection

Answer 41

antidepressants

Question 42

RAmsay Hunt Syndrome is an HZV infection of the external _____. It involves CN VII and sometime ____. there is acute pain, ipsilateral facial paresis with loss of taste, secretory function, decreased and hypersensitive hearing, along with vertigo, and nystagmus.

Answer 42

ear; CN VIII

Question 43

Sphenopalatine ganglion neuralgia is severe unilateral or bilateral pain around root of nose, eyes, upper teeth, gums, jaws. Residual neck tenderness following attack. Photobophobia, conjunctivitis, and lacrimation. You get stuffy, itch, watery nose and pain on swallowing, anasthesia of soft palate, itching of hard _______. Damage here causes brain freeze!

Answer 43

palate