Oral Medicine Lec6

7/27/2019 Oral Medicine Lec6

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Intracranial causes of facial pain

1. Trigeminal neuralgia.2. Multiple sclerosis.3. Herpes zoster.4. post herpetic neuralgia.5. Acromegaly.6. Migranous headache "cluster headache".

7. Cranial base lesion.8. Intracranial tumor. (brain tumor)9. Bell's palsy.

10. Psychogenic pain (atypical facial pain).


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Neurogenous Painis discomfort resulting from anNeurogenous pain :

abnormality of the peripheral nerve rather thantissues innervated.

is defined as any functionalNeuropathy :abnormality of nerves , and sensory neuropathy isgenerally either neuritis or neuralgia.

is inflammation of the nerve trunk that isNeuritis :perceived as a burning sensation in the mostinstances.

refers to paroxysmal pain along theNeuralgia :distribution of a nerve that is caused by conditionssuch as vascular spasm and central nervous system

disease.


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Fac ial neur alg ia Characterized by

1- Brief episodes of shooting, often electric shock-like pain along the course of the affected nervebranch.

2- Trigger zones on the skin or mucosa thatprecipitated painful attacks when touched.

3- Refractory period :Pain- free periods betweenattacks , immediately after an attack , duringwhich a new episode can not be triggered.

- The clinical characteristics differ from neuropathicpain, which tends to be constant and has a burning

the presence of trigger zones.withoutquality


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- Constant neuropathic pain or brief episodes

of shooting pain depends on both the natureof the underlying disorder and the position of the lesion along the course of the nerve .for example ,tumors involving the trigeminalnerve between the pontine angle in theposterior cranial fossa and the ganglion in themiddle cranial fossa will usually result in thelancinating pain of trigeminal neuralgiawhereas more peripheral lesions will usuallyresult in neuropathic pain.


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Trigeminal neuralgiaApproximately 10% of cases have detected

underlying pathology such as a tumor of thecerebellar pontine angle, a demylinating plaque of multiple sclerosis , or a vascular malformation. Thereminder of cases of TN are classified as idiopathic.

Characteristic features of TN :1- pain confined to distribution of one or more

divisions of the trigeminal nerve.2- pain paroxysmal and very severe for few seconds.3- trigger zone in the area.4- absence of objective sensory loss.

5- absence of detectable organic cause.


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Treatment:Anticonvulsant drugs are most frequently used and

are most effective.Carbamazepine (tegretol) is the most commonlyused drug .Patients who do not respond tocarbamazepine alone may obtain relief frombaclofen or by combination carbamazepine withbaclofen.Tegretol 100mg 1200mg /daily ,the action of drug:inhibit nerve impulses

The side effects of anticonvulsant drugs:Drowsiness, dry mouth , nausea ,vomiting , diarrhea,

leucopenia and neutropenia.


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If patient can not with stand the sideeffects of anticonvulsant drugs sosurgery is indicated ( cryo therapy to

trigeminal nerve )if fail ------cryo therapy to the base of skull , if fail -----microvascular

decompression of otic ganglion byalcohol or phenol.


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Glossopharyngeal neuralgia- paroxysmal pain that similar to but less intense

than pain of TN.- pain sensation follows the distribution of the

glossopharyngeal nerve , (the pharynx , posterior tongue and ear).

- pain triggered by :swallowing ,chewing andcoughing.

-- glossopharyngeal neuralgia also may beassociated with vagal symptoms, such as syncopeand arrhythemia, due to the close anatomic

proximity of the two nerves.-

Treatment by tegretol.


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Geniculate neuralgia

- Geniculate neuralgia is an uncommonparoxysmal neuralgia of cranial nerveVII characterized by pain in the ear and (lessfrequently) the anterior tongue or soft palate.

- the pain is not as sharp or intense as in TN ,and there is often some degree of facialparalysis , indicating the simultaneousinvolvement of the motor root.


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-- Geniculate neuralgia commonly results fromherpes zoster of the geniculate ganglion of CN VII,

a condition referred to as (Ramsy Hunt syndrome).Viral vesicles may be observed in the ear canal or on the tympanic membrane.

-- The symptoms result from inflammatoryneural degeneration , and a short course (2 to 3)of high dose steroid therapy is beneficial .

- Acyclovir significantly reduce the duration of thepain . Patients with geniculate neuralgia are alsotreated with carbamazepine andantidepressants.


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Post herpetic neuralgia

Herpes zoster ( shingles )is caused by thereactivation of latent varicella-zoster virus infectionthat result in both pain and vesicular lesions along

the course of the affected nerve.

Approximately 15-20% of cases of herpes zoster involve the trigeminal nerve although the majority of the cases affected the ophthalmic division of thefifth nerve, resulting in pain and lesions in the regionof the eyes and forehead.


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In majority of cases , the pain of herpes zoster resolves within a month after the lesions heal. Painthat persist longer than a month is classified as postherpetic neuralgia (PHN).

Patient with PHN experience persistent pain ,parasthesia, hyperesthesia, and allodynia ( pain dueto stimulus that dose not normally provoke pain )months to years after the zoster lesions have

healed.

Diagnosis is straight forward because there ishistory of facial scars or rash of the pervious attack.


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Prevention of PHN is now possible, and use of a liveattenuated varcella-zoster vaccine for patients over 60 years of age significantly reduce the incidence of herpes zoster and squeal of PHN.

For patients who develop herpes zoster use of antiviral drugs ( Acyclovir) early in the course of thedisease reduce the risk of PHN.

of PHN depend on the severity of Treatmentsymptoms and include: Topical therapy includes theuse of topical anesthetic agents, such as lidocaine ,or analgesics.


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The use of tricyclic antidepressants such asamitriptyline and nortiptyline is a well-

established method of reducing the chronicburning pain that is characteristic of PHN.

Patients who undergo episodes of shootingpain may experience relief through the use of anticonvulsant drugs, such as carbamazepineor phenytoin. When the medical therapy hasbeen ineffective in managing the pain , nerveblocks or surgery at the level of the peripheralnerve or dorsal root has been effective for

some patients.


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Other intracranial causes of facial pain

include:

-- Tumor of brain Some cases of brain tumor present itself asmild facial pain , weakness, disturbance inhearing in association with diplopia andvisual disturbance and disturbance of facialsensation and reflex loss.C.T scan and angiography is essential aids indiagnosis.


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-- Cranial base lesions Injury to the cranium (as in car accident ), paget'sdisease ,petrous ostitis and cranial hyperosteosis.Characteristic of pain is that continuous with loss of hearing and disturb of vision.

-- Acromegaly There is continuous headache, patient has facialfeatures changes with bilateral hemianopia.

-- Multiple sclerosis-- Bell's palsy


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Dysphagiait is difficulty in the swallowing with or Dysphagia :

without pain, the presence of pain refers to an

inflammatory condition. It could be oral, pharyngeal,or oesophageal.Caus es o f dys ph ag ia : 1/ Lesions in the mouth or pharynx (oral &

pharyngeal)a- stomatitis, glossitis ,herpes simplex, tonsillitis ,

diphtheria , candida and titanus.b- quinsy " pus associated with tonsillitis" ,

retropharyngeal abscess.c- hyperplasia of tonsils.d- lymphoma or oral cancer that localized in

posterior 1/3 of the tongue and the posterior partof the floor of the mouth.


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2/ Foreign body in the pharynx or esophagus, e.gfish bone.

3/ Intrinsic diseases :a- plummer-vinson syndrome "paterson- Kelly

syndrome"b- pharyngeal pouches (stricture)c- systemic sclerosis.d- esophageal achalasia , reflex esophagitis ,

diffuse spasm of esophagus and failure of cardiac sphincter to relax ,failure of peristalytic

movement.e- inflammation.f- scarring following long term naso-gastric

intubations or due to ingestion of erosive

substances.


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4/ Extrensic compression :a- tumor of the neck

b- mediastinal tumor.c- retrosternal goiter.d- lymph node enlargement.e- bronchogenic carcinoma or costal aneurysm.

5/ CNS lesions :a- bulbar palsy : this is characterized by difficulties

in swallowing and phonation, hoarseness, facialweakness and weakness of mastication.

b- myasthenia gravis.c- congenital muscular incoordination.d- C.V.A.

6 / miscellaneous : e.g. snake bite, fear.etc


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Plummer- Vinson syndrome It is acquired syndrome characterized by irondeficiency anemia , glossitis ,post-cricoid dysphagia(at the level of C5 &C6)The iron deficiency anemia is due to inadequate

dietary intake of iron or malabsorption , which leadto secondary degeneration of the esophagealmuscles and atrophy of esophageal epithelium(narrowing)

Clinical features:Women at the middle age complain of 1/ Anemia which is hypochromic and microcytic.


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Also we have painless gingival swelling ,palatal andbuccal mucosa swelling and lip swelling.

The condition could be referred to "chelitisgranulomatosa" , that result in diffused lip which isfirm (granulomatous tissue) and not tender for

palpation.

Chelitis granulomatosa could occur in associationwith median fissured tongue and facial nerveparalysis, this unusual trait is referred to asMelkersson Rosenthal syndrome.


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TetanusCaused by Clostridium tetani, they enter the bodythrough the wounds in the leg during walking in thesoil , or stabbing wounds and may occur in the birthtake place in unhygienic environment or may resultfrom the infection of the umbilical stump.

The spores remain dormant for years if thecircumstances unfavorable to the growth.The organism secrete exotoxins which arehemolysin and tetanus spasmin which either go to

the blood stream or directly to the motor roots of spinal cord causing tonic rigidity and spasm of themuscles of mastication lead to difficulty in chewingand swallowing then spasm increase and finally leadto lock jaw.


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Treatment Administration of antitoxin , preferably humantetanus immunoglobulin ; thorough wounddebridement , antibiotic usually penicillin ;and

sedative to control muscle rigidity and spasm , andmaintenance of nourishment through thenasogastric tube (because of locked jaw)

If muscles of facial expressions are involved thecorner of mouth are drawn back, the lips are

protruded ,and the forehead wrinkled ,giving thecharacteristic appearance of risus sardonicus.


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DiphtheriaCaused by Corynebacterium diphtheriae, occur most commonly in the upper respiratory tract andthe sore throat is frequently the presenting feature.We have production of exotoxin which leads to thedamage of heart muscle and nervous systemincubation period is about 2-4 days.

The characteristic features is wash-leather elevatedgrayish green membrane on the tonsils surrounded

by a zone of inflammation , the membrane is firmlyattached (adherent) . there may be swelling of theneck called " Bull-Neck" and tender enlargement of lymph nodes, and there is possibility of laryngeal or

nasal infection.


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Compl ica t ion Laryngeal obstruction , Myocarditis and peripheralneuropathy.

Treatment Benzyl penicillin 600mg 6 hourly for 7 days.

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