Facial pain has a long list of possible causes but the diagnosis can often be made by a good history and examination. The common causes are often benign and self-limiting but it is essential not to miss those conditions that require urgent treatment - eg, temporal arteritis, or early diagnosis - eg, malignancy. There is a tendency to overdiagnose bacterial sinusitis when the real cause may be a viral upper respiratory tract infection or, much less frequently, a more serious cause of facial pain.
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- Sinus: sinusitis, trauma, carcinoma.
- Nose: upper respiratory tract infection, nasal injury and foreign bodies.
- Ear: otitis media, otitis externa.
- Mastoid: mastoiditis.
- Teeth: dental abscess.
- Local soft tissue infection: cellulitis, erysipelas.
- Neurological: trigeminal neuralgia, herpes zoster.
- Parotid gland: mumps, other causes of parotitis, abscess, duct obstruction, calculi, tumour.
- Eye: orbital cellulitis, glaucoma.
- Temporomandibular joint dysfunction and pain.
- Cluster headaches, migraine.
- Temporal arteritis.
- Tumours: nasopharyngeal, oral, posterior fossa, brainstem gliomas.
- Bone: maxillary or mandibular osteitis, cyst.
- Atypical facial pain: more common in the elderly and in women; often linked with depression.
- Lung cancer (upper lobe).
- Pain in the region of the ear may be referred from the skin, teeth, tonsils, pharynx, larynx or neck.
- Tenderness over the maxilla may be due to sinusitis, dental abscess or carcinoma.
- Trigeminal neuralgia: intermittent sharp, severe pain in the distribution of the divisions of the trigeminal nerve.
- Infections of teeth, mastoid and ear: often dull, aching quality.
- Precipitating factors:
- Precipitated by food or chewing: dental abscess, salivary gland disorder, temporomandibular joint disorder or jaw claudication due to temporal arteritis.
- Trigeminal neuralgia: even the slightest touch of the skin causes intense pain.
- Associated symptoms:
- Obstruction of the lacrimal duct by nasopharyngeal carcinoma may cause watering of the eyes.
- Otorrhoea and/or hearing loss suggest an ear or mastoid cause.
- Nasal obstruction and rhinorrhoea may be due to maxillary sinusitis or carcinoma of the maxillary antrum. Carcinoma of the maxillary antrum may also present with unilateral epistaxis.
- Proximal muscle weakness and pain may be due to polymyalgia rheumatica, associated with temporal arteritis.
- 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).
- Localised erythema or swelling: localised infection or carcinoma.
- Inspection of the nose and throat may demonstrate a nasopharyngeal tumour.
- Facial palsy: may be due to a tumour of the parotid gland.
- Tenderness of the superficial temporal artery associated with temporal arteritis.
- Cervical lymphadenopathy: infection or carcinoma.
- FBC: raised white cell count in infection or malignancy.
- ESR, CRP: increase in infection, malignancy, temporal arteritis.
- Opacification of the sinus and destruction of bone with carcinoma of sinuses.
- Opacification may also occur in sinusitis.
- Mastoid films may show opacification in cases of mastoiditis.
- MRI scan with and without gadolinium is the investigation of choice. CT scan with contrast is less useful because there is less resolution of the cranial nerves and posterior fossa. .
- Sialography: parotid conditions - eg, duct stones, sialectasis.
- Fine needle aspiration: parotid tumours.
- The essential aspect of management in primary care is to make an accurate diagnosis. The management will then depend on the identified cause of facial pain.
- The first-line treatment for atypical facial pain is a tricyclic antidepressant such as amitriptyline. Fluoxetine and venlafaxine can also been considered. Peripheral subcutaneous field stimulation may be an alternative for patients with intractable pain.
- Specialist referral should be made according to local guidelines. One such guideline suggests referring patients who have:
- Facial pain persisting for more than three months.
- Persistent temporomandibular disorders not responding to simple analgesics, lifestyle changes and reassurance.
- Persisting pain affecting function and causing distress.
- Widespread pain.
- Pain which is part of systemic disease.
- Significant psychological or social problems.
- Co-existing mental health problems which have an impact on treatment.
- Compliance problems - eg, side-effects.
- A recognised pain syndrome such as trigeminal neuralgia.
- Patients with special needs - eg, learning disabled, communication problems.
Further reading & references
- Aggarwal VR, Macfarlane GJ, Farragher TM, et al; Risk factors for onset of chronic oro-facial pain--results of the North Cheshire oro-facial pain prospective population study. Pain. 2010 May;149(2):354-9. Epub 2010 Mar 20.
- Krolczyk SJ; Persistent Idiopathic Facial Pain, Medscape, Mar 2012
- Ruffatti S, Zanchin G, Maggioni F; A case of intractable facial pain secondary to metastatic lung cancer. Neurol Sci. 2008 Apr;29(2):117-9. Epub 2008 May 16.
- Raval T et al; Facial Pain and Headache, Medscape, Nov 2011
- Cornelissen P, van Kleef M, Mekhail N, et al; Evidence-based interventional pain medicine according to clinical diagnoses. 3. Persistent idiopathic facial pain. Pain Pract. 2009 Nov-Dec;9(6):443-8.
- Yakovlev AE, Resch BE; Treatment of chronic intractable atypical facial pain using peripheral subcutaneous field stimulation. Neuromodulation. 2010 Apr;13(2):137-40. doi: 10.1111/j.1525-1403.2009.00249.x. Epub 2010 Jan 12.
- How to refer - Facial pain, University College London Hospitals (links to Word document)
|Original Author: Dr Colin Tidy||Current Version: Dr Laurence Knott||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 02/11/2012||Document ID: 2129 Version: 23||© EMIS|
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