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, e.g. temporal arteritis, or early diagnosis, e.g. 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.

Causes

• Sinus: sinusitis, trauma, carcinoma
• Nose: upper respiratory tract infection, nasal injury and foreign bodies
• Ear: otitis media, otitis externa
• Mastoid: mastoiditis
• Teeth: dental abscess
• 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
• 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)¹

Presentation

Symptoms

• Site:
  • 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.
• Character:
  • 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 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.

Signs

• 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 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.

Investigations

• Full blood count: raised white cell count in infection or malignancy.
• ESR, CRP: increase in infection, malignancy, temporal arteritis.
• X-rays:
  • 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.
• CT or MRI scan: carcinoma sinuses, nasopharyngeal carcinoma, parotid conditions. Extent of tumours and invasion.
• Sialography: parotid conditions, e.g. duct stones, sialectasis.
• Fine needle aspiration: parotid tumours.

Management

• 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.
• Tricyclic antidepressants may be useful for persistent pain.