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).

Neurogenous Pain
Neurogenous pain : is discomfort resulting from an abnormality of the peripheral nerve rather than tissues innervated. Neuropathy : is defined as any functional abnormality of nerves , and sensory neuropathy is generally either neuritis or neuralgia. Neuritis : is inflammation of the nerve trunk that is perceived as a burning sensation in the most instances. Neuralgia : refers to paroxysmal pain along the distribution of a nerve that is caused by conditions such as vascular spasm and central nervous system disease.

Facial neuralgia
Characterized by 1- Brief episodes of shooting, often electric shocklike pain along the course of the affected nerve branch. 2- Trigger zones on the skin or mucosa that precipitated painful attacks when touched. 3- Refractory period :Pain- free periods between attacks , immediately after an attack , during which a new episode can not be triggered. - The clinical characteristics differ from neuropathic pain, which tends to be constant and has a burning quality without the presence of trigger zones.

- Constant neuropathic pain or brief episodes of shooting pain depends on both the nature of the underlying disorder and the position of the lesion along the course of the nerve .for example ,tumors involving the trigeminal nerve between the pontine angle in the posterior cranial fossa and the ganglion in the middle cranial fossa will usually result in the lancinating pain of trigeminal neuralgia whereas more peripheral lesions will usually result in neuropathic pain.

Trigeminal neuralgia
Approximately 10% of cases have detected underlying pathology such as a tumor of the cerebellar pontine angle, a demylinating plaque of multiple sclerosis , or a vascular malformation. The reminder 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.

Treatment:
Anticonvulsant drugs are most frequently used and are most effective. Carbamazepine (tegretol) is the most commonly used drug .Patients who do not respond to carbamazepine alone may obtain relief from baclofen or by combination carbamazepine with baclofen. 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.

If patient can not with stand the side effects of anticonvulsant drugs so surgery is indicated ( cryo therapy to trigeminal nerve ) if fail ------cryo therapy to the base of skull , if fail -----microvascular decompression of otic ganglion by alcohol or phenol.

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 and coughing. - glossopharyngeal neuralgia also may be associated with vagal symptoms, such as syncope and arrhythemia, due to the close anatomic proximity of the two nerves. Treatment by tegretol.

Geniculate neuralgia
- Geniculate neuralgia is an uncommon paroxysmal neuralgia of cranial nerve VII characterized by pain in the ear and (less frequently) the anterior tongue or soft palate. - the pain is not as sharp or intense as in TN , and there is often some degree of facial paralysis , indicating the simultaneous involvement of the motor root.

- Geniculate neuralgia commonly results from herpes 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 inflammatory neural degeneration , and a short course (2 to 3) of high dose steroid therapy is beneficial . - Acyclovir significantly reduce the duration of the pain . Patients with geniculate neuralgia are also treated with carbamazepine and antidepressants.

Post herpetic neuralgia

Herpes zoster ( shingles )is caused by the reactivation of latent varicella-zoster virus infection that 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 the fifth nerve, resulting in pain and lesions in the region of the eyes and forehead.

In majority of cases , the pain of herpes zoster resolves within a month after the lesions heal. Pain that persist longer than a month is classified as post herpetic neuralgia (PHN). Patient with PHN experience persistent pain , parasthesia, hyperesthesia, and allodynia ( pain due to stimulus that dose not normally provoke pain ) months to years after the zoster lesions have healed. Diagnosis is straight forward because there is history of facial scars or rash of the pervious attack.

Prevention of PHN is now possible, and use of a live attenuated 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 the disease reduce the risk of PHN. Treatment of PHN depend on the severity of symptoms and include: Topical therapy includes the use of topical anesthetic agents, such as lidocaine , or analgesics.

The use of tricyclic antidepressants such as amitriptyline and nortiptyline is a wellestablished method of reducing the chronic burning pain that is characteristic of PHN. Patients who undergo episodes of shooting pain may experience relief through the use of anticonvulsant drugs, such as carbamazepine or phenytoin. When the medical therapy has been ineffective in managing the pain , nerve blocks or surgery at the level of the peripheral nerve or dorsal root has been effective for some patients.

Other intracranial causes of facial pain include:

-- Tumor of brain
Some cases of brain tumor present itself as mild facial pain , weakness, disturbance in hearing in association with diplopia and visual disturbance and disturbance of facial sensation and reflex loss. C.T scan and angiography is essential aids in diagnosis.

-- Cranial base lesions

Injury to the cranium (as in car accident ), paget's disease ,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 facial features changes with bilateral hemianopia.

-- Multiple sclerosis -- Bell's palsy

Dysphagia
Dysphagia :it is difficulty in the swallowing with or without pain, the presence of pain refers to an inflammatory condition. It could be oral, pharyngeal, or oesophageal. Causes of dysphagia : 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 part of the floor of the mouth.

2/ Foreign body in the pharynx or esophagus, e.g fish 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.

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, facial weakness and weakness of mastication. b- myasthenia gravis. c- congenital muscular incoordination. d- C.V.A. 6/ miscellaneous : e.g. snake bite, fear.etc

Plummer- Vinson syndrome

It is acquired syndrome characterized by iron deficiency 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 lead to secondary degeneration of the esophageal muscles and atrophy of esophageal epithelium (narrowing)
Clinical features: Women at the middle age complain of 1/ Anemia which is hypochromic and microcytic.

2/ Weakness, facial pallor, brittle spoon shaped nails (koilonychias) ,atrophy of the mucosa, depapilation of the tongue ,burning sensation , angular chelitis. 3/ The vermilion border is thin. 4/ reduce the width of the mouth. 5/ dry eye.

Sarcoidosis
Is a chronic granulomatous disease of unknown and uncertain cause with multi-system involvement. In oral structures the salivary gland are the most common site for involvement which lead to uni- or bilateral swelling.

Also we have painless gingival swelling ,palatal and buccal mucosa swelling and lip swelling. The condition could be referred to "chelitis granulomatosa" , that result in diffused lip which is firm (granulomatous tissue) and not tender for palpation. Chelitis granulomatosa could occur in association with median fissured tongue and facial nerve paralysis, this unusual trait is referred to as Melkersson Rosenthal syndrome.

Tetanus
Caused by Clostridium tetani, they enter the body through the wounds in the leg during walking in the soil , or stabbing wounds and may occur in the birth take place in unhygienic environment or may result from the infection of the umbilical stump. The spores remain dormant for years if the circumstances unfavorable to the growth. The organism secrete exotoxins which are hemolysin 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 the muscles of mastication lead to difficulty in chewing and swallowing then spasm increase and finally lead to lock jaw.

If muscles of facial expressions are involved the corner of mouth are drawn back, the lips are protruded ,and the forehead wrinkled ,giving the characteristic appearance of risus sardonicus. Treatment Administration of antitoxin , preferably human tetanus immunoglobulin ; thorough wound debridement , antibiotic usually penicillin ;and sedative to control muscle rigidity and spasm , and maintenance of nourishment through the nasogastric tube (because of locked jaw)

Diphtheria
Caused by Corynebacterium diphtheriae, occur most commonly in the upper respiratory tract and the sore throat is frequently the presenting feature. We have production of exotoxin which leads to the damage of heart muscle and nervous system incubation period is about 2-4 days. The characteristic features is wash-leather elevated grayish green membrane on the tonsils surrounded by a zone of inflammation , the membrane is firmly attached (adherent) . there may be swelling of the neck called " Bull-Neck" and tender enlargement of lymph nodes, and there is possibility of laryngeal or nasal infection.

Complication Laryngeal obstruction , Myocarditis and peripheral neuropathy.

Treatment Benzyl penicillin 600mg 6 hourly for 7 days.