Facial pain

Probability diagnosis

Dental pain:

• caries

• periapical/dental abscess

• fractured tooth

Maxillary/frontal sinusitis

Herpes zoster (shingles)

Serious disorders not to be missed

Cardiovascular:

• myocardial ischaemia

• aneurysm of cavernous sinus

• internal carotid aneurysm

• ischaemia of posterior inferior cerebellar artery

• temporal arteritis

Cancer/neoplasia:

• cancer: mouth, sinuses, posterior fossa, nasopharynx, tonsils, tongue, larynx

• metastases: orbital, base of brain, bone

Infection:

• orbital cellulitis

• erysipelas

• periapical abscess → osteomyelitis

• acute sinusitis → spreading infection

Pitfalls (often missed)

TMJ dysfunction

Migraine variants:

• facial migraine

• chronic paroxysmal hemicrania

Atypical facial pain

Eye disorders:

• glaucoma

• iritis

• optic neuritis

Chronic dental neuralgia

Facial bone diesease

Parotid gland: mumps, cancer, sialectasis, abscess

Acute glaucoma (upper face)

Cranial nerve neuralgias:

• post-herpetic neuralgia

• trigeminal neuralgia

• glossopharyngeal neuralgia

Masquerades checklist

Depression

Spinal dysfunction

Is the patient trying to tell me something?

Quite probably. Atypical facial pain has underlying psychogenic elements.

Key history

Diagnosis of virtually all types of facial pain must be based entirely on the history. Include the typical pain analysis, especially site and radiation.

Key examination

• Palpate the face and neck to include the parotid glands, eyes, regional lymph nodes and skin

• Inspect the TMJs and cervical spine

• Carefully inspect the nose, mouth (esp. each tooth), pharynx and postnasal space

• Inspect the sinuses with transillumination

• Perform a neurological examination of the cranial nerves

Key investigations

Referral may be appropriate. The association of tumours with neuralgias may have to be investigated. Radiological investigations to consider include:

• plain X-rays of the paranasal sinuses

• CT scans

• MRI

• orthopantomograms.

Diagnostic tips

• Facial pain never crosses the midline; bilateral pain means bilateral lesions.

• Malignancy must be excluded in the elderly with facial pain.

• Problems from the molar teeth, especially the third (wisdom) commonly presents with peri-auricular pain and pain in the posterior check.

• Don’t overdiagnose sinusitis: many URTIs may produce mild facial ache (vacuum effect).