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Facial Pain: Diagnosis and treatment. Ahmed M. Raslan, MD Assistant Professor Department of Neurological Surgery OHSU, Portland, OR, USA. Disclosure. None. Diagnosis of Facial Pain. Clinical ! Imaging. Classification of Facial Pain. Trigeminal distribution Other cranial Nerves.
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Facial Pain: Diagnosis and treatment Ahmed M. Raslan, MD Assistant Professor Department of Neurological Surgery OHSU, Portland, OR, USA
Disclosure • None
Diagnosis of Facial Pain • Clinical ! • Imaging
Classification of Facial Pain • Trigeminal distribution • Other cranial Nerves • Cluster • Migraine • TMJ
Classification of Facial Pain • TN1 • TN2 • Symptomatic • Neuropathic • Postherpetic • Deafferentation • Atypical • Rare syndromes • Trigeminal distribution • Other cranial Nerves
Classification of Facial Pain • Trigeminal distribution • Other cranial Nerves • Glossopharyngeal • NervusIntermedius • Ramsy-Hunt
Other Cranial Neuralgia • Unilateral • Throat pain • Syncope/ Swallow-syncope • Base of tongue-tonsillar fossa-angle of mandible, ear pain • Glossopharyngeal • NervusIntermedius • Ramsy-Hunt
Other Cranial Neuralgia • Unilateral • Sharp episodic pain deep in the EXTERNAL ear • Glossopharyngeal • NervusIntermedius • Ramsy-Hunt
Other Cranial Neuralgia • Glossopharyngeal • NervusIntermedius • Ramsy-Hunt • Sudden onset • Retroauricular and facial pain • Followed 2 days later by facial palsy • Vesicular eruptions ?
Classification of facial pain Burchiel K. A new classification of facial pain. Neurosurgery 53 (5) 2003: 1164-1176 Eller J, Raslan A, Burchiel K. Trigeminal Neuralgia: Definition and classification. Neurosurg Focus 18 (5) 2005: E3
1- TN1 • Represents the classic TN • Severe abrupt stabbing , electric or shock-like pains is the hallmark • Dull aching or burning pain is absent or present for less than 50 % of the time the patient experience the pain • Presence of pain free intervals • Straight forward diagnosis • May progress to TN2 ..?
2- TN2 • Still the patient experience sharp pains, but the hallmark is dull aching, burning pain or back ground pain that constitute more than 50 % of the time • Constant back ground pain is the most significant attribute with the absence of any structural abnormality
TN2 • Type A • Progressed from prior TN1 • Type B • Started de novo a TN2 ; ? Trigeminal ganaglion dysfunction
3- Symptomatic TN • Represents what is usually called secondary TN • There is another disease or diagnosis that causes demyelination of the trigeminal nerve • Trigeminal nerve can be still compressed and sometimes can be treated by treatment of the cause
4- Neuropathic TN • Patients complain of pain of constant nature, with areas of numbness as a hallmark • Due to un-intentional injury to the trigeminal nerve during surgery or trauma, could be spontaneous
5- Post Herpetic TN • Constitutes a severe form of neuropathy to the trigeminal nerve • Easily diagnosed by history of eruptions
6- Deafferentation facial painAnesthesia Dolorosa • Means “ Painful Anesthesia” • Doctors’ induced pain syndrome • Follows destructive procedures for trigeminal neualgia • Surgical rhizotomy • RF procedures, Balloon, rarely Glycerol • Radiosurgery • Very severe and difficult to treat
7- Atypical Facial Pain • We use this term to describe patients who complain of facial pain as a part of somatoform pain disorder • Can be diagnosed by Neuro-psychological evaluation • Patients usually describe the following symptoms • Bilateral pain, or pain that cross the midline • Pain outside the distribution of trigeminal nerve • Multiple complaints in multiple body parts • Patients often carries diagnoses like “chronic fatigue syndrome”, “Fibromyalgia” . • Surgical treatment is contra-indicated
Non- Ablative Possibly Curative MVD Modulation of Pain MCS Trigeminal Stimulation DBS Vent. Opioids Ablative Surgical Rhizotomy Caudalis DREZ Percutanous RF Rhizotomy Balloon Glycerol Tractotomy Radiosurgical Gamma Knife Lin-Ac Surgical Management of Facial Pain
