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FACIAL NEUROPATHOLOGY

FACIAL NEUROPATHOLOGY. OROFACIAL PAIN. NOCICEPTORS:1-5MM DIAMETER NERVE FIBERS. A-DELTA: Responsible for temperature and fast or first pain. Faster Conduction velocity is 12-45 m/sec Myelinated. C-FIBERS: Responsible for slow or second pain, and temperature. Is unmyelinated

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FACIAL NEUROPATHOLOGY

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  1. FACIAL NEUROPATHOLOGY OROFACIAL PAIN

  2. NOCICEPTORS:1-5MM DIAMETER NERVE FIBERS.

  3. A-DELTA: Responsible for temperature and fast or first pain. Faster Conduction velocity is 12-45 m/sec Myelinated C-FIBERS: Responsible for slow or second pain, and temperature. Is unmyelinated Much slower Conduction velocity is 0.2-2.0 m/sec Odontogenic pain from pulp is associated with this PAIN FIBERS(PERIPHERAL NERVE FIBERS)

  4. TYPES OF CUTANEOUS PAIN • 1. Pricking pain, which is felt rapidly. It is felt that pricking pain is mediated by A-delta fibers. A fibers also conduct touch, warmth, and cold • When you first feel the stick from a needle • 2. Dull, aching sometimes burning pain, which is mediated by C fibers. C fibers also conduct itch, warmth, and cold

  5. THE TRIGEMINAL SYSTEM • All sensory input from the face and mouth is carried by V (trigeminal). • Cell bodies of the trigeminal afferent neurons are located in the gasserian ganglion • Impulses carried by V enter directly into brainstem(pons) and synapse in the trigeminal spinal tract nucleus • Spinal tract nucleus responsible in most cases in significant pain

  6. SPINAL TRACT NUCLEUS • Divided into 3 parts: A. the subnucleus oralis Significant for association with oral pain mechanisms B. the subnucleus interpolaris C. the subnucleus caudalis-predominates in trigeminal nociception

  7. PRIMARY NEUROTRANSMITTERS FOR PAIN TRANSMISSION Glutamate - an amino acid Substance P – a peptide

  8. TISSUE INJURY:causes K+, bradykinin and arachidonic acid release

  9. Release of Substance P cause release of histamine and serotonin(5HT), and more bradykinin

  10. Release of substance P, histamine, serotonin initiate more nociception

  11. PAIN EXPERIENCE • Involves the psychologic (past experiences, cultural behaviors and emotional state) and • Physiologic aspects(involves the transduction,transmission and modulation of pain) • The experience of pain is linked to emotional,behavioral, and cognitive phenomena

  12. EVALUATION OF MAXILLOFACIAL PAINSENSORY DYSFUNCTION • Obtain a chief complaint and include onset, clinical course since onset, intensity and location • Ask for assessment by the pt for objective/subjective descriptors i.e. is dysfunction intermittent/continuous; character of pain (throbbing, deep, area/face feel wooden); does it occur in relation to other functions (with function or spontaneous); precipitants or reliever of sxs; associated sxs etc

  13. Numb Tingling Wet Rubbery Stretched Swollen Crawling Itching Prickling Electric You have blood flow but you have transmission that is affected Tender Painful Burning Very problematic because it is hyperalgesia If it gets here you will probably have to section the nerve to make it stop If you don’t you will probably have to put the patient on anti-seizure medications to make it stop DESCRIPTORS OF ALTERED SENSATION

  14. EVALUATE CRANIAL NERVES

  15. INSPECTION / EXAMINATION • Skin changes in color or texture • More pitted and more pallor • Atrophic changes • Iatrogenic induced trauma • If the patient is numb the will probably have areas where they have bit their tongue • Decreased/altered taste (affected lingual nerve), difficulty in chewing • Difficulty in speaking or facial animation • Difficulty speaking is usually associated with the lingual nerve

  16. AXIS I (PHYSICAL CONDITIONS) • Cutaneous and mucogingival pains • Mucosal pains of the pharynx, nose, and paranasal sinuses • Pains of the musculoskel. Structures of the mouth/face • Pains of the visceral structures of mouth/face • Pains of the neural structures of mouth/face

  17. AXIS II (PSYCHOLOGIC CONDITIONS) • Anxiety disorders • Mood disorders • Somatoform disorders • Other conditions, such as psychologic factors affecting a medical condition PSYCHOLOGIC INTENSIFICATION OF PAIN

  18. FACIAL NEURALGIAS • Trigeminal Neuralgia • Glossopharyngeal Neuralgia • Geniculate Neuralgia • Superior Laryngeal Neuralgia • Occipital Neuralgia

  19. NEURALGIA: Defined as paroxysmal, intermittent pain confined to specific nerve branches

  20. Characterized by severe recurrent episodic attacks of unilateral pain distributed over a branch or, after many years, more than one branch of V. Associated with trigger zones Incidence per 100,000: 2.7 men and 5.0 for women Pain usu. in V-2 or V-3 in 60% of pts. More often on Rt side of body 70% of pts over the age of 50 TRIGEMINAL NEURALGIA

  21. KEY: No sensory/motor loss Everything is intact Compression or distortion of the nerve root by an aberrant arterial loop 2-4% of cases of TN have MS TX: 1.Anti-Epileptic Drugs: Gabapentin,baclo- fen,lamotrigine,carbamazepine,oxcarbamazepine 2.SURG:Radiofrequency thermolysis, Microvascular nerve root decompression (requires opening up of the skull),Gam- ma knife radiation TRIGEMINAL NEURALGIA

  22. VASOGLOSSOPHARYNGEAL NEURALGIA • Rarer than trigeminal neuralgia • Charac. by unilateral paroxysmal stabbing pain in the posterior 1/3 of the tongue, pharynx,larynx, and soft palate. Cranial nn IX & X involved • Pain assd. with trigger zone, talking and swallowing usual stimulus • Bradycardia, hypoten., and syncope seen from activation of X • Tx: tegretol or phenytoin, topical anesthesia of pharyngeal mucosa

  23. POST-ZOSTER NEURALGIARAMSAY HUNT SYNDROME • Herpes zoster is a self-limiting dz • M=F in frequency; 65% over age 70n • Syndrome arises from geniculate gangliositis. This results in a)facial paralysis, b)loss of taste of anterior 2/3 of tongue , c)loss of lacrimation, d)vesicular eruption of the external ear and e)severe pain in EAC

  24. RAMSAY HUNT CON,T • Pain in the ear is severe and paroxysmal • Pain persists for weeks to years after eruption disappears • Herpes zoster (shingles) is the consequence of reactivation of the latent varicella-zoster(also causes chickenpox) virus.

  25. POSTHERPETIC NEURALGIA-TRIGEMINAL GANGLIA • Similar syndrome as Ramsay Hunt except inflammation of the trigeminal ganglion by herpes zoster. • The dermatomal distribution is now associated with V-1, V-2, or V-3, and is associated with viral reactivation • 10-15% of cases, reactivation is in the ophthalmic division (ophthalmic zoster)

  26. POST HERPETIC NEURALGIA • TX:Acyclovir, famciclovir, or valaciclovir. Result in more rapid resolution of cutaneous lesions and decreased viral shedding. Famciclovir associated with accelerated resolution of postherpetic neuralgia

  27. SUPERIOR LARYNGEAL NEURALGIA • The superior laryngeal nerve is a br. of the Vagus, innervates the cricothyroid muscle. Will see periodic, unilateral submandibular pain radiating through eye, ear, and shoulder. Similar to IX neuralgia • Provoked by swallow/turn of the head/sneezing/yawning/nose blowing

  28. OCCIPITAL NEURALGIA • The greater occipital nerve is a continuation of the C2 nerve and innervates the posterior scalp. • Will feel paroxysmal pain in posterior occipital region and cervical region

  29. ATYPICAL FACIAL PAIN • Usually is a dx. of exclusion • Pain does not follow anatomic distribution of the Trigeminal nerve, crosses the midline and not limited to sensory distribution of a single nerve • More common than trigeminal neuralgia • 4th-5th decade; F>M; classified as a)psychogenic b)organic c)indeterminate

  30. HEADACHES • Types: 1) Tension a)episodic or b)chronic. The chronic type may have a duration of 5 years or longer in 75% of pts. Tx with antidepressants(tricyclic)or NSAIADs 2)Vascular a)Migraines:paroxysmal headache lasting 24-72 hrs, usually unilateral. Frequency variable and aura or prodrome may precede

  31. HEADACHES CON’T • 2-a) Migraines con’t: 80% of pts with family history. In childhood M>F, but after menarche F>M. Tx with compression of temporal artery, cold compress, biofeedback,narcotics. 2-b: Cluster also called Horton’s headache. 8X more common in men. May see family aggregation. Last from 15 min to 2 hrs but may occur 5-10x a day, periorbital in location and unilateral. Tx:Lithium, O2, intranasal lidocaine spray

  32. HEADACHE CON’T • 3)Temporal arteritis, is an inflammation of medium- and large-sized arteries. Usually involves a branch of the carotid artery, but is a systemic dz, and may involve arteries in multiple locations. Occurs over the age of 55, F>M, and associated with polymyalgia rheumatica. Complex of fever,anemia, high ESR and HA. Tx with steroids.

  33. TRAUMATIC NERVE INJURIES

  34. NERVE INJURIES-CAUSATION • Inferior alveolar: Fractures of mandible, BSSO, 3rd molar removal, resection of mand.,preprosthetic surgery, implant- nerve repositioning procedures • Lingual: 3rd molar removal, resection, salivary gl. Removal, fracture and repair of mand. Angle fxs

  35. NERVE INJURY CLASSIFICATION • Seddon: neuropraxia, axonotmesis, and neurotmesis • Sunderland: 1st through 5th degree

  36. PATIENT EXAMINATION

  37. PATIENT EXAM CON’T

  38. PATIENT EXAM CON’T

  39. MAPPING

  40. PIN PRESSURE NOCICEPTION

  41. THERMAL DISCRIMINATION

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