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FACIAL PAIN AND HEADACHE INTRODUCTION Patients with facial pain are frequently referred to ENT Patients with facial pain are frequently referred to ENT.

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Presentation on theme: "FACIAL PAIN AND HEADACHE INTRODUCTION Patients with facial pain are frequently referred to ENT Patients with facial pain are frequently referred to ENT."— Presentation transcript:

1

2 FACIAL PAIN AND HEADACHE

3 INTRODUCTION Patients with facial pain are frequently referred to ENT Patients with facial pain are frequently referred to ENT Most have initial diagnosis of sinusitis Most have initial diagnosis of sinusitis In reality few have sinogenic pain In reality few have sinogenic pain

4 SINONASAL INNERVATION Sinonasal mucosa innervated by ophthalmic and maxillary division of trigeminal nerve Sinonasal mucosa innervated by ophthalmic and maxillary division of trigeminal nerve Minor contribution by greater superficial petrosal branch of facial nerve Minor contribution by greater superficial petrosal branch of facial nerve Ostiomeatal complex > turbinates > septum > sinus mucosa (order of sensitivity to pain) Ostiomeatal complex > turbinates > septum > sinus mucosa (order of sensitivity to pain)

5 FRONTAL SINUS Ophthalmic branch of trigeminal nerve Pain referred to forehead and anterior cranial fossa

6 ANTERIOR ETHMOIDAL SINUS Innervated by ophtalmic division of trigeminal via anterior ethmoidal nerve (an offshoot of nasociliary nerve) Innervated by ophtalmic division of trigeminal via anterior ethmoidal nerve (an offshoot of nasociliary nerve)

7 POSTERIOR ETHMOIDAL AND SPHENOID SINUS Maxillary division of trigeminal nerve through posterior ethmoidal nerve Maxillary division of trigeminal nerve through posterior ethmoidal nerve Ophthalmic division of trigeminal nerve Ophthalmic division of trigeminal nerve Greater superficial petrosal nerve Greater superficial petrosal nerve

8 MAXILLARY SINUS Maxillary division of trigeminal nerve Maxillary division of trigeminal nerve Posterior superior alveolar nerve Posterior superior alveolar nerve Infraorbital Infraorbital Anterior superior alveolar Anterior superior alveolar

9 Pain afferents Majority of painful stimuli from face are transmitted via afferents in the trigeminal nerve Majority of painful stimuli from face are transmitted via afferents in the trigeminal nerve Rest through 7, 8,9 and 10 th nerves Rest through 7, 8,9 and 10 th nerves Facial pain from deep structures dull due to unmyelinated afferent nerves Facial pain from deep structures dull due to unmyelinated afferent nerves From superficial structures, it is sharp due to myelinated fibers From superficial structures, it is sharp due to myelinated fibers

10 CLASSIFICATION Rhinological pain Rhinological pain Sinusitis Sinusitis Post trauma or surgery Post trauma or surgery Dental pain Dental pain Painful teeth Painful teeth Phantom tooth pain Phantom tooth pain TM joint dysfunction TM joint dysfunction Myofascial pain Myofascial pain

11 CLASSIFICATION Vascular pain Vascular pain Migraine Migraine Cluster headache Cluster headache Paroxysmal hemicrania Paroxysmal hemicrania Temporal arteritis Temporal arteritis Sluders neuralgia Sluders neuralgia Neuralgias Neuralgias Trigeminal neuralgia Trigeminal neuralgia Glossopharyngeal neuralgia Glossopharyngeal neuralgia Postherpetic neuralgia Postherpetic neuralgia

12 CLASSIFICATION Misc Misc Pain caused by tumours Pain caused by tumours Tension type headache Tension type headache Midfacial segmental pain Midfacial segmental pain Atypical facial pain Atypical facial pain

13 HISTORY Where is the pain and does it radiate? Where is the pain and does it radiate? Is the pain continuous or intermittent? Is the pain continuous or intermittent? Character of the pain? Character of the pain? Precipitating factors? Precipitating factors? Relieving factors? Relieving factors? Effect on daily life? Effect on daily life?

14 PAST MEDICAL HISTORY Head injuries, infections, surgeries? Head injuries, infections, surgeries? Psychiatric illness? Psychiatric illness? Alcohol, tobacco use? Alcohol, tobacco use? Medications? Medications? Oral contraceptives Oral contraceptives Antihypertensive Antihypertensive Herbal medications Herbal medications

15 EXAMINATION General physical examination General physical examination Complete head and neck examination Complete head and neck examination TMJ & muscles of mastication TMJ & muscles of mastication Trigger points Trigger points Neurological examination Neurological examination

16 SINUSITIS In acute sinusitis there is nasal obstruction, rhinorrhoea, facial pain in association with URTI In acute sinusitis there is nasal obstruction, rhinorrhoea, facial pain in association with URTI Chronic sinusitis often painless except during acute exacerbations Chronic sinusitis often painless except during acute exacerbations Pain often unilateral and dull and increases in intensity on bending forward Pain often unilateral and dull and increases in intensity on bending forward

17 PAINFUL TEETH Offending tooth is painful to percussion Offending tooth is painful to percussion Can radiate to surrounding structures and opposite jaw Can radiate to surrounding structures and opposite jaw

18 TMJ DYSFUNCTION May be localized to the joint or extend over the periauricular area extending to the temporoparietal and cervical regions May be localized to the joint or extend over the periauricular area extending to the temporoparietal and cervical regions May present with deep otalgia May present with deep otalgia Chewing exacerbates pain Chewing exacerbates pain TMJ and surrounding muscles may be tender on direct palpation TMJ and surrounding muscles may be tender on direct palpation

19 MYOFASCIAL PAIN Five times more common in post menopausal women and strong association with stress Five times more common in post menopausal women and strong association with stress Poorly defined aching in the neck, jaw and ear Poorly defined aching in the neck, jaw and ear Tender points in the sternocleidomastoid and trapezius muscles Tender points in the sternocleidomastoid and trapezius muscles

20 MIGRAINE Aura precedes onset of headache Aura precedes onset of headache Visual disturbances Visual disturbances Unusual tastes and aromas Unusual tastes and aromas Throbbing unilateral pain Throbbing unilateral pain Can last upto 72 hours Can last upto 72 hours Trigger factors Trigger factors Various foods Various foods Sleep disturbance Sleep disturbance Withdrawal of stress Withdrawal of stress (Saturday morning headaches) (Saturday morning headaches)

21 CLUSTER HEADACHE Typically affects men yrs old Typically affects men yrs old Pain is commonly frontal, temporal,extends over the cheeck or even into the teeth Pain is commonly frontal, temporal,extends over the cheeck or even into the teeth There may be lacrimation, rhinorrhoea and nasal obstruction There may be lacrimation, rhinorrhoea and nasal obstruction Distressing throbbing pain that wakes patient up Distressing throbbing pain that wakes patient up Feel like banging their head against a wall Feel like banging their head against a wall Lasts for 15 mins to 3 hours Lasts for 15 mins to 3 hours

22 SLUDERS NEURALGIA Vascular origin Vascular origin A collective group of neuralgic, motor,sensory and gustatory symptoms and signs including facial pain A collective group of neuralgic, motor,sensory and gustatory symptoms and signs including facial pain Caused by inflammation of sphenopalatine ganglion and mucosal contact with the lateral nasal wall causing facial pain Caused by inflammation of sphenopalatine ganglion and mucosal contact with the lateral nasal wall causing facial pain

23 Trigeminal neuralgia Paroxysms of severe lancinating pain induced by a specific trigger point Paroxysms of severe lancinating pain induced by a specific trigger point In more than one third pain arises in both the maxillary and mandibular divisions In more than one third pain arises in both the maxillary and mandibular divisions One fifth is confined to the maxillary division One fifth is confined to the maxillary division In small number ophthalmic division affected In small number ophthalmic division affected

24 TRIGEMINAL NEURALGIA Typical trigger points are lips and nasolabial folds Typical trigger points are lips and nasolabial folds May also be triggered by touching the gingivae May also be triggered by touching the gingivae Flush over the face Flush over the face Remissions are common Remissions are common

25 TENSION TYPE HEADACHE Feeling of thightness, pressure or constriction which varies in intensity, frequency and duration Feeling of thightness, pressure or constriction which varies in intensity, frequency and duration May be at vertex,eyes or temple and often an occipital component May be at vertex,eyes or temple and often an occipital component Usually present on waking Usually present on waking Does not worsen with routine physical activity Does not worsen with routine physical activity Rarely interferes with patient getting to sleep Rarely interferes with patient getting to sleep

26 MIDFACIAL SEGMENT PAIN Similar to tension type headache except that symmetrical facial pain involves the midface and retro-orbital region Similar to tension type headache except that symmetrical facial pain involves the midface and retro-orbital region Hyperaesthesia of the skin and soft tissues in the area affected Hyperaesthesia of the skin and soft tissues in the area affected Pain lasts for hours on daily basis Pain lasts for hours on daily basis Pain reduces in stress free environment (weekends) Pain reduces in stress free environment (weekends)

27 ATYPICAL FACIAL PAIN Diagnosis of exclusion Diagnosis of exclusion History often vague and inconsistent History often vague and inconsistent Pain moves from one part of face to other between different consultations Pain moves from one part of face to other between different consultations Feeling of Mucus moving in the sinuses Feeling of Mucus moving in the sinuses Patients have completely fixed ideas about their condition Patients have completely fixed ideas about their condition History of depression and significant psychological disturbance History of depression and significant psychological disturbance

28 SUMMARY History taking key to accurate diagnosis History taking key to accurate diagnosis Sinusitis is a rare cause of chronic facial pain and most patients with facial pain do not warrant surgery Sinusitis is a rare cause of chronic facial pain and most patients with facial pain do not warrant surgery Sinogenic pain is intermittent and associated with rhinological symptoms Sinogenic pain is intermittent and associated with rhinological symptoms Sinus mucosal thickening on a CT scan does not indicate that pain is sinogenic Sinus mucosal thickening on a CT scan does not indicate that pain is sinogenic

29 SUMMARY Vascular pain such as migraine and cluster headaches can cause rhinorrhoea and nasal congestion Vascular pain such as migraine and cluster headaches can cause rhinorrhoea and nasal congestion Many patients with chronic facial pain benefit from the appropriate neurological medication Many patients with chronic facial pain benefit from the appropriate neurological medication

30 THANK YOU

31 Questions??


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