Trigeminal Nueralgia: Journal Review

1. Sumabat, Arrantxa Danielle M. , DMD
Resident, Oral & Maxillofacial Surgery Department
Craniofacial Foundation of the Philippines

2. Trigeminal Neuralgia
 Also known as “ Tic douloureux”
 is a long-term condition - a
chronic condition - which usually
gets gradually worse
 Its a nueropathic pain that is
described as sharp, shooting or
lancinating that may last from
seconds or few minutes.
 Pain is triggered by soft touch of
the lips and cheeks, a gentle
breeze, jarring action of walking
and mouth opening.
 Women more commonly affected
 Mostly between ages 50 - 70

3. Trigeminal
Neuralgia
 Etiology: unknown
 Theories had been proposed
such as:
○ Degeneration or gross
abnormality of the myelin
sheath
○ Extrinsic pressure against the
nerve or ganglion (such as
arteriovenous malformations,
or slow growing tumors)
○ Bony cavities in the jaws due
to lost of dentition
○ Family history (genes,
inherited) - 4.1% of patients
with unilateral trigeminal
neuralgia and 17% of those
with bilateral trigeminal
neuralgia have close relatives
with the disorder.

4. Trigerminal Neuralgia
 Tic douleroux – used in reference with
symptomatic symptoms (sharp, shooting pain,
etc.)
 Trigerminal nueralgia – depicts both diagnostic
symptom complex and specific nerve involve.
1. electric shock like, brief, stabbing pains
2. pain-free intervals between attacks
3. unilateral pain during any one attack
4. pain of abrupt onset & abrupt termination
5. minimal or no sensory loss in the trigeminal distribution
6. pain triggered by ipsilateral soft sensory stimulation
and frequently perioral region

5. Trigerminal
Neuralgia
• 2 types
• Typical
Trigeminal
Neuralgia
• Atypical
Trigeminal
neuralgia

6. Diagnosis: signs & symptoms
 Other conditions that might be mistaken
as trigeminal neuralgia:
 Myofacial pain – constant radiating pain with
flactuation in pain
 Atypical facial

7. Treatment:
 Medications
 Anticonvulsants
○ Carbamazepine (Tegretol,Carbatrol) 200mg – 800mg
○ Phenytoin (Dilantin, Phenytek) 200 mg – 300 mg
○ Oxcarbazepine (Trileptal).
○ Others: Lamictal / Nuerotin
 Antispasticity agents
○ Baclofen

8. Treatment:
 Medication
 Local Anesthetic
○ 2% lidocaine with 1:100,000 epinephrine (Xylocaine)
○ 2% Mepivacaine (Carbocaine) with 1:20,000
levonordephrine (Neo-Cobrfrin)
○ LA 0.5% Bupivacaine (Marcaine) with 1:20,000
epinephrine
 Alcohol Injection
** Injected into the peripheral nerve branches that
may provide temporary relief.

9. Treatment:
 Surgical
 Microvascular decompression
(MVD)
- this involves relocating or
removing the blood vessel which
is pressing against the trigeminal
nerve - at its root - and
separating the nerve root and
blood vessels.
- 20% pain recurrence in 10 yrs.
 Percutaneous glycerol
rhizotomy (PGR)
- also called glycerol injection.
- commonly used in elderly,
without anaesthesia dolorosa
- 50% of patients experience
pain recurrence within 3 to 4
years

10. Treatment
 Surgical
 PBCTN (percutaneous balloon
compression of the trigeminal
nerve)
- The pressure from the balloon
damages the nerve and blocks
pain signals.
- 20% of patients experience pain
recurrence within 3 years
 PSRTR (Percutaneous
stereotactic radiofrequency
thermal rhizotomy)
- electric currents to destroy
specifically selected nerve fibers
linked to pain
- 20% of patients experience pain
recurrence within 15 years

11. Treatment:
 Surgical
 PSR (partial sensory
rhizotomy)
- part of the trigeminal
nerve at the base of the
brain is severed (cut).
 GKR (gamma-knife
radiosurgery)
- a high dose of radiation is
aimed at the root of the
trigeminal nerve and
destroys it.
- 50% of patients, pain
recurs 3 to 5 years after
treatment

12. References:
 Br J Neurosurg. 2011 Apr;25(2):268-72. doi:
10.3109/02688697.2011.558946.Percutaneous glycerol
rhizotomy for trigeminal neuralgia: safety and efficacy
of repeat procedures.Harries AM, Mitchell RD.
 Taha JM, Tew JM Jr: Comparison of surgical treatments for
trigeminal neuralgia: Reevaluation of radiofrequency
rhizotomy. Neurosurgery 38:865-871, 1996
 Tew JM: Therapeutic Decisions in Facial Pain. Clinical
Neurosurgery 46:410-431, 2000
 Gronseth G, et al.: Practice Parameter: The diagnostic
evaluation and treatment of trigeminal neuralgia (an
evidence-based review). Neurology 71:1183-90, 2008

13. Case Report
 44 yr old black woman sought treatment
in the university emergency dental clinic
for pain in the mandibular right region.
 Palliative treatment was given:
 Mandibular block (carbocaine) with
levonordefrin (neo- Cobefrin) 1:20,000 and
800 mg of ibuprofen orally

14. Chief Complaint
 Px described a sharp, shooting, electric-
shock like pain that started in the right
posterior mandible region and preceded
to the ear after which there was severe
pain in her cheek and jaw.

15. Hx of Chief Complaint
 Pain started nine months previously and was
confined on the soft tissue area buccal to the
mandibular right first molar (# 30)
 After a month the tooth # 30 was extracted
 During the next 4 months, there were episodes of
pain, so a bridge on tooth #29 and #31 was placed
 3 weeks later, symptoms started again and px was
referred to an endodontic treatment on tooth #31
 2 weeks later, the pain returned and px was placed
on Penicillin (500mg 3x daily)- with no relief

16. Medical History
 Px had history of normal childhood diseases
 She had hysterectomy without complications
 Recent symptomatology included
 Marked weight change
 Night sweats
 Sore gingival tissue
 Dental problems
 Swelling of the ankles
 Difficulty in swallowing due to the pain
 Joint pains
 Depression (secondary to the pain)

17. Social History
 Has 6 siblings
 Divorced
 Has two children (21 and 22 yrs old)
 She said she is reasonably happy with
her job as a hospital procurement
assistant.

18. Clinical Examination
 Px was well- developed, slightly obese black woman with
no abnormal facial asymmetry nor skin abnormalities.
 Superfacial temporal arteries were within normal limits and
palpation pressure did not alter pain sensations.
 The right masseter, lateral pterygoid region and insertion of
the temporalis at the coronoid were extremely tender to
palpation
 TMJ exhibit normal range of motion
 Percussion to teeth or palpations on the apices didn’t
produce dental pain.
 No intraoral lesions were noted
 Palpation to the R cheek elicited a small area of extreme
sensitivity just adjacent to the region of teeth #30.

19. Initial Diagnosis
 Trigerminal Nueralgia with concomitant
myofacial pain.
 Treatment:
○ Px was given phenytoin (dilantin, 100mg 2x
daily)
○ Promethazine hydrochloride

20. Clinical Course
 Five days later, there is a dramatic decrease in
pain and no problems with medication. The
trigger zone was slightly active. The phenytoin
was increased to a dosage of 300mg per day.
 3 weeks later she reported that the pain had
returned and she got her bridge removed and
had her #31 extracted.
 Clinical examinations revealed inflammation,
swelling, and odor in the alveolus of the extracted
tooth.
 Histologic examination: cortical and bone marrow
infiltration by numerous small basophilic cells,
probably lymphocytes.

21. Clinical Course
 2 days after the biopsy she was rushed in the
emergency room and received an IAN block.
 3 days after that she returned to the oral surgery
clinic and was given another block with
bupivacaine.
 Treatment consisted of a stellate ganglion block
and prescription of carbamezepine
(tegretol,100mg 2x a day) – this had given her
excellent relief and partial continual pain
reduction while other therapies are being
considered.

22. 7th Cranial Nerve: Bell’s Palsy

23. Bell’s Palsy
• Also know as “idiopathic
facial paralysis”
• most common facial nerve
disease and one of most
common cause of facial
asymmetry
• Incidence rate: 23 per
100,000 on general
population; higher in
diabetic pxs and pregnant
women

24. Bell’s Palsy
 Etiology: unknown
 Predisposing factors:
 Cold-induced nerve damage (secondary to cold draft) with
swelling or edema of the nerve
 Allergic reactions
 Trauma
 Neoplasms
 Toxic Bacterial infections
 Facial nerve schemia
 Autoimmune disorders
 Viruses (HSV1, Herpes Zoster, Epstein Barr virus & HIV –
I)

25. Diagnosis and Differential
Diagnosis
 Usually diagnosed based on clinical findings
 Half of the cases, the typical hx includes viral
prodrome
 Often foll0wed 7-14 days later by post auricular
pain
 Pain often precedes neurological signs &
symptoms
 In other 50 – 60% there is no prodorme and
unilateral facial paralysis occurs suddenly

26. Bell’s Phenomenon

27. Criteria for diagnosis
1. Sudden onset of complete or partial
paralysis of muscles supplied by the
seventh cranial nerve
2. Absence of other signs and symptoms of
CNS dse
3. Absence of disease of the middle ear or
posterior cranial fossa
4. Absence of (geniculate) herpes zoster
oticus, known as Ramsey Hunt Syndrome

28. Electrodiagnostic Test
 Electromyography
 Electronuerography (EnoG)
 Reheobase and chronaxie

29. Other examinations
 Taste stimulation using
sugar, saline, citic acid
solutions
 Gustometry
 Schimer’s test
 1.5 cm normal
 Stapedius reflex
 Otoscopy (mandatory)
 Opththalmoscopy

30. Diagnostic Test for Idiopathic
facial paralysis
 2 hours postprandial glucose
determination
 To exclude diabetes mellitus and HIV -1
 Serology Test
 In pxs with high risk of AIDS

31. Clinical Findings in Bell’s Palsy
(Decreasing frequency from top to bottom)
Facial distortion
Facial Discomfort/dysesthesia
Epiphora
Dysguesia
Facial and retrobulbar pain
Hyperacausia
Trigerminal motor weakness/TMJ syndrome
Decrease tearing
Drooling
Corneal Irritation
Other Problems

32.  Corticosteroids
 Dosage
○ Adult dose for prednisone: 1mg/kg/day
○ McArthur: 60mg daily for 4 days and reduced
gradually for the next two weeks
 If paralysis is complete: 60mg for 2 weeks and then
tapered off
○ Another Variation:
 60mg divided dosage (morning/evening) for 4 days,
reducing dose of 5mg everyday until a dose of 5mg is
reached
Management

33.  Eye care
 Prevention of corneal damage by using artificial tears
(hydroxypropyl methylcellulose drops)
 Patching / covering eyes
 Use of bland protective ophthalmic ointment at night
 Use of steroids around the eyes is contraindicated
 Physical/Rehabilitative therapy
1. Infrared heat to relieve pain and assist in resorption of the
products of inflammation
2. Electrical stimulation
3. Facial massage and myofacial exercise
4. Biofeedback
 Persistent Pain Management
 Steroids
 Carbamazepine (tegretol)
○ Dosage: 200 – 1200 mg/day
 Surgical decompression of the facial nerve
Management

34. Complications
 80% can expect complete recovery
 20% may experience some chronic
complications
 Cawthorne, Kettle and Sullivan
“Recovery is never seen when there is no signs of
beginning recovery at the end of two months”

35. Common chronic complications
1. Synkinesias
2. Contracture of facial muscle
3. Inappropriate excessive tearing on
eating (crocodile tears)
4. Complete failure to recover

36. CASE REPORT
 25 yr old female referred to neurology section of the
Out Patient Department of the UERMMC
 Chief Complaint:
○ Facial Asymmetry
 HPI:
○ Condition started 2 days prior to consultation with a sandy
feeling and flickering sensation on her right eye lids
○ A day later experienced numbness on the right side of her face
which was followed 4 hours later by facial distortion and
drowsy-looking eyes. Some difficulty of speech no loss of
vision and any irritation in the eye.
 Past Medical History:
○ Unremarkable
 Clinical Examination:
○ Right sided asymmetry and inadequate closure of right eyelid
○ Physical examination was essentially normal

37. CASE REPORT
 25 yr old female referred to neurology section of the
Out Patient Department of the UERMMC
 Initial Diagnosis
○ Bell’s Palsy
 Treatment
○ Artificial tears (methylcellulose) 1 drop hourly/ as needed
○ Right eyelid to be closed with micropore at bedtime
○ Prednisone 30mg for 3 days, which was then tapered off for
the next 10 days
○ Antacids
 Follow – Up
○ 10 days after revealed marked improvement with px’s chance
of full recovery being excellent

38. CASE REPORT
 29 year old male was referred to the neurology section of the Out-Oatient
Department of UERMMC
 Chief Complaint
○ Facial Palsy
 HPI:
○ Started 4 days ago prior to consultationwhen he suddenly felt a nape & occipital pains, with
intense pain posterior to his pinna
○ 2 days later, he noticed right side of his face was immobile and saliva would occasionally
drip from the right side of his mouth, partial loss of taste was noted
○ A day later he consulted a physician and was given (amoxicillin 500mg q 8h) and vitamin B
complex (Neurobion 1 tab/day)
 Past – Medical History:
○ unremarkable
 Treatment :
○ Prednisone: initial dose of 60mg divided into two doses and was tapered off gradually for
next 11 days.
○ Antacids
○ Eye care (eye drops)
○ Referred to rehabilitation department for physiotherapy
 Follow – Up
○ Revealed an improvement with good prognosis