trigeminal neuralgia and facial palsy

1. TRIGEMINAL
NEURALGIA
AND
FACIAL PALSY
BY: DR. KOMAL MADAAN

2. CONTENTS
1. NEURALGIA 2. TRIGEMINAL NEURALGIA
 DEFINITION
 CLASSIFICATION
 CAUSES
 TRIGEMINAL NERVE
 INTRODUCTION
 DEFINITION
 HISTORICAL REVIEW
 HISTORY, CULTURE&
SOCIETY
 TIC DOULOUREUX
 ETIOLOGY
 PATHOGENESIS
 TYPES
 GENERAL
CHARACTERISTICS
 CLINICAL
CHARACTERISTICS
 DIAGNOSIS

3. 3. FACIAL PALSY
 FACIAL NERVE
 INTRODUCTION
 DEFINITION
 HISTORICAL REVIEW
 ETIOLOGY
 ASSOCIATED SYNDROME
 CLASSIFICATION
 GENERAL CHARACTERISTICS
 SIGN AND SYMPTOM
 DIAGNOSIS
 DIFFERENTIAL DIAGNOSIS
 TREATMENT
 CONCLUSION

5. DEFINITION:
Neuralgia (Greek neuron, "nerve" +
algos, "pain") is pain in the distribution
of a nerve or nerves, as in intercostal
neuralgia, trigeminal neuralgia, and
glossopharyngeal neuralgia

6. CLASSIFICATION:
Under the general heading of neuralgia
are:
 Trigeminal neuralgia
 Occipital neuralgia
 Glossopharyngeal neuralgia
 Postherpetic neuralgia
 Intercostal neuralgia

7. 1.TRIGEMINAL NEURALGIA
• most debilitating form of neuralgia
affecting the sensory branches of 5th
C.N.
• Disorder of peripheral or central fibres
of TN
• in this there is sudden usually
unilateral, severe, brief, stabbing,
lancinating, recurring pain in the
distribution of one or more branches of
TN

8. 2. OCCIPITAL NEURALGIA
 also known as C2 neuralgia or Amold’s Neuralgia
 a medical condition characterized by chronic pain in the
upper neck, back of the head and behind the eyes.

9. 3. GLOSSOPHARYNGEAL
NEURALGIA
 consist of recurring attack of severe pain in the back of the
throat, the area near the tonsils, the back of the tongue, and
part of the ear.
 The pain is due to malfunction of the glossopharyngeal nerve
(CN IX), which moves the muscles of the throat and carries
information from the throat, tonsils, and tongue to the brain

10. 4. POSTHERPETIC NEURALGIA:
- occurs as complication of shingles. Shingles is a viral
infection characterised by painful rash and blisters.
- Neuralgia can occur wherever the outbreak of shingles
occurred. Can be mild, severe, persistant or intermittent.

11. 5. INTERCOSTAL NEURALGIA
 rare condition causes pain along the
intercostal nerve located in between
ribs.
 Common causes of neuralgia include
pregnancy, tumors, chest or rib injury,
surgery to chest or organs in the chest
cavity and shingles.

12. CAUSES:
- main cause is damage to nerve leading to demyelination of nerve
leading to stabbing, severe, shock like pain of neuralgia results.
FACTORS CAUSING DAMAGE ARE-
 Old age
 Infection( postherpetic neuralgia)
 Multiple sclerosis
 Pressure on nerves
 Diabetes

13. TRIGEMINAL NEURALGIA
( TIC DOULOUREUX,
TRIFACIAL NEURALGIA,
FOTHERGILL’S
NEURALGIA)

14. TRIGEMINAL NERVE

15. INTRODUCTION:
 It is the most debilitating form of
neuralgia that affects the sensory
branches of the Vth cranial nerve.
 It is a disorder of the peripheral or
central fibres of the trigeminal nerve in
which the dominant symptom is pain
in the anterior half of the head.

16. DEFINITION:
 It is defined as sudden, usually unilateral, severe,
brief, stabbing, lancinating, recurring pain in the
distribution of one or more branches of the Vth
cranial nerve
 Trigeminal neuralgia also known as prosopalgia or
fothergill’s disease is aneuropathic disorder
characterized by episodes of intense pain in the
face, originating from trigeminal nerve

17. HISTORICAL REVIEW:
 JOHN LOCKE in 1677 gave the first full
description with its treatment
 NICHOLAS ANDRE in 1756 coined the term
‘Tic Doloureux
 JOHN FOTHERGILL in 1773 published detailed
description of trigeminal neuralgia

18. HISTORY, CULTURE & SOCIETY
 TN has been called "suicide disease" in the
past. Some example cases of TN include:
 Entrepreneur and author Melissa
Seymour was diagnosed with TN in 2009
and underwent microvascular
decompression surgery in a well
documented case covered by magazines
and newspapers which helped to raise
public awareness of the illness in Australia.
Seymour was subsequently made a Patron
of the Trigeminal Neuralgia Association of
Australia

19. TIC DOULOUREUX:
 TiC DOULOUREUX painful
jerking.
 It is a truly agonizing condition, in
which the patient may clunch the
hand over the face & experience
severe, lancinating pain associated
with spasmodic contractions of the
facial muscles during attacks
-a feature that led to use of this term

20. ETIOLOGY:
 Usually idiopathic
 Demylination of the nerve
 Multiple sclerosis
 Petrous ridge compression
 Post – traumatic neuralgia
 Intracranial tumors
 Intracranial vascular abnormalities
 Viral etiology

21. PATHOGENESIS:

22. TYPES OF TRIGEMINAL NEURALGIA
AND THEIR CAUSES:
 TYPICAL TRIGEMINAL NEURALGIA
 ATYPICAL TRIGEMINAL NEURALGIA
 PRE- TRIGEMINAL NEURALGIA
 MULTIPLE SCLEROSIS RELATED TRIGEMINAL
NEURALGIA
 SECONDARY OR TUMOR RELATED
TRIGEMINAL NEURALGIA
 TRIGEMINAL NEUROPATHY OR POST-
TRAUMATIC TRIGEMINAL NEURALGIA
 FAILED TRIGEMINAL NEURALGIA

23. 1. TYPICAL TRIGEMINAL NEURALGIA:
• most common form, previously termed CLASSICAL,
IDIOPATHIC and ESSENTIAL TN. Nearly all cases of
typical TN caused by blood vessel compressing the
trigeminal nerve root.
 pulsation of vessels upon the
trigeminal nerve root do not visibly
damage the nerve. However irritation
from repeated pulsations may lead to
changes of nerve function, delivery
of abnormal signals to the trigeminal
nerve nucleus , this causes
hyperactivity of trigeminal nerve root
leading to trigeminal nerve pain

24. 2. ATYPICAL TRIGEMINAL
NEURALGIA:
 it is characterized by a unilateral,
prominent constant and severe aching
and burning pain superimposed upon
otherwise typical symptom.
 Some believe that atypical TN is due
to vascular compression upon specific
part of the trigeminal nerve( the portio
minor) while other theorize atypical TN
as more severe progression of typical
TN

25. 3. PRE- TRIGEMINAL NEURALGIA:
- Days to years before the first attack of TN pain, some
sufferers experience odd sensations of pain,( such as
toothache) or discomfort( parasthesia).
4. MULTIPLE SCLEROSIS RELATED
TN:
- symptoms of MS related TN are identical to
typical TN. Bilateral TN is more commonly seen in
people with MS. MS involves formation of
demyelinating plaques within the brain.

26. 5. SECONDARY OR TUMOR
RELATED TN:
TN pain caused by a lesion, such as a tumor. Tumor
that severely compresses or distorts the trigeminal
nerve may cause numbness, weakness of chewing
muscles or constant aching pain
6. FAILED TRIGEMINAL NEURALGIA:
In a very small proportion of suferres, all medications,
surgical procedures prove ineffective in controlling TN
pain
Such individual also suffer from additional trigeminal
neuropathy as a result of destructive intervention they
underwent.

27. GENERAL CHARACTERISTICS
 INCIDENCE- 8: 100000
 AGE- 5th-6th decade of life
 SEX- female> male
 AFFLICTION FOR SIDE- right> left
 DEVISION OF TRIGEMINAL NERVE
INVOLVEMENT- V3>V2>V1
TRIGGERING
ZONES

28. CLINICAL CHARACTERISTICS
 Manifests as a sudden, unilateral, intermittent paroxysmal,
sharp, shooting, lancinating , shock like pain, elicited by slight
touching superficial ‘trigger points’ which radiates from that
point, across the distribution of one or more branches of the
trigeminal nerve
 Pain is usually confined to one part of one division of trigeminal
nerve
 Pain rarely crosses the midline
 Attacks do not occur during sleep
 Pain is of short duration, but may recur with variable frequency.
 In extreme cases, the patient will have a motionless face – the
‘frozen or mask like face’.
 Common trigger zone include- cutaneous( corner of the lips,
cheek, ala of the nose, lateral brow); intraoral( teeth, gingivae,
tongue). Trigger area on the face are so sensitive that touching
or even air currents can trigger an episode.
 10-12% of cases are bilateral, or occurring on both sides. This
mainly seen in cases with systemic involvement include multiple
sclerosis or expanding cranial tumor

29. DIAGNOSIS
 From a well taken history
 CT- scan
 MRI
 Diagnostic nerve block

30. DIFERENTIAL DIAGNOSIS
 MIGRAINE- severe type of periodic headache is
persistent, at least over a period of hours and it has no
trigger zone.
 SINUSITIS- pain is not paroxysmal, in this pain is
persistent, associated nasal symptoms.
 DENTAL PAIN- localized, related to biting or hot or cold
foods, visible abnormalities on oral examination.
 Tumors of nasopharynx - in this similar type of pain is
produced, manifested in the lower jaw, tongue and side of
the head with associated middle ear deafness. This
complex lesion is called TROTTER’S syndrome. Patient
exhibit asymmetry and defective mobility of the soft
palate and affected side. As the tumor progresses,
trismus of internal pterygoid muscle develops, and patient
is unable to open the mouth. Here actual cause of pain is
involvement of mandibular nerve in the foramen ovale.
 Post herpetic neuralgia- pain is usually involved in
ophthalmic division. The history of skin lesion prior to
onset of neuralgia, pain is persistent, associated nasal

31. TREATMENT
1. MEDICAL
• First line of treatment is: CARBAMAZIPINE ( anticonvulsant)
• Second line of treatment is: BACLOFEN, LAMOTRIGINE,
OXCARBAZEPINE, PHENYTOIN, GABAPENTIN, PREGABALIN,
SODIUM VALPROATE
• Low dose of Antidepressants such as AMITRYPTILINE are thought to
be effective in treating neuropathic pain. Antidepressant are also used
to counteract a medication side effect.
• DULOXETINE is helpful where neuropathic pain and depression are
combined.
• Opiates such as MORPHINE and OXYCODONE, there is evidence of
their effectiveness on neuropathic pain, especially if combined with
gabapentin, gallium maltoate in a cream or ointment base has been
reported to relieve refractory postherpetic TN

32. 2. SURGICAL
 INJECTION OF NERVE WITH ANESTHETIC
AGENT
• Long acting anesthetic agents
• Alcohol injection
 PERIPHERAL GLYCEROL INJECTION
MVD
 PERIPHERAL NEURECTOMY( NERVE AVULSION)
 OPEN PROCEDURES ( INTRACRANIAL PROCEDURES)
- MICROVASCULAR DECOMPRESSION
- PERCUTANEOUS RHIZOTOMIES
- GAMMA KNIFE RADIOSURGERY

33. FACIAL NERVE
Each nerve controls:
 Eye blinking and closing
 Facial expressions
 Smiling and frowning
 Tear glands
 Saliva glands
 Muscle of small bone in middle of ear
called the stapes
 Taste sensations

34. BELL’S PALSY
INTRODUCTION:
Bell's palsy is a form of facial paralysis resulting from a dysfunction of the
cranial nerve VII (the facial nerve) causing an inability to control facial muscles
on the affected side
Several conditions can cause facial paralysis eg. Brain tumor, stroke,
myasthenia gravis, lyme disease.
if no specific cause can be identified, the condition is known as Bell's palsy
DEFINITION: - Bell's palsy is defined as an
idiopathic unilateral facial nerve paralysis, usually
self-limiting. The hallmark of this condition is a rapid
onset of partial or complete paralysis that
often occurs overnight.

35. HISTORICAL REVIEW: Charles Bell
-Well known for his studies on the nervous system and the brain
-In the 19th century discovered that lesions of the 7th cranial nerve
causes facial paralysis
ETIOLOGY:
1. Facial nucleus : Cerebrovascular disease, moebius syndrome,
multiple sclerosis, syphilis, HIV
2. Between nucleus and geniculate gangion : Fracture base of skull,
post cranial fossa tumors, sacroidosis
3. Between geniculate ganglion and stylomastoid canal : Middle ear
infection, ramsay threat sign, mastoiditis
4. In stylomastoid canal or extracranially : misplaced inferior alveolar
nerve anaesthetic, parotid tumor, sarcoidosis
5. Branch of facial nerve (extra cranially) : Local anesthesia, parotid
gland surgery, TMJ arthroscopy, facial asthetic surgery, facial trauma

36. ASSOCIATED SYNDROME:
1. MELKERSON ROSENTHAL SYNDROME( a triad of fissured tongue, persistent or
recurring lip or facial swelling and cranial nerve 8th paralysis)
2. CROCODILE TEAR SYNDROME(Due to injury to facial nerve proximal to the genicular
ganglion, there may be misdirection of the nerve fibers to the lacrimal gland instead of going to
the submandibular through greater petrosal nerve. As a result the patient lacrimates while
eating. This is treated by dividing the greater petrosal nerve.
3. RAMSAY HUNT SYNDROME( Severe facial paralysis with vesicles in the ipsilateral
pharynx and external auditory canal may be due to herpes zoster of the geniculate ganglion of
the facial nerve.)
BILATERAL FACIAL PARALYSIS is rare may be due to acute idiopathic polyneuritis,
sarcoidosis, post cranial fossa tumors.

37. – Brackman
(1985):
Grade I: Normal function without weakness
Grade II: Mild dysfunction, with slight facial assymmetry
Grade III: Moderate dysfunction – obvious but not disfiguring,
assymetry with contracture.
Grade IV: Moderately severe dysfunction, disfuguring
assymmetry with lack of forehead motion and incomplete closure of
eye.
Grade V: Severe dysfunction. Asymmetry at rest and only
slight facial movement.
Grade VI: Total paralysis complete absence of tone or motion.
Prognosis is grade dependent
INCIDENCE- 20: 100000
AGE- middle age group
SEX- female> male

38. SIGN AND SYMPTOM
 This is characterized by unilateral paralysis of all muscles of facial expression for both voluntary and
emotional movements.
 Forehead is unfurrowed.
 Patient is unable to cross eye on that side, any attempted closure causes rolling of eye upwards (Bell’s
sign).
 Tears tend to overflow ( epiphora ). Tears fail to enter the lacrimal puncta because they are no longer in
contact with the conjunctiva. Conjunctival reflex is absent.
 Corner of the mouth droops and nasolabial fold is obliterated. Saliva dribbles and food collects in the
vestibule because of paralysis of buccinator.
The lips remain in contact and cannot be pursued,
in attempting to smile the angle of mouth is not
drawn up on the affected side. The mouth takes
a triangular form.
 Paralysis of the masticatory muscles by the involvement
of motor trigeminal nucleus.
 Sensory loss on face from involvement of the principal
sensory and spinal trigeminal nuclei or spinothalamic
tract and paralysis of the upper or lower limbs
due to cortico spinal lesions.
 Due to lesions in posterior cranial fossa or in internal acoustic meatus,
may be loss in taste sensation of anterior 2/3rd of tongue.
 Most common cause of bells palsy in inflammation of facial nerve near
the stylomastoid foramen, with oedema of nerve and compression
of its fibers in facial canal or stylomastoid foramen

39. DIAGNOSIS
 Careful history for the onset of characteristics, duration of condition.
 Acute onset on awakening in the morning is typical in Bell’s palsy. Sudden onset
may also be due to infections or inflammatory etiology (Herpes zoster, multiple
sclerosis).
 Patients with neoplasms usually demonstrate progressive paresis over a long
period with initial mild symptoms. In trauma patients gives a history of trauma.
Delayed onset of facial paralysis has a better prognosis. In temporal bone
neoplasms there might be involvement of 9th, 10th, 11th nerves.
 Examination of face at rest and in motion, noting muscular tone and symmetry.
Differentiate between weakness (paresis) and total flaccidity (paralysis).
 Functioning of orbicularis oculi muscle allows for a complete closure of eyelid and
absence of visible upwards rotation and exposure of sclera.
 A forced smile for detecting asymmetrise of perioral muscles. Patient is asked to
blow.
 Side comparisons of deeper of nasolabial fold and symmetric contractions of
platysma.
 Pure taste sensation is carried out using samples of sweat, bitter, salty
substances on anterior tongue.
 CT scan of skull base fracture.
 MRI to detect intracranial lesions.

40. DIFFERENTIAL DIAGNOSIS
 STROKE- it will cause few additional symptoms, such
as numbness or weakness in the arms and legs. Unlike
bell’s palsy, stroke will usually let patients control the
upper part of their faces. Some wrinkling on their
forehead is also seen.
 Involvement of facial nerve in infections with the
HERPES ZOSTER VIRUS. Small blisters or vesicles,
on the external ear and hearing disturbances, but these
findings may occasionally be lacking( zoster spine
herpete)
 Reactivation of existing herpes zoster infection leading
to facial paralysis in a bell’s palsy type is known as
RAMSAY HUNT SYNDROME
 LYME DISEASE- Lyme specific antibodies in the blood
or erythema migrans.

41.  PHYSIOTHERAPY should be started as early as possible, consists of
electrical stimuli by galvanism, gentle massage and facial exercise.
 MEDICATION
 If patient is seen within 2-3 weeks of onset of symptoms then tab
prednisolone 1 mg/kg/d for 10-14 days with gradual tapering vitamins
B1, B6, B12.
 If patient is seen after 3-4 weeks, then steroids are of no use. CT, MRI
and EMG done.
 If incomplete eye closure is present
- artificial lubrication
- taping the eye,
- Opthalmologist is referred.
 In hyperkinesias-offending muscle groups are de-enervated or
botulinium toxin are used.
- Clostridium botulinium toxin (Botax) is a neurotoxin that interferes with
acetychline release, causing skeletal muscle paralysis, weakening the
contralateral side to allow centering of mouth. Effect lasts for 4-6
months.
 In hypokinesia – requires nerve transfer, muscle transfer or static rings.

42. SURGICAL
1. Internal decompression:
- Nerve exposed in fallopian canal and pressure is relieved.
- Epineural sheath is opened to visualize the nerve fibers and
release
adhesions or re-establish continuity.
2. External decompression by releasing of epineural sheath from
surrounding scar tissue, bone or foreign body.
3. Nerve anastomosis – reanimation- anastomosis of the central end
of
hypoglossal or spinal accessory nerve with the distal end of the facial
nerve is done.
4. Nerve grafting – whenever there is evidence
of neuroma or loss of portion
of a nerve, grafting is done.
If due to effect of local anaesthesia:
- reassure the patient- mostly it resolves
without any residual effects
- eye patch to prevent corneal ulceration
- instruct to avoid wearing contact lens till
the effect wears among.

43. Surgical approaches are performed
when medication can not control pain,
patients can not tolerate the adverse
effects of the medication, or in
medically complex patients with poly
pharmacy for other coditions.

44.  GRAY’S ANATOMY
 TEXTBOOK OF ORAL SURGERY-
NEELIMA MALIK
 TEXT BOOK OF ORAL PATHOLOGY-
SHEFFER’S
 TEXTBOOK OF ORAL PATHOLOGY-
NEVILE
 TEXTBOOK OF LOCAL ANESTHESIA-
MONHIMS
 TEXTBOOK OF ORAL MEDICINE- ANIL
GHOM’S