Facial pain
Facial pain may result from various neurologic, vascular, or infectious disorders. The most common cause of facial pain is trigeminal neuralgia (tic douloureux). In this disorder, intense, paroxysmal facial pain may occur along the pathway of a specific facial nerve or nerve branch, usually cranial nerve V (trigeminal nerve) or cranial nerve VII (facial nerve). Pain can also be referred to the face in disorders of the ear, nose, paranasal sinuses, teeth, neck, and jaw.
Atypical facial pain is a constant burning pain with limited distribution at onset; it typically spreads to the rest of the face and may involve the neck or back of the head as well. This type of facial pain is common in middle-aged women, especially those who are clinically depressed.
History and physical examination
Begin by characterizing the patient’s facial pain. Is it stabbing, throbbing, or dull? When did it begin? How long has it lasted? What relieves or worsens it? Ask the patient to point to the painful area. If facial pain is recurrent, have him describe a typical episode. Review his medical and dental history, noting especially previous head trauma, dental disease, and infection.
Carefully examine the face and head. Inspect the ear for vesicles and changes in the tympanic membrane to rule out referred ear pain. Inspect the nose for deformity or asymmetry. Evaluate the condition of the mucous membranes and septum as well as the size and shape of the turbinates. Characterize any secretions. Palpate the frontal, ethmoid, and maxillary sinuses for tenderness and swelling.
Evaluate oral hygiene by inspecting the teeth for caries, percussing any diseased teeth for pain, and asking the patient about any sensitivity to hot, cold, or sweet liquids or foods. Have him open and close his mouth as you palpate the temporomandibular joint for tenderness, spasm, locking, and crepitus.
Examine the function of cranial nerves V and VII. To evaluate cranial nerve V, instruct the patient to clench his teeth. Then palpate the temporal and masseter muscles and evaluate muscle contraction. Test pain and sensation on his forehead, cheeks, and jaw. Next, test the corneal reflex by lightly touching the cornea with a piece of cotton.
To evaluate cranial nerve VII, inspect the face for symmetry and then have the patient perform facial movements that demonstrate facial muscle strength—raising his eyebrows, frowning, showing his teeth, closing his eyes tightly, and wrinkling his nose. (See Major nerve pathways of the face.)
Medical causes
Angina pectoris
Occasionally, jaw pain may indicate angina pectoris. A more comprehensive history and evaluation is needed to determine cardiac origin.
Dental caries
Caries in the mandibular molars can produce ear, preauricular, and temporal pain; caries in the maxillary teeth can produce maxillary, orbital, retro-orbital, and parietal pain. Other dental causes of facial pain are an abnormal bite and faulty dentures. Facial pain related to chewing or temperature changes may suggest dental problems.
Glaucoma
In glaucoma, an important cause of facial pain, the pain is usually located in the periorbital region.
Glossopharyngeal neuralgia
The pain in this uncommon disorder is similar to that of trigeminal neuralgia. It typically occurs in the throat near the tonsillar fossa and may radiate to the ear and posterior aspect of the tongue. It may be aggravated by swallowing, chewing, talking, or yawning. No underlying structural abnormality is usually present.
Herpes zoster oticus (Ramsay Hunt syndrome)
This disorder causes severe pain around the ear, followed by vesicles in the ear and occasionally on the oral mucosa, tonsils, and posterior tongue. Other findings may include hearing loss, vertigo, and transient ipsilateral facial paralysis.
Multiple sclerosis (MS)
Facial pain in MS may resemble that of trigeminal neuralgia and is accompanied by jaw and facial weakness. Other common findings include visual blurring, diplopia, and nystagmus; sensory impairment such as paresthesia; generalized muscle weakness and gait abnormalities; urinary disturbances; and emotional lability.
Postherpetic neuralgia
Burning, itching, prickly pain persists along any of the three trigeminal nerve divisions and worsens with contact or movement. Mild hypoesthesia or paresthesia and vesicles affect the area before the onset of pain.
Sinus cancer
In ethmoid sinus cancer, facial pain is a late symptom, preceded by exophthalmos. In maxillary sinus cancer, persistent pain along the second division of cranial nerve V is a late symptom.
Sinusitis (acute)
Acute maxillary sinusitis produces unilateral or bilateral pressure, fullness, or burning pain over the cheekbone and upper teeth and around the eyes. Bending over increases the pain. Other findings include nasal congestion and purulent discharge; red, swollen nasal mucosa; tenderness and swelling over the cheekbone; fever; and malaise.
Acute frontal sinusitis commonly produces severe pain above or around the eyes, which worsens when the patient is in a supine position. It also causes nasal obstruction, inflamed nasal mucosa, fever, and tenderness and swelling above the eyes.
Acute ethmoid sinusitis produces pain at or around the inner corner of the eye and sometimes temporal headaches. Other findings include nasal congestion, purulent rhinorrhea, fever, and tenderness at the medial edge of the eye.
In acute sphenoid sinusitis, a deep-seated pain persists behind the eyes or nose or on the top of the head. The pain increases on bending forward and may be accompanied by fever.
Sinusitis (chronic)
Chronic maxillary sinusitis produces a feeling of pressure below the eyes or a chronic toothache. Discomfort typically worsens throughout the day. Nasal congestion and tenderness over the cheekbone are usually mild.
Chronic frontal sinusitis produces a persistent low-grade pain above the eyes. The patient usually has a history of trauma or long-standing inflammation.
Chronic ethmoid sinusitis is characterized by nasal congestion, an intermittent purulent nasal discharge, and low-grade discomfort at the medial corners of the eyes. Also common are recurrent sore throat, halitosis, ear fullness, and involvement of the other sinuses.
A low-grade, diffuse headache or retro-orbital discomfort is common in chronic sphenoid sinusitis.
Sphenopalatine neuralgia
In this type of neuralgia, unilateral deep, boring pain occurs below the ear and may radiate to the eye, ear, cheek, nose, palate, maxillary teeth, temple, back of the head, neck, or shoulder. Attacks also cause increased tearing and salivation, rhinorrhea, a sensation of fullness in the ear, tinnitus, vertigo, taste disturbances, pruritus, and shoulder stiffness or weakness.
Temporal arteritis
Unilateral pain occurs behind the eye or in the scalp, jaw, tongue, or neck. A typical episode consists of a severe throbbing or boring temporal headache with redness, swelling, and nodulation of the temporal artery.
Temporomandibular joint syndrome
In this syndrome, intermittent pain, usually unilateral, is described as a severe, dull ache or an intense spasm that radiates to the cheek, temple, lower jaw, ear, or mastoid area. Associated findings include trismus, malocclusion, and clicking, crepitus, and tenderness in the temporomandibular joint.
Trigeminal neuralgia
Paroxysms of intense pain, lasting up to 15 minutes, shoot along any or all of the three branches of the trigeminal nerve. The pain can be triggered by touching the nose, cheek, or mouth; by being exposed to hot or cold weather; by consuming hot or cold foods or beverages; or even by smiling or talking. Between attacks, the pain may diminish to a dull ache or may disappear. This disorder is most common in middle and later life, affecting more women than men.
Special considerations
Prepare the patient for diagnostic tests, such as sinus, skull, or dental X-rays; sinus transillumination; and intracranial or sinus computed tomography scans. Give pain medications, and apply direct heat or administer a muscle relaxant to ease muscle spasms. Provide a humidifier, vaporizer, or decongestant to relieve nasal or sinus congestion.
Pediatric pointers
Facial pain may be difficult to assess in a young child if his language skills aren’t sufficiently developed for him to describe the pain. Be alert for subtle signs of pain, such as facial rubbing, irritability, or poor eating habits.
Patient counseling
If appropriate, instruct the patient with trigeminal neuralgia to avoid stressful situations, hot and cold foods, and sudden jarring movements, which can trigger painful attacks.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Face swelling
Read excerpts from these other book chapters related to Face swelling:
Medical Books Excerpts
- FACE PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Facial pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Edema, facial
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Facial pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Face swelling
» Next page: Facial / Dental / Temporomandibular Pain (Field Guide to Bedside Diagnosis)
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