Trigeminal neuralgia
Trigeminal neuralgia: Excerpt from Professional Guide to Diseases (Eighth Edition)
Trigeminal neuralgia, also called tic douloureux, is a painful disorder of one or more branches of the fifth cranial (trigeminal) nerve that produces paroxysmal attacks of excruciating facial pain precipitated by stimulation of a trigger zone. It can subside spontaneously, and remissions may last from several months to years.
Causes and incidence
Although the cause remains undetermined, trigeminal neuralgia may reflect an afferent reflex in the brain stem or in the sensory root of the trigeminal nerve. Such neuralgia may also be related to compression of the nerve root by posterior fossa tumors, middle fossa tumors, or vascular lesions (subclinical aneurysm), although such lesions usually produce simultaneous loss of sensation. Occasionally, trigeminal neuralgia is a manifestation of multiple sclerosis or herpes zoster. Whatever the cause, the pain of trigeminal neuralgia is probably produced by an interaction or short-circuiting of touch and pain fibers.
Trigeminal neuralgia occurs mostly in people older than age 40, in women more commonly than men, and on the right side of the face more commonly than the left. Incidence is 4 to 5 cases per 100,000 people.
Signs and symptoms
Typically, the patient reports a searing or burning pain that occurs in lightninglike jabs and lasts from 1 to 15 minutes (usually 1 to 2 minutes) in an area innervated by one of the divisions of the trigeminal nerve, primarily the superior mandibular or maxillary division. The pain rarely affects more than one division and seldom the first division (ophthalmic) or both sides of the face. It affects the second (maxillary) and third (mandibular) divisions of the trigeminal nerve equally. (See Trigeminal nerve function and distribution.)
These attacks characteristically follow stimulation of a trigger zone, usually by a light touch to a hypersensitive area, such as the tip of the nose, the cheeks, or the gums. Although attacks can occur at any time, they may follow a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. The frequency of attacks varies greatly, from many times a day to several times a month or year. Between attacks, most patients are free from pain, although some have a constant, dull ache. No patient is ever free from the fear of the next attack.
Diagnosis
The patient’s pain history is the basis for diagnosis because trigeminal neuralgia produces no objective clinical or pathologic changes. Physical examination shows no impairment of sensory or motor function; indeed, sensory impairment implies a space-occupying lesion as the cause of pain.
Observation during the examination shows the patient favoring (splinting) the affected area. To ward off a painful attack, the patient commonly holds his face immobile when talking. He may also leave the affected side of his face unwashed and unshaven or protect it with a coat or shawl. When asked where the pain occurs, he points to — but never touches — the affected area. Witnessing a typical attack helps to confirm diagnosis. Rarely, a tumor in the posterior fossa can produce pain that’s clinically indistinguishable from trigeminal neuralgia. Skull X-rays, computed tomography scan, and magnetic resonance imaging rule out sinus or tooth infections and tumors. If the patient has trigeminal neuralgia, these test results are normal.
Treatment
Oral administration of carbamazepine or phenytoin may temporarily relieve or prevent pain. Narcotics may be helpful during the pain episode. Caution should be used when treating a chronic problem with opioids.
When these medical measures fail or attacks become increasingly frequent or severe, neurosurgical procedures may provide permanent relief. The preferred procedure is percutaneous electrocoagulation of nerve rootlets under local anesthetic. New treatments include a percutaneous radio frequency procedure, which causes partial root destruction and relieves pain, and microsurgery for vascular decompression of the trigeminal nerve.
Special considerations
The focus here is management of pain.
❑Observe and record the characteristics of each attack, including the patient’s protective mechanisms.
❑Provide adequate nutrition in small, frequent meals served at room temperature.
❑Avoid jarring the bed and causing increased discomfort.
❑If the patient is receiving carbamazepine, watch for cutaneous and hematologic reactions (erythematous and pruritic rashes, urticaria, photosensitivity, exfoliative dermatitis, leukopenia, agranulocytosis, eosinophilia, aplastic anemia, and thrombocytopenia) and, possibly, urine retention and transient drowsiness. For the first 3 months of carbamazepine therapy, complete blood count and liver function should be monitored weekly, then monthly thereafter. Warn the patient to immediately report fever, sore throat, mouth ulcers, easy bruising, or petechial or purpuric hemorrhage because these may signal thrombocytopenia or aplastic anemia and may require discontinuation of drug therapy.
❑If the patient is receiving phenytoin, also watch for adverse effects, including ataxia, skin eruptions, gingival hyperplasia, and nystagmus.
❑After resection of the first branch of the trigeminal nerve, tell the patient to avoid rubbing his eyes and using aerosol spray. Advise him to wear glasses or goggles outdoors and to blink often.
❑After surgery to sever the second or third branch, tell the patient to avoid hot foods and drinks, which could burn his mouth, and to chew carefully to avoid biting his mouth. It may be necessary for the patient to take pureed food, possibly through a straw. Advise him to place food in the unaffected side of his mouth when chewing, to brush his teeth and rinse his mouth often, and to see the dentist twice a year to detect cavities because he won’t experience pain from cavities in the area of the severed nerve.
❑After surgical decompression of the root or partial nerve dissection, check neurologic and vital signs often.
❑Provide emotional support, and encourage the patient to express his feelings. Promote independence through self-care and maximum physical activity. Reinforce natural avoidance of stimulation (air, heat, and cold) of trigger zones (lips, cheeks, and gums).
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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