Pain in the face

PROGRESSIVE CONDITION

Facial pain or trigeminal neuralgia (TN) is a pain that can be felt in any part of the face, including the mouth and eyes. Although it is normally caused by an injury or headache, facial pain may also be caused due to some serious medical conditions. However, if you have facial pain that seems to come without any known cause, then it might be a facial paralytic attack. So, call your doctor for evaluation.

TN affects the trigeminal nerve, one of the largest nerves in the head, that causes extreme, sudden or shock-like facial pain in the areas of the face such as lips, eyes, nose, scalp, forehead, upper jaw, and lower jaw. The pain episodes last from a few
seconds to as long as two minutes. Facial pain can be caused by anything from an infection to nerve damage in the face. Common causes for facial pain include:

Oral infections
Ulcers (open sores)
Skin abscess (collection of pus under the skin)
Headache
Facial injury
Toothache
Shingles
Migraine
Sinusitis (sinus infection)
Nerve disorder

Facial pain is often described as cramp-like, stabbing, or achy. The most frequent cause of TN is a blood vessel pressing on the nerve near the brain stem. Over time, changes in the blood vessels of the brain can result in blood vessels rubbing against the trigeminal nerve root. The constant rubbing with each heartbeat wears away the insulating membrane of the nerve, resulting in nerve irritation.

The common kinds of facial pain are:

Glossopharyngeal neuralgia: This is a rare condition that is sometimes confused with TN. The nature of the pain is identical and affects one side of the face. The pain can be triggered by touching the ear or swallowing. Doctors use the same methods to diagnose glossopharyngeal neuralgia as they use for TN. The drugs used to treat it are also the same.

 Post-herpetic neuralgia: This is a form of chronic face pain after an attack of shingles on the face. The type of pain that occurs with post-herpetic neuralgia is called neuropathic pain. It occurs with aching or throbbing pain that is often accompanied by extreme tenderness.

Neuropathic pain is the chronic pain that usually occurs when tissue get injured. The nerve fibres themselves may be damaged, dysfunctional, or injured. These damaged nerve fibres send incorrect signals to other pain centres. The impact of nerve fibre injury includes a change in nerve function both at the site of injury and areas around the injury.

Shingles: Herpes zoster or shingles is caused by the chicken pox virus, which most people get at a young age. But shingles usually affects older people. It occurs in individuals who have previously been exposed to the varicella zoster-virus.
The major surgical interventions for TN include:

 Microvascular Decompression

Surgery (MVD): This procedure removes the cause of the TN pain. MVD
offers the best chance of long-term relief without damaging the nerve. The goal of the neurosurgeon is to lift the offending vessel from the trigeminal nerve by placing a padding between them. This procedure requires a craniotomy (surgical removal of a section of bone from the skull for the purpose of operating on the underlying tissues) and has the longest recovery time.

 Damaging the nerve: Several procedures can be done to stop the transmission of pain signals to the brain. These procedures actually cause damage to the nerve and can be effective for varying lengths of time. Procedures that go through the cheek with a needle are glycerol injections, balloon compression, and rhizotomy (radiofrequency lesioning).
TN diagnosis is based primarily on the person’s history and description of symptoms, along with results from physical and neurological examinations. Obtaining a correct diagnosis is difficult, but finding the cause of the pain is important as the treatments for different types of pain may differ.

Common analgesics and opioids are not usually helpful in treating the pain as the condition is progressive. The attacks often worsen over time, with fewer and shorter pain-free periods before they recur. Eventually, the pain-free intervals disappear and medication to control the pain becomes less effective. Patients opt to have surgery, which may or may not be effective. Sometimes, surgery exacerbates the pain. Pain-free periods after surgery usually vary.

(The author is ENT specialist, ADIVA Centre for Hearing, New Delhi)