Clinical aspects of neurological disease Facial pain
Neurological diagnosis <ul><li>History and examination </li></ul><ul><li>Site of lesion </li></ul><ul><li>Pathology </li><...
Multiple sclerosis <ul><li>Inflammatory demyelinating disease of the CNS </li></ul><ul><li>Prevalence 100/100 000 in UK </...
MS: Symptoms and signs <ul><li>Optic nerves </li></ul><ul><li>Cervical cord </li></ul><ul><li>Brainstem </li></ul><ul><li>...
MS: Symptoms and signs  <ul><li>Loss of vision </li></ul><ul><li>Weakness and sensory loss </li></ul><ul><li>Loss of bladd...
MS: Diagnosis <ul><li>History and examination </li></ul><ul><li>MRI </li></ul><ul><li>Visually Evoked Responses </li></ul>...
MS: Disease Course <ul><li>Relapsing remitting </li></ul><ul><li>Progressive </li></ul>
Cerebrovascular disease <ul><li>Thrombosis </li></ul><ul><li>Haemorrhage </li></ul>
Risk factors <ul><li>Hypertension </li></ul><ul><li>Ischaemic heart disease, peripheral vascular disease </li></ul><ul><li...
Facial pain <ul><li>Age/sex </li></ul><ul><li>Site of pain </li></ul><ul><li>Nature of pain </li></ul><ul><li>Special feat...
Causes of facial pain <ul><li>Trigeminal neuralgia </li></ul><ul><li>Atypical facial pain </li></ul><ul><li>Migraine </li>...
Trigeminal neuralgia <ul><li>Location of pain : V2 and V3 </li></ul><ul><li>Mouth-ear zone (60%), nose-orbit zone (30%) </...
TGN symptoms <ul><li>Pain is not continual </li></ul><ul><li>Triggering factors: chewing, smiling, yawning (motor), hot an...
TGN Natural History <ul><li>Increasing frequency of attacks </li></ul><ul><li>Recurrent attacks more disabling </li></ul><...
TGN Treatment <ul><li>Medical: Carbamazepine, Gabapentin, Phenytoin  </li></ul><ul><li>Surgical neurovascular decompressio...
Atypical facial pain <ul><li>Maxillary </li></ul><ul><li>Deep, burning, continual </li></ul><ul><li>Behind ear, on to neck...
Facial migraine <ul><li>Retro-orbital pain </li></ul><ul><li>Throbbing </li></ul><ul><li>Associated features: Nausea, phot...
Cluster headache <ul><li>Severe pain </li></ul><ul><li>Localises around eye  </li></ul><ul><li>‘ Alarm clock’ headache </l...
Postherpetic neuralgia <ul><li>Ophthalmic herpes occurs in the elderly </li></ul><ul><li>30% develop postherpetic neuralgi...
Case History <ul><li>47 year old Algerian man </li></ul><ul><li>7 year history of right facial pain </li></ul><ul><li>Jabb...
Case history (2) <ul><li>Outpatient MRI of brain </li></ul><ul><li>Large tortuous vessels surrounding the right trigeminal...
Conclusions <ul><li>Careful history taking is essential to correctly diagnose facial pain </li></ul><ul><li>Remember the a...
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Neurological Disease

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Neurological Disease

  1. 1. Clinical aspects of neurological disease Facial pain
  2. 2. Neurological diagnosis <ul><li>History and examination </li></ul><ul><li>Site of lesion </li></ul><ul><li>Pathology </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Plan of investigation </li></ul><ul><li>Management </li></ul>
  3. 3. Multiple sclerosis <ul><li>Inflammatory demyelinating disease of the CNS </li></ul><ul><li>Prevalence 100/100 000 in UK </li></ul><ul><li>Latitudinal gradient </li></ul><ul><li>Aetiology: Genetic susceptibility / environmental factor </li></ul>
  4. 4. MS: Symptoms and signs <ul><li>Optic nerves </li></ul><ul><li>Cervical cord </li></ul><ul><li>Brainstem </li></ul><ul><li>Periventricular white matter </li></ul>
  5. 5. MS: Symptoms and signs <ul><li>Loss of vision </li></ul><ul><li>Weakness and sensory loss </li></ul><ul><li>Loss of bladder and bowel control </li></ul><ul><li>Double vision </li></ul><ul><li>Dysarthria and dysphagia </li></ul><ul><li>Loss of balance </li></ul><ul><li>Fatigue </li></ul>
  6. 6. MS: Diagnosis <ul><li>History and examination </li></ul><ul><li>MRI </li></ul><ul><li>Visually Evoked Responses </li></ul><ul><li>Lumbar puncture </li></ul><ul><li>Clinical evidence of more than one lesion disseminated in time </li></ul><ul><li>Laboratory evidence of more than one lesion </li></ul><ul><li>Inflammation within the CNS </li></ul>
  7. 7. MS: Disease Course <ul><li>Relapsing remitting </li></ul><ul><li>Progressive </li></ul>
  8. 8. Cerebrovascular disease <ul><li>Thrombosis </li></ul><ul><li>Haemorrhage </li></ul>
  9. 9. Risk factors <ul><li>Hypertension </li></ul><ul><li>Ischaemic heart disease, peripheral vascular disease </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Smoking </li></ul><ul><li>Cholesterol </li></ul>
  10. 10. Facial pain <ul><li>Age/sex </li></ul><ul><li>Site of pain </li></ul><ul><li>Nature of pain </li></ul><ul><li>Special features </li></ul><ul><li>Aggravating factors </li></ul><ul><li>Relieving factors </li></ul>
  11. 11. Causes of facial pain <ul><li>Trigeminal neuralgia </li></ul><ul><li>Atypical facial pain </li></ul><ul><li>Migraine </li></ul><ul><li>Post-herpetic neuralgia </li></ul>
  12. 12. Trigeminal neuralgia <ul><li>Location of pain : V2 and V3 </li></ul><ul><li>Mouth-ear zone (60%), nose-orbit zone (30%) </li></ul><ul><li>V1 involved in less than 5% of cases </li></ul><ul><li>Quality of pain: ‘red hot needles’ </li></ul><ul><li>Excruciating pain lasting for a few seconds </li></ul><ul><li>Followed by unpleasant aching pain </li></ul>
  13. 13. TGN symptoms <ul><li>Pain is not continual </li></ul><ul><li>Triggering factors: chewing, smiling, yawning (motor), hot and cold fluids, brushing teeth, draught on face (cutaneous) </li></ul><ul><li>Diurnal variation - attacks at night rare </li></ul>
  14. 14. TGN Natural History <ul><li>Increasing frequency of attacks </li></ul><ul><li>Recurrent attacks more disabling </li></ul><ul><li>Most patients over 60 years except in multiple sclerosis </li></ul><ul><li>Used as a diagnostic pointer in people under 45 years </li></ul>
  15. 15. TGN Treatment <ul><li>Medical: Carbamazepine, Gabapentin, Phenytoin </li></ul><ul><li>Surgical neurovascular decompression </li></ul><ul><li>Stereotactic thermocoagulation of the ganglion </li></ul>
  16. 16. Atypical facial pain <ul><li>Maxillary </li></ul><ul><li>Deep, burning, continual </li></ul><ul><li>Behind ear, on to neck, across to opposite maxillary area i.e. crosses anatomical boundaries </li></ul><ul><li>Often clutch their face </li></ul><ul><li>Treatment with antidepressants </li></ul>
  17. 17. Facial migraine <ul><li>Retro-orbital pain </li></ul><ul><li>Throbbing </li></ul><ul><li>Associated features: Nausea, photophobia, phonophobia </li></ul><ul><li>Previous history of migraine </li></ul><ul><li>Mainly in women ages 25 to 50 </li></ul>
  18. 18. Cluster headache <ul><li>Severe pain </li></ul><ul><li>Localises around eye </li></ul><ul><li>‘ Alarm clock’ headache </li></ul><ul><li>Conjunctival injection, miosis, ptosis </li></ul><ul><li>Rhinorrhoea </li></ul>
  19. 19. Postherpetic neuralgia <ul><li>Ophthalmic herpes occurs in the elderly </li></ul><ul><li>30% develop postherpetic neuralgia </li></ul><ul><li>Continual dull burning pain </li></ul><ul><li>Triggered by touching the eyebrow or brushing the hair </li></ul><ul><li>May remit after 12-18 months </li></ul><ul><li>Very distressing with a high suicide risk </li></ul>
  20. 20. Case History <ul><li>47 year old Algerian man </li></ul><ul><li>7 year history of right facial pain </li></ul><ul><li>Jabbing pain triggered by touching his lip </li></ul><ul><li>Treated with Carbamazepine </li></ul><ul><li>Depressed </li></ul><ul><li>No abnormal signs on examination </li></ul>
  21. 21. Case history (2) <ul><li>Outpatient MRI of brain </li></ul><ul><li>Large tortuous vessels surrounding the right trigeminal nerve </li></ul><ul><li>Requires angiography before intervention </li></ul>
  22. 22. Conclusions <ul><li>Careful history taking is essential to correctly diagnose facial pain </li></ul><ul><li>Remember the anatomy of the trigeminal nerve </li></ul><ul><li>Many facial pain syndromes are wrongly attributed to disease of the teeth or sinuses </li></ul>
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