New Book: Oral, Nasal and Pharyngeal Complaints, Geoffrey Quail

Oral, Nasal andPharyngeal Complaints A P R A C TIC A L G UID E ly on s ge pa e pl m sa GEOFFREY G. QUAIL

Chapter 6 Facial painInvestigating facial pain • neoplasm • osteonecrosis (from radiotherapy or bisphosphonates)Together with headache, back and abdominal pain,facial pain is one of the most common neurological Oral mucosa/pharyngealcomplaints. In most cases, its etiology can be ascer- • infectiontained from a detailed history and examination. • neoplasm• the oral cavity and, in particular, dental structures • oral ulceration (other causes) are the most common sources Salivary gland disease• pain does not cross the mid-line unless there is • infection ly a systemic cause or bilateral lesions as in TMJ • duct obstruction by a calculus dysfunction• the source of the pain may be obscure as oral tissues have multiple innervations, and referred Paranasal sinus disease Neurological on pain, particularly to the ear, is common s • trigeminal neuralgia • migraine/cluster headache geCommon Causes • glossopharyngeal neuralgiaDental • Bell’s palsy pa• dental caries Neurological/infective• fractured tooth • herpes simplex/zoster and post infective neuralgia• periodontal disease/abscess e• dry socket Vascular pl • cranial arteritisOral or facial trauma • angina pectoris mTemporomandibular joint dysfunction Dermatological saFacial bone disease • furunculosis• infection • erysipelas 83

Oral, nasal and pharyngeal complaintsPsychogenic • a fractured crown is painful if dentine is exposed• depression/anxiety • impacted, infected lower third molars are a common source of facial pain in adolescents andCentral young adults—untreated infected third molars• cerebral neoplasm or infection may lead to abscess formation or cellulitis, which can involve deep facial veins and lead to cavernous sinus thrombosis CAUTION: Unilateral facial pain is dentally related until proved otherwise. Pain in the ear is frequently due to a remote CAUTION: Facial cellulitis often arises from an infected tooth or facial trauma. It may lesion. involve sublingual and submandibular spaces (Ludwig’s angina) and increase rapidly. It is potentially life-threatening and must be treatedClinical examination vigorously and promptly.and management offacial pain investigations Oral examination • palpate apical region of suspected toothDental pain • percuss teeth—only the affected tooth should• patient is usually able to localise pain to a quadrant be tender of the mouth, though often not a specific tooth • palpate regional lymph nodes• dental pain most commonly results from dental caries involving the pulp management• while analgesics and antibiotics may alleviate Pain relief with: ly symptoms temporarily, urgent dental referral is • paracetamol—1 gm orally, 4 hrly to 4 gms essential• pain is commonly aggravated or precipitated by chewing, biting or thermal change—may be daily in divided doses on • codeine compound—as above, ibuprofen 400 mg 4–6 hrly constant or throbbing s Antibiotic therapy is indicated if pulpal• cold substances causing pain suggests the dental infection is suspected: ge pulp is still vital (pulpitis) or cementum at neck of • Amoxycillin 500 mg (child 15 mg/kg) 8 hrly is tooth exposed for 5 days pa• heat causes pain through expansion of gases in a • For penicillin allergy—clindamycin adult necrotic or dying pulp 450 mg (child 10 mg/kg) 8 hrly for 5 days• pulpal infection extending to the periapical tissues In severe cases add metronidazole 400 mg e may produce abscess formation and pain (child 10 mg/kg) 12 hrly for 5 days• premature contact of teeth (high filling) or pl grinding/clenching as in psychological stress m produces an ache that is worse when the tooth is Post-extraction pain: dry socket (alveolar percussed osteitis) sa• pain may be referred to the ear or the maxillary Post-extraction pain is a relatively common complica- sinus tion of dental extraction. It:84

Chapter 6 Facial pain• is due to loss of the blood clot from the socket, most accurate for unilateral maxillary sinus causing impaired tissue repair disease.• occurs 1–3 days post-surgery • CT scanning often shows mucosal thickening• causes constant pain and tenderness at the without fluid levels or obstruction of ostia; extraction site; halitosis is common plain films are not indicated.• usually resolves spontaneously in 2–3 weeks; if it persists or if systemic changes are present, consider Acute sinusitis osteonecrosis, osteomyelitis or a pre-existing SCC • usually associated with symptoms of URTI at the site. including blocked nasal airway and haemopurulent discharge management • often diffuse pain in region of upper teeth, • 0.2% chlorhexidine mouthwash to prevent headache or a feeling of fullness in cheeks secondary infection • may be halitosis, post-nasal discharge • Dental referral for emollient dressing in the management socket • Over 90% of cases are viral in origin • Analgesia, such as codeine phosphate 30 mg/ • The mainstay of treatment is topical paracetamol 500 mg 4 hrly vaso-constrictors. These drugs improve the Note: as the condition is not caused by airway and aid drainage. Use tramazoline or infection, antibiotics are not indicated. oxymetazoline or oral decongestant containing pseudoephedrineNasal sinus pain Note: rebound vaso-constriction may occur if• often there is a history of URTI, previous sinusitis nasal sprays used > 5 days or allergy/hay fever • A bacterial cause should be suspected if there• frequently dull, constant mid- or upper-face pain is a combination of: ly• often worse if head is down or if there is increased — persistent mucopurulent discharge > 7 days atmospheric pressure (e.g. aircraft landing) — facial pain• maxillary sinus pain may be confused with the pain of dental infection on — tenderness on palpation of the sinuses or percussion of the upper posterior teeth• dental infection may be transmitted to the where there is no dental disease s maxillary sinus from periapically infected tooth — inadequate response to decongestants ge• frontal sinus pain may be confused with migraine Prescribe:• ethmoidal and sphenoidal pain are felt at the inner • amoxycillin 500 mg (child 15 mg/kg) orally, pa canthus of the eye or retro-orbitally 8 hrly for 5 days or Diagnosis • cefaclor 375 mg, 12 hrly (child 10 mg/kg e • Take a patient history (see above). to 250 mg 8 hrly) for 7 days or doxycycline • Palpate the sinus areas for tenderness. 100 mg daily if over 8 years pl Commence and finish by palpating non- • if there is a poor response—suspect an m tender areas (zygoma) to avoid false positives. organism producing B lactamase; substitute • Transilluminate sinuses using pocket torch amoxycillin/clavulanate sa intra-orally in a darkened room (lip seal is Note: Antihistamines and mucolytics are of no required); point torch in an orbital direction: value in treating sinusitis 85

Oral, nasal and pharyngeal complaintsChronic sinusitis • pain is thought to be due to an aberrant loop• pain and tenderness are often mistaken for of the middle cerebral artery compressing the maxillary molar disease, and occasionally the trigeminal nerve where it enters the pons, or reverse in multiple sclerosis by an impinging plaque of• there is an associated frontal headache demyelination• there is often sharp pain in the antral region when • the patient frequently considers pain is of walking or running dental origin• surgery improves drainage and makes the condition easier to treat but is not a cure CAUTION: Shock-like pain in a patient under 40 years may be due to multiple sclerosis. management An MRI of the brain is mandatory. • As for acute sinusitis (see above) • Macrolides are effective and have an anti- inflammatory action management Medical:sharp, lanCing faCial pain • trial of carbamazepine 100 mg 12 hrly, 50 mg 12 hrly (elderly) increasing in 3 days toPatients sometimes complain of severe stabbing or 200 mg 12 hrly‘shock-like’ facial pain over the distribution of the • monitor adverse neurological response: ataxia,trigeminal nerve or in the oro-pharynx (IX nerve dizziness, visual disturbance, drowsinesslesion). Causes include: • an alternative is phenytoin or gabapentin• acute dental pulpitis (see above) (initially 100 mg 8 hrly) alone or in• trigeminal neuralgia combination• multiple sclerosis • reduce drug once pain relief obtained• glossopharyngeal neuralgia ly Surgical techniques include vascular• atypical facial pain decompression of the trigeminal nerve• cluster headache• pressure of the lower denture on the mental nerve Multiple sclerosis onTrigeminal neuralgia s • the most common severe neurological condition• recurrent lightning pain in the distribution of in 20–50-year-olds ge the second and third divisions of the trigeminal • approximately 6% have features of trigeminal nerve neuralgia pa• if pain persists after initial paroxysm, it is probably due to cluster headache and not trigeminal Diagnosis neuralgia • An MRI demonstrates myelin plaques e• occurs mainly over 50 years of age • A lumbar puncture reveals monoclonal IgG in• is precipitated by touching or moving the trigger pl 90% of cases zone of the face or mouth, including teeth, such as m in talking, eating or exposure to wind• an area of paraesthesia corresponding to the Glossopharyngeal neuralgia sa trigger zone is frequently present • an uncommon condition occurring much less• trigger zone is refractive to repeated stimulation frequently than trigeminal neuralgia (TN)86

Chapter 6 Facial pain• presents like TN, with lancing pain at the back of • herpes zoster/herpatic neuralgia involving the throat and posterior of tongue; site is difficult ophthalmic nerve (see page 88) to localise • pain may be felt in the ear from oral lesions such• may be associated with syncopal attacks as aphthous ulcers, dental caries/periapical lesions• onset is often sudden, with pain lasting up to or infected impacted third molars 60 seconds, recurs frequently over half an hour • pain from an oral lesion may be transmitted via sensory nerve branches: auriculotemporal (trigeminal), auricular (vagus), tympanic management (glossopharyngeal) nerves to ear As for trigeminal neuralgia • pain may emanate from ulcers at the base of tongue (frequently neoplastic), floor of mouth orCluster headache oro-pharynx• variant of migraine • temporomandibular joint dysfunction (see• five times more common in males—mainly in page 88) 30–40 age group; commonly have high cigarette/ Temporal (cranial) arteritis alcohol intake • giant cell vasculitis affecting media of middle-• very severe episodic unilateral pain of short sized arteries in particular—ophthalmic and duration (< 60 minutes) centred around the eye superficial temporal• frequently occurs at same time each day, often • most common in females over 70 years early morning • frequently, insidious onset of constant diffuse headache which may be localised to ear, management temporal or occipital areas Sumatriptin subcutaneously or orally • tenderness of scalp and superficial temporal artery are common, as is jaw pain when ly chewing (claudication) from involvement ofpain arounD the ear the masseteric arteryConsider:• pain frequently does not reflect an aural problem on • malaise, fatigue, weight loss, fever, sweating • visual disturbance from involvement of• pain can be localised to the ear from the upper posterior ciliary artery; can lead to damage s cervical spine (C3, C4) via great auricular, lesser to optic nerve with loss of colour perception, ge and greater occipital nerves; examination for acuity and field defects cervical spine dysfunction is mandatory • may be uncomfortable to lie on affected side pa• MRI is the investigation of choice• temporal arteritis Diagnosis• otological causes may be infective (acute/ • Clinical findings together with a raised ESR e chronic otitis media, otitis externa, furunculosis) > 60 or traumatic (baro-trauma, foreign body or pl • Diagnosis may be confirmed by a positive perichondritis); these conditions are usually temporal artery biopsy, however as skip lesions m easily diagnosed by a carefully taken history and are common, false negatives may occur examination sa 87

Oral, nasal and pharyngeal complaints Diagnosis CAUTION: Due to sometimes rapid • TMJ dysfunction is not a diagnosis of progression to blindness, steroid therapy exclusion; rather, it must be made from (prednisolone 60 mg daily) should be started positive clinical findings as soon as CRP or ESR is obtained as, once • Plain TMJ films (open and closed) may reveal established, blindness rarely improves. pathology but the gold standard is MRI Prednisolone dosage is determined by serial ESR results but generally at least one year of therapy is management necessary. Relapse occurs in 30% of cases. • Advise the patient to rest the jaw by limiting opening (avoid biting apples, vigorousTemporomandibular joint (TMJ) dysfunction chewing)• a relatively common complaint affecting 12% of • Use a removable dental (occlusal) splint to adults. More common in females prevent grinding and reduce clenching, and so rest muscles • Apply heat locally etiology • Recommend isometric stretching of Possible causes: masticatory muscles by biting on a soft • many cases are idiopathic wooden block • occlusal disharmony due to missing teeth • Consider non-steroidal anti-inflammatory • facial trauma drugs; these may provide symptomatic relief • connective tissue disease • If there is a history of jaw clenching or teeth • osteoarthritis grinding, diazepam 5 mg BD may relieve • abnormal condylar morphology: condylar anxiety and reduce muscle spasm dysplasia, hyperplasia, condylysis. other Causes of faCial pain ly Clinical presentation Post-herpetic neuralgia • Pain and stiffness, often maximal on waking or with mandibular movements on • herpes zoster (HZ) results from the reactivation of herpes virus dormant in the dorsal root ganglion of • Oral examination may reveal an unbalanced sensory nerves. Acquired in childhood chicken pox s occlusion, often related to missing teeth • as in other sites, HZ may present with a burning ge • Tenderness over TMJ may be elicited on sensation in the affected dermatome 3–4 days opening or at insertion of masseter or before vesicles appear (see Figs. 6.1 and 6.2) pa temporalis muscles when jaws clenched • pain is generally constant and burning in nature; • A clicking joint does not necessarily result tenderness over affected dermatome (see Fig. 6.3) in pain • often involves ophthalmic division of trigeminal e • History of locking of jaw or limited opening nerve (< 20 mm) indicates significant joint • inspection of eye is essential as cornea is usually pl dysfunction affected, leading to ulceration m • In many cases a state of anxiety leads to • geniculate ganglion (facial nerve) may be involved clenching of jaws or grinding teeth; diazepam (Ramsey Hunt syndrome) causing vesicles in external sa 5 mg BD may help eliminate anxiety and ear and buccal mucosa, unilateral facial paralysis reduce muscle spasm and loss of taste (chorda tympani involvement)88

Chapter 6 Facial pain• most common in the elderly and immuno- Bell’s palsy compromised • etiology unclear but occurs in 20% of cases of• severe infection suggests immune deficiency multiple sclerosis and is sometimes a complication• virus from lesions may cause chicken pox in of herpes (simplex or zoster) susceptible individuals, but not shingles • while primarily a unilateral facial nerve palsy,• post-herpetic neuralgia may persist up to 6 months symptoms may develop over several hours, initially after lesions resolve with pain around the ear • patients commonly complain of persisting management numbness of affected side of the face but this • Early treatment with the aciclovir analogue cannot be confirmed on neurological testing valaciclovir 1 gm 8 hrly is essential to reduce • lesions occurring in the facial canal due to post herpetic neuralgia recrudescent herpes infection may cause oedema • In established pain, carbamazepine (100 mg of the facial nerve and, if the nerve to the stapedius 12 hrly), amitriptyline (25–50 mg nocte) or is involved, hyperacusis gabapentin (300mg daily) with incremental • tear and saliva production may be decreased increases may minimise this distressing • vesicles present on palate and external ear symptom indicate herpes zoster as a cause (Ramsay Hunt • A live, attenuated viral vaccine to prevent syndrome–see page 88) HZ has recently been approved in USA for immunocompetent people > 60 years ly on s ge pa e pl m saFigure 6.1 Herpes zoster affecting maxillary division of trigeminal nerve 89

Oral, nasal and pharyngeal complaints ly on s ge pa e pl m saFigure 6.2 (above) and Figure 6.3 (below) Herpes zoster affecting mandibular division of trigeminal nerve90

Chapter 6 Facial pain management oral CanCer • Start immediately—prednisolone 40–60 mg (See also Chapter 3) daily for 7 days; the addition of valaciclovir may hasten resolution Oral cancer can produce pain in the mouth or pharynx • The majority recover fully within 3 months, and may be referred to the ear. but resolution is slower in the elderly • The use of artificial tears and taping the eyes at night helps to reduce the incidence of CAUTION: Beware conditions not seen in routine examination: keratitis • cranial arteritis: always perform ESR in • Decreased salivary flow necessitates careful suspicious cases attention to oral hygiene • nasopharyngeal carcinoma (see oral/pharyngeal cancer in Chapter 4) • thalamic infarcts: typically cause burning pain CAUTION: Differentiate Bell’s palsy from • cerebral neoplasms an upper motor neuron lesion where the frontalis CT and MRI are valuable investigations in muscle is spared. excluding the last three conditions.atypiCal faCial pain REFERENCES• commonly constant, unremitting and centred over maxilla Hayreh SS. ‘Steroid therapy for visual loss in patients• such a diagnosis should only be made after with giant cell arteritis.’ Lancet 2000: 355: 1572–73 exhaustive investigation has excluded other causes Lance JW. Mechanisms and management of headache• psychological disorders may underlie or magnify 5th edn. London Butterworth-Heinmann 1993 ly such pain Mashford ML. ‘Therapeutic Guidelines. Analgesia.’• most frequently seen in elderly females• an empirical trial of carbamazepine or amitriptyline may ameliorate symptoms on Melbourne: Therapeutic Guidelines Ltd 2002 Quail G. ‘Atypical facial pain.’ Aust Family Physician 34: 641–45 2005 sNote: if injection of a long acting analgesic at site Stevens M. ‘Diagnosis and management of sinusitis.’relieves pain, a central cause is excluded. Modern Medicine 16–26: 1991 ge Walton J (ed). Brain’s Diseases of the Nervous System 10th edn. Oxford Oxford University Press 1993 pa e pl m sa 91

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New Book: Oral, Nasal and Pharyngeal Complaints, Geoffrey Quail

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