Trigeminal neuralgia

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trigeminal neuralgia and facial palsy

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Trigeminal neuralgia

  1. 1. TRIGEMINAL NEURALGIA AND FACIAL PALSY BY: DR. KOMAL MADAAN
  2. 2. CONTENTS 1. NEURALGIA 2. TRIGEMINAL NEURALGIA  DEFINITION  CLASSIFICATION  CAUSES  TRIGEMINAL NERVE  INTRODUCTION  DEFINITION  HISTORICAL REVIEW  HISTORY, CULTURE& SOCIETY  TIC DOULOUREUX  ETIOLOGY  PATHOGENESIS  TYPES  GENERAL CHARACTERISTICS  CLINICAL CHARACTERISTICS  DIAGNOSIS
  3. 3. 3. FACIAL PALSY  FACIAL NERVE  INTRODUCTION  DEFINITION  HISTORICAL REVIEW  ETIOLOGY  ASSOCIATED SYNDROME  CLASSIFICATION  GENERAL CHARACTERISTICS  SIGN AND SYMPTOM  DIAGNOSIS  DIFFERENTIAL DIAGNOSIS  TREATMENT  CONCLUSION
  4. 4. DEFINITION: Neuralgia (Greek neuron, "nerve" + algos, "pain") is pain in the distribution of a nerve or nerves, as in intercostal neuralgia, trigeminal neuralgia, and glossopharyngeal neuralgia
  5. 5. CLASSIFICATION: Under the general heading of neuralgia are:  Trigeminal neuralgia  Occipital neuralgia  Glossopharyngeal neuralgia  Postherpetic neuralgia  Intercostal neuralgia
  6. 6. 1.TRIGEMINAL NEURALGIA • most debilitating form of neuralgia affecting the sensory branches of 5th C.N. • Disorder of peripheral or central fibres of TN • in this there is sudden usually unilateral, severe, brief, stabbing, lancinating, recurring pain in the distribution of one or more branches of TN
  7. 7. 2. OCCIPITAL NEURALGIA  also known as C2 neuralgia or Amold’s Neuralgia  a medical condition characterized by chronic pain in the upper neck, back of the head and behind the eyes.
  8. 8. 3. GLOSSOPHARYNGEAL NEURALGIA  consist of recurring attack of severe pain in the back of the throat, the area near the tonsils, the back of the tongue, and part of the ear.  The pain is due to malfunction of the glossopharyngeal nerve (CN IX), which moves the muscles of the throat and carries information from the throat, tonsils, and tongue to the brain
  9. 9. 4. POSTHERPETIC NEURALGIA: - occurs as complication of shingles. Shingles is a viral infection characterised by painful rash and blisters. - Neuralgia can occur wherever the outbreak of shingles occurred. Can be mild, severe, persistant or intermittent.
  10. 10. 5. INTERCOSTAL NEURALGIA  rare condition causes pain along the intercostal nerve located in between ribs.  Common causes of neuralgia include pregnancy, tumors, chest or rib injury, surgery to chest or organs in the chest cavity and shingles.
  11. 11. CAUSES: - main cause is damage to nerve leading to demyelination of nerve leading to stabbing, severe, shock like pain of neuralgia results. FACTORS CAUSING DAMAGE ARE-  Old age  Infection( postherpetic neuralgia)  Multiple sclerosis  Pressure on nerves  Diabetes
  12. 12. TRIGEMINAL NEURALGIA ( TIC DOULOUREUX, TRIFACIAL NEURALGIA, FOTHERGILL’S NEURALGIA)
  13. 13. TRIGEMINAL NERVE
  14. 14. INTRODUCTION:  It is the most debilitating form of neuralgia that affects the sensory branches of the Vth cranial nerve.  It is a disorder of the peripheral or central fibres of the trigeminal nerve in which the dominant symptom is pain in the anterior half of the head.
  15. 15. DEFINITION:  It is defined as sudden, usually unilateral, severe, brief, stabbing, lancinating, recurring pain in the distribution of one or more branches of the Vth cranial nerve  Trigeminal neuralgia also known as prosopalgia or fothergill’s disease is aneuropathic disorder characterized by episodes of intense pain in the face, originating from trigeminal nerve
  16. 16. HISTORICAL REVIEW:  JOHN LOCKE in 1677 gave the first full description with its treatment  NICHOLAS ANDRE in 1756 coined the term ‘Tic Doloureux  JOHN FOTHERGILL in 1773 published detailed description of trigeminal neuralgia
  17. 17. HISTORY, CULTURE & SOCIETY  TN has been called "suicide disease" in the past. Some example cases of TN include:  Entrepreneur and author Melissa Seymour was diagnosed with TN in 2009 and underwent microvascular decompression surgery in a well documented case covered by magazines and newspapers which helped to raise public awareness of the illness in Australia. Seymour was subsequently made a Patron of the Trigeminal Neuralgia Association of Australia
  18. 18. TIC DOULOUREUX:  TiC DOULOUREUX painful jerking.  It is a truly agonizing condition, in which the patient may clunch the hand over the face & experience severe, lancinating pain associated with spasmodic contractions of the facial muscles during attacks -a feature that led to use of this term
  19. 19. ETIOLOGY:  Usually idiopathic  Demylination of the nerve  Multiple sclerosis  Petrous ridge compression  Post – traumatic neuralgia  Intracranial tumors  Intracranial vascular abnormalities  Viral etiology
  20. 20. PATHOGENESIS:
  21. 21. TYPES OF TRIGEMINAL NEURALGIA AND THEIR CAUSES:  TYPICAL TRIGEMINAL NEURALGIA  ATYPICAL TRIGEMINAL NEURALGIA  PRE- TRIGEMINAL NEURALGIA  MULTIPLE SCLEROSIS RELATED TRIGEMINAL NEURALGIA  SECONDARY OR TUMOR RELATED TRIGEMINAL NEURALGIA  TRIGEMINAL NEUROPATHY OR POST- TRAUMATIC TRIGEMINAL NEURALGIA  FAILED TRIGEMINAL NEURALGIA
  22. 22. 1. TYPICAL TRIGEMINAL NEURALGIA: • most common form, previously termed CLASSICAL, IDIOPATHIC and ESSENTIAL TN. Nearly all cases of typical TN caused by blood vessel compressing the trigeminal nerve root.  pulsation of vessels upon the trigeminal nerve root do not visibly damage the nerve. However irritation from repeated pulsations may lead to changes of nerve function, delivery of abnormal signals to the trigeminal nerve nucleus , this causes hyperactivity of trigeminal nerve root leading to trigeminal nerve pain
  23. 23. 2. ATYPICAL TRIGEMINAL NEURALGIA:  it is characterized by a unilateral, prominent constant and severe aching and burning pain superimposed upon otherwise typical symptom.  Some believe that atypical TN is due to vascular compression upon specific part of the trigeminal nerve( the portio minor) while other theorize atypical TN as more severe progression of typical TN
  24. 24. 3. PRE- TRIGEMINAL NEURALGIA: - Days to years before the first attack of TN pain, some sufferers experience odd sensations of pain,( such as toothache) or discomfort( parasthesia). 4. MULTIPLE SCLEROSIS RELATED TN: - symptoms of MS related TN are identical to typical TN. Bilateral TN is more commonly seen in people with MS. MS involves formation of demyelinating plaques within the brain.
  25. 25. 5. SECONDARY OR TUMOR RELATED TN: TN pain caused by a lesion, such as a tumor. Tumor that severely compresses or distorts the trigeminal nerve may cause numbness, weakness of chewing muscles or constant aching pain 6. FAILED TRIGEMINAL NEURALGIA: In a very small proportion of suferres, all medications, surgical procedures prove ineffective in controlling TN pain Such individual also suffer from additional trigeminal neuropathy as a result of destructive intervention they underwent.
  26. 26. GENERAL CHARACTERISTICS  INCIDENCE- 8: 100000  AGE- 5th-6th decade of life  SEX- female> male  AFFLICTION FOR SIDE- right> left  DEVISION OF TRIGEMINAL NERVE INVOLVEMENT- V3>V2>V1 TRIGGERING ZONES
  27. 27. CLINICAL CHARACTERISTICS  Manifests as a sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating , shock like pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point, across the distribution of one or more branches of the trigeminal nerve  Pain is usually confined to one part of one division of trigeminal nerve  Pain rarely crosses the midline  Attacks do not occur during sleep  Pain is of short duration, but may recur with variable frequency.  In extreme cases, the patient will have a motionless face – the ‘frozen or mask like face’.  Common trigger zone include- cutaneous( corner of the lips, cheek, ala of the nose, lateral brow); intraoral( teeth, gingivae, tongue). Trigger area on the face are so sensitive that touching or even air currents can trigger an episode.  10-12% of cases are bilateral, or occurring on both sides. This mainly seen in cases with systemic involvement include multiple sclerosis or expanding cranial tumor
  28. 28. DIAGNOSIS  From a well taken history  CT- scan  MRI  Diagnostic nerve block
  29. 29. DIFERENTIAL DIAGNOSIS  MIGRAINE- severe type of periodic headache is persistent, at least over a period of hours and it has no trigger zone.  SINUSITIS- pain is not paroxysmal, in this pain is persistent, associated nasal symptoms.  DENTAL PAIN- localized, related to biting or hot or cold foods, visible abnormalities on oral examination.  Tumors of nasopharynx - in this similar type of pain is produced, manifested in the lower jaw, tongue and side of the head with associated middle ear deafness. This complex lesion is called TROTTER’S syndrome. Patient exhibit asymmetry and defective mobility of the soft palate and affected side. As the tumor progresses, trismus of internal pterygoid muscle develops, and patient is unable to open the mouth. Here actual cause of pain is involvement of mandibular nerve in the foramen ovale.  Post herpetic neuralgia- pain is usually involved in ophthalmic division. The history of skin lesion prior to onset of neuralgia, pain is persistent, associated nasal
  30. 30. TREATMENT 1. MEDICAL • First line of treatment is: CARBAMAZIPINE ( anticonvulsant) • Second line of treatment is: BACLOFEN, LAMOTRIGINE, OXCARBAZEPINE, PHENYTOIN, GABAPENTIN, PREGABALIN, SODIUM VALPROATE • Low dose of Antidepressants such as AMITRYPTILINE are thought to be effective in treating neuropathic pain. Antidepressant are also used to counteract a medication side effect. • DULOXETINE is helpful where neuropathic pain and depression are combined. • Opiates such as MORPHINE and OXYCODONE, there is evidence of their effectiveness on neuropathic pain, especially if combined with gabapentin, gallium maltoate in a cream or ointment base has been reported to relieve refractory postherpetic TN
  31. 31. 2. SURGICAL  INJECTION OF NERVE WITH ANESTHETIC AGENT • Long acting anesthetic agents • Alcohol injection  PERIPHERAL GLYCEROL INJECTION MVD  PERIPHERAL NEURECTOMY( NERVE AVULSION)  OPEN PROCEDURES ( INTRACRANIAL PROCEDURES) - MICROVASCULAR DECOMPRESSION - PERCUTANEOUS RHIZOTOMIES - GAMMA KNIFE RADIOSURGERY
  32. 32. FACIAL NERVE Each nerve controls:  Eye blinking and closing  Facial expressions  Smiling and frowning  Tear glands  Saliva glands  Muscle of small bone in middle of ear called the stapes  Taste sensations
  33. 33. BELL’S PALSY INTRODUCTION: Bell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) causing an inability to control facial muscles on the affected side Several conditions can cause facial paralysis eg. Brain tumor, stroke, myasthenia gravis, lyme disease. if no specific cause can be identified, the condition is known as Bell's palsy DEFINITION: - Bell's palsy is defined as an idiopathic unilateral facial nerve paralysis, usually self-limiting. The hallmark of this condition is a rapid onset of partial or complete paralysis that often occurs overnight.
  34. 34. HISTORICAL REVIEW: Charles Bell -Well known for his studies on the nervous system and the brain -In the 19th century discovered that lesions of the 7th cranial nerve causes facial paralysis ETIOLOGY: 1. Facial nucleus : Cerebrovascular disease, moebius syndrome, multiple sclerosis, syphilis, HIV 2. Between nucleus and geniculate gangion : Fracture base of skull, post cranial fossa tumors, sacroidosis 3. Between geniculate ganglion and stylomastoid canal : Middle ear infection, ramsay threat sign, mastoiditis 4. In stylomastoid canal or extracranially : misplaced inferior alveolar nerve anaesthetic, parotid tumor, sarcoidosis 5. Branch of facial nerve (extra cranially) : Local anesthesia, parotid gland surgery, TMJ arthroscopy, facial asthetic surgery, facial trauma
  35. 35. ASSOCIATED SYNDROME: 1. MELKERSON ROSENTHAL SYNDROME( a triad of fissured tongue, persistent or recurring lip or facial swelling and cranial nerve 8th paralysis) 2. CROCODILE TEAR SYNDROME(Due to injury to facial nerve proximal to the genicular ganglion, there may be misdirection of the nerve fibers to the lacrimal gland instead of going to the submandibular through greater petrosal nerve. As a result the patient lacrimates while eating. This is treated by dividing the greater petrosal nerve. 3. RAMSAY HUNT SYNDROME( Severe facial paralysis with vesicles in the ipsilateral pharynx and external auditory canal may be due to herpes zoster of the geniculate ganglion of the facial nerve.) BILATERAL FACIAL PARALYSIS is rare may be due to acute idiopathic polyneuritis, sarcoidosis, post cranial fossa tumors.
  36. 36. – Brackman (1985): Grade I: Normal function without weakness Grade II: Mild dysfunction, with slight facial assymmetry Grade III: Moderate dysfunction – obvious but not disfiguring, assymetry with contracture. Grade IV: Moderately severe dysfunction, disfuguring assymmetry with lack of forehead motion and incomplete closure of eye. Grade V: Severe dysfunction. Asymmetry at rest and only slight facial movement. Grade VI: Total paralysis complete absence of tone or motion. Prognosis is grade dependent INCIDENCE- 20: 100000 AGE- middle age group SEX- female> male
  37. 37. SIGN AND SYMPTOM  This is characterized by unilateral paralysis of all muscles of facial expression for both voluntary and emotional movements.  Forehead is unfurrowed.  Patient is unable to cross eye on that side, any attempted closure causes rolling of eye upwards (Bell’s sign).  Tears tend to overflow ( epiphora ). Tears fail to enter the lacrimal puncta because they are no longer in contact with the conjunctiva. Conjunctival reflex is absent.  Corner of the mouth droops and nasolabial fold is obliterated. Saliva dribbles and food collects in the vestibule because of paralysis of buccinator. The lips remain in contact and cannot be pursued, in attempting to smile the angle of mouth is not drawn up on the affected side. The mouth takes a triangular form.  Paralysis of the masticatory muscles by the involvement of motor trigeminal nucleus.  Sensory loss on face from involvement of the principal sensory and spinal trigeminal nuclei or spinothalamic tract and paralysis of the upper or lower limbs due to cortico spinal lesions.  Due to lesions in posterior cranial fossa or in internal acoustic meatus, may be loss in taste sensation of anterior 2/3rd of tongue.  Most common cause of bells palsy in inflammation of facial nerve near the stylomastoid foramen, with oedema of nerve and compression of its fibers in facial canal or stylomastoid foramen
  38. 38. DIAGNOSIS  Careful history for the onset of characteristics, duration of condition.  Acute onset on awakening in the morning is typical in Bell’s palsy. Sudden onset may also be due to infections or inflammatory etiology (Herpes zoster, multiple sclerosis).  Patients with neoplasms usually demonstrate progressive paresis over a long period with initial mild symptoms. In trauma patients gives a history of trauma. Delayed onset of facial paralysis has a better prognosis. In temporal bone neoplasms there might be involvement of 9th, 10th, 11th nerves.  Examination of face at rest and in motion, noting muscular tone and symmetry. Differentiate between weakness (paresis) and total flaccidity (paralysis).  Functioning of orbicularis oculi muscle allows for a complete closure of eyelid and absence of visible upwards rotation and exposure of sclera.  A forced smile for detecting asymmetrise of perioral muscles. Patient is asked to blow.  Side comparisons of deeper of nasolabial fold and symmetric contractions of platysma.  Pure taste sensation is carried out using samples of sweat, bitter, salty substances on anterior tongue.  CT scan of skull base fracture.  MRI to detect intracranial lesions.
  39. 39. DIFFERENTIAL DIAGNOSIS  STROKE- it will cause few additional symptoms, such as numbness or weakness in the arms and legs. Unlike bell’s palsy, stroke will usually let patients control the upper part of their faces. Some wrinkling on their forehead is also seen.  Involvement of facial nerve in infections with the HERPES ZOSTER VIRUS. Small blisters or vesicles, on the external ear and hearing disturbances, but these findings may occasionally be lacking( zoster spine herpete)  Reactivation of existing herpes zoster infection leading to facial paralysis in a bell’s palsy type is known as RAMSAY HUNT SYNDROME  LYME DISEASE- Lyme specific antibodies in the blood or erythema migrans.
  40. 40.  PHYSIOTHERAPY should be started as early as possible, consists of electrical stimuli by galvanism, gentle massage and facial exercise.  MEDICATION  If patient is seen within 2-3 weeks of onset of symptoms then tab prednisolone 1 mg/kg/d for 10-14 days with gradual tapering vitamins B1, B6, B12.  If patient is seen after 3-4 weeks, then steroids are of no use. CT, MRI and EMG done.  If incomplete eye closure is present - artificial lubrication - taping the eye, - Opthalmologist is referred.  In hyperkinesias-offending muscle groups are de-enervated or botulinium toxin are used. - Clostridium botulinium toxin (Botax) is a neurotoxin that interferes with acetychline release, causing skeletal muscle paralysis, weakening the contralateral side to allow centering of mouth. Effect lasts for 4-6 months.  In hypokinesia – requires nerve transfer, muscle transfer or static rings.
  41. 41. SURGICAL 1. Internal decompression: - Nerve exposed in fallopian canal and pressure is relieved. - Epineural sheath is opened to visualize the nerve fibers and release adhesions or re-establish continuity. 2. External decompression by releasing of epineural sheath from surrounding scar tissue, bone or foreign body. 3. Nerve anastomosis – reanimation- anastomosis of the central end of hypoglossal or spinal accessory nerve with the distal end of the facial nerve is done. 4. Nerve grafting – whenever there is evidence of neuroma or loss of portion of a nerve, grafting is done. If due to effect of local anaesthesia: - reassure the patient- mostly it resolves without any residual effects - eye patch to prevent corneal ulceration - instruct to avoid wearing contact lens till the effect wears among.
  42. 42. Surgical approaches are performed when medication can not control pain, patients can not tolerate the adverse effects of the medication, or in medically complex patients with poly pharmacy for other coditions.
  43. 43.  GRAY’S ANATOMY  TEXTBOOK OF ORAL SURGERY- NEELIMA MALIK  TEXT BOOK OF ORAL PATHOLOGY- SHEFFER’S  TEXTBOOK OF ORAL PATHOLOGY- NEVILE  TEXTBOOK OF LOCAL ANESTHESIA- MONHIMS  TEXTBOOK OF ORAL MEDICINE- ANIL GHOM’S

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