Trigeminal neuralgia

It is defined as sudden, usually unilateral, severe, brief, stabbing, lancinating paroxysmal recurring pain the distribution of one or more branches of 5^th cranial nerve.

It is an extremely painful condition as it is unique to humans. it is a syndrome in which symptoms are sufficiently distinctive to permit Oriel level reliable diagnosis on the basis of history it is a serious disorder which  causes highest suicidal rate.

Aetiology

• Usually, idiopathic

• Dental aetiology (Westrum and black 1976)
  • Infections
    • ratner’s jaw bone cavities
    • multiple sclerosis
    • Petrous Ridge compression
    • post traumatic neuralgia
    • intracranial tumours
    • intra cranial vascular abnormalities
• Viral aetiology

history of previous match varicella zoster

Clinical features

Age and location

• Generally, features occur in late middle age or later in 5^th or 6^th decade
• female predisposition
• V3 is more commonly involved than V2.

Nature and sight of pain

• Typically manifest as a sudden, unilateral, intermittent, paroxysmal, sharpshooting, lancinating, shock like pain elicited by slight touching of trigger points.

• Pain is usually confined to one part of the division that is one part of the pain is usually experienced with pain. Pain rarely crosses the midline.

• During attack patient grams with pain grimes his hands over the affected side of the face

•  male patient avoids shaving and patient avoid brushing of the teeth.

•  Paroxysm occur in cycles , each cycle last for weeks or months. with cycle appears closer and closer pain seems to be more intense and unbearable.

• The pain doesn’t occur during sleep
• Patient may lead very poor quality of life because of executing pain and patient might undergo dental extractions on affected side because to relive from pain as it might mimic the pain odontogenic origin.

Trigger points

• Facial skin, oral mucosa, light touch, smiling speaking brushing shaving or even washing the face
• V2 -points are located on the skin of upper lip, Ala off nose, cheek or upper gums
• V3- lower lip steep gums off lower teeth
• V1- supraorbital Ridge of affected sites

Aggravating factors

The pain is provoked by obvious stimuli of the face – a touch of air or  any movement of the face as in talking ,chewing , yawning ,smiling, swallowing etc.

Diagnosis

Diagnosis is done by clinical signs and symptoms and patient’s history confirmative diagnosis is further done by CT and MRI

Criteria by sweet and white

• Pain is paroxysmal, may be provoked by light touch to the face
•  pain is confined to trigeminal distribution
• pain is unilateral.
• Clinical sensory examination is normal

Differential diagnosis

1. Toothache, migraine, Tumours of nasopharynx
2. Sinusitis, stomatitis ,space occupying lesions
3. intra cranial anterior venous abnormalities
4.  acoustic neurilemoma
5. multiple sclerosis
6. post therapeutic neuroma
7. post traumatic neuralgia

Treatment

Medical line of treatment

• intramuscular morphine
• trichloroethylene
• diphenylhydantoin sodium
• carbamazepine

Surgical line of treatment

–EXTRACRANIAL

• Alcohol block in peripheral nerve
• Nerve section and avulsion
• Electrosurgery
• Cryosurgery
• Selective radio frequency

-INTRACRANIAL

• Alcohol blockage at gasserian ganglion
• Medullary tractotomy
• Midbrain tractotomy
• Intracranial nerve decompression

-PERIPHERAL NEURECTOMY

-NEWER APPROCH

• Physiologic inhibition of pain by TENS
• Acupuncture

-PHYSIOLOGICAL APPROCH

• Biofeedback
• Psychiatric counselling
• hypnosis

Contributor- Dr. Kavyashree M prasad