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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Facial pain has a long list of possible causes but the diagnosis can often be made by a good history and examination. The common causes of facial pain are often benign and self-limiting but it is essential not to miss those conditions that require urgent treatment - eg, temporal arteritis, or early diagnosis - eg, malignancy. There is a tendency to overdiagnose bacterial sinusitis when the real cause may be a viral upper respiratory tract infection or, much less frequently, a more serious cause of facial pain.
- Sinus: sinusitis, trauma, carcinoma.
- Nose: upper respiratory tract infection, nasal injury and foreign bodies.
- Ear: otitis media, otitis externa.
- Mastoid: mastoiditis.
- Teeth: dental abscess.
- Local soft tissue infection: cellulitis, erysipelas.
- Neurological: trigeminal neuralgia, herpes zoster, post-herpetic neuralgia.
- Parotid gland: mumps, other causes of parotitis, abscess, duct obstruction, calculi, tumour.
- Eye: orbital cellulitis, glaucoma.
- Temporomandibular joint dysfunction and pain.
- Cluster headaches, migraine, medication-overuse headache.
- Temporal arteritis.
- Tumours: nasopharyngeal, oral, brain tumours (posterior fossa, brain stem gliomas).
- Bone: maxillary or mandibular osteitis, cyst.
- Atypical or idiopathic facial pain: may be worse with fatigue or stress; often linked with depression or mood disturbance.
- Lung cancer (upper lobe).
- Persistent idiopathic facial pain.
- Myofascial pain syndrome.
- Establish if unilateral or bilateral and whether it relates to a nerve distribution. Unilateral pain occurs in dental conditions, trigeminal neuralgia, salivary gland conditions. Pain may be either bilateral or unilateral in sinus infection, temporomandibular disorders, headaches and giant cell arteritis.
- Pain in the region of the ear may be referred from the skin, teeth, tonsils, pharynx, larynx or neck.
- Tenderness over the maxilla may be due to sinusitis, dental abscess or carcinoma.
- Establish whether it is continuous or episodic and the severity and nature of the pain.
- Trigeminal neuralgia: intermittent sharp, severe pain in the distribution of the divisions of the trigeminal nerve.
- Infections of teeth, mastoid and ear: often dull, aching quality.
- Precipitating factors:
- Precipitated by food or chewing: dental abscess, salivary gland disorder, temporomandibular joint disorder or jaw claudication due to temporal arteritis.
- Trigeminal neuralgia: can be precipitated by various factors, including eating, talking and touching or washing the face. Even the slightest touch of the skin can cause intense pain.
- Associated facial pain symptoms:
- Obstruction of the lacrimal duct by nasopharyngeal carcinoma may cause watering of the eyes.
- Otorrhoea and/or hearing loss suggest an ear or mastoid cause.
- Nasal obstruction and rhinorrhoea may be due to maxillary sinusitis or carcinoma of the maxillary antrum. Carcinoma of the maxillary antrum may also present with unilateral epistaxis.
- Proximal muscle weakness and pain may be due to polymyalgia rheumatica, associated with temporal arteritis.
- Intermittent presence of a lump around the jaw may suggest salivary duct obstruction.
- Impact of pain: effect on mood, sleep, eating and quality of life.
- Unilateral erythema and vesicles in the distribution of the trigeminal nerve: herpes zoster infection (may not be present in the early stages of the disease).
- Localised erythema or swelling: localised infection or carcinoma.
- Inspection of the nose and throat may demonstrate a nasopharyngeal tumour.
- Intraoral inspection may reveal any obvious pathology but may require dental expertise.
- Examine the cranial nerves.
- Facial palsy: may be due to a tumour of the parotid gland.
- Tenderness of the superficial temporal artery associated with temporal arteritis.
- Tenderness over one or more sinuses may indicate sinus infection.
- Cervical lymphadenopathy: infection or carcinoma.
- Lumps over the parotid area may indicate salivary gland tumours or blockage of the gland (whether the lump is intermittently present or continuously so is helpful).
- Pain or crepitus on movement of the jaw may indicate temporomandibular joint dysfunction.
Further investigation will be guided by the results of findings on history and examination.
- FBC: raised white cell count in infection or malignancy.
- ESR, CRP: increase in infection, malignancy, temporal arteritis.
- Dental x-rays can be carried out by community dentists where there is suspected dental pathology.
- Opacification of the sinus and destruction of bone with carcinoma of sinuses.
- Opacification may also occur in sinusitis.
- Mastoid films may show opacification in cases of mastoiditis.
- Ultrasound scans are useful as first-line investigation for suspected salivary gland pathology.
- MRI or CT scans may be necessary for some conditions.
- Sialography: parotid conditions - eg, duct stones, sialectasis.
- Fine-needle aspiration: parotid tumours.
Facial pain treatment and management
- The essential aspect of management in primary care is to make an accurate diagnosis. The management will then depend on the identified cause of facial pain.
- The first-line treatment for atypical facial pain is a tricyclic antidepressant such as amitriptyline. Fluoxetine and venlafaxine can also been considered.
- Cognitive behavioural therapy (CBT) may be combined with antidepressant treatment.
- With advancing techniques and technology, neurostimulation can be promising in treating intractable pain of the head and face.
- Specialist referral (usually to a maxillofacial clinic, unless clinical findings suggest a diagnosis where ENT/community dentistry/neurology/rheumatology referral may be more appropriate) should be made according to local guidelines. One such guideline suggests referring patients who have:
- Facial pain persisting for more than three months.
- Persistent temporomandibular disorders not responding to simple analgesics, lifestyle changes and reassurance.
- Persisting pain affecting function and causing distress.
- Widespread pain.
- Pain which is part of systemic disease.
- Significant psychological or social problems.
- Co-existing mental health problems which have an impact on treatment.
- Compliance problems - eg, side-effects.
- A recognised pain syndrome such as trigeminal neuralgia.
- Patients with special needs - eg, learning disabled, communication problems.
Further reading and references
Aggarwal VR, Macfarlane GJ, Farragher TM, et al; Risk factors for onset of chronic oro-facial pain--results of the North Cheshire oro-facial pain prospective population study. Pain. 2010 May149(2):354-9. Epub 2010 Mar 20.
Forssell H, Jaaskelainen S, List T, et al; An update on pathophysiological mechanisms related to idiopathic oro-facial pain conditions with implications for management. J Oral Rehabil. 2015 Apr42(4):300-22. doi: 10.1111/joor.12256. Epub 2014 Dec 8.
Zakrzewska JM; Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013 Jul111(1):95-104. doi: 10.1093/bja/aet125.
Gerwin R; Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome-An Evidence-Based Narrative Review and Etiological Hypothesis. Int J Environ Res Public Health. 2020 Sep 2517(19). pii: ijerph17197012. doi: 10.3390/ijerph17197012.
De Corso E, Kar M, Cantone E, et al; Facial pain: sinus or not? Acta Otorhinolaryngol Ital. 2018 Dec38(6):485-496. doi: 10.14639/0392-100X-1721.
Ruffatti S, Zanchin G, Maggioni F; A case of intractable facial pain secondary to metastatic lung cancer. Neurol Sci. 2008 Apr29(2):117-9. Epub 2008 May 16.
Van Deun L, de Witte M, Goessens T, et al; Facial Pain: A Comprehensive Review and Proposal for a Pragmatic Diagnostic Approach. Eur Neurol. 202083(1):5-16. doi: 10.1159/000505727. Epub 2020 Mar 27.
Ziegeler C, Beikler T, Gosau M, et al; Idiopathic Facial Pain Syndromes-An Overview and Clinical Implications. Dtsch Arztebl Int. 2021 Feb 12118(6):81-87. doi: 10.3238/arztebl.m2021.0006.
Trigeminal neuralgia; NICE CKS, January 2018 (UK access only)
Cornelissen P, van Kleef M, Mekhail N, et al; Evidence-based interventional pain medicine according to clinical diagnoses. 3. Persistent idiopathic facial pain. Pain Pract. 2009 Nov-Dec9(6):443-8.
Antony AB, Mazzola AJ, Dhaliwal GS, et al; Neurostimulation for the Treatment of Chronic Head and Facial Pain: A Literature Review. Pain Physician. 2019 Sep22(5):447-477.
How to refer - Facial pain; University College London Hospitals