Facial pain

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.

Facial pain causes^{1 2 3}

• 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).⁴

• Persistent idiopathic facial pain.

• Myofascial pain syndrome.

Facial pain, alone or combined with other symptoms, is a frequent complaint.⁵ However idiopathic facial pain syndromes are relatively rare.⁶

Clinical assessment of facial pain^{1 7}

History

• Site:
  

  • 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.

• Character:
  

  • 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.

Examination

• 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.

Investigations

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.

• X-rays:
  

  • 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.⁹

• Cognitive behavioural therapy (CBT) may be combined with antidepressant treatment.¹

• With advancing techniques and technology, neurostimulation can be promising in treating intractable pain of the head and face.¹⁰

• 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:¹¹
  

  • 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.