[DYSPHAGIA] Bilateral facial pain and bitter taste in mouth

Subject: [DYSPHAGIA] Bilateral facial pain and bitter taste in mouth

From: eripley@yahoo.com (Irene Campbell-Taylor)

Date: Sun, 12 Mar 2000 10:07:19 -0800 (PST)

This is a friend's mother (99 yo) who is edentulous. At first glance, it would seem that the trigeminal is involved in both symptoms. The fact that the pain is bilateral is troubling as it suggests a central rather than peripheral process. It is, however, rare but possible to have bilateral pain with trigeminal neuralgia as well as taste alterations. Her very advanced age makes certain tests difficult but one would: test integrity of brainstem and crV by testing corneal and blink reflexes. See if she can raise eyebrows, frown. identify locus of pain : eyebrow, upper gingiva, area in front of ear, upper lip, cheek etc. following the three divisions of the trigeminal. There are multiple brain stem and midbrain possibilities, but using Occam's razor, one would try to eliminate the most obvious first, namely involvement of the trigeminal system. Trigeminal neuralgia does not extend outside the boundaries of the face so that, if she has any extension beyond the hairline, it may be temoral arteritis, requiring attention ASAP. Is she by any chance taking digoxin (digitalis)? This phenomenon you have described has been found in digitalis toxicity. Irene.

Trigeminal neuralgia (Tic douloureux)
Overview	Most common paroxysmal pain of the face Incidence: 4-5/100,000 population. 1% of MS patient Etiology: not clear 1-2% has posterior fossa lesion, tends to be younger patients. Rest is idiopathic Most patients > 50 yo, female more than male. Post-traumatic trigeminal neuralgia: 5 to 10% after facial trauma or oral surgery. May represent trigeminal "neuroma" or deafferentation pain. This diagnosis overlaps substantially with atypical facial pain.
Signs & Symptoms	Brief, recurrent electric like pain Trigger zone over skin or mucous membrane Usually involves a single Trigeminal division, at times 2 adjacent ones 4% bilateral involvement: suspect multiple sclerosis Triggering stimuli includes talking, eating, toothbrushing, and wind or cold temperatures on the face. Spontaneous remissions common
Medical Treatment of Trigeminal Neuralgia
Carbamazepine 100-200 mg bid, titrate up. Monitor WBC, may cause leukopenia. Gabapentin (Neurontin) may be effective. 300 mg per day, titrate up by 300 mg every 2 to 3 days, given qid until relief is achieved. Some patients can tolerate up to 4000 mg per day Baclofen 5-10 mg tid, up to 60 mg / day 70% of patients respond at least initially to medical management. As time goes on, the drugs become less effective in many patients.
Surgical treatment of Trigeminal Neuralgia
Percutaneous procedures: Less risk local or brief general anesthesia A needle or trocar is inserted on the cheek just lateral to the corner of the mouth, under fluoroscopic guidance, introduced into the ipsilateral foramen ovale. Gangliolysis is performed. Different types of procedure Percutaneous radiofrequency trigeminal gangliolysis (PRTG) Percutaneous retrogasserian glycerol rhizotomy (PRGR) Percutaneous balloon microcompression (PBM). Microvascular decompression: Requires general anesthesia 2.5- to 3-cm craniectomy is performed, the dura is opened, and the cerebellum is microsurgically retracted. Typically, an artery or other vascular cross-compression of the nerve is identified, the vascular structure is padded away from the nerve with polytetrafluoroethylene (Teflon) felt. This operation has a low mortality rate 0.1 and 0.5% in most series. Serious morbidity probably between 1 and 5%. numbness, hearing loss, dizziness, cerebellar syndrome, CSF leaks, meningitis, diplopia. Expected pain-free interval PRGR or PBM: approximately 1.5 to 2 years PRTG: about 3 to 4 years Microvascular decompression: pain relief can be expected to last an average of 15 years. Further reading MGH Trigeminal Neuralgia page
Glossopharyngeal neuralgia
Overview	Brief, electric like pain around tonsil & ear Relatively rare Consider skull base tumor ENT evaluation to rule out occult neoplasm
Treatment	If no evidence of compressive lesion, medical treatment similar to Trigeminal Neuralgia
Ophthalmic herpes zoster & post herpetic neuralgia
Overview	From reactivation of latent virus in Trigeminal sensory ganglion Patient with severe pain and over 80 yo more prone to develop post herpetic neuralgia
Signs & Symptoms	Nausea, malaise, fever in acute phase Burning or lacinating pain in V1 distribution Watch for corneal ulceration May have residue scar & sensory deficit
Test	Rising Herpes Zoster antibody titer
Treatment	see Herpes zoster page
Atypical facial pain
Overview	Facial pain, no organic etiology found Most common in middle age female
S/S	Deep, poorly localized pain Aching, drawing all the time, "pain is ruining my life". Mood swings, irritability, insomnia common. Examination negative except for some tenderness on face. Failed multiple medications & procedures, seen multiple specialists.
Treatment	Difficult, ?antidepressant
Cluster headache
Review	see cluster headache page
Temporomandibular joint disorder
Overview	Diagnosis is controversial & difficult. Many patients who have dental malocclusion but do not have TMJ. Many asymptomatic patients have abnormal imaging study. Joint tenderness & EMG abnormality occur with equal frequency for patients & control.
Treatment	?antidepressant
Temporal arteritis
Review	see Temporal arteritis page
Other disorders causing facial pain
Paranasal sinus disease	Acute sinusitis is usually evident Chronic sinusitis, especially sphenoid sinusitis may be difficult to diagnose. ?MRI of head
Optic neuritis	Retro-orbital pain with color desaturation of the affected eye
Ocular pain	Glaucoma Uveitis
Thalamic pain	Central pain such as from small infarct
Tolosa Hunt Syndrome - Baylor Atypical facial pain - emedicine

Please Help - Pain Help

This article submitted by on 6/8/99.
Email Address: adgal352@aol.com

I am a male, 58 year old retired teacher and need some information/help. In April, 1998, I went to the ER with paralysis on the left side of my face. The previous symptoms were painful sores in my mouth, and two doctors said I had nothing to worry about - well, in the ER, I was diagnosed by a neurologist with Ramsey Hunt Syndrome. I was admitted for observation. At 11 p.m., the right side of my face was also paralyzed. I was ambulanced to University Hospital. After an MRI and spinal tap it was confirmed RHS. I had severe facial pain, couldn't close my eyes, speak, smile, eat, drink, etc.

The doctors indicated that paralysis on both sides of my face was extremely rare and my recovery would take considerable amount of time. They gave me the percents for recovering but indicated my RHS was complicated. I remained in the hospital six days. There were blessings - no damage to my eyes and only minor loss in hearing. Facial pain and tearing in my eyes were my constant companions.

Now after a year, I'm actually in good shape - 90%. Except for facial neurological pressure and pain on both sides of my face and my left eye tearing. I can talk, smile, eat, close my eyes and most of the time I can tolerate the facial pain (I was given Depakote, it doesn't seem to work). When my pain gets out of control I suffer extensive sharp and continuous facial pain - sometimes for a couple of days. Once the ER was necessary for the pain.

I would like to know if anyone had both sides of the face paralyzed and the outcome. I also would like to know if anyone suffered from neurological facial pain and what was done for the pain. Doctors usually don't spend a lot of time discussing this issue.

I guess psychologically and emotionally I need to know - it's been a long year. Thanks.

You can personally respond to me at my daughters e-mail address which is adgal352@aol.com.