There were no recent bloods to identify cardiac risk factors such as cholesterol or diabetes.
BP was 160/90.
ECG was "normal"
Troponin was negative and other bloods were noncontributory. Auto-immune serology is still pending.
The patients usual GP had arranged an MRI for the following week of her neck and I added a request for brain and left ear imaging/ report.
I can't recall medications etc but here are the questions I particularly wanted to look up:
- What are the causes of unilateral facial/ ear pain?
- What is somatisation and what are other similar syndromes?
- What are the diagnostic criteria of chronic fatigue?
What are the causes of unilateral facial pain?
"The causes are myriad, and misdiagnosis and mismanagement are common." Up To DateCENTRAL CAUSES OF FACIAL PAIN
Anasthesia dolorosa
Persistent, painful anaesthesia in the distribution of the trigeminal or occipital nerve. The patient has sensory loss (decreased sensation to pin-prick testing) but can feel pain. This may be a complication of thermocoagulation used to treat trigeminal neuralgia.
Central Post Stroke Pain
Pain and altered sensation in any area of the face following a stroke.
Facial pain cased by Multiple Sclerosis
Can occur unilaterlly or bilaterally
Persistent idiopathic facial pain
This basically means the patient has facial pain but no one can find a cause.
Burning Mouth Syndrome
Sensation of burning mouth for which no medical or dental cause can be found. There are a number of Internet sites for patients who have this syndrome. Generally there is a lot of associated distress and fear of not being taken seriously.
NEURALGIAS
Pain is usually severe at onset and is described as lancinating, "electric shocks," or as "jabbing." The pain can last a fraction of a second, or for several seconds. Some neuralgic conditions have trigger zones--areas that when stimulated provoke an attack.
Glosso-pharyngeal neuralgia
Neuralgic-type pain in the region of the glossopharyngeal nerve (CN IX and X)
Glossopharyngeal nerve (IX) |
Causes spasms of severe, stabbing pain of the ear, tonsillar fossa, base of the tongue, or beneath the angle of the jaw. Triggers include chewing, swallowing, coughing, speaking and yawning.
The pain spreads upward from the oropharynx toward the ear. The severe spasms last for seconds to minutes, but there may also be a mild constant background pain. The spasms may awaken the patients from sleep.
There are "idiopathic" and "secondary" forms of glossopharyngeal neuralgia. Secondary causes include demyelinating lesions, cerebellopontine angle tumor, peritonsillar abscess and carotid aneurysm.
The evaluation of a patient suspected of suffering from glossopharyngeal neuralgia includes a careful history, especially enquiring about the presence of trigger factors and nocturnal awakening.
MRA are indicated in virtually all patients to rule out a mass lesion or vascular pathology.
Nervus intermedius neuralgia
A rare disorder characterized by brief paroxysms of pain felt deeply in the auditory canal. Also called geniculate neuralgia or Hunt neuralgia.
Nervus intermedius anatomy |
This is a very RARE disorder.
The International Classification of Headache Disorders requires that all three of the following are present:
- Pain (otalgia) not due to another cause such as glossopharyngeal neuralgia.
- Pain paroxysms of intermittent occurrence, lasting for seconds or minutes, in the depth of the ear
- Presence of a trigger area in the posterior wall of the auditory canal
Occipital nerve from Brown: Atlas of Regional Anesthesia, |
Cutaneous fields of the head and neck (from Up To Date) |
The cause is unknown but may result from occipital nerves getting squashed a bit by neck and scalp muscles.
Occipital neuralgia causes jabs of electric-shock like pain in the back of the head (usually on one side). the pain starts in the back of the neck (around C3) and spreads to the front of the head. There may be sensitivity/ tenderness over the branches of the nerve.
Occipital neuralgia Pain starts in the neck and spreads forwards |
Other causes of occipital neck pain include:
- Muscular problems (trapezius or sternocleidomastoid)
- C2 and C3 disc pathology (eg cervical discogenic pain from degeneration)
- C2 and C3 facet joint problems (often chronic following "whip-lash" like injury)
- Vertebral artery problems
An occipital nerve block is almost diagnostic. If the pain doesn't go away then there is most likely another diagnosis for the pain.
Postherpetic neuralgia
Neuropathic pain following an episode of herpes zoster (shingles).
Trigeminal Neuralgia (Tic douloureux)
A VERY COMMON cause of facial pain characterised by spasms of electric-shock like pain in the trigeminal distribution (V1 or V2 or V3). It is more common in women and is probably caused by the trigeminal nerve getting squashed by an artery. The nerve may also be compressed by an acoustic neuroma (or other tumor) or by an epidermoid cyst.
Secondary causes (such as tumor) are unlikely but may be present even if the neurological examination is normal (one studied found this to be the case 15% of the time).
Carbemazepine is the standard treatment
Baclofen may be useful. the starting dose is 5mg TDS with gradual titration to 50mg a day.
Sedation, dizziness, and dyspepsia can occur with treatment, and the drug should be discontinued slowly.
Adjunct therapy with lamotrigine (400 mg daily) may be helpful.
Surgical therapy is a possibility in refractory cases.
Other casues of unilateral facial pain
- Temporal arteritis (50% have claudication; pain may be in the temporal or occipital region; visual loss is a feared complication)
- Dental pain
- Cancer pain
What is somatisation?
The DSMV-IV-TR and ICD 10 both discuss somatisation/ somatiform disorder.Essentially the patient presents with one or more medically unexplainable symptoms. The symptoms usually lead to significant impairment in functioning. Patients are often preoccupied with their symptoms. It is very common in women, especially those who are poorly educated and marginalised. There is often a history of childhood sexual abuse or violence.
What are the diagnostic criteria of chronic fatigue?
Everyone seems to present differently but there are some commonalities:
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Four or more of the following symptoms that persist or recur during six or more consecutive months of illness and that do not predate the fatigue: |
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