Facial Pain
Pain in the face may either be due to local disease of any of the major structures of the face, or conditions affecting the innervation. The latter can occur anywhere between the posterior fossa and the ends of the trigeminal nerve. A good examination is not difficult but should be within the practitioners’s scope of professional practice.
Differential diagnosis
Common Diagnoses
- Maxillary/Frontal Sinusitis
- Trigeminal Neuralgia (TN)
- Dental Abscess
- Temporomandibular Joint (TMJ) Dysfunction
- Shingles (Herpes Zoster)
Occasional Diagnoses
- Cluster Headache (Periodic Migrainous Neuralgia)
- Temporal Arteritis
- Parotid: Mumps, Abscess and Duct Obstruction (Stone/Tumour)
- Upper Cervical Spondylosis
- Mandibular or Maxillary Osteitis or Cyst
- Cellulitis
Rare Diagnoses
- Multiple Sclerosis
- Atypical Facial Pain (May be Linked with Depression)
- Nasopharyngeal, Sinus and Lingual Carcinoma
- Posterior Fossa Tumours
- Gummatous Meningitis and Tabes
- Glaucoma and Iritis
Ready reckoner
Key distinguishing features of the most common diagnoses
| Sinusitis | TN | Dental Abscess | TMJ | Shingles | |
|---|---|---|---|---|---|
| Fever and Malaise | Possible | No | Possible | No | Possible |
| Lymphadenopathy | Possible | No | Yes | No | Yes |
| Pain Worse on Bending | Yes | No | Yes | No | No |
| Pain on Tapping Teeth | Possible | No | Yes | No | No |
| Lancinating Pain | No | Yes | No | No | Possible |
Possible investigations
Likely: None.
Possible: FBC, ESR/CRP, sinus x-ray.
Small Print: X-ray of TMJ, temporal artery biopsy, sialogram, CT/MRI scan.
- FBC: WCC and ESR/CRP raised in infection; ESR/CRP raised in temporal arteritis and tumour (ESR more useful than CRP in suspected temporal arteritis).
- X-rays: Sinus X-ray of little help in acute sinusitis but may help in chronic pain to assess for possible chronic sinusitis or tumour; TMJ views and dental plain film for abscess likely to be arranged by dentist; parotid sialogram for stone/tumour.
- Temporal artery biopsy: May be necessary to clinch diagnosis of temporal arteritis.
- CT/MRI scan the only practical way to examine the posterior cranial fossa and Gasserian ganglion – a specialist investigation.
Top Tips
- Don’t over-diagnose sinusitis – many URTIs will produce mild facial ache through a vacuum effect.
- Remember that shingles can produce pain before the rash – in the acute onset of unexplained unilateral facial pain, warn the patient to report back to the surgery should a blistering rash develop.
- Refer dental abscesses to a dentist without treating first, to ensure proper investigation, treatment and follow-up – and to encourage the patient to present to the correct agency in future.
Red Flags
- If no obvious cause is found for persistent facial pain, refer to exclude sinister pathology.
- Trigeminal neuralgia is usually idiopathic, but may have a serious underlying cause, especially if there is associated motor disturbance or other neurological symptoms or signs.
- Temporal arteritis is a clinical diagnosis. If suspected, treat immediately with high-dose steroids to prevent blindness. ESR is for retrospective confirmation only.
- If the eyeball is red and tender in frontal facial pain, consider glaucoma, iritis or orbital cellulitis. Refer urgently..
- Out-of-hours dental treatment can be very hard for patients to access in the UK. You may find yourself ethically obliged to provide some form of treatment, but be sure to give the advice (and document it) that the patient should contact their own dentist as soon as the dental surgery is open. Send a copy of your clinical notes to the dentist as you would any other clinician. You should never feel pressured to work outside your areas of competence, so don’t hesitate to refer to the local hospital facio-maxillary team on call if you have any doubts about diagnosis or emergency management.