What are the manifestations and how to diagnose trigeminal neuralgia?
(A) Pain site: it does not go beyond the distribution of trigeminal nerve, often confined to one side, mostly involving one branch, with the second and third branch being most frequently involved, accounting for about 95%.
(b) Nature of pain: the pain is episodic electric shock-like, knife-like, tear-like pain, with sudden onset and stop. Each pain lasts for several seconds to tens of seconds. The interval between attacks is gradually shortened and the pain is gradually increased. Frequent attacks may affect eating and rest. Ma Songhe, Department of Pain, Henan Provincial People’s Hospital
(C) Trigger factors and “trigger points”: pain attacks are often triggered by talking, chewing, brushing teeth, washing face and other actions, and even wind blowing or loud sounds can cause attacks. In some patients, pain attacks can be triggered by touching the area around the nose, mouth, gums, and the inner end of the arch of the eyebrow, and these sensitive areas are called “trigger points” or “trigger points”. These sensitive areas are called “trigger points” or “trigger points”. Anesthesia of the “trigger points” can often provide temporary relief from pain attacks. Therefore, patients are often afraid to wash their faces, speak loudly, or even eat in order to avoid attacks.
(D) Signs: The attack may be accompanied by ipsilateral facial muscle twitching, facial flushing, lacrimation and salivation, so it is also called painful twitching. The patient often rubs the ipsilateral side of the face during painful attacks, and over time the facial skin becomes rough, thickened, and the eyebrows fall off, and then the patient often appears thin, emaciated, unkempt, and depressed because he does not dare to eat, wash his face, or trim his face. The objective examination is mostly free of trigeminal nerve deficits and other limited neurological signs, but sometimes facial pain and tactile sensation may be diminished due to roughness and thickening of facial skin or closed treatment.
What tests should be done for trigeminal neuralgia?
1.Laboratory tests have auxiliary significance for clinical diagnosis.
2.Electromyography.
What diseases are trigeminal neuralgia easily confused with?
Although the diagnosis of trigeminal neuralgia is not difficult, misdiagnosis does occur. The disease should be differentiated from the following disorders: (a) trigeminal neuritis is secondary to trigeminal neuralgia, which mostly occurs in the supraorbital nerve and is persistent and severe, with herpes zoster on the frontal area of some patients a few days after the attack (see figure). In a few patients, keratitis and ulcers may occur. The etiology is a virus. The disease is self-limiting and most heal within 1 to 3 weeks. Analgesic drugs, vitamins or local anesthetics, glucocorticoid solutions, are effective.
(B) Toothache
It is a secondary trigeminal neuralgia, and it is often encountered in the clinic that this disease is misdiagnosed as toothache, and several tooth extractions always fail to stop the pain. Check carefully whether there is any lesion in the tooth; the paroxysm of toothache is not too obvious; there is no “trigger point” for toothache, and the onset of toothache is greatly related to hot and cold food.
(C) Paranasal sinusitis or tumor
Patients with maxillary sinus, maxillary sinus and septal sinus disease can cause head and facial pain. Special attention should be paid to the differentiation: nasal examination, whether the two sides are as smooth, detailed examination of the pressure points of each sinus; whether there is a history of mucus or pus in the nasal cavity; the episodic nature of the pain is not obvious, this point is more significant in the upper frontal sinus cancer; the affected side is sometimes swollen; fluoroscopy of the maxillary and frontal sinuses; X-ray examination can help clarify the diagnosis.
(IV) Tumors near the semilunar ganglion
Tumors in the semilunar ganglion and cerebellopontine angle are not uncommon, such as auditory nerve fibroma, cholesteatoma, hemangioma, meningioma or dermatomatous cyst, etc. The pain caused by these tumors is usually not very serious, unlike trigeminal neuralgia, which is a severe pain attack. In addition, there may be concurrent adductor nerve palsy, facial nerve palsy, tinnitus, vertigo, hearing loss, sensory loss of trigeminal nerve branches, and other symptoms of intracranial tumors such as headache, vomiting and optic nerve papilledema. On skull base X-ray, there is sometimes bone destruction in the apical region of the rock bone or in the region of the inner ear canal. CT and X-ray imaging can help in the diagnosis.
(E) Knee ganglion pain
The geniculate ganglion sends out the superficial rock nerve before sending out the bulbar nerve, which supplies the lacrimal gland with parasympathetic nerve fibers to manage the secretion of the lacrimal gland. The median nerve is mainly responsible for the sensation of taste in the anterior 2/3 of the tongue and the sensation of the ear drum and the posterior wall of the external auditory canal, and some fibers are also responsible for the secretion of the submandibular and sublingual glands and the mucus glands of the mouth and nasal cavity. The geniculate ganglion neuralgia is paroxysmal, but the pain is deep in the ear and radiates to the nearby eyes, cheeks, nose, lips, etc. There is mostly a “trigger point” in the posterior wall of the external auditory canal. In these patients, facial nerve palsy or facial twitching is often combined with herpes and loss of taste in the soft palate, tonsillar fossa and external auditory canal.
(F) Glossopharyngeal neuralgia
The pain is also paroxysmal and mostly attacks during swallowing. The pain starts from the tonsillar region and tongue root and radiates to the external auditory canal, or to the front of the ear, behind the ear, the auricle or half of the face on the side. During the attack, the patient often presses the lower frontal angle with his hand. There is a “trigger point” at the lateral back of the tongue root and tonsils, but there is no “trigger point” on the skin outside the neck. Swallowing, talking, turning the head and laughing can cause attacks, and swallowing sour or bitter food is more fearful. It is easily accompanied by bradycardia or vertigo. Patients are mostly 35 to 65 years old. The disease is quite rare, and the incidence is about 1% of trigeminal neuralgia. The attack can be stopped by applying a 1% solution of cocaine to the “trigger point” of the posterior pharyngeal wall or tonsillar area. In addition, trigeminal neuralgia with pain at the tip and edge of the tongue can be differentiated.
(VII) Vascular migraine
Vascular migraine is a periodic, unilateral headache of varying severity, sometimes manifested as a forehead headache. The attack is usually preceded by an aura, such as seeing a spark in the same eye, or a loss of vision, or even temporary ipsilateral hemianopia. Headache attacks can last from a few hours to several days. The attacks have a certain time pattern. Oral ergotamine can help in differential diagnosis when it is difficult to confirm the diagnosis. (H) In addition to vascular migraine, the presence of headache epilepsy and abdominal epilepsy should be further considered in clinical cases of headache or abdominal pain in children or adolescents. Differentiation of the two.
1. In addition to headache and abdominal pain, patients with headache-type and abdominal epilepsy also show loss of contact with the surroundings, i.e., impaired consciousness, during seizures, whereas patients with vascular migraine have clear consciousness, except for a few who have syncope.
2. Patients with epilepsy mostly have limb convulsions, while migraine is less likely to have convulsions.
3.Patients with epilepsy can have seizures during sleep, while migraine attacks disappear during sleep.
4. 1% to 3% of epilepsy patients have a history of migraine, while about 70% of migraine patients have a family history of migraine.
5. Epilepsy patients often have epileptic discharges during seizures, while the EEG of migraine attacks is basically normal.
6. With antiepileptic treatment, the patient’s headache and abdominal pain are relieved, while migraine is poorly treated with antiepileptic drugs and can still have recurrent attacks.
What diseases can be complicated by trigeminal neuralgia?
During pain attack, the patient’s expression is painful, some keep fixed posture and dare not move much, some moan, keep inhaling, chew, or rub the face with hands impatiently, a few patients have jumping and convulsions, also accompanied by facial flushing, lacrimation, runny nose, sweating, high blood pressure and other symptoms.
How should trigeminal neuralgia be treated?
(A) Drug treatment: ①Amidrazine, also known as carbamazepine. It has a good effect on trigeminal neuralgia, usually starting with a small dose of 100mg, 2/d, and then increasing 100mg daily until the pain is controlled or not tolerated. Side effects may include drowsiness, nausea, vomiting, vertigo, ataxia, drug diagnosis and leukopenia. They are usually not serious and can be eliminated by reducing the dose or stopping the drug. ②Phenytoin sodium. The usual dose is 0.1-0.2g, 2-3/d, total daily dose should not exceed 0.6g. Side effects include gingival hyperplasia, ataxia, leukopenia, etc. ③ Vitamin B drugs. Vitamin B1, B6 10-20mg each, 3/d. Vitamin B12 100-200μg, intramuscular injection 1/d. ④ Scopolamine (654-2). 10mg, intramuscular injection, 2/d or 5-10mg, oral, 3/d. ⑤ Niacinamide 100mg, oral, 3/d.
(B) Physiotherapy: Intermittent electrical (sparse and dense wave) therapy or rotational magnet therapy is available. Laser therapy can also be used, using nitrogen-neon laser to irradiate the semilunar ganglion.
(C) Chinese medicine acupuncture therapy: ① Body acupuncture. The first branch of the trigeminal nerve pain can be acupuncture points such as the affected side of the sun, head dimension; the second branch of pain can be acupuncture points such as Sibai, Shimonoseki, zygomatic s; the third branch of pain can be acupuncture points such as buccal car and Chengjiao, which can be combined with Gu. ② Ear acupuncture. Take the points of maxillary, mandibular and Shen Men.
(iv) nerve block therapy: when drug therapy is ineffective or has adverse reactions, and the pain is severe, nerve block therapy is feasible. The most commonly used injectable drug is anhydrous alcohol. The trigeminal nerve semilunar ganglion or peripheral branches, due to the destruction of sensory nerves and pain relief. The effect can last for several months to years, but it is easy to recur.
(e) Radiofrequency current percutaneous selective thermocoagulation: the advantage of this procedure is that it can selectively destroy the nociceptive fibers of the trigeminal nerve without basically damaging the tactile fibers. The recent efficacy is quite good, but it is easy to recur. It is usually done 1 to 2 times with an interval of 1 to 2 days.
(f) Surgical treatment: commonly used are trigeminal nerve peripheral branchotomy and trigeminal nerve sensory root partial excision. At present, it is less commonly used because it can cause numbness on the affected side after surgery.