by Local Disease
This category includes the greatest number of oral and facial
pains encountered in clinical practice. By means of a careful history
and appropriate tests, the etiology can be determined.
Pain arising from the teeth, supporting structures, and jaws
usually is diagnosed accurately by the patient. Hypersensitivity
of a tooth as a result of an exposed root surface or a recent deep
restoration is described as sharp, usually transient, and well localized.
It is aggravated by hot, cold, or sweet foods. A cracked tooth also
may cause transient sharp pain on biting. This may be difficult to
identify and lead to an erroneous diagnosis. If the pulp is involved
in an inflammatory reaction resulting from dental caries, the pain
is spontaneous, severe, and less well localized. Heat aggravates
and cold relieves the pain; it may persist for minutes or hours.
In time, the pain stops, indicating complete necrosis of the pulpal
tissue. This may progress to a periapical abscess in which signs
of infection are present, and the tooth is tender to bite on and
to percussion. Endodontic treatment will save the tooth and eliminate
The infection, however, may progress to cellulitis and abscess
formation. Incision and drainage can usually be accomplished under
local anesthesia, but occasionally, a general anesthetic is required.
In the most extreme situation, Ludwig’s angina may develop.
The infection spreads to the sublingual, submental, submandibular,
and pterygomandibular spaces bilaterally and then through the retropharyngeal,
pretracheal, and carotid sheath to the mediastinum. In these cases, the
airway may be compromised severely. These infections were invariably
fatal before antibiotics were discovered. Even today with aggressive
antibiotic therapy, surgical drainage, and supportive care, fatalities
A particularly painful condition occasionally arises after tooth
extraction, usually of a mandibular molar. This is termed localized
osteitis (frequently called dry socket). The pain is severe and
constant, starting 2 to 3 days after the extraction and lasting
for 10 to 14 days thereafter. The socket should be irrigated and
dressed on a regular basis until granulation occurs. Osteomyelitis
of the jaw (usually the mandible) is rare today, but it may present
as an intense deep-seated pain, accompanied by appropriate physical
and radiographic signs. The chronic sclerotic variety is more insidious
and less readily diagnosed. Treatment is surgical debridement with
vigorous antibiotic therapy. Osteoradionecrosis is a relentless,
extremely painful condition characterized by postirradiation bone
necrosis, predominantly of the mandible, with exposure of the bone
into the mouth or externally. In most cases, the condition can be
controlled only by radical surgical excision of the affected bone.
Hyperbaric oxygen may plan an adjunctive role and can markedly reduce
Referred pain occasionally is encountered. The patient complains
of pain in the mandible, but a maxillary tooth is found to be the
cause or vice versa. More common is the complaint of earache accompanying
an unidentifiable toothache. Referred pain to the ear indicates
mandibular tooth disease. The perception of the anatomic site apparently
is mistaken within the branches of the trigeminal nerve.
Joint Disorders and Diseases
Masticatory pain can arise from the muscles of mastication or
the temporomandibular joint itself.15–19 Although
these sites are a common cause of facial pain, a thorough history
and examination must be done to exclude other potentially more serious
Masticatory system disorders have been classified in many different
ways. Because of the difficulty encountered in establishing a precise
cause, these disorders often are defined on the basis of symptoms
and signs. However, broad categories of masticatory problems include
masticatory muscle spasm, internal derangement of the temporomandibular
joint, chronic hypomobility, trauma, degenerative joint disease,
growth disorders, infections, tumors, and congenital abnormalities.
It is imperative to take a detailed history and perform a thorough
clinical examination. In addition, the patient’s family,
social, and medical history should be ascertained. Clinical examination should
include (1) palpation of the muscles of mastication (temporalis,
masseter, and medial and lateral pterygoid), (2) observation and
measurement of mandibular motion (opening, closing, lateral excursion,
and protrusion), (3) palpation or auscultation of joint noises,
(4) examination of the dentition and occlusion, and (5) brief neurologic
examination of the trigeminal system.
Masticatory muscle spasm (temporomandibular joint or myofascial
pain dysfunction) is the most common of all masticatory system disorders.
Epidemiologic studies from many countries show that signs and symptoms
of such disorders are widespread, and that 28% to 88% of
people have detectable clinical signs of dysfunction. Fewer individuals
(12%–19%) are aware of symptoms. A smaller
group (5% or more) may require treatment.
It is generally agreed that patients with temporomandibular joint
dysfunction exhibit one or more of the following signs: (1) decreased
range of mandibular motion, (2) impaired function (e.g., deviation,
sounds, or sticking), and (3) pain on palpation of the masticatory
muscles or joint. One or more of the following symptoms also may
occur: (1) temporomandibular joint sounds, (2) fatigue or stiffness
of the jaws, (3) pain in the face or jaws, (4) pain on opening the
mouth wide, and (5) locking. Radiographic studies of the temporomandibular
joint show no evidence of disease.
The cause of this clinical complex is multifactorial. Among the
causes most commonly cited are functional, psychological, and structural
factors. It is important to understand that, for a particular patient,
a single clear etiologic factor rarely is apparent. More often,
several possible factors are identified. Likewise, treatment goals
should be formulated that address the several likely causes.
Most patients respond to simple noninvasive treatment plans,
and these should always be initiated before invasive therapy is
contemplated. These measures should include, but are not necessarily limited
to the following.
- 1. Reassurance. It is important that patients realize
they are not alone with their symptoms, that the symptoms are essentially
self-limiting, and that no disease exists. The role of muscle spasm and
its benign nature should be explained carefully.
- 2. Rest. Although it is not prudent to immobilize the mandible,
patients should be instructed to have a mechanically soft diet for
2 weeks and avoid yawning and laughing with the mouth open. Such
habits as chewing gum, biting fingernails, and posturing the jaws
should be discouraged.
- 3. Heat. The application of heat to the sides of the face
by heating pad, hot towel, or hot water bottle will be comforting
and help to relieve muscle spasms. More vigorous treatment can be achieved
with ultrasound or short-wave diathermy heat treatments. These are
available in physical therapy departments.
- 4. Medications. Nonsteroidal anti-inflammatory analgesics
are valuable in the acute stage. The drugs ibuprofen, naproxen,
and indomethocin at a low dose for 2 weeks are used most widely. Anxiolytic
agents, such as the benzodiazepines, also are used commonly. Several
regimens exist, and doses should be individualized. The usual regimen
consists of diazepam, 2.5 to 10 mg, two to four times daily, with
an increased bedtime dose as necessary to ensure restful sleep.
It is important that this treatment be limited to approximately
2 weeks because there is a potential for dependency. Narcotic analgesics
should be avoided.
- Antidepressants have a long history of effectiveness in the treatment
of chronic pain. In view of the strong association between temporomandibular
joint dysfunction and psychological factors, their use often is
justified especially when this disorder is a part of a more global
complex of muscle pains and other signs and symptoms of depression
are evident. The tricyclic antidepressants are used most widely.
A bedtime-only schedule of 25 to 100 mg of amitriptyline or doxopin
often can relieve the symptoms in 1 or 2 weeks. Treatment is maintained
for 2 to 4 months; then it is tapered to a low maintenance dose
or discontinued. The effect of other antidepressants has not been
well studied. There are case reports indicating that some of the
selective serotonin reuptake inhibitors may, in fact, potentiate
- 5. Occlusal therapy. There are many interocclusal appliances,
and their multiplicity suggests that the optimal design has not
been found. These devices usually are made of processed acrylic
and serve the following functions: (1) improving the function of
the temporomandibular joint, (2) improving the function of the masticatory
motor system and reducing abnormal muscle function, and (3) protecting
teeth from attrition and abnormal occlusal loading. In essence,
a full-arch occlusal stabilizing appliance (Fig. 26-1) is the type
that has been most effective. Partial-coverage appliances tend to
produce significant and irreversible changes in the dentition. An
appropriate appliance is effective in most patients (70%–90%).
They are most successful in reducing masticatory muscle pain and
controlling attrition and adverse tooth loading.
Full-arch occlusal stabilizing appliance. (Reproduced
with permission from Guralnick WC, Keith DA. Osteoarthritis of the
temporomandibular joint. In: Moskowitz RW, et al, eds. Osteoarthritis. Diagnosis
and Management. Philadelphia, Pa: Saunders; 1984;523–530.)
- There have been numerous claims that occlusal interferences of
various types are the chief cause of masticatory muscle pain and
that their elimination by occlusal adjustments will result in improvement.
Because masticatory dysfunction is a multifactorial problem, this
is unlikely to be true. The negative influence of malocclusion,
loss of teeth, and occlusal interferences on masticatory dysfunction
is not well supported. On general principles, however, occlusal
disharmony (including premature contacts) should be eliminated and
missing teeth replaced. The long-term efficacy of repositioning
adult nongrowing jaws with occlusal splints or functional appliances
has not been proved satisfactorily.
- 6. Behavioral modification. Bearing in mind the psychological
effect in this disorder, attempts to lower patient stress are important.
Relaxation techniques, conditioning, and biofeedback all have been
advantageous. The most important factor is undoubtedly the therapeutic
interaction of the practitioner with the patient.
- Internal derangement is another cause of masticatory system
disorders. Temporomandibular joint arthrography was developed in
the 1940s by Norgaard,20 but it was not until much
later that the potential contribution of internal derangement of
the meniscus to the spectrum of temporomandibular joint disorders
was recognized.21 The meniscus can, either temporarily
or permanently, be displaced and cause symptoms of sticking, clicking,
locking, and pain.
The main categories of internal derangement are, firstly, anterior
displacement with reduction. This occurs when the meniscus is displaced
in the closed-mouth position and reduces, with a click, to a normal
relationship at some time during opening. In these circumstances,
the patient complains of the click and a variable amount of pain.
On opening, the jaw deviates toward the affected side until the
click occurs, and then returns to the midline. Preventing the mouth
from closing fully by using a splint, tongue blades, or dental-mirror
handle eliminates the click. An MRI study will show a displaced
meniscus that is reduced on opening. This clinical situation may include
an intermittent locking and may progress to the second category,
anterior displacement without reduction (closed lock). Patients
again have a variable amount of pain or, if muscle spasm has been
relieved adequately, may be pain free. They feel, however, that
something in the joint is stopping it from opening. There is usually
a history of clicking with intermittent locking. Opening may be
limited to 25 to 30 mm, with restriction of motion to the contralateral
side. An MRI study shows displacement without reduction (closed
lock) and also may demonstrate perforation and degenerative changes.
In such cases, the signs and symptoms of degenerative joint disease
also may be present.
Initial treatment for internal derangements consists of the noninvasive
therapies used for temporomandibular joint disorders (as discussed
previously). In patients with anterior displacement with reduction
(intermittent locking), these strategies often are successful. In
patients with a closed lock, especially those in whom the condition
is long standing, these treatments may reduce muscle spasm and pain
and restore some motion, but the underlying displacement will remain.
When noninvasive treatment has been attempted for several months
and the patient remains restricted, arthroscopy or arthrocentesis
should be considered.
Chronic hypomobility is a rare but important cause of masticatory
system disorders. Ankylosis is the persistent inability to open
the jaws. It may result from pathologic involvement of the joint structures
(true ankylosis) or limitation produced by extraarticular causes
(false ankylosis). Infection and trauma (including previous surgery)
are the prime causes of true ankylosis. The findings are severe
limitation of opening, possibly with mandibular retrognathism if
mandibular growth has been restricted. Radiographs show destruction
of the joint surfaces, loss of joint space, and, in extreme cases,
ossification across the joint. False ankylosis may be caused by
various disorders that can be categorized as myogenic (e.g., masticatory
muscle contracture), neurogenic (tetanus), psychogenic (conversion
reaction), bone impingement (enlarged coronoid process), fibrous
adhesions (occurring after temporomandibular joint surgery, temporal
flap, or trauma), and tumors.
Many of these patients require surgery. In those with true ankylosis,
even under general anesthesia, it will not be possible to open their
mouths. A careful, awake, fiber optic–assisted intubation is
required. The key to successful therapy is to identify the cause
of the ankylosis and treat it as aggressively as possible. It should
be recognized, however, that true ankylosis with fibrosis and calcification
can be extremely recalcitrant to treatment.
Trauma is another cause of masticatory system disorders. A blow
to the jaw can sprain the temporomandibular joint, cause a joint
effusion, or fracture the neck of the mandibular condyle. In an acute
sprain, the joint is painful, and there is severe limitation of
motion caused by muscle spasm. Heat, rest, and nonsteroidal anti-inflammatory
medications resolve the acute symptoms, but other forms of treatment
may be required to alleviate residual muscle spasm and pain. In
the case of a joint effusion, in addition to pain and limitation,
patients are unable to close their teeth together on that side.
In a more severe injury, a hemarthrosis may develop, with damage
to the meniscus. Active physical therapy is required to restore
range of motion and prevent the development of ankylosis. A fracture
of the neck of the condyle is a common maxillofacial injury, and,
if undisplaced, requires analgesics and a soft diet for a few days.
In the unilateral displacement or dislocated variety, the patient
has a premature bite on the affected side and deviation to that
side on opening. Intermaxillary fixation for 10 days may be required
with active physical therapy thereafter to restore function. The
patient with bilateral fractures has an anterior open bite and posterior displacement
of the mandible, and more aggressive treatment is required to restore
the bite and function. Depending on the position of the displaced
fragment, it may interfere with mandibular motion.
Degenerative joint disease (osteoarthritis, osteoarthrosis) of
the temporomandibular joint is a further cause of masticatory system
disorders and may result from several different insults to the joint
structure that exceed its capacity to remodel and repair. These
insults may be traumatic (acute or chronic), chemical, infectious,
or metabolic. The patient complains of pain on jaw movement and
limitation of movement, with deviation to the affected side. There
may be acute tenderness over the joint itself. Joint sounds are
described as grating, grinding, or crunching (but not clicking or
popping). Initially, radiographs may be normal, but marked degenerative
and remodeling changes are seen later, possibly at a time when the
symptoms have subsided. The natural course of the disease suggests
that the pain and limitation will disappear after several months.
The features of degenerative temporomandibular joint disease
are different from those of most other joints in the body. There
is a strong predeliction for women to be affected. A significant number
of patients are in their third or fourth decades of life. Few have
Most patients can be kept comfortable until remission using the
noninvasive techniques outlined earlier. Some require injections
of corticosteroids into the joint. This treatment generally is reserved
for older patients and is limited to two or three injections. In
those who are refractory to these techniques, surgery may be indicated
to remove loose fragments of bone (so-called joint mice) and to
reshape the condyle. Attention should also be directed toward the
meniscus because its displacement may be a primary reason for the
Rheumatoid arthritis also can afflict the temporomandibular joint,
and reports of its incidence range widely. In young patients, an
association with micrognathia may be found. In advanced cases, ankylosis
may be the presenting complaint. Radiographic findings show joint
destruction, possibly involving both the condyle and the articular
eminence. Other stigmata of the disease are evident, and if medical
management is ineffective, alternative treatment of the degenerative
joint disease or ankylosis may be necessary.
Postnatal growth abnormalities also can cause masticatory system
disorders. Studies of facial growth show the major contribution
made by the mandibular condyle to the adaptive growth of the mandible
in the functional soft tissue matrix. Several conditions may reduce
growth, including hypothyroidism, hypopituitarism, and nutritional
deficiency, such as vitamin D deficiency. In gigantism, all skeletal
structures are enlarged; in acromegaly, a marked prognathism is
produced. Several local conditions, such as trauma, infection, rheumatoid
arthritis, exposure to radiation, and scarring from burns or surgery,
are other causes of reduced growth.
Temporomandibular joint infections are uncommon today. When seen,
the preauricular area is swollen, hot, and tender. Patients have
difficulty opening and closing their mouths. Radiographs may show
increased joint space, bony destruction, and sclerosis in the chronic
stage. Treatment includes drainage, debridement, and appropriate
Temporomandibular joint tumors are rare, but several varieties
of primary and metastatic tumors have been reported. The most common
are benign cartilaginous or bony tumors. These may cause limitation
of motion or malocclusion, but they are not always painful.
Congenital abnormalities constitute the final cause of masticatory
system disorders. Complex coordinated growth of the facial structures
is necessary to achieve normal form and function. On occasion, the
developmental process is altered, and malformations occur. It is
beyond the scope of this chapter to review all the possible anomalies
encountered in clinical practice, but many abnormalities of the
temporomandibular joint occur in conjunction with recognized syndromes,
for example, lateral facial dysplasia or Treacher Collins syndrome.
A full clinical and radiologic workup is necessary to evaluate the
defect fully. Treatment usually is undertaken by a multidisciplinary
The parotid and submandibular salivary glands occasionally are
the site of infection or disease. In the more common condition of
submandibular sialolithiasis, Wharton’s duct becomes blocked
by a stone or nonopaque “sludge.” Characteristically,
the gland swells, and pain is felt by the patient at the sight,
smell, or thought of food. The swelling and pain may decrease after
the meal, but they recur at the next meal. If the stone is in the
duct, a sialolithotomy often can be done to relieve the problem.
Surgical excision of the submandibular gland is frequently necessary,
because the gland structure is damaged considerably by repeated
infections. A gustatory neuralgia has been desribed after trauma
or surgery in the parotid region.
Nose and Paranasal
Experimental stimulation of various areas in the nose and paranasal
sinuses refers pain to well-defined regions of the mouth, face,
and cranium. Therefore, in any diagnosis of pain, rhinologic causes
should be sought. The most common diagnostic dilemma is differentiating
maxillary toothache from maxillary sinusitis, especially because
periapical infection from a maxillary premolar or molar occasionally
may cause sinusitis.
The many names ascribed to facial migrainous neuralgias have
confused clinicians, as shown by the considerable length of time
between onset of symptoms and appropriate diagnosis and treatment
of this condition. The Subcommittee on Taxonomy of the International
Association for the Study of Pain has provided a provisional summary
description for pain of vascular origin.22
Cluster headache (see Chap. 25) usually is unilateral in the
ocular, frontal, and temporal areas, but it also may be situated
in the infraorbital region and maxilla. The condition afflicts men
predominantly and usually starts between 18 and 40 years of age.
Attacks are grouped in bouts of several weeks to months, with pain-free
intervals of several months’ duration. Bouts often last
from 4 to 8 weeks, with one to three attacks every 24-hour period
and a maximum of eight attacks daily. The pain is excruciating.
It is described as constant, stabbing, burning, and throbbing. Associated
features include ipsilateral ptosis and miosis, tearing, rhinorrhea,
and blocked nose. Treatment includes ergot preparations, prednisone,
and methysergide. Chronic cluster headache is similar to cluster
headache, but it is rarer. The diagnosis requires at least two or
more attacks per week over a period of more than a year. Treatment
is the same as that for cluster headache, but lithium carbonate
tends to work better in patients with chronic cluster headache.
Chronic paroxysmal hemicrania (see Chap. 25) involves the ocular,
frontal, and temporal areas and, occasionally, the occipital, infraorbital,
aural, mastoid, and nuchal areas (invariably on the same side).
It occurs predominantly in women. Patients have attacks every day,
usually for 15 to 30 minutes in a 24-hour period. Characteristically,
the attacks fluctuate in frequency and severity. Attacks may last
5 to 45 minutes at their maximum, and are excruciating. Ipsilateral
conjunctival injection, lacrimation, nasal stuffiness, and rhinorrhea
occur in most patients. Attacks occur at regular intervals through
the day and night, and patients may be awakened by a nocturnal attack. Indomethacin
provides immediate and absolute relief. Although these vascular
pains usually are situated in the cranium, they can occur in the
infraorbital region of the maxilla and lead to confusion with sinus
or dental disease. Such patients frequently undergo extensive dental
treatment before the correct diagnosis is made.
Temporal giant cell arteritis (see Chap. 25) afflicts patients
older than 60 years of age. There is a dull persistent pain in the
temple after chewing. The temporal artery is nonpulsatile, tortuous,
and tender. Referral to an ophthalmologist is essential to exclude
ophthalmic artery involvement and the possibility of permanent blindness.
Corticosteroids ameliorate this condition.
from Nerve Trunks and Central Pathways
Group A: No
Abnormal Central Nervous System Signs
include the primary idiopathic neuralgias. These have been recognized
for many centuries and are among the most severe pains felt by humans.
The features of trigeminal neuralgia are well described.23 Characteristically,
there is a trigger zone in the area of the nasolabial fold or upper
or lower lip. When stimulated by washing, shaving, talking, or any
slight movement, pain occurs that is severe, lancinating, and lasts
only a few seconds. There is no objective sensory loss. An untreated
patient initially may present in an unkempt state, drooling from
the mouth, and unwilling to move or touch the trigger area. Injection
of a local anesthetic into the area abolishes the trigger for the duration
of the anesthesia. Remission for months or years commonly occurs.
Although this description is classic and usually well recognized,
patients who have undergone various treatments in the past may give
different descriptions that may confuse the diagnosis. Furthermore,
several less typical features may be reported, such as continuous
or long-lasting aching or burning between paroxysms and spontaneous
changes in sensation.
Although no cause has been found, some patients describe a previous
traumatic event. Pathologic examination of resected nerve tissue
has shown evidence of hypomyelination or demyelination in the region
of the trigeminal ganglion. Some neurosurgeons believe that impingement
of blood vessels on the nerve in the region of the ganglion is the
cause of this disease. It is important to recognize that, in some
patients, especially those younger than 40 years of age, symptoms
of trigeminal neuralgia may indicate an underlying disease, such
as multiple sclerosis or a space-occupying lesion at the cerebellopontine
A similar condition, glossopharyngeal neuralgia, has the same
characteristics except that the trigger zones are in the tonsil,
lateral pharyngeal wall, or base of the tongue. This condition should not
be confused with Eagle’s syndrome,25 in
which an elongated styloid process may impinge on the soft tissue
of the throat during neck movement or swallowing, or Trotter’s
syndrome,26 in which a tumor of the nasopharynx
may cause pain in the lower jaw, tongue, and side of the head. In
these cases, however, other signs such as deafness (from occlusion
of the eustachian tube) and asymmetry in mobility of the soft palate
(from tumor invasion of the levator palati muscle) should be sought.
Treatment of the primary neuralgias initially is medical.27 Carbamazepine,
baclofen, or neurontin are effective in many cases. Some patients,
however, are allergic to these medications or develop bone marrow
depression as an adverse effect. Traditionally, peripheral neurectomy
of the maxillary or mandibular division of cranial nerve V or phenol
or alcohol blocks have been used to denervate the area permanently.
With the introduction of the radiofrequency lesion, the pain fibers specifically
supplying the trigger zone may be destroyed selectively without
necessarily interfering with sensory function. This is a relatively
benign procedure with excellent long-term results. Other neurosurgeons
prefer intracranial surgery, in which vascular structures are dissected
off the trigeminal ganglion; good results can be obtained despite
the greater risks of this major surgical intervention.28,29 Glycerol
injection and other surgical procedures also have been used successfully
(see Chap. 35). Gamma knife treatment has recently been suggested
as an alternative approach.
Another group A disorder is postherpetic neuralgia30,31 (see
Chap. 40). A significant number of patients (approximately 25%)
develop chronic pain after acute herpes zoster, and its incidence
increases with age. Although the mechanism is poorly understood,
it appears that the initial acute inflammation results in fibrosis
of the nerve sheath and dorsal root ganglion, with loss of large
Herpes zoster also may occur in the distribution of the trigeminal
nerve. The first division, especially, is affected, and the possibility
of corneal ulceration and scarring should be remembered. The pain
is described as a constant burning sensation, with a stabbing component.
Hyper- or hypesthesia may be present.
Treatment is not entirely satisfactory. Various medications may
reduce the pain of acute herpes zoster, such as topical idoxuridine,
oral amantadine, intramuscular interferon, intravenous acyclovir,
and intravenous vidarabine. Steroids also have been advocated, and
sympathetic block can be useful.
In chronic postherpetic neuralgia, few approaches provide significant
relief. Anticonvulsants, antidepressants, and antipsychotic agents
all have been used. Occasionally, neurosurgical procedures are indicated.
Group B: Abnormal
Central Nervous System Signs
The cause in these syndromes may be extracranial or intracranial.
This includes trauma, osteomyelitis, Paget disease, primary or metastatic
tumors32 or space-occupying lesions at the cerebellopontine
angle24 and the middle cranial fossa, disseminated
sclerosis, cerebrovascular disease, syphilis, and syringobulbia.
from Outside the Face
Pain perceived in the face may be a result of irritation of pain
receptors in tissues that are related embryologically to the segmental
innervation of the face. This pain may originate in the eyes, ears,
heart, or cervical spine. Common ocular causes of pain33 include
refractive error, convergence insufficiency, extraocular muscle
imbalance, trauma (e.g., abrasion, contact lens damage, or foreign
body), otitis, angle-closure glaucoma, and so-called dry eye syndrome.
Common causes of ear pain are outlined in Table 26-1.
Table 26-1 Common Causes
of Ear Pain ||Download (.pdf)
Table 26-1 Common Causes
of Ear Pain
|Infection||Acute otitis media|
|Acute otitis externa|
|Malignant otitis externa|
|Infected cyst of ear canal|
|Tumor||Carcinoma of the ear|
|Infection||Pharyngitis or tonsillitis|
|Any cause of cervical adenopathy|
|Ramsay Hunt syndrome|
|Tumor||Carcinoma of the oropharynx, nasopharynx, hypopharynx, or larynx|
|Other||Temporomandibular joint syndrome|
|Atypical facial neuralgias|
Coronary artery disease classically is described as left substernal
pain referred to the arm and side of the neck that is brought on
by physical exertion, emotional upset, or ingestion of food. It
is relieved rapidly by rest or sublingual nitroglycerine. On occasion,
the pain sweeps up the neck and into the angle of the jaw. If the
pain occurs in the jaw without other related symptoms, the diagnosis
may be missed. The dorsal root of cervical nerve III supplies the
skin overlying the angle of the mandible. A cervical strain injury,
cervical osteoarthritis, or spondylitis may irritate these nerves
and cause pain in their distribution. Pressure on the occipital
nerve (cervical nerve II) can cause occipital neuralgia with a sharp
lancinating quality that shoots forward over the head. Local anesthetic
and steroid injections may be necessary.
Facial and Oral Pain34–37
Many patients have intractable facial pain that may be termed
atypical facial pain. In these patients, the pain is a multifactorial
problem characterized by equivocal physical findings, diffuse descriptions,
and ill-defined psychiatric symptoms. In addition, malingerers,
drug abusers, and patients with Munchausen syndrome may be encountered.
In an effort to diagnose and treat patients with chronic joint
pain, a chronic facial pain group (consisting of an oral and maxillofacial
surgeon, psychopharmacologist, neurologist, and neurosurgeon), which
interviewed and examined patients at the same time. The pain was
classified using the McGill-Melzack scale,38 the
International Association for the Study of Pain axes, the Diagnostic
and Statistical Manual, Third Edition, Revised psychiatric classification,
and the International Classification of Disease. In a study39 of
107 patients, 88 were women, and 19, men (mean age, 44.6 years;
range, 17–87 years). These patients had experienced pain
for a mean of 7.8 years (range, 0.5–46 years) and had consulted
a mean of 5.8 physicians. They typically described their pain as
continuous and fluctuating in intensity. All patients had used some
medications (mean, 5.7); 58% had used narcotic analgesics,
and 34% had used antidepressant medications.
Fifty-one percent of these patients had undergone some previous
surgical intervention, and 14% had undergone temporomandibular
joint surgery (15 patients and 23 operations). Forty percent of the
patients had been treated with physical therapy, and 33% of
the patients had used occlusal splints of one type or another. In
addition to the facial pain (42% bilateral, 30% left,
and 28% right), 58% of the patients had cranial
pain, 36% had neck pain, and 46% had pain in other
Most of these patients had more than one diagnosis. According
to the classification systems, 65% of the patients had
definable psychiatric problems, chiefly depression (38%);
36% had symptoms attributable to the masticatory system
(temporomandibular joint and muscles); 29% had neuralgias
of the trigeminal nerve; and 15% had pain of vascular origin.
The rest were classified as atypical facial pain of unknown or mixed
A variant of atypical facial pain is phantom-tooth pain or atypical
odontalgia40 in which pain is reported in a tooth
or its supporting structures. Fillings, endodontic treatment, extractions,
and bone currettage often are performed without relief. The same
sequence is followed in a neighboring tooth until a whole region
of the mouth is rendered edentulous.
Burning mouth and burning tongue (glossodynia) is a troublesome
condition with several different causes.41 On first
presentation, a complete oral examination should be performed and
a comprehensive history taken. Laboratory tests are necessary to
exclude diabetes mellitus, pernicious anemia, and vitamin B12 and
folate deficiency. Other causes include xerostomia, geographic tongue,
median rhomboid glossitis, trauma, candidiasis, and psychogenic
factors. In all cases of atypical pain, a thorough physical and
radiographic examination is necessary, and a psychiatric workup
is indicated. Evidence now exists that burning mouth syndrome may
be a neuropathy of thermal sensitivity.
As indicated, depression frequently is associated with chronic
pain, either as a premorbid or reactive condition. In either instance,
the patient will benefit greatly from treatment. Antidepressant medications
have a long history of effectiveness and safety. They can reduce
anxiety, reverse both mood and vegetative signs and symptoms of
depression, and improve sleep patterns. The tricyclic antidepressants
(amitriptyline and doxepin) are used most widely, and a bedtime-only
schedule of 25 to 100 mg often achieves improvement in 1 to 2 weeks.42 The
treatment can be continued for several months and then tapered to
a low maintenance dose. Monoamine oxidase inhibitors and lithium
salts also may be prescibed on occasion.
Anxiety sometimes is associated with chronic facial pain, and
it may or may not be associated with a specific major life change,
for example, illness, death, or acute stress. A careful history usually
uncovers many symptoms, including tachycardia, dizzy spells, headaches,
unsteadiness, paresthesias, breathing difficulties, trembling, excessive
perspiration, a choking sensation, or hyperventilation. Relaxation
techniques (such as meditation, hypnotherapy, behavior therapy,
and biofeedback) are useful, and the minor tranquilizers (chlordiazepoxide
and diazepam) are prescried widely.43
Other psychiatric conditions also may present with pain; for
example, hysteria, schizophrenia, and hypochondriasis. Even when
these diagnoses have been excluded, there remain many patients with
various emotional problems that may contribute to or cause pain.
Hackett44 developed the Madison scale to describe
the characteristics that correlate with the psychogenicity of pain
and are helpful in evaluating such patients.
Treatment for patients with chronic facial pain depends on its
cause and may consist of multiple concurrent approaches.45,46 A
multidisciplinary approach has been found to be helpful in the diagnosis
and treatment of these patients, but it is evident that, despite
the best efforts of physicians and the use of sophisticated imaging
techniques and tests, the needs of many of these patients are not
met. They continue to seek medical consultations and undergo surgical
intervention with no relief of their pain. A pain management program
may ultimately be helpful for these individuals.