Facial Pain Causes, Symptoms, and Treatment

Facial pain has a long list of possible causes but the diagnosis can often be made by a good history and examination. The common causes of facial pain are often benign and self-limiting but it is essential not to miss those conditions that require urgent treatment - eg, temporal arteritis, or early diagnosis - eg, malignancy. There is a tendency to overdiagnose bacterial sinusitis when the real cause may be a viral upper respiratory tract infection or, much less frequently, a more serious cause of facial pain.

Facial pain causes^{[1, 2, 3]}

• Sinus: sinusitis, trauma, carcinoma.
• Nose: upper respiratory tract infection, nasal injury and foreign bodies.
• Ear: otitis media, otitis externa.
• Mastoid: mastoiditis.
• Teeth: dental abscess.
• Local soft tissue infection: cellulitis, erysipelas.
• Neurological: trigeminal neuralgia, herpes zoster, post-herpetic neuralgia.
• Parotid gland: mumps, other causes of parotitis, abscess, duct obstruction, calculi, tumour.
• Eye: orbital cellulitis, glaucoma.
• Temporomandibular joint dysfunction and pain.
• Cluster headaches, migraine, medication-overuse headache.
• Temporal arteritis.
• Tumours: nasopharyngeal, oral, brain tumours (posterior fossa, brain stem gliomas).
• Bone: maxillary or mandibular osteitis, cyst.
• Atypical or idiopathic facial pain: may be worse with fatigue or stress; often linked with depression or mood disturbance.
• Lung cancer (upper lobe).^[4]
• Persistent idiopathic facial pain.
• Myofascial pain syndrome.

Facial pain, alone or combined with other symptoms, is a frequent complaint.^[5] However idiopathic facial pain syndromes are relatively rare.^[6]

Clinical assessment of facial pain^{[1, 7]}

History

• Site:
  • Establish if unilateral or bilateral and whether it relates to a nerve distribution. Unilateral pain occurs in dental conditions, trigeminal neuralgia, salivary gland conditions. Pain may be either bilateral or unilateral in sinus infection, temporomandibular disorders, headaches and giant cell arteritis.
  • Pain in the region of the ear may be referred from the skin, teeth, tonsils, pharynx, larynx or neck.
  • Tenderness over the maxilla may be due to sinusitis, dental abscess or carcinoma.
• Character:
  • Establish whether it is continuous or episodic and the severity and nature of the pain.
  • Trigeminal neuralgia: intermittent sharp, severe pain in the distribution of the divisions of the trigeminal nerve.
  • Infections of teeth, mastoid and ear: often dull, aching quality.
• Precipitating factors:
  • Precipitated by food or chewing: dental abscess, salivary gland disorder, temporomandibular joint disorder or jaw claudication due to temporal arteritis.
  • Trigeminal neuralgia: can be precipitated by various factors, including eating, talking and touching or washing the face. Even the slightest touch of the skin can cause intense pain.
• Associated facial pain symptoms:
  • Obstruction of the lacrimal duct by nasopharyngeal carcinoma may cause watering of the eyes.
  • Otorrhoea and/or hearing loss suggest an ear or mastoid cause.
  • Nasal obstruction and rhinorrhoea may be due to maxillary sinusitis or carcinoma of the maxillary antrum. Carcinoma of the maxillary antrum may also present with unilateral epistaxis.
  • Proximal muscle weakness and pain may be due to polymyalgia rheumatica, associated with temporal arteritis.
  • Intermittent presence of a lump around the jaw may suggest salivary duct obstruction.

• Impact of pain: effect on mood, sleep, eating and quality of life.

Examination

• Unilateral erythema and vesicles in the distribution of the trigeminal nerve: herpes zoster infection (may not be present in the early stages of the disease).
• Localised erythema or swelling: localised infection or carcinoma.
• Inspection of the nose and throat may demonstrate a nasopharyngeal tumour.
• Intraoral inspection may reveal any obvious pathology but may require dental expertise.
• Examine the cranial nerves.
• Facial palsy: may be due to a tumour of the parotid gland.
• Tenderness of the superficial temporal artery associated with temporal arteritis.
• Tenderness over one or more sinuses may indicate sinus infection.
• Cervical lymphadenopathy: infection or carcinoma.
• Lumps over the parotid area may indicate salivary gland tumours or blockage of the gland (whether the lump is intermittently present or continuously so is helpful).
• Pain or crepitus on movement of the jaw may indicate temporomandibular joint dysfunction.

Investigations

Further investigation will be guided by the results of findings on history and examination.

• FBC: raised white cell count in infection or malignancy.
• ESR, CRP: increase in infection, malignancy, temporal arteritis.
• X-rays:
  • Dental x-rays can be carried out by community dentists where there is suspected dental pathology.
  • Opacification of the sinus and destruction of bone with carcinoma of sinuses.
  • Opacification may also occur in sinusitis.
  • Mastoid films may show opacification in cases of mastoiditis.
• Ultrasound scans are useful as first-line investigation for suspected salivary gland pathology.
• MRI or CT scans may be necessary for some conditions.
• Sialography: parotid conditions - eg, duct stones, sialectasis.
• Fine-needle aspiration: parotid tumours.

Facial pain treatment and management

• The essential aspect of management in primary care is to make an accurate diagnosis. The management will then depend on the identified cause of facial pain.
• The first-line treatment for atypical facial pain is a tricyclic antidepressant such as amitriptyline. Fluoxetine and venlafaxine can also been considered.^[9]
• Cognitive behavioural therapy (CBT) may be combined with antidepressant treatment.^[1]
• With advancing techniques and technology, neurostimulation can be promising in treating intractable pain of the head and face.^[10]
• Specialist referral (usually to a maxillofacial clinic, unless clinical findings suggest a diagnosis where ENT/community dentistry/neurology/rheumatology referral may be more appropriate) should be made according to local guidelines. One such guideline suggests referring patients who have:^[11]
  • Facial pain persisting for more than three months.
  • Persistent temporomandibular disorders not responding to simple analgesics, lifestyle changes and reassurance.
  • Persisting pain affecting function and causing distress.
  • Widespread pain.
  • Pain which is part of systemic disease.
  • Significant psychological or social problems.
  • Co-existing mental health problems which have an impact on treatment.
  • Compliance problems - eg, side-effects.
  • A recognised pain syndrome such as trigeminal neuralgia.
  • Patients with special needs - eg, learning disabled, communication problems.