Facial Pain


Flowchart

Facial Pain.png

Red flags

Unilateral severe pain, blood stained nasal discharge/epistaxis, weight loss, neck lump, unilateral watery eye, anosmia, personality/behavioural change, non healing oral ulcer

 

Assessment

History

  • Nature of the pain (aching or sharp, shooting, electrical?)

  • Timing (continuous or episodic?)

  • Location (particular trigeminal distribution?)

  • Trigger (palpation, jaw movement)

  • Nasal symptoms (nasal obstruction / rhinorrhoea / anosmia / epistaxis)

  • Dentition (pain, swelling, ulcers, previous dental history)

  • Autonomic symptoms (watering nose or eyes, nasal congestion with episodes)

  • Migraine symptoms (photo- or phonophobia)

  • Impact on life (disabling episodes or not)

 

Examination

  • Skin changes (erythema or swelling)

  • Cranial nerve exam

  • Nasal Exam: unilateral mass

  • Oral exam: dentition, ulceration, swelling, erythema

 

Differential Diagnosis:

Tension-type headache / midfacial segment pain

Very common and frequently misdiagnosed as “sinus pain”. Tension headache are typically a tight, band like or pressure sensation bilaterally. Midfacial segment pain is more localised and hyperaesthesia is commonly present. Management with a tricyclic antidepressant is commonly used.

Facial migraine

Very common and frequently misdiagnosed as “sinus pain”. Can be unilateral or bilateral; more common in females. Associated features such as aura or dizziness, photo/phonophobia, lethargy should raise suspicion of migraine. (https://cks.nice.org.uk/topics/migraine/management/adults/).

Dental

Disease of the teeth or gum can cause a localised pain which is exacerbated on palpation. Patient may have a history of poor dentition or dental issues. Referral should be made to the patient’s dentist.

Trigeminal neuralgia

Episodic, unilateral, short-lived, severe shooting pain in the distribution of one or more trigeminal nerve branches, usually jaw or cheek. Stimulated by a range of triggers (eating, talking, wind, touching face). First line management is with carbamazepine.

Trigeminal autonomic cephalgia (TAC)

Episodic, usually severe unilateral facial pain, associated with autonomic features (conjunctival injection, eye and nose watering, sweating). Umbrella term encompassing cluster headache, hemicrania continua and other diagnoses.

Temporomandibular joint dysfunction

Aching jaw, ear or hemifacial pain. There may be associated jaw clicking, locking or trismus. Patients may have tenderness on palpation or on mouth opening. Refer to dentist or oral/maxillofacial surgery. The NHS website also has useful self help advice: https://www.nhs.uk/conditions/temporomandibular-disorder-tmd/.

Sinus disease

Patients with facial pain as their primary presenting symptom rarely have sinus disease. This is especially true in chronic symptoms (> 12 weeks). Patients must have nasal blockage or rhinorrhoea as primary symptoms for facial pain to be potentially sinonasal in origin.

Acute rhinosinusitis (ARS) develops from a cold, and thus acute/episodic facial pain without coryzal symptoms is not likely to be ARS. Treat as per NICE guidelines: https://www.nice.org.uk/guidance/ng79

Malignancy

Facial pain can rarely be one of the first symptoms of malignancy (sinonasal, salivary, oral cavity). Be aware of red flags such as unilateral epistaxis/bloodstained discharge, proptosis, ophthalmoplegia, personality change, nasal blockage, anosmia, eye watering, neck mass, facial palsy, oral ulceration.

Refer via cancer-wait pathway to the appropriate speciality. 

Management in primary care/when to refer

2 week wait referral

·      Suspicion of sinonasal, salivary, oral cavity malignancy

Routine referral to neurologist

·      Patients suspected of having any neurological cause of facial pain

Routine referral to ENT

·      Patients suspected of having recurrent acute rhinosinusitis not responding to regular steroid nasal spray.

  • Patients suspected of having chronic sinus disease (prominent nasal symptoms lasting >12 weeks).

Routine referral to dentist / oral and maxillofacial surgery

·      Patients suspected of having TMJ dysfunction not responding to first-line measures.

Current evidence and guidelines

·      https://patient.info/doctor/facial-pain (summary of facial pain)

·      https://bjaed.org/article/S2058-5349(20)30002-0/fulltext (summary of facial pain)

·      https://www.entandaudiologynews.com/features/ent-features/post/facial-pain-the-differential-diagnosis-in-an-ent-clinic (summary of facial pain)


Authors:

Mr Elliot Heward, ENT Registrar, North West Deanery

Mr Thomas Jacques, Consultant Rhinologist/ENT Surgeon, St. George’s Hospital, London