Temporal artery ultrasonography for the diagnosis of giant cell arteritis: a case report.

Orofacial pain is a worldwide pain problem, with many patients unable to find appropriate diagnosis and treatment. Orofacial pain includes pain arising from the odontogenic and nonodontogenic structures in the head and neck region. Dental clinicians need to have a thorough knowledge and skill to diagnose, manage, and treat patients with odontogenic pain or refer patients for treatment of nonodontogenic pain to specialists such as orofacial pain specialists, neurologists, otolaryngologists, and rheumatologists. More often, dental practitioners diagnose patients with a temporomandibular disorder (TMD), and when treatment is ineffective, term it "atypical facial pain." The first requirement for effective treatment is an accurate diagnosis. Dental clinicians must be aware of giant cell arteritis (GCA), a chronic large-vessel vasculitis, primarily affecting adults over the age of 50 years, as it frequently mimics and is misdiagnosed as TMD. GCA is associated with loss of vision, and stroke and can be a life-threatening disorder. Therefore, diagnostic testing for GCA and differential diagnosis should be common knowledge in the armamentarium of all dental clinicians. Historically, temporal artery biopsy was considered the definitive diagnostic test for GCA. Temporal artery ultrasound (TAUSG), a safe and noninvasive imaging modality, has replaced the previous diagnostic gold standard for GCA, the temporal artery biopsy, owing to its enhanced diagnostic capabilities and safety profile. The present case report describes a patient with GCA, and the role TAUSG played in the diagnosis. Case report: A 72-year-old woman presented with left-sided facial pain, jaw claudication, dysesthesia of the tongue, and episodic loss of vision of 2 years' duration. She was diagnosed with and treated for a myriad of dental conditions including endodontia and temporomandibular joint therapy with no benefit. A thorough history and physical examination, combined with serologic analysis, led to the diagnosis of GCA and TAUSG, which confirmed the diagnosis. Conclusion: This report underscores the responsibility of differential diagnosis and early recognition of GCA facilitated by TAUSG in optimizing treatment outcomes as a viable, noninvasive diagnostic tool. (Quintessence Int 2024;55:336-343; doi: 10.3290/j.qi.b4938419).

Recommendations for imaging of the temporomandibular joint. Position statement from the American Academy of Oral and Maxillofacial Radiology and the American Academy of Orofacial Pain.

This position statement was developed by an ad hoc committee of the American Academy of Oral and Maxillofacial Radiology and the American Academy of Orofacial Pain. The committee reviewed pertinent literature and drafted recommendations for imaging. The statement provides evidence-based recommendations and clinical guidance to apply appropriate diagnostic imaging to evaluate the temporomandibular joint.

Imaging of Trigeminal Neuralgia and Other Facial Pain.

We review and illustrate the radiology of facial pain, emphasizing trigeminal neuralgia, relevant anatomy, current classification, concepts about etiology, and the role of imaging and its influence on the choice of treatment. We discuss glossopharyngeal neuralgia, other neuropathic causes of facial pain, postinflammatory and neoplastic causes, and nociceptive (end-organ) causes of facial pain, as well as referred otalgia. Other conditions that may present with facial pain, including trigeminal autonomic cephalgias and giant cell arteritis, are reviewed briefly. We discuss the elements of a comprehensive MR imaging protocol to enable detection of these diverse causes of facial pain.

Decompression of the Greater Occipital Nerve for Persistent Headache Attributed to Whiplash Accompanying Referred Facial Trigeminal Pain.

OBJECTIVE: Persistent headache attributed to whiplash (PHAW) is defined as a headache that occurs for the first time in close temporal relation to whiplash lasting more than 3 months. We investigated the results of decompression of the greater occipital nerve (GON) in patients with PHAW who presented with referred trigeminal facial pain caused by sensitization of the trigeminocervical complex) along with occipital headache. METHODS: A 1-year follow-up study of GON decompression was conducted in 7 patients with PHAW manifesting referred facial trigeminal pain. The degree of pain reduction was analyzed using the numeric rating scale (NRS-11) and percent pain relief before and 1 year after surgery. Success was defined by at least 50% reduction in pain measured via NRS-11. To assess the degree of subjective satisfaction, a 10-point Likert scale was used. Clinical characteristics of headache and facial pain and surgical findings were studied. RESULTS: GON decompression was effective in all 7 patients with PHAW manifesting referred trigeminal pain, with a percent pain relief of 83.06 ± 17.30. The pain had disappeared in 3 of 7 patients (42.9%) within 6 months and no further treatment was needed. Patients' assessment of subjective improvement based on a 10-point Likert scale was 7.23 ± 1.25. It was effective in both occipital and facial pain. CONCLUSIONS: Although chronic GON entrapment itself is an individual constitutional issue, postwhiplash inflammatory changes seem to trigger chronic occipital headaches in GON distribution and unexplained referred trigeminal pain caused by sensitization of the trigeminocervical complex.

Trigeminal Neuralgia Secondary to Intracranial Neoplastic Lesions: a Case Series and Comprehensive Review.

It is known that intracranial tumors may trigger trigeminal neuralgia (TN) in some patients although the exact prevalence and occurrence is not completely defined yet. In the present study, we present a case series of patients with brain tumor and a clinical diagnosis of TN as the first and main manifestation of the disease. A retrospective analysis was performed involving patients diagnosed with brain tumor whose exclusive clinical feature our department focused on was TN. In addition, a review of all published cases was performed. From January 2017 to November 2018, 718 patients with brain tumor were admitted to our department, 17 of which suffered of TN, of which 8 patients presented with at least another neurologic symptom and 9 patients presented with TN alone, with typical symptoms of stubbing electric pain in 6 cases. In our series, we found that 2.3% of patients admitted for brain tumors had TN. In 0.8% of cases, TN was the main clinical symptom. The prevalence of tumor lesion in patients with facial neuropathic pain is not defined, but it is a well-known recognized initial symptom; however, early cerebral magnetic resonance imaging (MRI) is not yet strongly recommended in patients with newly diagnosed trigeminal neuralgia. The purpose of this article is, especially in unusual cases, to show that the application of such MR techniques and preoperative evaluation may contribute to diagnosis, indication, and surgery planning.

Occurrence of nonarticular incidental findings on panoramic radiographs in painful temporomandibular disorders / Ocurrencia de hallazgos incidentales no articulares en ortopantomografias en los trastornos temporomandibulares dolorosos

Facial pain is one of the symptoms of temporomandibular disorders (TMDs) but can be associated with other pathological conditions. The present study retrospectively evaluated the occurrence of nonarticular incidental findings in panoramic radiographs in a group of patients with painful TMDs. Outpatients with a diagnosis of TMD were included and distributed into three groups: arthralgia, myalgia or arthralgia and myalgia, according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Nonarticular incidental findings of their panoramic radiographs were classified in relation to pathological, dental and endodontic status. The dependency relationships among the variables were analyzed using the likelihood test. Sixty patients (38 women and 22 men; mean age: 36.9 years) were evaluated. There was a predominance of arthralgia plus disc displacement (43.4 %), followed by myopain plus arthralgia and disc displacement (38.3 %) and myopain (18.3 %). Pathologic radiographic changes such as bone loss, caries, maxillary sinus opacification and periapical lesions were frequent. Dental alterations such as the absence and altered position of teeth and impacted teeth were frequent. Endodontic changes such as periapical lesions with or without endodontic treatment were frequent. There was no significant difference between groups except for gyroversion. The incidental findings were compatible with caries, sinusitis, impacted tooth and periapical lesion, which may be associated with orofacial pain and could potentially be superimposed on the initial diagnosis, although this hypothesis was discarded. Findings such as the absence and altered position of teeth were also frequent, which may represent occlusal factors associated with TMDs.

El dolor orofacial es uno de los síntomas de los trastornos temporomandibulares (TTM), pero puede estar asociado con otras afecciones patológicas. El presente estudio evaluó retrospectivamente la aparición de hallazgos incidentales no articulares a través de ortopantomografías en un grupo de pacientes con TTM dolorosas. Se incluyeron pacientes con diagnóstico de TTM y se distribuyeron en tres grupos: artralgia, mialgia o artralgia y mialgia, de acuerdo con los criterios de diagnóstico para los trastornos temporomandibulares (DC/TMD). Los hallazgos incidentales no articulares de las ortopantomografias se clasificaron en relación al estado patológico, dental y endodóncico. Las relaciones de dependencia entre las variables se analizaron mediante la prueba de probabilidad. Fueron evaluados 60 pacientes (38 mujeres y 22 hombres; edad media: 36,9 años). Hubo predominio de artralgia más desplazamiento de disco (43,4 %), seguido de mialgia más artralgia y desplazamiento de disco (38,3 %) y mialgia (18,3 %). Las alteraciones radiográficas patológicas como pérdida ósea, carie dentaria, opacificación del seno maxilar y lesiones periapicales fueron frecuentes. Entre las alteraciones dentales, las impactaciones, malposiciones o ausencias dentarias fueron frecuentes. Entre las alteraciones endodóncicas, las lesiones periapicales frecuentes. No hubo diferencias significativas entre los grupos, excepto para la girosversión dentaria. Los hallazgos incidentales fueron compatibles con carie dentaria, sinusitis, diente impactado y lesión periapical, lo que podría estar asociado con el dolor orofacial y así estar sobrepuesto en el diagnóstico inicial, aunque esta hipótesis fue descartada. Hallazgos como la ausencia y la posición alterada de los dientes también fueron frecuentes, lo que puede representar factores oclusales asociados con TTM.

Treatment outcomes in acute invasive fungal rhinosinusitis extending to the extrasinonasal area.

Acute invasive fungal rhinosinusitis (AIFRS) can spread beyond the sinonasal cavity. It is necessary to analyze the association between the specific site involved in the extrasinonasal area and the survival rate to predict patient prognosis. We investigated 50 patients who had extrasinonasal lesions on preoperative gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) scan and underwent wide surgical resection of AIFRS. The specific sites with loss of contrast enhancement (LoCE) on Gd-enhanced MRI were analyzed for AIFRS-specific survival rate. The most common underlying disease was diabetes mellitus followed by hematological malignancy. The most common symptoms were headache and facial pain. Seven patients (14.0%) expired because of AIFRS progression. Poor prognosis was independently associated with LoCE at the skull base on preoperative MRI (HR = 35.846, P = 0.004). In patients with AIFRS extending to the extrasinonasal area, LoCE at the skull base was an independent poor prognostic factor.

A Case of Nervus Intermedius Neuralgia.

BACKGROUND: Nervus intermedius neuralgia is an extremely rare craniofacial neuralgia characterized by paroxysmal episodes of pain located deep in the ear, typically triggered by sensory or mechanical stimuli at the wall of the auditory canal without underlying pathology. Pain is sometimes associated with disorders of lacrimation, salivation, and taste. CASE DESCRIPTION: We present a case of a surgically treated 68-year-old man with left paroxysmal deep ear pain for 20 years before presentation. Preoperative 3-dimensional magnetic resonance cisternography/magnetic resonance angiography (3D-MRC/MRA) fusion imaging showed severe compression of the facial nerve by the anterior inferior cerebellar artery in the cisternal portion with associated nerve deformity. We suspected nervus intermedius neuralgia and decided to perform microvascular decompression of the facial nerve. Transposition of the artery led to sufficient decompression of the nerve. The pain disappeared immediately after surgery. CONCLUSIONS: It is important to keep in mind the possibility of nervus intermedius neuralgia in patients who present with intermittent episodes of pain located deep in the ear. Furthermore, 3D-MRC/MRA fusion imaging is useful for decision-making in surgery. Microvascular decompression was highly effective in our case. Based on radiological findings, microvascular decompression should be considered a viable treatment option.

Placement and Anchoring of Trigeminal Neurostimulation Electrodes: Technical Report.

BACKGROUND: Peripheral neurostimulation (PNS) for medically refractory trigeminal and craniofacial pain is an emerging alternative to traditional surgical approaches. Technical problems with craniofacial PNS have included electrode migration and erosion, limiting the utility and cost-effectiveness of this procedure. OBJECTIVE: To review our institutional surgical technique for trigeminal PNS implantation, focusing on a novel technique for electrode anchoring. METHODS: Consecutive cases of permanent craniofacial PNS placement by a single surgeon over 36 months were reviewed for surgical technique and technical outcomes. Electrodes were placed percutaneously with open anchoring to the pericranium at a separate parietal incision. RESULTS: Sixteen systems (53 electrodes) were implanted in 14 patients. Median follow-up was 13 months (range, 5-29 months). Electrode placement was successful in all cases with no intraoperative complications. There was 1 lead migration (6.3% per patient; 1.8% per lead) and no cases of erosion. Two patients (14.3%) required explant for infection, 1 of whom was successfully reimplanted. Three patients (21.4%) underwent surgical revision other than for infection. CONCLUSIONS: We present an improved method for craniofacial PNS surgery which introduces a separate incision for electrode anchoring at the parietal boss. This technique simplifies the procedure and greatly reduces rates of erosion and migration, improving patient comfort and satisfaction.

Evaluation of routine magnetic resonance imaging of patients with chronic orofacial pain.

The aim of this study was to evaluate the reported presence of magnetic resonance imaging (MRI) pathologies (demyelination, space-occupying lesions, or trigeminal neurovascular contact within the transition zone) in patients with orofacial pain. Patient histories, demographic characteristics, and clinical features were compared between those with and without a reported MRI pathology. A retrospective service evaluation of all patients who had undergone MRI scanning to aid the diagnosis of orofacial pain conditions between 2012 and 2016 was conducted. Data were collected and statistical analyses (frequency and descriptive) performed. One hundred and twenty-five patients (34 male and 91 female) with a mean age of 50 years were included. MRI pathologies included space-occupying lesions (2.4%), trigeminal neurovascular contact (22.4%), other pathology including small vessel cerebrovascular disease (20%), pineal cyst (1.6%), sinus pathologies (1.6%), and degenerative changes to the cervical spine (0.8%). This study found that patients with a provisional diagnosis of trigeminal neuralgia or trigeminal autonomic cephalalgia, as well as patients with elicited pain, were more likely to have abnormal findings on MRI scanning.

Surgical Management of Trigeminal Neuralgia in Children.

BACKGROUND: Trigeminal neuralgia (TN) is a well-recognized facial pain syndrome. Discrete forms with disparate pain symptoms include classic and atypical. However, atypical facial pain includes neuralgiform pain along a spectrum. Most cases of TN are diagnosed in the adult population. Case reports and series of children have presented TN as a similar entity, with treatment similar to that for adults. We reviewed the pertinent data and present 2 pediatric TN cases successfully treated with microvascular decompression (MVD). CASE DESCRIPTION: Two pediatric patients (age 12 and 15 years) with TN refractory to previous medical therapy were identified. Both patients were deemed appropriate surgical candidates and underwent MVD to manage their TN. TN compression was arterial in both cases and involved portions of the anterior inferior cerebellar artery. Patient 1 was pain free 6 months after the procedure. Patient 2 was pain free immediately after the procedure and had been weaned off preoperative symptomatic management at the latest follow-up visit. The most recent follow-up examination was 12 and 8 months for patients 1 and 2, respectively, with both experiencing continued freedom from pain. CONCLUSIONS: Few studies have reported on the effectiveness of MVD in the pediatric population for the management of TN. The supporting data and our 2 cases have demonstrated that MVD is effective for pediatric patients to treat their TN. Furthermore, the side effects appear to be minimal, with excellent pain relief after MVD in this patient population.

Metastatic adenocarcinoma of mandible: in search of the primary.

We present here a case of a 64-year-old female patient who reported with a complaint of pain in the chin region of 3-month duration. The radiographs revealed an irregular radiolucent lesion in the anterior part of the mandible. An incisional biopsy was carried out and the microscopy showed features of adenocarcinoma. Suspecting a metastatic lesion, the patient was then sent for whole body examination which showed a mass in the lungs. A whole body scan also showed metastasis to other organs such as kidney, gallbladder and vertebrae. This case is unusual in that the patient complained only of a vague jaw pain with no other systemic symptoms even in the presence of widespread disease.

The relationship between masseter muscle pain and T2 values in temporomandibular joint disorders.

OBJECTIVE: Myofascial pain in temporomandibular joint disorders (TMDs) is evoked by various factors, including edematous change. We investigated whether the pain pattern is related to edematous change by using T2 mapping generated by magnetic resonance imaging to detect water content in the tissue. STUDY DESIGN: One hundred and five patients diagnosed with TMDs, with or without unilateral masseter muscle pain, were divided into 6 groups according to their pain experience: pain on compression (23 cases), pain on movement (13 cases), spontaneous pain (4 cases), pain on compression and movement (14 cases), pain on compression and spontaneous pain (2 cases), and no pain (49 cases). Differences in the mean T2 values of the masseter muscle between the group with pain on only one side (5 unilateral pain groups) or pain-free on both the right and left sides (pain-free group) were compared with paired t tests. Significant differences were assumed at P < .05. RESULTS: Significant differences in mean T2 values were found between the painful and pain-free sides in the group with pain on compression. CONCLUSIONS: The findings of edematous change in the masseter muscle of patients with pain on compression may affect treatment planning and lead to investigation of treatment options for myofascial pain in TMDs.

Correlation between pain and MRI findings in TMD patients.

INTRODUCTION: Magnetic resonance imaging has been established as the gold standard for assessment of the temporomandibular joint. Apart from an excellent assessment of the soft tissues it has the advantage not to expose the patient to ionizing radiation. There is a lack of literature concerning the correlation between pain intensity and radiological findings of the temporomandibular joint. Moreover there is the question of whether a progressive degeneration of the cartilaginous components is accompanied by an increasing degeneration of the osseous parts of the mandibular joint and vice versa. Therefore, this study aims at analyzing correlations between pain and radiological findings. Furthermore, the link between osseous and cartilaginous degeneration is studied. MATERIALS AND METHODS: 91 patients who attend our outpatient clinic for temporomandibular disorders are included in this prospective study. Apart from a detailed anamnesis and clinical examination - adapted to the Research Diagnostic Criteria for Temporomandibular Disorders -magnetic resonance imaging of both mandibular joints is performed. Pain intensity is measured using the visual analog scale. To assess and grade the radiological findings a classification system is established. The evaluation of the osseous components is based on the classification of osteoarthritis by Kellgren and Lawrence whereas the rating of the cartilaginous components is adapted to the Research Diagnostic Criteria for Temporomandibular Disorders. Correlations are verified by Spearman-Rho. RESULTS: 83,5% of all patients are female. Most of the time, both sides are affected (47.25%). Women state an average pain of 5.7 (±2.4), men 3.5 (±2.5). 182 discs are examined and assessed with our classification system. Most discs (n = 71) show no pathological changes. The majority of patients show no dislocation (n = 104). The most common forms of dislocation are anterior dislocations (n = 51). The majority of patients show no changes in the osseous component (n = 115). Weak to moderate correlations are found between disc and bone degeneration. Moderate to strong correlations are found between left and right TMJ. CONCLUSIONS: The classification system which is designed and applied during the study proves to be a reliable and practical Instrument. A standardized evaluation of pathologies concerning the temporomandibular joint is possible by using this system. Numerous patients attending our outpatient clinic do not show any signs of degenerative dysfunctions in the mandibular joints. Degenerations of the osseous components tend to be connected with degenerations of the cartilaginous components and vice versa. The question remains if in the future new procedures in imaging will be able to record pathologies not yet detected.

Chronic fibrosing osteomyelitis of the jaws: an important cause of recalcitrant facial pain. A clinicopathologic study of 331 cases in 227 patients.

OBJECTIVE: This was a retrospective and follow-up analysis of 331 cases of chronic fibrosing osteomyelitis of the jaws (CFOJ) in 227 patients. STUDY DESIGN: Demographic, clinical, surgical, and microscopic characteristics were tabulated for all patients. A follow-up mail survey was used to determine the degree of symptom relief experienced after surgery. RESULTS: The female to male ratio approached 7:1, and mean age of patients was 53 years. The most common sites were the mandibular posterior region, followed by the maxillary posterior region. Consistent clinical findings included intractable jaw pain mimicking that of odontogenic origin but unresponsive to usual therapies, minimal or undetectable radiographic abnormalities on plain films but dramatic radiolucencies detected on cone beam computed tomography, and large cavities that were either empty or filled with blood mixed with lipid globules encountered at surgery. The most common histomorphologic findings were vital lamellar bone, prominent resting and reversal lines, microshards and splaying of trabeculae, rounded trabeculae, marrow fibrosis, and pools of erythrocytes and lipid globules, often together. Moderate to complete relief of symptoms for periods up to 108 months after surgery were reported by 83% of the 70 patients who returned the survey. CONCLUSIONS: On the basis of the findings of this study, CFOJ can be considered a unique entity with consistent clinicopathologic features. Its features suggest a pathogenesis based on bone marrow ischemia. CFOJ can be treated on a rational basis with a justifiable expectation of success and probable cure.

Is Facial or Head Pain Related to the Location of Lesions on Computed Tomography in Chronic Rhinosinusitis?

BACKGROUND: Facial or head pain is not an infrequent symptom among patients diagnosed with chronic rhinosinusitis (CRS), but few reports have investigated the pain in CRS, including the relationship between pain and sites of CRS. The aim of this study was to investigate whether pain is related to the location of lesions on computed tomography (CT) in CRS. METHODS: We analyzed 203 patients who underwent endoscopic sinus surgery (ESS) for 2 years. Patients were assessed using the questionnaires on pain, provided 1 day prior to the operation and 6 months post operation. Sites of CRS were evaluated using CT. We analyzed whether the degree of inflammation in each sinus had an effect on the location of pain. RESULTS: Seventy-eight patients (38.4%) had preoperative facial or head pain. There was no difference in the sinus inflammation scores in CT findings, based on the presence of pain. Pain was most commonly located in the periorbital area, followed by the frontal, vertex, occipital, and facial areas. No significant correlation was found between the sinuses and the location of pain. CONCLUSIONS: This study indicates that in CRS patients, several sites of pain are involved, particularly in the periorbital area; these sites were not found to be related to the location of CRS.

Chronic temporomandibular joint pain: two cases of osteoid osteoma and a review of the literature.

Osteoid osteoma is a benign bone tumour with self-limiting growth potential occurring in any part of the body. Two rare cases of a pathologically proven osteoid osteoma invading the temporomandibular joint (TMJ) are reported herein. This article also reviews the cases of osteoid osteoma of the craniofacial complex reported in the English-language literature to date. Although the clinical presentation of osteoid osteoma in the jaw differs from that of osteoid osteoma in the more common locations, the radiographic features are similar. In both cases presented, computed tomography revealed a small round osseous lesion with sharp margins in the TMJ. Bone scintigraphy was performed in order to differentiate the lesions from other osseous lesions. Both patients underwent surgical excision of the lesion with immediate relief of the pain. The importance of early recognition of the clinical and imaging characteristics of an osteoid osteoma of the TMJ is emphasized, in order to prevent misdiagnosis and avoid discouraging therapies.