Surgical management of headache and facial pain/pressure in chronic rhinosinusitis: A systematic review and meta-analysis.

BACKGROUND: Headache and facial pain are common symptoms of chronic rhinosinusitis (CRS). However, given the numerous etiologies that can cause these symptoms, the impact of sinus surgery is not well characterized. METHODS: A systematic review was performed by searching the literature from inception through June 6, 2023. English-language articles reporting outcomes for facial pain/pressure or headache following endoscopic sinus surgery were selected for inclusion. Meta-analyses were performed using random and fixed effect models on continuous measures (mean), mean difference (Δ), and proportions (%). RESULTS: A total of 26 articles reporting on 2839 patients were selected for inclusion. The mean patient age was 44.0 ± 3.9 (range 16.0-84.0), with an average symptom duration of 5.3 ± 2.8 years. Among these patients, 56.5% (95% confidence interval [CI]: 52.3-60.6) were male and 77.0% (95% CI: 56.6-92.3) had nasal polyposis (NP). Patients with and without NP reported substantial reductions in both 22-item sino-nasal outcome test facial pain/pressure (with NP: -1.4 [95% CI: -1.6 to -1.2; relative reduction 59.1%]; without NP: -1.5 [95% CI: -1.9 to -1.1; relative reduction 60.9%]) and visual analogue scale (VAS) headache (with NP: -2.5 [95% CI: -2.8 to -2.1; relative reduction 67.2%]; without NP: -2.8 [95% CI: -4.7 to -1.0; relative reduction 42.7%]). Symptom reductions were greater in the without NP versus with NP group; VAS facial pain/pressure: Δ0.4 (95% CI: 0.2-0.6; p = 0.0006) and VAS headache: Δ0.4 (95% CI: 0.1-0.7; p = 0.02). CONCLUSIONS: Our findings suggest that CRS patients, regardless of polyp status, benefit from significant reductions in facial pain/pressure and headache following surgical therapy.

Arthroscopy for the Treatment of Temporomandibular Disorders.

How to cite this article: Mosaddad SA. Arthroscopy for the Treatment of Temporomandibular Disorders. J Contemp Dent Pract 2024;25(3):197-198. Keywords: Arthroscopy, Facial pain, Temporomandibular joint, Temporomandibular joint disorders.

Severe facial pain and removal of maxillary sinus mucous retention cyst.

Maxillary sinus retention cysts (MRCs) are typically asymptomatic and require no treatment. An early 30s man presented with a decade-long history of severe left-sided chronic facial pain (CFP). Multiple prior treatments resulted in an edentulous patient with persistent pain. Imaging revealed a dome-shaped radiopaque change in the left maxillary sinus. History and clinical examination suggested persistent idiopathic facial pain, and doubts about the outcome of a surgical intervention were explained to the patient. Surgical removal of the MRC via lateral antrotomy led to complete symptom resolution of CFP. This case substantiates the importance of considering MRCs as a possible cause of CFP. It also emphasises the need for a systematic multidisciplinary approach in cases of unexplained CFP.

Facial Pain Triggered by Inferior Turbinate Partial Resection in a Patient with a Previous History of Inferior Meatal Antrostomy: A Case Report.

OBJECTIVES: Inferior meatal antrostomy (IMA) is regarded as a safe method, with minimal complications, for managing various lesions in the maxillary sinus. However, in patients with persisting IMA window, resection of the inferior turbinate may result in direct airflow into the antrum, irritating the antral mucosa. METHODS: Case report and review of literature. RESULTS/CASE: The present report describes a 29-year-old man who previously underwent unilateral IMA for the excision of a dentigerous cyst. The patient did not report any facial pain following the excision of the cyst. One year later, this patient underwent partial resection of the inferior turbinate for the resolution of nasal stuffiness by another surgeon. Soon after surgery, the patient developed severe facial and ocular pain on the side of the IMA, with the pain being especially aggravated upon inhalation. Endoscopy and computed tomography (CT) revealed a persisting IMA window. The patient's severe discomfort was thought to result from direct airflow into the maxillary sinus, as the resected turbinate may have altered normal nasal airflow. A unilateral inferior meatal augmentation procedure (IMAP) with an autologous ear cartilage implant was performed, resulting in complete relief of pain and discomfort. CONCLUSIONS: Although IMA alone is a relatively safe surgical procedure, care should be taken when performing inferior turbinoplasty in patients with persistent IMA opening.

Microvascular Decompression for Trigeminal Neuralgia Caused by Vascular Compression on the Trigeminal Sensory Nucleus and Descending Trigeminal Tract.

BACKGROUND: Trigeminal neuralgia (TN) is characterized by paroxysmal episodes of severe shocklike orofacial pain typically resulting from arterial compression on the trigeminal root entry zone. However, neurovascular conflict in more proximal parts of the trigeminal pathway within the pons is extremely rare. METHODS: The authors present a case of microvascular decompression for TN caused by dual arterial compression on the dorsolateral pons, along with a brief literature review. RESULTS: Our patient was a 74-year-old man with episodic left-sided facial stabbing pain. Brain magnetic resonance imaging revealed a dual arterial compression on dorsolateral pons, the known site of the trigeminal sensory nucleus and descending trigeminal tract. Microvascular decompression was performed via a retrosigmoid approach. Complete pain relief and partial improvement of the facial hypesthesia were achieved immediately after surgery and the Barrow Neurological Institute (BNI) pain intensity score improved from V to I, and the BNI hypesthesia score decreased from III to II within a month following surgery. The literature review identified 1 case of TN secondary to an arteriovenous malformation in root entry zone with lateral pontine extension. One month following partial coagulation of the draining vein, the patient was reportedly able to reduce medication dosage by half to achieve an improvement of BNI pain intensity score from V to IIIa. CONCLUSIONS: Neurovascular compression in the trigeminal tract and nucleus is a rare but potential cause of TN. A thorough investigation of the trigeminal pathway should be considered during preoperative evaluation and intraoperative inspection, particularly if no clear offending vessel is identified.

Open and Percutaneous Trigeminal Nucleotractotomy: A Case Series and Literature Review.

INTRODUCTION: Nucleotractotomy is an efficient surgical technique that provides a high pain relief rate for specific clinical indications. There are two main approaches for performing this operation: an open and percutaneous technique. METHODS: In the Federal Center of Neurosurgery (Novosibirsk, Russia) from 2016 to 2022, 13 trigeminal nucleotractotomies (7 open and 6 percutaneous) were performed in 12 patients (5 women and 7 men). The indications for surgery were deafferentation pain and chronic drug-resistant pain syndrome caused by malignancy in the facial region. A neurological examination was done on each patient 1 day before the surgery, right after the surgery, and at the follow-up (examinations were done after 1, 6, and 12 months, or when the patient independently applied to our hospital). In the early postoperative period, patients underwent brain MRI. RESULTS: The average pain intensity score before nucleotractotomy on the 11-point (0-10) visual analog scale (VAS) was 9.3. The effectiveness of open interventions was somewhat higher; the average VAS score in the early postoperative period for the open technique was 1.57, in the group of patients who underwent percutaneous nucleotractotomy were 2.66. Complete regression of the pain syndrome was achieved in 6 patients; in 5 patients, the pain in the face decreased by more than 50%. One case had an unsatisfactory outcome. In the open-surgery group in the early postoperative period, according to MRI, the average length of the visualized area of signal change was longer (21.5 mm, the average diameter was 3.75 mm) than in a percutaneous nucleotractotomy group (16 mm, the average diameter was 3.75 mm). During the postoperative period (average follow-up 40 months), the pain recurred in 3 patients (30%): 2 patients after percutaneous nucleotractotomy (3 and 18 months after surgery) and in 1 patient 4 months after the open surgery. The mean VAS score at the last follow-up was 2.6. CONCLUSION: Trigeminal nucleotractotomy is an effective approach to the treatment of intractable facial pain. Our experience suggests this technique is highly effective in patients with drug-resistant pain caused by craniofacial tumors and deafferentation conditions after treating trigeminal neuralgia.

Frailty Predicts Worse Pain Outcomes for Older TN Patients Treated with Microvascular Decompression.

BACKGROUND: Trigeminal neuralgia (TN) is a debilitating orofacial pain disorder. Recent data from a national database suggest that microvascular decompression (MVD) in frail patients is associated with more postoperative complications. However, the long-term pain outcomes for frail TN patients are not known. We aimed to elucidate the relationship between frailty and long-term pain outcomes after MVD for TN. METHODS: From 2007 to 2020, 368 TN patients aged ≥60 years underwent MVD at our institution. Patient demographics, clinical characteristics, postoperative complications, and long-term pain outcomes were recorded. Frailty was assessed using the modified 5-item frailty index (mFI-5) score, and the patients were dichotomized into nonfrail (mFI-5 <2) and frail (mFI-5 >1). Differences were assessed via the t test, χ2 test, multivariate ordinal regression, and Cox proportional hazards analysis. RESULTS: Of the 368 patients analyzed, 9.8% were frail. The frail patients were significantly older (P = 0.02) with a higher body mass index (P = 0.01) and a greater incidence of comorbidities (P < 0.001). Frail patients presented with significantly higher pain levels at the final follow-up (P = 0.04). On multivariate analysis, frailty was independently associated with more pain at follow-up (P = 0.01), as was younger age, female sex, and black race. The relationship between frailty and postoperative pain recurrence showed a trend toward significance (P = 0.06), and younger age and black race were significantly associated with recurrence. CONCLUSIONS: Frail patients undergoing MVD are at risk of worse long-term pain outcomes. Our results provide clinicians with useful information pertaining to the influence of frailty on the long-term efficacy of MVD in treating TN.

Endoscopic microvascular decompression versus microscopic microvascular decompression for trigeminal neuralgia: A systematic review and meta-analysis.

BACKGROUND: To compare the efficacy and safety of full endoscopic or endoscope-assisted microvascular decompression (E-MVD) and microscopic microvascular decompression (M-MVD) for primary trigeminal neuralgia (TN). METHODS: We systematically searched the online database, including PubMed, Embase and Cochrane Library. The search terms used included, but were not limited to, "Trigeminal Neuralgia", "Microvascular Decompression Surgery" and "Endoscope". Postoperative facial pain relief and postoperative complications were considered for meta-analysis. All the outcomes were calculated as odds ratios (ORs) with 95% confidence intervals using R language. RESULTS: A total of three studies involving 442 (E-MVD [218] versus M-MVD [224]) patients were included for analysis in our study. Postoperative facial pain relief (very much improved or much improved) was no difference between the two groups (OR, 0.95;95% CI, 0.57-1.58; I2 = 0%; p = 0.83). In addition, the occurrence of some postoperative complications was not statistically different between the two groups, including CSFleak (OR, 1.35;95% CI, 0.16-11.13; I2 = 0%; p = 0.94), facial paralysis (OR, 0.26;95% CI, 0.03-2.54; I2 = 0%; p = 0.67), hearing loss (OR, 0.87;95% CI, 0.30-2.55; I2 = 32%; p = 0.22), facial numbness (OR, 1.03;95% CI, 0.56-1.87; I2 = 62%; p = 0.10). CONCLUSIONS: Both endoscopic microvascular decompression and microscopic microvascular decompression for trigeminal neuralgia appear to provide patients with equivalent facial pain relief outcomes. Complication rates were also similar between the groups.

Manejo das disfunções temporomandibulares. Parte II: tratamento cirúrgico / Management of temporomandibular joint disorders. Part II: surgical treatment

Objetivo: Apresentar as modalidades de tratamentos cirúrgicas mais usadas disponíveis no arsenal terapêutico das desordens temporomandibulares (DTMs). Revisão da literatura: As DTMs são muito frequentes e são responsáveis ​​por dor e desconforto em um número importante de pacientes. A avaliação e o diagnóstico são as chaves para determinar um plano de manejo adequado dessas doenças. Embora o tratamento conservador seja bem-sucedido na maioria dos pacientes, os tratamentos cirúrgicos podem ser a única opção para aqueles que não respondem ao tratamento conservador ou para casos com indicação cirúrgica inicial como, por exemplo, algumas neoplasias articulares. Dentre as alternativas cirúrgicas, podemos citar a artrocentese, artroscopia, reposicionamento do disco articular por cirurgia aberta, discectomia e tratamentos cirúrgicos para hipermobilidade e anquilose da articulação temporomandibular. Considerações finais: A seleção adequada dos casos é requisito obrigatório para uma intervenção cirúrgica bem-sucedida, a fim de alcançar o resultado desejado do tratamento, como alívio dos sintomas e melhora da função.

Aim: To present the most commonly used surgical treatment modalities available in the therapeutic arsenal for temporomandibular disorders (TMD). Literature review: TMD is very common and is responsible for pain and dysfunction in a significant number of patients. Assessment and diagnosis are key to determining a management plan for these diseases. Although conservative treatment is successful in most patients, surgical treatments may be the only option for those who do not respond to conservative treatment or for some cases with an initial surgical indication, such as some joint neoplasms. Surgical alternatives include arthrocentesis, arthroscopy, repositioning of the articular disc by open surgery, discectomy and surgical treatments for temporomandibular joint hypermobility and ankylosis. Conclusions: Proper case selection is the mandatory requirement for successful surgical intervention in order to achieve the desired treatment outcome, such as symptom relief and improved function.

Gamma Knife Radiosurgery Targeting the Trigeminal Nerve for Tumor-Related Trigeminal Neuralgia: A Case Series.

BACKGROUND: Tumor-related trigeminal neuralgia (TN) is a challenging condition to manage that is commonly treated by surgical resection of the tumor. Stereotactic radiosurgery targeting the tumor is used to control pain and tumor growth in patients unsuitable for surgery. Stereotactic radiosurgery targeting the trigeminal nerve has been explored as a viable treatment for patients with tumor-related TN who are unsuitable for surgical removal of the tumor or whose pain is refractory to radiation therapy targeting the tumor. Information regarding the efficacy of this procedure is limited to only a few studies. We report the outcomes of Leskell Gamma Knife radiosurgery (GKRS) targeting the trigeminal nerve for tumor-related TN from a case series. METHODS: A retrospective review of our GKRS database identified 6 patients with unilateral tumor-related TN treated with GKRS targeting the trigeminal nerve between 2014 and 2020. Five patients had undergone previous radiation therapy targeting the tumor. Facial pain and sensory function were evaluated using the Barrow Neurological Institute scales. RESULTS: Three patients achieved a Barrow Neurological Institute score of IIIb or better, indicating pain reduction, within a mean period of 4.3 months after GKRS. The maximum dose for GKRS ranged from 80 to 88 Gy. Pain recurred in 1 patient at 64 months after GKRS. No patient developed permanent facial sensory disturbances. No adverse event was recorded. CONCLUSIONS: GKRS targeting the trigeminal nerve could be a safe and effective treatment for a subset of patients with tumor-related TN who are unsuitable for surgical removal of the tumor or whose pain is refractory to radiation therapy targeting the tumor.

Open surgery vs. stereotactic radiosurgery for tumour-related trigeminal neuralgia: A systematic review.

BACKGROUND: Secondary trigeminal neuralgia is a facial pain in trigeminal nerve dermatome caused by an underlying disease, such as cerebellopontine angle tumours. Treatment options to relieve the pains were surgical tumour resection and stereotactic radiosurgery of the tumour or trigeminal nerve. This study aims to review the efficacy of open surgery and stereotactic radiosurgery and recommend the treatment of choice for secondary trigeminal neuralgia due to cerebellopontine angle tumours. METHOD: The inclusion criteria were studies covering patients with trigeminal neuralgia associated with cerebellopontine angle tumours that were treated with either open surgery or stereotactic radiosurgery and reported pain outcomes after treatment. Non-English articles or studies with a population of less than five were excluded. We systematically searched studies from PubMed, Ebscohost, and Cochrane Library from inception until December 20, 2021. Several works of literature from manual search were also added. Selected articles were appraised using a critical appraisal tool for prognostic studies. RESULT: Included articles were 26 retrospective studies and one prospective study comprising 517 patients. Of 127 schwannomas, 226 epidermoids, 154 meningiomas, and ten other tumours, 320 cases received surgical tumour excision with or without MVD, 196 had tumour-targeted radiosurgery, and 22 underwent nerve-targeted radiosurgery. In surgical series, 92.2 % gained pain improvement, 2.8 % were unchanged, and 4.5 % had recurrence; none of the patients had worsened outcomes. In cases treated with tumour-targeted radiosurgery, the improvement rate was 79.1 %, unchanged at 14.3 %, recurrence at 26.5 %, and worse symptoms rate after the intervention was 6.6 %. Six patients with recurrent pain after tumour-targeted radiosurgery received secondary nerve-targeted radiosurgery with improved outcomes. Only one patient in our review underwent primary nerve-targeted radiosurgery, and the result was satisfactory. One study treated 15 patients with a single session of tumour-targeted and nerve-targeted radiosurgery, with an improvement rate of 93.3 % and a recurrence rate of 21.4 %. CONCLUSION: Open surgery releasing the nerve root from compressive lesions is advocated to be the first-line treatment to gain satisfactory outcomes. Total removal surgery is recommended if possible. Nerve-targeted radiosurgery should be reserved as a secondary treatment for recurrent cases.

Combined Anterior (Kawase) and Posterior Petrosectomy (pre-sigmoid/ retro-labyrinthine) for Resection of Post-Radiosurgery Recurrent Cavernous Sinus and Meckel's cave Meningioma; with Simultaneous Microvascular Decompression for Trigeminal Neuralgia: 2 Dimensional Operative video, and Review of Literature.

BACKGROUND: A 70-year male had previous gamma knife (GK) for left cavernous sinus and Meckel's cave meningioma for facial numbness. He presented 11 years later with facial pain (both typical and atypical) and worsening numbness. OBSERVATIONS: MRI showed tumor growth and an infratentorial extension. FIESTA MRI showed left superior cerebellar artery (SCA) contact with the V nerve root entry zone (REZ) accounting for Type 1/ lancinating pain. After discussing available options, he opted for surgery. Lumbar drain, and a middle fossa anterior petrosectomy (Kawase) combined with posterior petrosectomy (retrolabyrinthine) approach was employed to perform tumor debulking along with microvascular decompression (mobilization of SCA). SSEP, BAERS, MEP, V nerve monitoring were performed. Fat graft was used for multilayered closure. He experienced resolution of both type 1 & type 2 facial pain, improvement in sensation in V3. Symptomatic improvement was recorded at 11 months follow up. LESSONS: The combined skull base approach provided visualization of the entire length of V nerve (Cisternal, Meckel's cave, V2 and V3) allowing for decompression at various points to achieve relief of both types of facial pain. The patient provided consent for use of his images and operative video for publication.

Continued persistent facial pain despite several surgical interventions in the temporomandibular joint.

This article describes a woman in her forties who spontaneously developed facial pain 19 years after double-jaw orthognathic surgery. The focus of her pain was the left side of the face, including the temporomandibular joint (TMJ). Conservative treatment was initiated, including several occlusal splints, in addition to injections with local anesthesia, botulinum toxin, and corticosteroids, with limited effects. Surgical treatments with arthroscopy and discectomy, and ultimately a TMJ prosthesis, improved the patient's joint function but did not reduce pain. The question is whether the degenerated joint was due to progression of the original disease process or to multiple surgical procedures.

Thirty-year clinical experience in gamma knife radiosurgery for trigeminal schwannomas.

We aimed to evaluate the radiographic and clinical outcomes after gamma knife radiosurgery (GKRS) for trigeminal schwannomas (TSs). A total of 87 patients who underwent GKRS for TSs between 1990 and 2020 were enrolled. The mean tumor volume was 4.3 cm3. The median prescribed dose for the margins of the tumor was 13 Gy. The median follow-up duration was 64.3 months (range 12.0-311.5 months). The overall local tumor control rate was 90%, and the symptom response rate was 93%. The response rate for each symptom was 88% for facial pain, 97% for facial sensory change, and 86% for cranial nerve deficits. Nineteen (22%) patients showed transient swelling, which had regressed at the time of the last follow-up. Cystic tumors were associated with transient swelling (p = 0.04). A tumor volume of < 2.7 cm3 was associated with local tumor control in univariable analysis. Transient swelling was associated with symptom control failure in both univariable and multivariable analyses (p = 0.04, odds ratio 14.538). GKRS is an effective treatment for TSs, both for local control and symptom control.

Assessment of epidermoid cyst with trigeminal neuralgia before neuroendoscopy: A high-resolution MR study based on 3D-FIESTA and MR angiography.

PURPOSE: To assess the value of preoperative 3D-FIESTA and MR angiography (MRA) in endoscopic resection of epidermoid cysts presenting with trigeminal neuralgia (TN). METHODS: 3D-FIESTA and MRA were performed before neuroendoscopy in 32 cases of epidermoid cysts with TN, and the tumors were grouped into types A, B, C, and D according to the relationship between the tumor and adjacent nerves and arteries (Hitoshi Kobata's classification). Evaluation of the neuroendoscopic resectability of different types of tumors, included gross total tumor removal (GTR), subtotal tumor removal (STR), and partial tumor removal (PTR). During the 5-year follow-up, symptoms were assessed based on facial pain relief using the Barrow Neurological Institute (BNI) score. RESULTS: The coincidence rate between MRI classification of the tumor and the operation was 100%. Type B tumors were the most common (18/32, 56.3%). Type A tumors showed the highest resectability (9/9, 100%), followed by type B tumors (14/18, 77.8%). Moreover, microvascular decompression was performed in all 4 cases of type C and 1 case of type D tumors. During follow-up, 23 patients showed marked improvement in symptoms (15, 8 of BNI I or II), 8 cases showed partial improvement (BNI III), and only 1 case of type C tumor was associated with poor facial pain relief, which recurred 5 years later (BNI IV). CONCLUSIONS: Preoperative high-resolution MR can accurately analyze the relationship between epidermoid cysts and adjacent nerves and arteries. It could act as a powerful tool in the evaluation of tumor resectability and the prognosis of surgery.

Multidata Analysis Based on an Artificial Neural Network Model for Long-Term Pain Outcome and Key Predictors of Microvascular Decompression in Trigeminal Neuralgia.

OBJECTIVE: To investigate use of multidata analysis based on an artificial neural network (ANN) to predict long-term pain outcomes after microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and to explore key predictors. METHODS: Perioperative and long-term follow-up multidata of 1041 patients with TN who received MVD surgery at Hangzhou First People's Hospital from March 2013 to May 2018 were collected to construct an ANN model for prediction. The prediction results were compared with the actual follow-up outcomes, and the variables in each input layer were changed to test the effectiveness of ANN and explore the factors that had the greatest impact on prediction accuracy. RESULTS: The ANN model could predict the long-term pain outcomes after MVD in patients with TN with an accuracy rate of 95.2% and area under the curve of 0.862. Four factors contributed the most to the predictive performance of the ANN: whether the neurovascular offending site of the trigeminal nerve corresponded the region of facial pain, immediate postoperative pain remission after MVD, degree of nerve compression by culprit vessels, and the type of culprit vessels. After these factors were sequentially removed, the accuracy of the ANN model decreased to 74.5%, 78.6%, 87.2%, and 90.1%, while the area under the curve was 0.705, 0.761, 0.793, and 0.810. CONCLUSIONS: The ANN model, constructed using multiple data, predicted long-term pain prognosis after MVD in patients with TN objectively and accurately. The model was able to assess the importance of each factor in the prediction of pain outcome.

A Review of Medical and Surgical Options for the Treatment of Facial Pain.

Facial pain is a common medical complaint that is easily misdiagnosed. As a result, this pain often goes mistreated. Despite this, there are a variety of pharmacologic, surgical, and neuromodulatory options for the treatment of facial pain. In this review, the authors detail the forms of facial pain and their treatment options. They discuss the common medications used in the first-line treatment of facial pain and the second-line surgical and neuromodulatory options available to patients when pharmacologic options fail.

Microsurgical Technique for Resection of a Cerebellopontine Angle Epidermoid Tumor.

Epidermoid tumors are slow-growing, benign, congenital lesions.1 They commonly arise in the cerebellopontine angle, fourth ventricle, suprasellar region, or spinal cord.2 Symptoms may include hearing loss, facial pain, and headaches. The management options include observation or surgical resection. If the patient has symptoms, surgical resection is the treatment option of choice with the goal of gross total resection. In Video 1, we discuss the microsurgical technique for the resection of a right cerebellopontine angle epidermoid tumor. A 22-year-old male patient presented with chronic headache, decreased right-sided hearing, right facial pain, and right facial twitching. Magnetic resonance imaging revealed the characteristic finding of an epidermoid tumor, which appeared as isointense on T1 and hyperintense on T2 with diffusion-weighted imaging. The patient was taken to the operating room, and a retrosigmoid craniotomy was performed on the basis of the transverse and sigmoid sinuses. The tumor capsule was opened, and the tumor was decompressed by removing the internal components consisting of epithelial keratin and cholesterol crystals, allowing for a gross total resection to be achieved. The patient's postoperative computed tomography scan showed no residual tumor, and the patient was discharged on postoperative day 1 in stable condition.

First Bite Syndrome - An Underrecognized and Underdiagnosed Pain Complication After Temporomandibular Joint Surgery.

PURPOSE: First bite syndrome (FBS) can develop after head and neck surgical procedures. The aim of this study is to identify patients diagnosed with FSB after temporomandibular joint (TMJ) surgery, including their pain characteristics and risk factors for FBS. METHODS: Using a retrospective study design, a cohort of 24 patients with confirmed diagnosis of FBS were identified from the oral and maxillofacial surgery and orofacial pain (OFP) practices at Massachusetts General Hospital and Research Patient Data Registry (RPDR) between 1975 and 2019. The inclusion criteria were facial pain that was triggered by taste stimulus only and followed by a refractory period until the next gustatory stimulus. RESULTS: Of the 24 patients identified, 19 had undergone TMJ surgery, 3 patients had idiopathic FBS, 1 had a parapharyngeal space tumor and 1 developed FBS after facial burns. In the surgical patients, the median duration of onset was 2.75 months post-surgery. Most patients reported pain in the parotid region. Pain was only triggered by a taste stimulus and subsided with subsequent bites of food. 2 patients underwent spontaneous resolution of their symptoms and 1 reported complete resolution with onabotulinum toxin A (BTX) injections. Anxiety and depression were the most common comorbid conditions. CONCLUSION: FBS is an underrecognized pain complication in TMJ surgery patients. A precise history and accurate description of the pain is necessary for correct diagnosis which is important for improved treatment outcomes.

Facial pain and sensory outcomes following resection of tumors compressing the trigeminal nerve.

OBJECTIVE: Tumors compressing the trigeminal nerve can cause facial pain, numbness, or paresthesias. Limited data exist describing how these symptoms change after resection and what factors predict symptom improvement. The objective of this study was to report trigeminal pain and sensory outcomes after tumor resection and identify factors predicting postoperative symptom improvement. METHODS: This retrospective study included patients with tumors causing facial pain, numbness, or paresthesias who underwent resection. Trigeminal schwannomas were excluded. Logistic regression, recursive partitioning, and time-to-event analyses were used to report outcomes and identify variables associated with facial sensory outcomes. RESULTS: Eighty-six patients met inclusion criteria, and the median follow-up was 3.1 years; 63 patients (73%) had meningiomas and 23 (27%) had vestibular schwannomas (VSs). Meningioma patients presented with pain, numbness, and paresthesias in 56%, 76%, and 25% of cases, respectively, compared with 9%, 91%, and 39%, respectively, for patients with VS. Most meningioma patients had symptoms for less than 1 year (60%), whereas the majority of VS patients had symptoms for 1-5 years (59%). The median meningioma and VS diameters were 3.0 and 3.4 cm, respectively. For patients with meningiomas, gross-total resection (GTR) was achieved in 27% of patients, near-total resection (NTR) in 29%, and subtotal resection (STR) in 44%. For patients with VS, GTR was achieved in 9%, NTR in 30%, and STR in 61%. Pain improved immediately after tumor resection in 81% of patients and in 92% of patients by 6 weeks. Paresthesias improved immediately in 80% of patients, increasing to 84% by 6 weeks. Numbness improved more slowly, with 52% of patients improving immediately, increasing to 79% by 2 years. Pain recurred in 22% of patients with meningiomas and 0% of patients with VSs. After resection, the Barrow Neurological Institute (BNI) facial pain intensity score improved in 73% of patients. The tumor diameter significantly predicted improvement in BNI score (OR 0.47/cm larger, 95% CI 0.22-0.99; p = 0.047). Complete decompression of the trigeminal nerve was associated with qualitative improvement in pain (p = 0.037) and decreased pain recurrence (OR 0.08, 95% CI 0.01-0.67; p = 0.024). CONCLUSIONS: Most patients with facial sensory symptoms caused by meningiomas or VSs experienced improvement after resection. Surgery led to immediate and sustained improvement in pain and paresthesias, whereas numbness was slower to improve. Patients with smaller tumors and complete decompression of the trigeminal nerve were more likely to experience improvement in facial pain.