Patients frequently present with problems in the oral, nasal and pharyngeal regions. Unfortunately, many texts do not adequately cover these conditions and they are often misdiagnosed. This new text aims to fill this gap by providing practitioners and students with a highly illustrated, practical and succinct guide, designed to be used in emergency departments and general practice. It will also provide dental practitioners with valuable information to better assess head and neck problems.

1. Oral, Nasal
and
Pharyngeal Complaints
A P R A C TIC A L G UID E
ly
on
s
ge
pa
e
pl
m
sa
GEOFFREY G. QUAIL

2. Chapter 6
Facial pain
Investigating facial pain • neoplasm
• osteonecrosis (from radiotherapy or
bisphosphonates)
Together with headache, back and abdominal pain,
facial pain is one of the most common neurological Oral mucosa/pharyngeal
complaints. In most cases, its etiology can be ascer- • infection
tained from a detailed history and examination. • neoplasm
• the oral cavity and, in particular, dental structures • oral ulceration (other causes)
are the most common sources
Salivary gland disease
• pain does not cross the mid-line unless there is
• infection
ly
a systemic cause or bilateral lesions as in TMJ
• duct obstruction by a calculus
dysfunction
• the source of the pain may be obscure as oral
tissues have multiple innervations, and referred
Paranasal sinus disease
Neurological
on
pain, particularly to the ear, is common
s
• trigeminal neuralgia
• migraine/cluster headache
ge
Common Causes
• glossopharyngeal neuralgia
Dental • Bell’s palsy
pa
• dental caries
Neurological/infective
• fractured tooth
• herpes simplex/zoster and post infective neuralgia
• periodontal disease/abscess
e
• dry socket Vascular
pl
• cranial arteritis
Oral or facial trauma
• angina pectoris
m
Temporomandibular joint dysfunction
Dermatological
sa
Facial bone disease • furunculosis
• infection • erysipelas
83

3. Oral, nasal and pharyngeal complaints
Psychogenic • a fractured crown is painful if dentine is exposed
• depression/anxiety • impacted, infected lower third molars are a
common source of facial pain in adolescents and
Central
young adults—untreated infected third molars
• cerebral neoplasm or infection
may lead to abscess formation or cellulitis, which
can involve deep facial veins and lead to cavernous
sinus thrombosis
CAUTION: Unilateral facial pain is dentally
related until proved otherwise.
Pain in the ear is frequently due to a remote
CAUTION: Facial cellulitis often arises
from an infected tooth or facial trauma. It may
lesion.
involve sublingual and submandibular spaces
(Ludwig’s angina) and increase rapidly. It is
potentially life-threatening and must be treated
Clinical examination vigorously and promptly.
and management of
facial pain investigations
Oral examination
• palpate apical region of suspected tooth
Dental pain • percuss teeth—only the affected tooth should
• patient is usually able to localise pain to a quadrant be tender
of the mouth, though often not a specific tooth • palpate regional lymph nodes
• dental pain most commonly results from dental
caries involving the pulp
management
• while analgesics and antibiotics may alleviate
Pain relief with:
ly
symptoms temporarily, urgent dental referral is
• paracetamol—1 gm orally, 4 hrly to 4 gms
essential
• pain is commonly aggravated or precipitated
by chewing, biting or thermal change—may be
daily in divided doses
on
• codeine compound—as above, ibuprofen
400 mg 4–6 hrly
constant or throbbing
s
Antibiotic therapy is indicated if pulpal
• cold substances causing pain suggests the dental
infection is suspected:
ge
pulp is still vital (pulpitis) or cementum at neck of
• Amoxycillin 500 mg (child 15 mg/kg) 8 hrly
is tooth exposed
for 5 days
pa
• heat causes pain through expansion of gases in a
• For penicillin allergy—clindamycin adult
necrotic or dying pulp
450 mg (child 10 mg/kg) 8 hrly for 5 days
• pulpal infection extending to the periapical tissues
In severe cases add metronidazole 400 mg
e
may produce abscess formation and pain
(child 10 mg/kg) 12 hrly for 5 days
• premature contact of teeth (high filling) or
pl
grinding/clenching as in psychological stress
m
produces an ache that is worse when the tooth is Post-extraction pain: dry socket (alveolar
percussed osteitis)
sa
• pain may be referred to the ear or the maxillary Post-extraction pain is a relatively common complica-
sinus tion of dental extraction. It:
84

4. Chapter 6 Facial pain
• is due to loss of the blood clot from the socket, most accurate for unilateral maxillary sinus
causing impaired tissue repair disease.
• occurs 1–3 days post-surgery • CT scanning often shows mucosal thickening
• causes constant pain and tenderness at the without fluid levels or obstruction of ostia;
extraction site; halitosis is common plain films are not indicated.
• usually resolves spontaneously in 2–3 weeks; if it
persists or if systemic changes are present, consider Acute sinusitis
osteonecrosis, osteomyelitis or a pre-existing SCC • usually associated with symptoms of URTI
at the site. including blocked nasal airway and haemopurulent
discharge
management • often diffuse pain in region of upper teeth,
• 0.2% chlorhexidine mouthwash to prevent headache or a feeling of fullness in cheeks
secondary infection • may be halitosis, post-nasal discharge
• Dental referral for emollient dressing in the
management
socket
• Over 90% of cases are viral in origin
• Analgesia, such as codeine phosphate 30 mg/
• The mainstay of treatment is topical
paracetamol 500 mg 4 hrly
vaso-constrictors. These drugs improve the
Note: as the condition is not caused by
airway and aid drainage. Use tramazoline or
infection, antibiotics are not indicated.
oxymetazoline or oral decongestant containing
pseudoephedrine
Nasal sinus pain Note: rebound vaso-constriction may occur if
• often there is a history of URTI, previous sinusitis nasal sprays used > 5 days
or allergy/hay fever • A bacterial cause should be suspected if there
• frequently dull, constant mid- or upper-face pain is a combination of:
ly
• often worse if head is down or if there is increased — persistent mucopurulent discharge > 7 days
atmospheric pressure (e.g. aircraft landing) — facial pain
• maxillary sinus pain may be confused with the
pain of dental infection
on
— tenderness on palpation of the sinuses or
percussion of the upper posterior teeth
• dental infection may be transmitted to the where there is no dental disease
s
maxillary sinus from periapically infected tooth — inadequate response to decongestants
ge
• frontal sinus pain may be confused with migraine Prescribe:
• ethmoidal and sphenoidal pain are felt at the inner • amoxycillin 500 mg (child 15 mg/kg) orally,
pa
canthus of the eye or retro-orbitally 8 hrly for 5 days
or
Diagnosis • cefaclor 375 mg, 12 hrly (child 10 mg/kg
e
• Take a patient history (see above). to 250 mg 8 hrly) for 7 days or doxycycline
• Palpate the sinus areas for tenderness. 100 mg daily if over 8 years
pl
Commence and finish by palpating non- • if there is a poor response—suspect an
m
tender areas (zygoma) to avoid false positives. organism producing B lactamase; substitute
• Transilluminate sinuses using pocket torch amoxycillin/clavulanate
sa
intra-orally in a darkened room (lip seal is Note: Antihistamines and mucolytics are of no
required); point torch in an orbital direction: value in treating sinusitis
85

5. Oral, nasal and pharyngeal complaints
Chronic sinusitis • pain is thought to be due to an aberrant loop
• pain and tenderness are often mistaken for of the middle cerebral artery compressing the
maxillary molar disease, and occasionally the trigeminal nerve where it enters the pons, or
reverse in multiple sclerosis by an impinging plaque of
• there is an associated frontal headache demyelination
• there is often sharp pain in the antral region when • the patient frequently considers pain is of
walking or running dental origin
• surgery improves drainage and makes the
condition easier to treat but is not a cure
CAUTION: Shock-like pain in a patient
under 40 years may be due to multiple sclerosis.
management
An MRI of the brain is mandatory.
• As for acute sinusitis (see above)
• Macrolides are effective and have an anti-
inflammatory action
management
Medical:
sharp, lanCing faCial pain • trial of carbamazepine 100 mg 12 hrly,
50 mg 12 hrly (elderly) increasing in 3 days to
Patients sometimes complain of severe stabbing or
200 mg 12 hrly
‘shock-like’ facial pain over the distribution of the
• monitor adverse neurological response: ataxia,
trigeminal nerve or in the oro-pharynx (IX nerve
dizziness, visual disturbance, drowsiness
lesion). Causes include:
• an alternative is phenytoin or gabapentin
• acute dental pulpitis (see above)
(initially 100 mg 8 hrly) alone or in
• trigeminal neuralgia
combination
• multiple sclerosis
• reduce drug once pain relief obtained
• glossopharyngeal neuralgia
ly
Surgical techniques include vascular
• atypical facial pain
decompression of the trigeminal nerve
• cluster headache
• pressure of the lower denture on the mental nerve
Multiple sclerosis
on
Trigeminal neuralgia
s
• the most common severe neurological condition
• recurrent lightning pain in the distribution of
in 20–50-year-olds
ge
the second and third divisions of the trigeminal
• approximately 6% have features of trigeminal
nerve
neuralgia
pa
• if pain persists after initial paroxysm, it is probably
due to cluster headache and not trigeminal
Diagnosis
neuralgia
• An MRI demonstrates myelin plaques
e
• occurs mainly over 50 years of age
• A lumbar puncture reveals monoclonal IgG in
• is precipitated by touching or moving the trigger
pl
90% of cases
zone of the face or mouth, including teeth, such as
m
in talking, eating or exposure to wind
• an area of paraesthesia corresponding to the Glossopharyngeal neuralgia
sa
trigger zone is frequently present • an uncommon condition occurring much less
• trigger zone is refractive to repeated stimulation frequently than trigeminal neuralgia (TN)
86

6. Chapter 6 Facial pain
• presents like TN, with lancing pain at the back of • herpes zoster/herpatic neuralgia involving
the throat and posterior of tongue; site is difficult ophthalmic nerve (see page 88)
to localise • pain may be felt in the ear from oral lesions such
• may be associated with syncopal attacks as aphthous ulcers, dental caries/periapical lesions
• onset is often sudden, with pain lasting up to or infected impacted third molars
60 seconds, recurs frequently over half an hour • pain from an oral lesion may be transmitted
via sensory nerve branches: auriculotemporal
(trigeminal), auricular (vagus), tympanic
management
(glossopharyngeal) nerves to ear
As for trigeminal neuralgia
• pain may emanate from ulcers at the base of
tongue (frequently neoplastic), floor of mouth or
Cluster headache oro-pharynx
• variant of migraine • temporomandibular joint dysfunction (see
• five times more common in males—mainly in page 88)
30–40 age group; commonly have high cigarette/
Temporal (cranial) arteritis
alcohol intake
• giant cell vasculitis affecting media of middle-
• very severe episodic unilateral pain of short
sized arteries in particular—ophthalmic and
duration (< 60 minutes) centred around the eye
superficial temporal
• frequently occurs at same time each day, often
• most common in females over 70 years
early morning
• frequently, insidious onset of constant diffuse
headache which may be localised to ear,
management temporal or occipital areas
Sumatriptin subcutaneously or orally • tenderness of scalp and superficial temporal
artery are common, as is jaw pain when
ly
chewing (claudication) from involvement of
pain arounD the ear
the masseteric artery
Consider:
• pain frequently does not reflect an aural problem
on
• malaise, fatigue, weight loss, fever, sweating
• visual disturbance from involvement of
• pain can be localised to the ear from the upper posterior ciliary artery; can lead to damage
s
cervical spine (C3, C4) via great auricular, lesser to optic nerve with loss of colour perception,
ge
and greater occipital nerves; examination for acuity and field defects
cervical spine dysfunction is mandatory • may be uncomfortable to lie on affected side
pa
• MRI is the investigation of choice
• temporal arteritis Diagnosis
• otological causes may be infective (acute/ • Clinical findings together with a raised ESR
e
chronic otitis media, otitis externa, furunculosis) > 60
or traumatic (baro-trauma, foreign body or
pl
• Diagnosis may be confirmed by a positive
perichondritis); these conditions are usually temporal artery biopsy, however as skip lesions
m
easily diagnosed by a carefully taken history and are common, false negatives may occur
examination
sa
87

7. Oral, nasal and pharyngeal complaints
Diagnosis
CAUTION: Due to sometimes rapid
• TMJ dysfunction is not a diagnosis of
progression to blindness, steroid therapy
exclusion; rather, it must be made from
(prednisolone 60 mg daily) should be started
positive clinical findings
as soon as CRP or ESR is obtained as, once
• Plain TMJ films (open and closed) may reveal
established, blindness rarely improves.
pathology but the gold standard is MRI
Prednisolone dosage is determined by serial ESR
results but generally at least one year of therapy is
management
necessary. Relapse occurs in 30% of cases.
• Advise the patient to rest the jaw by limiting
opening (avoid biting apples, vigorous
Temporomandibular joint (TMJ) dysfunction chewing)
• a relatively common complaint affecting 12% of • Use a removable dental (occlusal) splint to
adults. More common in females prevent grinding and reduce clenching, and so
rest muscles
• Apply heat locally
etiology
• Recommend isometric stretching of
Possible causes:
masticatory muscles by biting on a soft
• many cases are idiopathic
wooden block
• occlusal disharmony due to missing teeth
• Consider non-steroidal anti-inflammatory
• facial trauma
drugs; these may provide symptomatic relief
• connective tissue disease
• If there is a history of jaw clenching or teeth
• osteoarthritis
grinding, diazepam 5 mg BD may relieve
• abnormal condylar morphology: condylar
anxiety and reduce muscle spasm
dysplasia, hyperplasia, condylysis.
other Causes of faCial pain
ly
Clinical presentation Post-herpetic neuralgia
• Pain and stiffness, often maximal on waking
or with mandibular movements
on
• herpes zoster (HZ) results from the reactivation of
herpes virus dormant in the dorsal root ganglion of
• Oral examination may reveal an unbalanced sensory nerves. Acquired in childhood chicken pox
s
occlusion, often related to missing teeth • as in other sites, HZ may present with a burning
ge
• Tenderness over TMJ may be elicited on sensation in the affected dermatome 3–4 days
opening or at insertion of masseter or before vesicles appear (see Figs. 6.1 and 6.2)
pa
temporalis muscles when jaws clenched • pain is generally constant and burning in nature;
• A clicking joint does not necessarily result tenderness over affected dermatome (see Fig. 6.3)
in pain • often involves ophthalmic division of trigeminal
e
• History of locking of jaw or limited opening nerve
(< 20 mm) indicates significant joint • inspection of eye is essential as cornea is usually
pl
dysfunction affected, leading to ulceration
m
• In many cases a state of anxiety leads to • geniculate ganglion (facial nerve) may be involved
clenching of jaws or grinding teeth; diazepam (Ramsey Hunt syndrome) causing vesicles in external
sa
5 mg BD may help eliminate anxiety and ear and buccal mucosa, unilateral facial paralysis
reduce muscle spasm and loss of taste (chorda tympani involvement)
88

8. Chapter 6 Facial pain
• most common in the elderly and immuno- Bell’s palsy
compromised • etiology unclear but occurs in 20% of cases of
• severe infection suggests immune deficiency multiple sclerosis and is sometimes a complication
• virus from lesions may cause chicken pox in of herpes (simplex or zoster)
susceptible individuals, but not shingles • while primarily a unilateral facial nerve palsy,
• post-herpetic neuralgia may persist up to 6 months symptoms may develop over several hours, initially
after lesions resolve with pain around the ear
• patients commonly complain of persisting
management numbness of affected side of the face but this
• Early treatment with the aciclovir analogue cannot be confirmed on neurological testing
valaciclovir 1 gm 8 hrly is essential to reduce • lesions occurring in the facial canal due to
post herpetic neuralgia recrudescent herpes infection may cause oedema
• In established pain, carbamazepine (100 mg of the facial nerve and, if the nerve to the stapedius
12 hrly), amitriptyline (25–50 mg nocte) or is involved, hyperacusis
gabapentin (300mg daily) with incremental • tear and saliva production may be decreased
increases may minimise this distressing • vesicles present on palate and external ear
symptom indicate herpes zoster as a cause (Ramsay Hunt
• A live, attenuated viral vaccine to prevent syndrome–see page 88)
HZ has recently been approved in USA for
immunocompetent people > 60 years
ly
on
s
ge
pa
e
pl
m
sa
Figure 6.1 Herpes zoster affecting maxillary division of trigeminal nerve
89

9. Oral, nasal and pharyngeal complaints
ly
on
s
ge
pa
e
pl
m
sa
Figure 6.2 (above) and Figure 6.3 (below) Herpes zoster affecting mandibular division of trigeminal nerve
90

10. Chapter 6 Facial pain
management oral CanCer
• Start immediately—prednisolone 40–60 mg
(See also Chapter 3)
daily for 7 days; the addition of valaciclovir
may hasten resolution Oral cancer can produce pain in the mouth or pharynx
• The majority recover fully within 3 months, and may be referred to the ear.
but resolution is slower in the elderly
• The use of artificial tears and taping the eyes
at night helps to reduce the incidence of
CAUTION: Beware conditions not seen in
routine examination:
keratitis
• cranial arteritis: always perform ESR in
• Decreased salivary flow necessitates careful
suspicious cases
attention to oral hygiene
• nasopharyngeal carcinoma (see oral/pharyngeal
cancer in Chapter 4)
• thalamic infarcts: typically cause burning pain
CAUTION: Differentiate Bell’s palsy from • cerebral neoplasms
an upper motor neuron lesion where the frontalis CT and MRI are valuable investigations in
muscle is spared. excluding the last three conditions.
atypiCal faCial pain
REFERENCES
• commonly constant, unremitting and centred
over maxilla
Hayreh SS. ‘Steroid therapy for visual loss in patients
• such a diagnosis should only be made after
with giant cell arteritis.’ Lancet 2000: 355: 1572–73
exhaustive investigation has excluded other causes
Lance JW. Mechanisms and management of headache
• psychological disorders may underlie or magnify
5th edn. London Butterworth-Heinmann 1993
ly
such pain
Mashford ML. ‘Therapeutic Guidelines. Analgesia.’
• most frequently seen in elderly females
• an empirical trial of carbamazepine or
amitriptyline may ameliorate symptoms
on
Melbourne: Therapeutic Guidelines Ltd 2002
Quail G. ‘Atypical facial pain.’ Aust Family Physician
34: 641–45 2005
s
Note: if injection of a long acting analgesic at site Stevens M. ‘Diagnosis and management of sinusitis.’
relieves pain, a central cause is excluded. Modern Medicine 16–26: 1991
ge
Walton J (ed). Brain’s Diseases of the Nervous System
10th edn. Oxford Oxford University Press 1993
pa
e
pl
m
sa
91

11. sa
m
pl
e
pa
ge
s
on
ly