In: Main9 Dec 2009
About 5 to 10% of trigeminal neuralgia has been considered to be symptomatic trigeminal neuralgias caused by brain tumors. Some of these patients complain of severe pain, which needs to be managed before surgical treatment. We present a case of symptomatic trigeminal neuralgia in which pain was relieved by trial stellate ganglion block (SGB).
A 29-year-old woman visited our hospital with complaints of sharp, shooting facial pain and continuous tingling pain. Approximately 4 years before presentation, numbness and a tingling pain developed in the left ala of the nose and over the infraorbital region. These symptoms disappeared 1-2 months later. Dental evaluation could not identify the cause. The sharp, shooting pain occasionally recurred briefly until presentation. discount drugs canda
Figure 1. Computerized tomography scanning shows no abnormalities.
The patient sought evaluation with our group when the pain recurred and increased in severity. The sharp, shooting pain was triggered by light touch applied to the infraorbital region or was induced by moving the angle of the mouth with a dental mirror. The pain lasted for about 1 minute, and the patient was unable to move during that time. Nocturnal pain was absent. Upon dental examination, the discomfort was found to be caused by percussion to the left maxillary incisor without any other clinical findings. There was an area of hypoesthe-sia at the infraorbital region. The remainder of the physical evaluation was essentially normal. Radiographs of the skull and a panoramic radiograph showed no abnormalities. Because of her age and nonclassical symptoms, symptomatic trigeminal neuralgia induced by an intracranial tumor was suspected. The next day, a computed tomography (CT) scan was performed, and it showed no mass signal (Figure 1). The patient was placed on a trial course of carbamazepine with onlv slight improvement for a short period. Magnetic resonance imaging (MRI) was scheduled for 2 weeks later. However, the pain increased in intensity and frequency, and the patient returned to the hospital 2 days later. SGB was applied to the C6 region with 5 mL of me-pivacaine. After the SGB with transient nausea and dizziness, the pain was noticeably relieved, and the effect lasted until she received the surgery. MRI was carried out on the scheduled day. On both axial and coronal MRI images, a mass was identified in the left cerebellopontine angle (Figure 2). At surgery, the mass was subtotally removed using a left lateral suboccipital approach. The tumor was observed among the cranial nerves, and the fifth cranial nerve was embedded in it. On the fourth postoperative day, brain edema developed and consciousness level decreased. However, successful drainage was carried out. Histological examination demonstrated an epidermoid tumor filled with ke-ratinous and sebaceous material. Surgery has relieved the facial pain up to the present time (approximately 5 years).
Figure 2. (A and B) Axial magnetic resonance images demonstrate a mass in the left cerebellopontine angle. A low-signal division in a Tl-weighted image (A) and a high-signal division in the T2-weighted image (B) are shown.
Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.