2005 Volume 2, Issue 1

www.painmanagementrounds.org

F ROM GR AN D ROU N DS AN D OTH ER CLI N IC AL CON F ER ENCES OF

T H E M G H PA I N C E N T E R , M A S S A C H U S E T T S G E N E R A L H O S P I TA L

MGH MASSACHUSETTS
Orofacial Pain 1811 GENERAL HOSPITAL

By ALEXANDRE F.M. DASILVA, DDS DMSC., AND MARTIN A. ACQUADRO, MD, DMD, FACP, FACPM

The assessment of head and neck pain requires a careful physical examination of multiple structures
and systems, a thorough history, and the employment of auxiliary diagnostic studies. Due to its complex-
ity, patients suffering with this type of pain are frequently followed by multiple healthcare professionals.
The goal of this issue of Pain Management Rounds is to present some of the clinical features, diagnostic MGH PAIN CENTER
tests, and treatments available for different chronic pain disorders in the orofacial area. Jane C. Ballantyne, M.D.
Chief, Division of Pain Medicine
Editor, Pain Management Rounds
TEMPOROMANDIBULAR AND MYOFASCIAL DISORDERS Salahadin Abdi, M.D., Ph.D.
Temporomandibular joint (TMJ) articular disorders Director, MGH Pain Center
TMJ damage can be the result of direct trauma, wear and tear from pathologic occlusal forces, or over- Martin Acquadro, M.D., D.M.D.
extension of jaw movements (Figure 1). Other conditions may also affect the TMJs, such as congenital and Director of Cancer Pain Service
developmental disorders, inflammatory disorders, osteoarthritis, and ankylosis. Similar to finding abnormalities Steve Barna, M.D.
of the lumbar spine with magnetic resonance imaging (MRI) in asymptomatic patients, evidence of Medical Director, MGH Pain Clinic
TMJ pathology may be apparent in asymptomatic individuals.1 However, if the patient complains of chronic Gary Brenner, M.D., Ph.D.
TMJ dysfunction with pain, a thorough evaluation by a pain specialist is warranted. Director, Pain Medicine Fellowship
Lucy Chen, M.D.
Temporomandibular muscle disorders (TMMDs)
Katharine Fleischmann, M.D.
TMMDs are characterized by dull aching pain that is exacerbated by mandibular function, muscle tender- Director, Acute Pain Service
ness in one or more masticatory muscles and, frequently, a decreased mandibular range of motion. A variety of Jatinder Gill, M.D.
terms exist to describe muscle disorders, with a number of classifications and sub-classifications. These include
Karla Hayes, M.D.
myofascial dysfunction, myositis, myalgia, myospasm, and myofibrotic contracture.2 The absence of clinical
Eugenia-Daniela Hord, M.D.
features referable to the TMJ and the presence of muscle tenderness distinguish TMMD from primary TMJ
articular disorders. Ronald Kulich, Ph.D.
Jianren Mao, M.D., Ph.D.
Myofascial pain dysfunction Director, Pain Research Group
Dysfunction of the muscles of the shoulders, neck, head, and face is relatively common in the general popu- Seyed Ali Mostoufi, M.D.
lation and can aggravate headaches and orofacial pain. Fibromyalgia is a type of myofascial dysfunction and is Anne Louise Oaklander, M.D., Ph.D.
described as a chronic disease with muscle pain and tenderness in multiple body quadrants. It can be exacerbated Director, Nerve Injury Unit
by stress and anxiety and may be accompanied by a variety of generalized symptoms such as fatigue, morning Director, Center for Shingles and
stiffness, and headache. The patient with fibromyalgia may initially present with facial pain and tenderness in Postherpetic Neuralgia
the muscles of mastication. 3 Other systemic myofascial disorders are polymyalgia, lupus erythematosus, Gary Polykoff, M.D.
polymyositis, and dermatomyositis. Milan Stojanovic, M.D.
Director, Interventional
Diagnosis Pain Management
Diagnostic evaluation includes a careful and thorough history and physical examination of the integrity and
function of the head and neck structures, with special attention to the TMJ complex and the cranial and cervical
muscles and nerves. Evaluation should include a review for a history of primary headaches, surgeries, traumas, MGH PAIN CENTER
and stressors. A review of daily activities, along with posture, repetitive movements, habits, and sleep patterns 15 Parkman Street, Suite 324
should be included. A history of parafunctional habits (clenching and grinding of teeth), awakening in the Boston, MA 02114
morning with sore jaw muscles, and joint noises when opening the mouth should be elicited. Examination of the Fax : 617-724-2719
oral cavity should look for abnormal occlusion (bite). Teeth sensitivity, painful muscles, and trigger points (TP) The editorial content of Pain Management
should be examined.2 Rounds is determined solely by the
MRI and computed tomography (CT) scan of the TMJs may be necessary to evaluate possible advanced MGH Pain Center, Massachusetts
General Hospital.
degenerative pathologies or tumors. However, radiographs frequently reveal abnormalities of the TMJ disk
position in asymptomatic joints that do not require treatment. Therefore, other than an initial panoramic radio-
graphy, imaging exams of the TMJ should only be requested in treatment-resistant chronic pain, unusual pain Pain Management Rounds is approved
by the Harvard Medical School
Department of Continuing Education
to offer continuing education credit
FIGURE 1: Temporomandibular disorders

Diagnosis TM joint articular disorders TM muscle disorders Myofascial disorders

Region

Pain localized in the pre-auricular area
Diagnostic during jaw function. Usually presence of
painful click or crepitus during mouth
features opening. Limited opening (<35 mm), deviated
or painful jaw movements.
Internal derangement of the TMJ with abnor-
mal function of the disc-condyle complex,
Diagnostic and/or degeneration of the joint surface.
Palpation is painful. Possible joint swelling in
evaluation
acute phases. MRI, CT, etc. of the joint may
rule-out tumors and advanced degenerative
stages.
Patient education and self-care.
Medication: NSAIDs, non-opiate analgesics.
Physical Therapy: exercise program.
Occlusal splints.
Treatment
Oral maxillofacial surgery: arthrocentesis,
arthroscopic surgery, open surgery.
Tenderness of the masticatory muscles.
Dull, aching pain exacerbated by jaw
function or palpation.
Tenderness during palpation of the
masticatory muscles and tendons.
Possible limited range of jaw movement
and during passive stretching exam.
Can be associated with a para-functional
habit (bruxism-early morning pain).
Patient education and self-care.
Medication: topical and systemic NSAIDs,
non-opiate analgesics, muscle-relaxants,
antidepressants (usually TCAs), anxiolytics,
anticonvulsants, BTX, trigger point injections
and vapocoolant spray.
Physical Therapy: TENS, massage, exercise
program.
Occlusal splints.
Cognitive-behavior: biofeedback, relaxation,
coping skills.
Diffused dull or aching pain affecting
multiple groups of muscles of the head
and neck region, as well as other parts
of the body.
Presence of trigger or tender points in
one or more groups of muscles. Pain can
radiate to distant areas with stimulation or
not of the trigger points. Rule out presence
of lupus erythematosus.
Patient education and self-care.
Medication: topical and systemic NSAIDs,
non -opiate analgesics, muscle-relaxants,
antidepressants (usually TCAs), anxiolytics,
anticonvulsants, BTX, trigger point injections
and vapocoolant spray.
Physical Therapy: TENS, massage, exercise
program.
Occlusal splints.
Cognitive-behavior: biofeedback, relaxation,
coping skills.

patterns, and sudden changes in occlusion.4 Consideration of other
diagnoses by history and physical exam will dictate additional
studies and referral to the appropriate specialist.
Treatment
Physical therapy: The patient diagnosed with TM disorders may
benefit from a complete evaluation and treatment by a physical
therapist. The treatment program may include stretching, strength-
ening, endurance exercises, transcutaneous electrical nerve stimula-
tion (TENS), ultrasound, and hot/cold applications. Outpatients
should follow an active exercise program with guidance from a
physical therapist.5
Pharmacologic therapy: Pharmacologic therapy includes judicious
use of non-steroidal anti-inflammatory drugs (NSAIDs) and other
analgesics, and selective use of tricyclic antidepressants (TCAs),
anticonvulsants, muscle relaxants, anxiolytics and, rarely, opioids.
There is marked inter-patient variability in the response to different
pharmacological agents, necessitating trials of agents until the opti-
mal response is obtained. NSAIDs may be used for both their anal-
gesic and anti-inflammatory properties. Although large doses of
NSAIDs may provide short-term relief, they have no proven value
in the long-term management of TMJ pain.6
Short-term use of centrally acting muscle relaxants include
cyclobenzapine (Flexeril) and carisoprodol (Soma). Benzodia-
zepines, such as diazepam and clonazepan, also decrease muscle
spasms, improve sleep, and are anxiolytic; however, their use should
be carefully controlled.7 TCAs may also improve sleep and act as
indirect analgesics.
Trigger point injections, botulinum toxin injections, and physi-
cal therapy: Trigger points can be localized by clinical exam and
then temporally inactivated by anesthetic injection. This provides
prolonged analgesia, allowing the patient a pain-free period to com-
mence physical therapy, with subsequent use of vapo-coolants and
stretching exercises at home.8 However, pain relief may last much
longer than the anesthetic effect. Corticosteroids can also be added
to the mixture. Botulinum toxin (BTX) injection has proven to be
an excellent therapeutic tool for the treatment of myofascial pain.
The clinical effects include reduction of muscular tone and contrac-
tility and graded chemical denervation in the injected muscular
area. Botulinum toxin may also reduce pain and clinical reports sup-
port its utility in some chronic pain diseases, including primary
headaches, inflammatory pain, and selected cases of neuropathic
pain.9,10 However, good level 1 randomized control clinical studies
are lacking.11 The beneficial effect of a BTX injection can last an
average 4 months and may be repeated if indicated.
Behavioral therapy: Biofeedback, relaxation techniques, and cogni-
tive behavioral therapy addressing aversive behaviors are useful and
should be considered in chronic cases of orofacial pain.12
Dental treatment: Advocates of occlusal appliances suggest that it
temporarily equilibrates occlusion, mechanically unloading the
TMJ and limiting masticatory muscle activity, therefore decreasing
symptoms of TM disorders. Occlusal appliance therapy seems to be
beneficial in cases of myofascial pain, even when there are no signs
of parafunctional habits (eg, bruxism).13 Malocclusions have an
inconsistent relationship to TMJ disorders, and correcting them
may improve masticatory function without guaranteeing pain relief.
Temporomandibular joint surgery: Open surgery of the TMJ is
associated with considerable morbidity and a lack of efficacy, unless
proper and careful patient selection is utilized by an experienced
oral and maxillofacial surgeon. 4 More conservative procedures,
such as arthrocentesis and arthroscopic surgeries, should be consid-
ered first.
ODONTOGENIC PAIN
Due to the rich innervation of the mouth, odontogenic pain
can present with numerous features, including local pain, headache,
FIGURE 2: Odontogenic pain

Diagnosis Pulpitis Periodontal Cracked tooth Dentinal

Region

Spontaneous and/or evoked Localized deep continuous pain Spontaneous or evoked brief Brief, sharp pain evoked by
Diagnostic deep /diffuse pain in compromised in compromised periodontium sharp pain in a tooth with history different kinds of stimulus to the
features dental pulp. Pain may be sharp, (eg, gingiva, periodontal ligament) of trauma or restorative work dentin (eg, hot or cold drinks).
throbbing, or dull. exacerbated by biting or chewing. (eg, crown, root canal )
Look for deep caries and recent Tooth percussion over compro- Presence of tooth fracture may Exposed dentin or cementum due
or extensive dental work. Pain mised periodontium provokes be detectable by x-ray. Percus- to recession of periodontium.
Diagnostic provoked/exacerbated by percus- pain. Look for inflammation or sion should elicit pain. Dental Possible erosion of dentinal
evaluation sion, thermal or electric stimula- abscess (eg, periodontitis, apical) x-rays are helpful (periapical structure. Cold stimulation
tion of affected tooth. Dental Dental x-rays helpful (bitewings, taken from different angles). reproduces pain.
x-rays helpful (periapical). periapical).
Medication: NSAIDs, nonopiate Medication: NSAIDs, non-opiate Medication: NSAIDs, non-opiate Medication: Mouthwash (fluoride),
analgesics. analgesics, antibiotics, mouth- analgesics. desensitizing toothpaste.
Dentistry: Remove carious lesion, washes. Dentistry: depends on level of the Dentistry: Fluoride or potassium
Treatment tooth restoration, endodontic Dentistry: drainage and debride- tooth fracture-restoration; treat- salts, tooth restoration, endodontic
treatment or tooth extraction. ment of periodontal pocket, ment, or extraction of the tooth. treatment.
scaling and root planing, perio- Patient education, diet, tooth
dontal surgery, endodontic treat- brushing force and frequency,
ment or tooth extraction proper toothpaste.

or eye symptoms. Differential diagnosis includes trigeminal neuro-
pathic pain, sinus disease, and primary headaches (eg, cluster
headache and migraine).
Diagnosis: During the history and clinical examination, odonto-
genic pain must be adequately assessed. Aggravating and relieving
factors, duration, and quality of the pain provide key information to
differentiate dental pathologies (Figure 2). The clinical exam should
include probing of the dental surfaces for cavities or fractures, per-
cussion of the teeth in multiple planes for mobility and fractures,
and electrical and thermal stimulation for pulpitis. Radiographic
exams contribute greatly to the diagnosis. However, if pathologies of
the hard or soft intra-oral structures are ruled-out, consideration of
less common disorders that mimic odontogenic pain is warranted.
Treatment: If dental disease is the obvious source of pain, referral
to a dentist should be made for proper evaluation and treatment.
A summary of treatments is provided in Figure 2.
TRIGEMINAL NEUROPATHIC PAIN DISORDERS
Trigeminal neuralgia
Trigeminal neuralgia is characterized by sudden, stabbing, and
severe unilateral facial pain in ≥1 of the 3 divisions of the trigeminal
nerve, most frequently the second. Onset is frequently triggered by
mechanical stimulation such as talking, chewing, or touch. Attacks
can last from seconds to a few minutes. Periods of attacks can last
weeks or months, followed by periods of remission for months or
years. Incidence increases with age, with the average onset at age 50
years; it more commonly presents in women.2 Limited information
is available about the etiology of trigeminal neuralgia other than the
possible compression of the trigeminal root by a vessel or tumor.15
Diagnosis: MRI is an important tool for excluding intracranial
masses and multiple sclerosis (MS), particularly in younger patients
with trigeminal neuralgia symptoms. Novel MRI studies can reveal
demyelinating lesions of the white matter associated with MS.16
Treatment: Carbamazepine is the drug of first choice for treat-
ment, with an initial beneficial response in >75% of patients.
Baclofen potentiates the action of carbamazepine and can be a use-
ful adjunct. Gabapentin is a safe and well-tolerated adjunct to
carbamazepine or may be used as sole treatment. Other less
frequently used agents include topiramate, zonisamide, oxcar-
bazepine, lamotrigine, clonazepam, and sodium valproate.17 Some
of the surgical approaches to the treatment of trigeminal neuralgia
include microvascular decompression, radiofrequency rhizothomy,
and gamma knife surgery. Microvascular decompression of the
trigeminal nerve provides immediate and long-term pain relief in
>70% of patients.18
Deafferentation pain
Teeth and dental nerves are commonly removed and, occasion-
ally, these procedures induce a phenomenon known as “phantom
tooth pain,” producing pain in previously extracted or endodonti-
cally-treated teeth.19 Other facial areas previously harmed by trauma
or surgeries may induce deafferentation pain. This pain may be con-
stant with sharp exacerbations, and is associated with local allodynia
(Figure 3).
Diagnosis: History and physical exam are important to elicit the
extent of dental work and other trauma or surgeries in the area.
History of prior severe dental pain of the extracted tooth or teeth, as
well as prior sinusitis pain, migraine history, and traumatic pain
may suggest possible peripheral or central sensitization. Neuroimag-
ing studies may help rule out tumors affecting the trigeminal
sensory system.
Treatment: Pain therapies are targeted at both the central and
peripheral components of deafferentation pain. Clinical studies have
demonstrated good results with gabapentin, and clonazepam and
baclofen are useful as adjunctive agents. Peripherally acting agents,
including topically applied drugs, and nerve blocks have been
applied topically with mixed results. A fixed daily dose of an opioid
has been used in severe cases, but is considered a last resort. Surgical
procedures are mostly ineffective in the treatment of phantom tooth
pain and may increase pain severity.20
Acute and post-herpetic neuralgia
Acute herpetic neuralgia (AHN) – shingles – usually affects the
ophthalmic division of the trigeminal nerve.21 Shingles is almost
always unilateral and may be recurrent. Pain is described as burn-
ing, itching, well-localized to the dermatome, with lancinating
episodes, and is associated with hyperesthesia and hyperalgesia22
(Figure 3). Pain persisting for >1 month after complete healing of
FIGURE 3: Trigeminal neuropathic pain disorders

Diagnosis Trigeminal neuralgia Deafferentation pain Acute and post- Burning mouth
herpetic neuralgia syndrome

Region

Brief severe lancinating pain
evoked by mechanical stimula-
Diagnostic tion of trigger zone (pain-free
features between attacks). Usually uni-
lateral, affects the V2/V3 areas
(rarely V1). Possible pain remis-
sion periods (for months/years).
MRI for evidence of tumor or
Diagnostic vasocompression of the trige-
minal tract or root (cerebro-
evaluation pontine angle). Rule-out MS,
especially in young adults.
Medication: anticonvulsants
(eg, carbamazepine, gaba-
pentin); antidepressants (eg,
amitriptyline, nortriptyline,
Treatment desipramine); non-opiate anal-
gesics, BTX. Combination of
baclofen and anticonvulsants
can produce good results.
Surgery: microvascular
decompression of trigeminal
root, ablative surgeries (eg,
rhizotomy, gamma knife).
Spontaneous or evoked pain
with prolonged after-sensation
after tactile stimulation. Trigger
zone due to surgery (tooth
extraction) or trauma. Positive
and negative descriptors (eg,
burning, nagging, boring).
Etiologic factors such as
trauma or surgery in the painful
area. Order MRI if the area is
intact to rule-out peripheral or
central lesions.
Medication: anticonvulsants
(eg, carbamazepine, gaba-
pentin); antidepressants;
non-opiate analgesics; topical
agents (eg, lidocaine 5%
patches). Combination of
baclofen and anticonvulsants
can produce good results.
Surgery: ablative surgeries
(eg, rhizotomy, gamma knife).
Pain associated with herpetic
lesions, usually in the V1
dermatome. Spontaneous pain
(burning and tingling), but
may present as dull and
aching. Occasional lancinating
evoked pain.
Small cutaneous vesicles
(AHN) or scarring (PHN),
usually affecting V1. Loss of
normal skin color. Corneal
ulceration can occur. Sensory
changes in affected area (eg,
hyperesthesia, dysesthesia).
Medication: acyclovir (acute
phase) anticonvulsants (eg,
carbamazepine,gabapentin);
antidepressants; non-opiate
analgesics; topical agents
(eg, lidocaine 5% patches).
Surgery: ablative surgeries
(eg, rhizotomy, gamma knife).
Constant burning pain of the
mucous membranes of the
tongue, mouth, hard or soft
palate, or lips. Usually affects
women age >50 years.
Rule-out salivary gland dys-
function (xerostomia) or tumor,
Sjögren’s, candidiasis, geo-
graphic or fissured tongue, and
chemical or mechanical irrita-
tion. Nutritional deficiencies
and menopause can be factors.
Medication: anticonvulsants
(eg, gabapentin); benzodi-
azepines (eg, clonazepan);
antidepressants; non-opiate
analgesics; topical agents
(eg, lidocaine mouthwashes).
Cognitive-behavior: biofeed-
back, relaxation, coping skills.

acute herpes zoster lesions is considered post-herpetic neuralgia
(PHN). The pain of PHN is diffuse, dull, and aching, with a
superficial allodynic sensation evoked by clothes or light touch.
Diagnosis: Diagnosis is clinical and based on the presence or
past presence of vesicles. Complications should be completely
evaluated with CT or MRI imaging.
Treatment: Early effective treatment of acute herpes zoster
shortens the episode and decreases acute pain and the inci-
dence of PHN. Antiviral therapy with acyclovir starting within
72 hours of the shingles eruption is particularly effective.
TCAs, anticonvulsants, and NSAIDs are useful for pain con-
trol in AHN; however, if pain remains uncontrolled, opioids
are judiciously added.
TCAs are the mainstay of treatment in PHN.23 The effi-
cacy of amitriptyline and desipramine has been confirmed in
controlled clinical trials; however, a secondary amine
(desipramine) which, theoretically, has less anticholinergic
effects when compared to a tertiary amine (amitriptyline), is
preferred in the elderly. Anxiolytics and anticonvulsants have
been used with less success. Topical agents (eg, the lidocaine
5% patch) can produce substantial pain relief with minimal
systemic absorption.24 Capsaicin is often poorly tolerated due
to cutaneous sensitivity.
Burning mouth syndrome
Burning mouth is characterized by burning pain of the
mucous membranes of the tongue, mouth, hard palate, or lips.
Its prevalence rates are 1.5%-2.5% in the general population.
Patients are more likely to be female (3:1) and >50 years old.
The onset of pain is gradual, with no precipitating event, and
it is usually bilateral. Associated symptoms are altered taste
and dry mouth. Although nutritional and menopausal factors
and chronic chemical or mechanical irritation have been
suggested as causes, there is inadequate evidence to pinpoint
these factors as the isolate etiology of burning mouth
syndrome25 (Figure 3).
Diagnosis: There are no useful radiographic or laboratory
examinations. As always, a careful history and physical exami-
nation is required to rule-out other treatable causes.
Treatment: In a study of 30 patients, clonazepam given daily
lessened pain in 70% of patients.26 Also, tricyclic antidepres-
sants may be effective. Since pharmacological therapy is unsuc-
cessful in many patients, psychological support is important.
PARANASAL, PERIOCULAR, PERIAURICULAR,
AND HEAD AND NECK CANCER PAIN
Paranasal sinus area pain and headache
Acute sinusitis presents with bilateral or unilateral throb-
bing or sharp facial pain. Frequently, pain is exacerbated by
leaning the head forward (Figure 4). Medial orbital pain with
radiation to the temple is a feature of ethmoid sinusitis.
Frontal sinusitis features forehead pain and headache; maxil-
lary sinusitis is suggested by pain over the upper teeth or orbit.
Chronic sinus area pain presents more of a diagnostic
dilemma. Pain that is perceived as emanating from the sinuses
can have other causes, including referred pain from dental,
musculoskeletal areas, and primary headaches.27 Other diag-
nostic features of sinusitis include purulent discharge from the
nasal passages or nasopharynx, intermittent fever, smell or
taste disorder, tenderness on tapping the maxillary teeth, and
tenderness over the maxillary, frontal, or ethmoidal sinuses.
A history of recurrent injury in the form of upper respiratory
tract infections and allergies may be elicited.
Diagnosis: A combination of history, endoscopic examina-
tion, and imaging studies is required to accurately diagnose
sinusitis, particularly prior to embarking on surgical treat-
FIGURE 4: Paranasal, periocular, periauricular and head and neck cancer pain

Diagnosis Paranasal sinus pain Periocular pain Periauricular pain Head and neck cancer

Region

Bilateral or unilateral throbbing Pain or tenderness with or
Diagnostic or pressure frontal area pain,
exacerbated by leaning
features forward or palpation over the
sinus.
History of chronic allergies,
frequent URIs, sinusitis,
Diagnostic headaches of various types,
evaluation sinus surgery. Refer to ENT for
endoscopic and/or CT study
(eg, sinus opacification)
ENT evaluation/ treatment
Medication: Sinusitis-topical
decongestants; systemic
antibiotics
Treatment
Chronic sinus pain-NSAIDs;
non-opiate analgesics.; topical
agents (lidocaine spray); anti-
convulsants (eg, gabapentin);
antidepressants (eg, amitripty-
line), BTX
Surgery
without eye movement, deep
orbital pain, and referred pain. (eg, otitis media).
Examine eyelids, lacrimal func-
tion, conjunctiva, sclera
(hemorrhage/ inflammation.).
Ophthalmoscopy and ophthal-
mology referral. Rule-out
primary headache (eg, cluster,
migraine), temporal arteritis,
orbital pseudotumor.
Proper ophthalmologic
evaluation and treatment.
Medication: NSAIDs; non-
opiate analgesics; cortico-
steroids; topical or systemic
antibiotics, BTX across fore-
head and glabellar areas in
selected cases.
Surgery
Diffuse aching or sudden pain Variety of symptoms. Pain may
with or without aural discharge be due to tumor, nerve com-
pression, secondary infection,
2nd myofascial pain, deaf-
ferentation, radiotherapy,
chemotherapy.
The area is innervated by multi- Complete evaluation by multi-
ple cranial and cervical nerves disciplinary team. CT, MRI,
so complete functional and endoscopy, biopsy and surveil-
structural exam necessary (eg, lance. Treatment coordination
inspect tympanic membrane, by oncologist
TMJ and myofascia). CT and
MRI invaluable for mastoiditis
and cholesteatoma.
Proper ENT evaluation and Oncologist evaluation and
treatment treatment.
Medication: NSAIDs; non- Medication: anticonvulsants
opiate analgesics; systemic (eg, gabapentin); antidepres-
antibiotics, topical cortico- sants (eg, amitriptyline); opiate
steroids, BTX in selected cases or non-opiate analgesics;
Surgery topical agents (eg, lidocaine
5% patches), muscle relaxants.
Surgery: ablative surgeries

ments28 (Figure 4). Of note, even the common cold can cause
mucosal thickening of the sinuses sufficient to be seen
on MRI.
Treatment : Otolaryngologic consultation should be
obtained. Endoscopic surgery should be considered if a 6-
month trial of medical therapy has failed. With careful patient
selection, endoscopic sinus surgery can achieve pain relief in
most patients. Difficulties arise in those with chronic sinus
area pain that mimics sinusitis. When imaging repeatedly
demonstrates normal sinuses and there is a lack of any objec-
tive evidence of sinusitis, a multidisciplinary approach is
required. These patients are unlikely to benefit from surgical
intervention.
Periocular pain
Ophthalmic pain results from stimulation of pain fibers
relating either directly or indirectly to the orbit and can be
classified as ocular, orbital, or referred29 (Figure 4).
Ocular pain: Corneal irritation or damage is associated with
local pain, photophobia, and lacrimation. Anterior scleritis
presents with severe ocular pain, while posterior scleritis is
characterized by less well-defined orbital pain. Either may be
associated with a systemic collagen vascular disease. A triad of
red eye, increased intra-ocular pressure, and mid-dilated pupil
is pathognomonic of acute angle glaucoma.
Orbital pain: Orbital cellulitis presents acutely with pain
exacerbated by palpation and movement. Orbital pseudo-
tumor is an inflammatory process of unknown etiology that
presents with pain, chemosis, diplopia, and red eye. Trochleitis
is characterized by orbital pain with movement, together with
exquisite superonasal point tenderness.
Referred pain: The proximity and convergence of afferent
trigeminal pain fibers produce referred pain. Occasionally,
pain from the area of the greater occipital nerve may radiate to
the eye and face, due to convergence and communication
between the cervical nerves, and the trigeminal sensory com-
plex. Migraine, cluster headache, sinusitis, otitis, mastoiditis,
temporal giant cell arteritis, and dental pain can be referred to
the eye.
Diagnosis: MRI is indicated in order to detect multiple scle-
rosis as a cause of optic neuritis. Raeder’s syndrome requires
imaging to rule-out a parasellar mass or carotid dissection.
Doppler flow studies are useful in detecting carotid stenosis as
a cause of orbital ischemia. A raised erythrocyte sedimentation
rate and increased C-reactive protein and fibrinogen levels are
strongly associated with temporal giant cell arteritis.
Treatment: If temporal arteritis, optic neuritis, or orbital
pseudotumor are suspected, high dose corticosteroids should
be started immediately, and the patient should be referred to
an ophthalmologist or rheumatologist, depending on the sus-
pected diagnosis. All patients with suspected eye pathology
should be seen by an ophthalmologist.
Periauricular pain
Otitis media presents with dull aching or sudden exquisite
pain, with or without aural discharge, inflamed tympanic
membrane, and systemic evidence of infection. Otitis externa
can be exquisitely painful and is generally an acute process.
Mastoiditis and otitis pain may be referred to the eye, phar-
ynx, and neck due to involvement of multiple cranial and cer-
vical nerves, and convergence into the trigeminal sensory
complex. A common cause of otalgia that is frequently over-
looked is referred myofascial pain from muscles of the neck,
pharynx, and face (Figure 4).
Diagnosis: Elevated white cell count is supportive, but non-
specific evidence for otitis media. CT and MRI are invaluable
for mastoiditis and cholesteatoma. History and physical exami-
nation should direct the appropriate otolaryngologic referral.30
Treatment: In general, urgent consultation with an otolaryngolo-
gist is required. Pain problems referred to a pain specialist are often
from an otolaryngologist who has successfully treated the primary
otologic problem, but the patient still suffers from chronic pain.
Treatment should be multidimensional and comprehensive, cover-
ing possible underlying myofascial and neuropathic pain.
Head and neck cancer
Head and neck cancers present with a wide variety of symp-
toms. Frequently, a multidimensional approach is required during
diagnosis, treatment, and recovery.31 Characteristic effects of the
various manifestations of malignant disease and its treatment are as
follows. Local tumor growth and invasion result in local tissue
destruction, secondary infection, nerve compression and secondary
myofascial pain. Surgical resection and reconstruction may result in
acute postoperative pain, nerve damage, and inadequate vasculariza-
tion of myocutaneous flaps. Chemotherapy may also result in nerve
damage and neuritis. Radiotherapy can induce osteoradionecrosis,
cheilosis, damage to salivary glands, secondary infection, and loss of
range of motion of the neck and facial muscles. Psychosocial factors
inducing fear and anxiety contribute to the overall pain response.
There are also cosmetic concerns and fears of tumor recurrence, that
cause patients to interpret symptoms as tumor recurrence, rather
than the expected secondary complications of therapies (Figure 4).
Diagnosis: CT and MRI, endoscopy, biopsy, and surveillance are
invaluable in the management of head and neck cancer.
Treatment: With particular reference to head and neck cancer,
pharmacological and physical therapy can improve the pain and the
range of motion of the neck, mouth, and TMJs. Myofascial pain of
the shoulders, neck, and head, and headache, are frequent secondary
occurrences, and may respond to physical therapy. Nutritional con-
sultation may be helpful, as may dental consultation, to aid with
oral function and cosmetics.
CONCLUSION
Orofacial pain derives from a vast number of complex etiolo-
gies and its successful treatment requires contributions from many
different specialties. This pain is one of the most distressing of all
painful syndromes and warrants aggressive and appropriate treat-
ment in a multidisciplinary setting.
Dr. Alex DaSilva is a dentist and researcher in orofacial pain and
headache. He received his DMSc in oral biology with clinical training in
orofacial pain from Harvard University. His research interests include the
application of multiple neuroimaging techniques, including MRI, to map
functional and structural neuronal changes in the brain in migraine and
trigeminal neuralgia patients. He is a researcher at the MIT/MGH/HMS
Martinos Center for Biomedical Imaging, Harvard Medical School, and
is a Harvard School of Dental Medicine Dean’s Scholars awardee.
Dr. Martin Acquadro is an Assistant Clinical Professor of Anesthesiol-
ogy at Harvard Medical School, and Associate Anesthesiologist, Director
of the Cancer Pain Service, and Director of the Head and Neck Pain
Service of the Massachusetts General Hospital.
This publication is made possible by an educational grant from
Pfizer, Inc.
© 2005 The MGH Pain Center, Massachusetts General Hospital, which is solely responsible for the contents. The opinions expressed in this publication do not necessarily reflect those of the publisher or
sponsor, but rather are those of the authoring institution based on the available scientific literature. Publisher: SNELL Medical Communication Inc. in cooperation with the MGH Pain Center,
Massachusetts General Hospital. All rights reserved. The administration of any therapies discussed or referred to in Pain Management Rounds should always be consistent with the recognized prescribing
information as required by the FDA. SNELL Medical Communication Inc. is committed to the development of superior Continuing Medical Education.
SNELL
Acknowledgement: Special thanks to Claudio Moreno for the help
with the drawings.
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Upcoming Scientific Meeting
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