Background & Aims

Orofacial pain is defined as pain from the regions of the face, mouth and others related structures, and it has been poorly described that it may be secondary to visceral diseases of torax and chest, such as symptoms of angina pectoris, heart attack, pericarditis, lungs pathologies, and even the esophagus (esophageal cancer, hiatal hernia, esophageal spasm, gastroesophageal reflux disease (GERD), esophageal candidiasis, among others, which could cause pain referred to the Head, Face, Neck, Jaw and Chest.
The aim of this research is present a clinical case of a female patient, 86 years-old, who came to the Orofacial Pain service of the University of Chile’s Clinical Hospital due to Glossopharyngeal Neuralgia (GN) secondary to visceral disease of the thorax, which After 10 years of studies, refractory to pharmacological treatment, it could be managed correctly by treating the associated gastroenterology pathologies.

Methods

The patient had paroxysmal pain in the right side of face and ear that was triggered when chewing or yawning. Concomitant pathologies, such as myofascial pain of masticatory muscles and arthralgia of the TMJ, were ruled out and treated. Carbamazepine, Lamotrigine, Gabapentin and Zolpidem were gradually prescribed. Trigeminal Neuralgia (TN) was initially suspected and brain MRI didn’t report lesions in right posterior fossa in the path of the V or the other nerves. One month after treatment, she had again paroxysmal ear and jaw angle pain that was triggered mainly by swallowing. Clinical examination revealed preserved pharyngeal reflex, with paroxysmal pain. The diagnosis was updated to Glossopharyngeal Neuralgia, refractory to pharmacological treatment. Remote anamnesis was taken to evaluate all possible causes described in the scientific literature that may cause GN, and it was referred to specialists in the area.

Results

Examination by an otorhinolaryngologist, reported otic examination was unremarkable. Gastroenterology specialist indicates the presence of Hiatal Hernia and GERD that have not been diagnosed or treated. AngioMRI of the neck showed dilation of the cervical esophagus and the thoracic portion, which could be related to the pathologies previously reported and may be causing this referred orofacial pain.
After 10 years of central sensitization of the different structures innervated by the IX nerve, it is necessary to carry out a treatment that includes the management of chronic pain along with the treatment of the possible causes that may provoke GN.
Once the treatments were carried out by specialists, and in addition to pharmacology for chronic orofacial pain, pain crises decrease. After a month, pharmacological adjustments are made, and currently the patient doesn’t feel any pain, with her primary pathologies treated and with studies in order.

Conclusions

In the study of GN, secondary causes must be ruled out, such as vascular compression or the existence of an underlying condition documented as the cause.
In the case of suspected GN refractory to treatment, pathologies that could involve the territory innervated by cranial nerves IX and X should always be ruled out and treated, mainly due to gastrointestinal pathologies.
The visceral pain referred to the orofacial region may not be as rare as we assumed, and the pathophysiological mechanism proposed could be the described neuronal convergence of the V, VII, IX and X cranial nerves at the level of the brainstem, so this could explain the variation and evolution of TN to a later GN.
Dentists can play a key role in the treatment of chronic pain in the orofacial region, ruling out odontogenic facial pain, working as a team and promptly referring to specialists in otorhinolaryngology, gastroenterologists, among others.

References

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Presenting Author

Héctor Sandoval

Poster Authors

Héctor Sandoval

Orofacial Pain Student

University of Chile

Lead Author

Claudia Corro

University Of Chile

Lead Author

Topics

  • Assessment and Diagnosis