Chapter XIII neuralgia and neuritis of trigeminal nerve

CHAPTER XIII


NEURALGIA AND NEURITIS OF TRIGEMINAL NERVE

Neuralgia and neuritis involving the trigeminal nerve (n.trigeminus) and its branches hold a special place in dental practice. The acute, unbearable pain accompanying these pathologies not only cause the weakness of the patients, but also impair their ability to work, normal nutrition and sleep. In some extreme situations the patients, who have fallen ill from these pathologies, need prompt and specialized medical aid from the physicians of other profiles (sok.56???).

Figure 56. Trigeminal neuralgia.

Triminal neuralgia is marked by acute pain attacks in the area of innervation of a trigeminal nerve branch or throughout the whole area innervated by all of its branches.

TRIGEMINAL NEURALGIA.

Trigeminal neuralgia cases are a common occurence. It is speculated that the trigeminal neuralgia is a polyetiologic condition. The list of the factors causing the trigeminal neuralgia includes? but is not limited to acute and chronic infectious diseases (influenza, angina, malaria, tuberculosis, syphilis, etc.), acute and chronic gastrointestinal tract diseases, cerebral tumours and vascular abnormalities, arachnoiditis, dentak healt, issues, chronic periodontitis, cysts, malocclusion, sinusitis, etc.

Special attention is now being paid to the damages of the cervical ganglia of the sympathetic trunk and abnormalities in the intervertebral discs of the cervigal area.
Some authors believe that the pathological processes taking place in the course of the trigeminal neuralgia involve, inter alia, the sympathetic nervous system structures. Neuralgia develops as a result of disruption of the normal connection between these structures. The medical practice makes distinction between the primary (idiopathic) and secondary (symphatetic). The primary neuralgia of trigeminal nerve is an independent disease, as it is impossible to determine the causes of its onset in the majority of cases. The secondary neuralgia develops as as a result of an underlying disease (infection, intoxication, tumors, brain diseases, stomatogenic processes).
Trigeminal neuralgia clinically presents with acute, stabbing pain episodes and burning sensation in oral cavity, lower or upper jaw. The pain is so severe that the patients become unable to talk and are forced to abandon eating. Certain patients may suffer acute pain episodes not only due to a physical factor, but even at the mere sight of a person in a white coat.
Generally, the pain episodes occur suddenly, lasting only a few seconds (less frequently - 1-2 minutes). The episodes are followed by a short refractory period. Acute pain attacks and their short duration are the main characteristic features of trigemnial neuralgia. It is required to exercise a certain degree of caution when diagnosing the trigeminal neuralgia in cases of longer pain attack periods (1-10 minutes).
Sometimes the feeling of pain is accompanied by vegetative disorders. Such disorders are manifested through the dermahemia, pupillary dilation, an increase in nasal secretion, saliva and tears secretion in the areas innervated by the damaged branch of the nerve. Trigeminal neuralgia also presents with mimic muscle seizure.
This disease most often is caused by an injury of one of 3 branches. The 1st branch, i. e. opthalmic branch (n.ophthalmicus) neuralgia is characterised by localisation of pain in the superciliary area, in the front of the temple, eye pit (tear glands and sclerotic coat. The neuralgia of the 2nd brand, the maxillary nerve (n.maxillaris), is characterised by the localization of pain in the areas of upper lip, nose alae, lower eyelids, nasolabial triangle (danger triangle), upper teeth, eye fissure and oral fissure. The neuralgia of the third branch - mandibular nerve (n.mandibularis) is distinguished by localisation of the pain in lips, submandibular region, lower teeth, pulp, masticatory muscles of related area; parotid, submandibular and sublingual salivary glands; external ear and temple area skin. Often the pathology involves both the 1st and 2nd branches, and rarer - only the 1st branch. Women tend to get sick with this disease more often than men.
The palpation of the facial area reveals the pain zones and hyperesthesia in the areas innervated by the damaged branch of trigeminal nerve, including the pain on the touch points (at the trigeminal nerve exit point). Pressing these areas increases the pain. Absence of pain during sleep is presented as a peculiar characteristic and is used for differentiation of trigeminal neuralgia from other diseases.
The presence of the pain in mandibulofacial area that is of a vegetative origin also should not be overlooked in the differential diagnosis.
İn some forms of the early injury of Vegetativ töramolarin (????) the pain symptoms caused by the ganglionitis of pterygopalatine ganglion and the sympathalgia of superficial temporal artery may be manifested as a feature of trigeminal neuralgia. However, the ganglionitis of pterygopalatine ganglion almost always has an unilateral and secondary nature. As a rule, this occurs as a result of common infectuous diseases or local inflammatory processes taking place in amygdala, teeth, middle ear, lower and upper jaws.
Ganglionitis of pterygopalatine ganglion clinically presents with sudden pain attacks in üzün dərinliyində (???? deep in the face?) and in the head, which radiates to the eyeballs, teeth, hard palate, ears, the shoulder segment of the damaged area and arms. The attacks usually last for hours, in some cases - for days.
The periods between the attacks are accompanied with a deep burning sensation in lower jaw and temple areas.
The upper sympathetic ganglion is often subjected to inflammatory processes (general infection or the inflammation of cervical soft parts, vertebral disc, vertebrae, mediastinum and pleura), in which case the pain attacks radiate to different segments of mandibulofacial area. Vasomotor and trophic disturbances are observed in the areas innervated by the nerve, along with certain .....???? of the eyeballs.
Sathi gicgah arteriyasının simpatalgiyasında göz alması nahiyəsində dözülməz ağrılar, həmin arteriyanın zədələnməsi ilə əlaqədar olaraq bunu üçlü innervasiyasının pozğunluqlan qeyd olunur.
sinirin 1 şaxəsinin nevralgiyası ilə qarışdırırlar.
Procaine block is used for differential diagnosis (solutions in concentrations of 1%, 3-5 ml) at the exit point of the frontal nerve branched from the opthalmic nerve of trigeminal nerve.
A characteristic feature of the acute pulpitis is that the pain increases at night, as well as under the influence of hot and cold irritants. The inflammatory processes of odontogenic origin (periodontitis, periostitis, osteomyelitis) are manifested through distinctive inflammatory symptoms.
The maxillary sinusitis as well as malignant tumors of jaw may also cause a sense of pain. The pain in such pathologies is permanent, with periodic amplifications.
The neuritis causes the pain of stable intensity, which differentiates it from episodic neuralgia pain attacks.
Thwe recommended treatment methods for the patients suffering from trigeminal neuralgia is conservative drug therapy and surgery. In some cases, if the neuralgia episodes take place after influenza, a single therapy cycle may offer good results. The patient recovers after removal of the odontogenic cyst or restoration of the dental bite.
The early forms of neuralgia are treated using conservative methods: mainly drug therapy and physiotherapy. The drug therapy involves the prescription of salicyl preparations, antibiotics, and anaesthetics. Often the use of B group vitamins ( (B1, B2.. B12) gives positive results.
In certain cease the treatment with prozerin also has a positive effect. When combined with other treatment methods, aminazin and scheduled tegretol use also give good results. The physiotherapeutic procedures (electrophoresis with prozerin, procaine, finlepsine, and procaine; Sollux lamp, paraffinotherapy, Bergonie half-mask) hold a special place in the treatment of trigeminal neuralgia. Applying procaine blocks on a damaged branch also has a positive effect. As a rule, a therapy regimen cycle consisting of procaine blocks involves 20-25 injections of 3-5 ml of 1% procaine solution. The block is carried out on a daily basis - once a day.
A single drop of 0,1% adrenaline solution may be added to the solution to increase the time of action of procaine. If the mentioned method does not give an effect, the use of alcohol injections, neurotomia, and neuroexeresis may be recommended. Əgər nevralgiya və nevrockzerez sinir lifinin mərkəzi şöbəsi arasında əlaqə pozularsa və sinir parçalanarsa, bu zaman sinirda «kimyəvi dağılma» gedir. These operations are accompanied by regional or infiltration anesthesia with the use of a procaine solution (2%, 2-5 ml).
The alcohol injection is accompanied by administration of 0.3-0.5 ml of 2% procaine solution. The degenerative processes triggered by alcohol disrupts the nerve conduction, eliminating the acute pain.
Not all mentioned surgical methods result in elimination of neuralgia. The regenerative processes lead to the recovery of the nervous connection between the central and peripheral nervous systems. As a result, the use of alcohol injections, neurotomia, and neuroexeresis have a positive treatment effect lasting from 3-6 to 12-13 months.
The pain reappears after this and the surgical operation needs to be repeated. Sometimes trigeminal neuralgia is stopped after a trigeminosympathetic procaine block The trigeminosympathetic procaine block is implemented if the previous treatment has failed, or in acute cases of post-influenza neuralgia, ganglionitis of pterygopalatine ganglion.
In cases of the secondary, i.e. sympathetic neuralgia, the intensive treatment of the underlying (primary) disease (intoxication, infectious diseases) should be carried out. Sanitation of the oral cavity and teeth is also of utmost importance.
The prognosis of the secondary neuralgia depends on the course of underlying disease (tumors, brain diseases). The prognosis of the idiopathic neuralgia is serious, as the long-lasting pain episodes disrupt the patient's normal course of life and dietary regimen.