Disorders of vision and ocular movement are discussed in Chap. 52 and dizziness and vertigo in Chap. 51.
FACIAL PAIN OR NUMBNESS (TRIGEMINAL NERVE [V])
The three major sensory divisions of the trigeminal nerve consist of the ophthalmic, maxillary, and mandibular nerves. (Adapted from Waxman SG: Clinical Neuroanatomy, 26th ed. http://www.accessmedicine.com. Copyright The McGraw-Hill Companies, Inc. All rights reserved.)
Trigeminal Neuralgia (Tic Douloureux)
Frequent, excruciating paroxysms of pain in lips, gums, cheek, or chin (rarely in ophthalmic division of fifth nerve) lasting seconds to minutes. Typically presents in middle or old age. Pain is often stimulated at trigger points. Sensory deficit cannot be demonstrated. Must be distinguished from other forms of facial pain arising from diseases of jaw, teeth, or sinuses. Rare causes are herpes zoster or a tumor. An onset in young adulthood or if bilateral raises the possibility of multiple sclerosis (Chap. 190).
TREATMENT: TRIGEMINAL NEURALGIA
Carbamazepine is effective in 50–75% of cases. Begin at 100-mg single daily dose taken with food and advance by 100 mg every 1–2 days until substantial (>50%) pain relief occurs. Most pts require 200 mg four times a day; doses >1200 mg daily usually provide no additional benefit.
Oxcarbazepine (300–1200 mg bid) is an alternative with less bone marrow toxicity and probably similar efficacy.
For nonresponders, lamotrigine (400 mg daily), phenytoin (300–400 mg/d), or baclofen (initially 5–10 mg three times a day) can be tried.
When medications fail, surgical microvascular decompression to relieve pressure on the trigeminal nerve can be offered.
Other options include gamma knife radiosurgery and radiofrequency thermal rhizotomy.
Usually presents as facial sensory loss or weakness of jaw muscles. Causes are varied (Table 187-1), including tumors of middle cranial fossa or trigeminal nerve, metastases to base of skull, or lesions in cavernous sinus (affecting first and second divisions of fifth nerve) or superior orbital fissure (affecting first division of fifth nerve).
TABLE 187-1TRIGEMINAL NERVE DISORDERS |Favorite Table|Download (.pdf) TABLE 187-1TRIGEMINAL NERVE DISORDERS
|Nuclear (brainstem) lesions ||Peripheral nerve lesions |
| Multiple sclerosis || Nasopharyngeal carcinoma |
| Stroke || Trauma |
| Syringobulbia || Guillain-Barré syndrome |
| Glioma || Sjögren’s syndrome |
| Lymphoma || Collagen-vascular diseases |
|Preganglionic lesions || Sarcoidosis |
| Acoustic neuroma || Leprosy |
| Meningioma || Drugs (stilbamidine, trichloroethylene) |
| Metastasis || Idiopathic trigeminal neuropathy |
| Chronic meningitis || |
| Cavernous carotid aneurysm || |
|Gasserian ganglion lesions || |
| Trigeminal neuroma || |
| Herpes zoster || |
| Infection (spread from otitis media or mastoiditis) || |
FACIAL WEAKNESS (FACIAL NERVE [VII])
Look for hemifacial weakness that includes muscles of forehead and orbicularis oculi (see Fig. 187-2). If lesion is in middle ear portion, taste is lost over the anterior two-thirds ...