Discussion w5 652

Q-1

TRIGEMINAL NEURALGIA (TN)

Presentation

Facial pain without associated neurologic deficit is essential in the diagnosis of trigeminal neuralgia. There is a restriction to the trigeminal nerve in the common distributions noting for the pattern, quality, duration and consistency of pain. In patients with symptomatic trigeminal neuralgia, bilateral involvement is more frequent. Distributions of the trigeminal nerve are: V1 ophthalmic, V2 maxillary and V3 mandibular. (Obermann, 2019).

Etiology

In the majority of patients, the etiology is associated with trigeminal nerve compression. Compression occurs to 80% to 90% of patients demonstrated focal compression of the trigeminal root at the root entry zone. Posterior fossa tumors can also produce symptoms imitating trigeminal neuralgia (TN). TN is twenty times more common in multiple sclerosis patients compared with the general population. MS patients with TN usually demonstrate demyelinating plaques in the pons that encompass the root entry zone of the trigeminal nerve (Obermann, 2019).

Common Differential Diagnosis

Dental caries, dental fracture, mandibular osteomyelitis, temporomandibular joint syndrome, migraine, glossopharyngeal neuralgia, post-herpetic neuralgia, temporal arteritis, or atypical facial pain (Bourenne et al., 2017).

Diagnostic Work-Up

Diagnosis is clinical with a history of outburst of sharp, superficial, stabbing, burning or intense pain lasting for up to 2 minutes. Triggers such as tooth brushing, eating, cold, and touch are common. Although most patients do not complain of neurologic deficit and are asymptomatic between episodes, patients are fearful of repeat attacks because of its intensity. Other important history to rule out TN are facial trauma, herpetic outbreak, rash or facial droop (Obermann, 2019).

Treatment Plan

Carbamazepine is the only anti-convulsant medication with efficacy proven in ramdomized controlled trials in TN and is typically first-line therapy. Seventy percent to seventy five percent of patients show at least partial improvement on Carbamazepine. Long-term use may be associated with decreased efficacy (Bourenne et al., 2017). Oxcarbazepine, a derivative of Carbamazepine with fewer drug-drug interactions, appear equally efficacious and may even be useful in patients with Carbamazepine resistant TN. There is some evidence for the effectiveness of Topiramate (Bourenne et al., 2017).

Referrals/Consultation

Patients started on medical therapy should be evaluated regularly for adverse reactions, documentation of efficacy of treatment, and/or dose adjustment until adequate pain control is achieved. Following uncomplicated surgical treatment, patients should be reevaluated about 1-week post-procedure to document resolution of symptoms and evaluate for the presence of complications. Subsequent evaluations are performed at longer time periods based on level of symptomatic relief, pain recurrence, and patient desire to wean medications (Bourenne et al., 2017).

Preventive Measures

No preventive strategies have been identified. However, patients may learn to avoid activities that trigger pain. Eat soft food, at room temperature warm or cool. Avoid food that trigger attacks such as caffeine and citrus fruits or other triggers that have caused pain in the past. If wind triggers pain, wear a scarf wrapped gently around the face in windy weather (Bourenne et al., 2017).

Reference:

Bourenne, J., Hraiech, S., Roch, A., Gainnier, M., Papazian, L., & Forel, J. (2017). Sedation and neuromuscular blocking agents in acute respiratory distress syndrome. Annals of Translational Medicine, 5(14), 291-291. doi:10.21037/atm.2017.07.19

Obermann, M. (2019, April 17). Recent advances in understanding/managing trigeminal neuralgia. Retrieved March 30, 2021, from https://f1000research.com/articles/8-505

 

Q-2

Peritonsillar abscesses generally occur after tonsillitis and a localized collection of pus occurs between the tonsillar capsule and constrictor muscle (Gupta, 2020). The patient generally presents with a sore throat, possible referred ear pain, painful swallowing, halitosis, drooling if unable to swallow, muffled speech, neck pain, inability to open mouth, and possible fever/chills, body aches, etc. If it extends further the patient could be in respiratory distress. Differentials include tonsillitis, mononucleosis, pharyngitis, dental abscess, epiglottitis, AIDS, and malignancies.

The workup would include CBC, throat cultures, rapid strep, Antibody test (r/o infectious mono), ultrasound of neck to help with aspiration guidance, CT soft tissue of the neck, aspiration of pus, physical exam, and history, CRP if worried about systemic sepsis. The gold standard of diagnosis is to aspirate the pus, do an incision and drainage, or tonsillectomy. If the provider is not comfortable with doing the aspiration then a consult would need to go out to an otolaryngology, ENT, or general surgeon depending on the setting/hospital services that you have (Galioto, 2017). The most common bacteria involved are Group A streptococcus and Streptococcus milleri and initial antibiotics should be broad spectrum to cover these such as penicillin VK 500mg and metronidazole 500mg Q6H, Augmentin 875 BID, clindamycin 300-450mg Q8H, or third generation cephalosporins (Galioto, 2017). Corticosteroids and analgesics are the other therapies that can be added. The patient could need close supervision during the first few days to monitor for complications.  Complications include aspiration of pus, airway obstruction, thrombophlebitis, deep neck infection, or puncture/hemorrhage from carotid artery. The reasons for admission are dehydration, airway concern, persistent dysphagia, and failure of outpatient management. In the geriatric population is less heard of but when it is a differential diagnosis could be lymphoma in this setting. Follow up could include tonsillectomy since there is typically a high rate of reoccurance.

Gupta G, McDowell RH. Peritonsillar Abscess. [Updated 2020 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519520/

 

Galioto NJ. Peritonsillar Abscess. Am Fam Physician. 2017 Apr 15;95(8):501-506. PMID: 28409615.

Q-3

Deep neck infections frequently arise from the tonsils, parotid glands, cervical lymph nodes, dental and periodontal structures. Clinical presentation is variable and based on whether the infection is local or systematic. In addition to fever and neck pain, associated symptoms might include dental pain, dysphagia, stridor, dysphonia, trismus, and respiratory distress. Inspection of the neck may reveal asymmetry, redness, swelling,  and regional lymphadenitis (Maharaj, Ahmed, & Pillay, 2019).

Malignancy would be on my differential list, as well as an infectious process such as an abscess. Infection can easily spread from dental abscesses, sublingual or submaxillary salivary glands, or oral infections following trauma. Medial displacement of the uvula along with tonsillar asymmetry would suggest a peritonsillar abscess. Ludwig’s angina can lead to life-threatening airway obstruction if untreated and should be part of the differential. It should be suspected when there is cellulitis on the floor of the mouth, along with drooling and inability to swallow. Cervical adenitis would also be suspected when patients present with sore throat, cough, fever, chills, or have other upper respiratory manifestations (Motahari et al., 2015).

 Diagnosing deep neck infection includes computed tomography with contrast and magnetic resonance imagining. Although not adequate for deep infections, ultrasound is useful to differentiate an abscess from phlegmon, which is unbounded and can keep spreading out along tissue. A chest x-ray would show active infection including tuberculosis, a foreign body, mediastinitis, pneumomediastinum, or empyema. I would order a CBC to look for leukocytosis, and blood cultures which may reveal frequently encountered microorganisms such as Streptococcus, Staphylococcus aureus, Klebsiella, gram-negative rods, and fungi. Furthermore, the type of causative organism would be influenced by the presence of risk factors such as immunocompromised state, diabetes, and intravenous drug use (Motahari et al., 2015).

Intravenous nafcillin or vancomycin plus gentamycin, ampicillin/sulbactam, or clindamycin are generally accepted initial choices. For MRSA infections, vancomycin or linezolid plus cefepime can be used. Consultation with infectious disease and ENT specialists, surgery, and oncology would be appropriate. Surgical drainage becomes necessary with persistent draining wounds or for infections not responding to standard medical management (Caccamese & Coletti, 2018).

 

Caccamese, J. F., Jr, & Coletti, D. P. (2018). Deep neck infections: clinical considerations in aggressive disease. Oral and maxillofacial surgery clinics of North America, 20(3), 367–380. https://doi.org/10.1016/j.coms.2008.03.001

Maharaj, S., Ahmed, S., & Pillay, P. (2019). Deep Neck Space Infections: A Case Series and Review of the Literature. Clinical medicine insights. Ear, nose and throat, 12, 1179550619871274. https://doi.org/10.1177/1179550619871274

Motahari, S. J., Poormoosa, R., Nikkhah, M., Bahari, M., Shirazy, S. M., & Khavarinejad, F. (2015). Treatment and prognosis of deep neck infections. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India, 67(Suppl 1), 134–137. https://doi.org/10.1007/s12070-014-0802-7