Dear doctors, following a female pt. 39 yr old reported with pain in rt side of face, pain gradually increased in severity to being very severe, she also developed swelling on the same side.. diffuse non specific.. with no local rise in temperature.. Pt. visited a pvt doctor some analgesic was prescribed she got temporary relief, but pain again increased in severity pt had to visit hospital emergency where she was given injectable analgesic.. pt. Was then referred to ENT... which simply prescribed analgesic and referred for dental opinion. My concerns are Intraoral examination shows nothing significant enough to elicit cause of pain... TMJ movements seem to be bilaterally symmetrical... The history seems to be vague.. nothing absolutely suggestive of neuralgia type pain.. Kindly suggest.. what to look for.. how to go about approaching such a case...?

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@Dr. Mayank Hans Your statement support? Did you ruleout Radilogically? OPG ...please share...if so Tmj view ? ENT report? Their findings? Never can go by just our clinical or their verbal versions. I would rule out one by one...
Sir , actually I thought like as clinically couldn't elicit anything significant, I don't have the OPG support in our hospital so I thought have to justify it as it's outsourced.. The ENT doctor report clearly states NAD. During their part of the examination. I happen to see the patient again today.. wasn't very clear on my choice of radiograph. I patiently tried examination again.. The points that made me ponder were... Patient says for the past five days pain is persistent, swelling diffuse was visible, patient didn't have any severe exacerbation of pain Rt side submandibular lymph node region was tender, Tenderness also present in the preauricular region, seems to be lower lobe of parotid.. Tenderness also present in postauricular region especially mastoid area, Patient also says pain increases on turning her head left, One more finding patient says she feels heaviness and intermittent numbness near the ear, My differential which I can think about is may be I check for elongated styloid process... Or may be refer to ENT again, Also may be prescribe her some anti anxiety drug. Thank you for your thoughtful reply, do guide me further.
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Mc cause of one sided facial swelling is a result of inflammation(soft tissue),one sided facial swelling of the face due abnormal tissue growth like tumor which may be either benign or malignant,other causes could be abscess(gingival,peritonsillar),Parotitis,lymphandenitis.
Hmm...some missing link....as intraoral examination doc finds nothing significant.!
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Any history of trauma??? Need not be recent.. Other possibility, if the patient had been under severe stress, it might have triggered neuralgia (herpetic). Just my opinion. Thank you.
Sir,I will ask for this part of history. Thank you.
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Pobly a case or neuralgia...get a brief history n try to find out da trigger zones...after dat Tab pregabalin 100mg TDS for 2 weeks...can gradually increase to 300mg..
ur opinion on diffuse swelling
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Presence of pain and swelling indicates inflammatory lesion. Detailed History and detailed IO examination is important followed by Radiographs.
Sir I will try to get the radiograph soon.
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Opg?? What's the clinical status of the teeth and mucosa in affected area
Dr mayank plz post radiographs.
Very soon I will try to post sir.
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If all dental, ENT & opthal causes have been ruled out. Clinically by what you have sent us, looking at the patient her nose is mildly deviated to the left, have you checked for DNS, possible inferior turbinate hypertropy? and subsequent or primary cause being the maxillary sinus? or PNSes?
Nasal endoscopy may show area of contact between Septum and turbinate or an occluded sinus ostium. CT scan of paranasal sinuses may reveal defects within sinuses. OPG may reveal unsuspected dental lesions. Have you tapped the relevant teeth and examined the TM joint ?
Sir I did examine intra-oral, also the TMJ.. but I am awaiting the OPG. Will get back to you with the radiograph.
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Opg must doc.rule out tooth pathology, look for tmj disorder.ask pt.about bruxism. Then look for neuralgic issue and look for parotid gland as well.
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