Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve, one of the most widely distributed nerves in the head. TN is a form of neuropathic pain (pain associated with nerve injury or nerve lesion.) The typical or "classic" form of the disorder (called "Type 1" or TN1) causes extreme, sporadic, sudden burning or shock-like facial pain that lasts anywhere from a few seconds to as long as two minutes per episode. The “atypical” form of the disorder (called "Type 2" or TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than Type 1. Both forms of pain may occur in the same person, sometimes at the same time. The intensity of pain can be physically and mentally incapacitating.
HISTORY:
Patient X experienced an aggressive case of shingles down the left side of their neck and left arm. Blisters also appeared within the left ear canal. Two weeks after the viral onset, the patient began to experience tingling in the corner of their left eye, and intermittent searing face pain to the teeth on the left side of the jaw. Two days later, while having dinner, the patient began to have trouble chewing, at which point it was noticed by other people that the left side of the face had drooped. The patient went to hospital and was cleared for stroke, resulting in the administration of Prednisolone for facial palsy. A few days after having been to hospital, the patient then developed dizziness and vertigo, and an imbalance mostly to the left. They were admitted to hospital again and injections were given to abate the vertigo. On discharge, without a specific diagnosis, the patient was still dizzy and imbalanced, with short episodes of vertigo presenting with rapid movement. they were also very dizzy when lying on the left side, so the patient began to avoid this as well as abrupt movement.
EXAMINATION:
When presenting 8 weeks later for assessment and intervention for the facial palsy, they continued to experience searing face pain when eating foods that were either too hot or cold. The eye had recently achieved full closure but it was a slow closure only – the fast-twitch blink response was still absent. Taste had also recently returned to normal. Speech was still clearly impaired, and the droop around the lips was still prominent. The patient did most of their eating on the right side of their mouth as they found food control on the left very difficult and were also biting their tongue and cheek frequently. The ear also continued to be very painful and some noises like cutlery being put away were noxious to the point of painful for the left ear. Dizziness and imbalance also continued though to a much lesser extent. The patient continued to avoid sleeping on the left, for fear of dizziness and because of ear pain. They also continued to avoid rapid and complex movements.
TREATMENT:
On assessment, it was determined that the patient was experiencing a triad of nerve impairment – inflammation of the facial, trigeminal and vestibular nerve, accounting for their complex presentation of multiple systems dysfunction. The facial palsy was treated with an immediate bombardment of exercises to increase the level of stimulation to the left side. This included eating everything on the left side, performance of quality facial expression without co-recruiting the wrong muscles or eliciting response from the right side of the face, and self massage techniques to control rebound tightness. Controlling the temperature of foods helped with the trigeminal neuralgia, but was not effective enough and eating on the left side became a reliable trigger to the searing face pain. Medication to control the nerve pain was started and the exercises for the facial palsy became more successful. The dizziness and imbalance was treated with appropriate exercises to re-stimulate vestibular function on the left, and included sleeping on the left side whenever possible. The left neck had become extremely tight and painful as a result of the stress of the whole situation, as well as being a secondary response to the dizziness. The neck was treated with dry needles and facet joint stretches which alleviated the situation very quickly. The neck treatment also improved the appearance of the face by eliminating the pull on the facial muscles by the muscles of the neck. The trigeminal neuralgia also improved with each subsequent neck treatment.
OUTCOME:
The dizziness had completely abated within four weeks of starting vestibular exercises, with patient being able to move in rapid and complex configurations without the onset of symptoms. The trigeminal neuralgia remained largely dormant, but demonstrated the capacity for flaring even at the nine months post-onset. The face did develop rebound tightness during recovery as evidenced by a spasm in the cheek and tightness around the eye which kept the eye partially closed compared to the right side. Dry needling at this point was implemented and continues to be conducted on a monthly basis to control the tightness and encourage ongoing recovery.