hrjames Posted April 1, 2011 Share Posted April 1, 2011 I got killed in clinic today, but this case is sticking in my craw. I'm tired, so perhaps I have missed something. If I have, my apologies, and thanks in advance for the input! 51 y/o male seen by a partner 6 days ago, dx with bronchitis and conjunctivitis. Placed on zpak & vigamox drops. Returns today with c/o persistent left red eye, bad cough not improved, occsionally productive, low grade fever and pain in right cheek when coughing. (The eye is a subconjunctival hemorrhage). The pain in his right cheek had sudden onset 2 days ago with a cough, where he felt a sharp pain starting in preauricular area, radiated along maxilla and then up side of nose. since then, whenever he coughs, he feels a sharp pain from preauricular area along maxilla but not along the nose anymore. I watched him wince in pain with each cough. NOTHING else triggers the pain (chewing, side to side jaw movement, swallowing, touch, vibration). He's never had anything like this before. otherwise fairly healthy, on PPI for Barretts, well controlled per pt. takes prn minocycline for recurrent folliculitis, hasn't needed that for 6 months. ROS neg otherwise Exam mildly ill, frequent cough with obvious wince & grabbing cheek each time. T99.9-88-16-170/90 98%RA left eye with mild subconjunctival hemorrhage, rest clear. TMs, nose, OP clear. no adenopathy. neck without bruit, carotid upstrokes full, symmetric lungs with scattered rhonchi, no wheeze or rales. COR- RRR no murmur. ext no edema, 2+symmetric pulses CN 2-12 intact, specifically no loss sensation in CN V branches. masseter tone normal. I cannot elicit pain with palpation or manipulation of TMJ, light touch, hard touch, percussion. no lab/xray done. I literally had 13 charts stacked & waiting for me as I saw this guy and no help readily available as someone was out sick. Any thoughts? I'm not aware of (and could not quickly find) any info on acute onset of trigeminal neuralgia with coughing, and that being the only trigger. I can't come up with much else in the differential for this pain, with the sudden onset and no other neuro findings. How would you have treated him? I'll share (or perhaps confess) what I did later on. Don't want to influence my jury here. Link to comment Share on other sites More sharing options...
jmj11 Posted April 1, 2011 Share Posted April 1, 2011 I would not call it TN. It may just be more of an "Atypical Face Pain" that is associated with this viral syndrome. Anytime someone is ill or stress nerves can misbehave, but then resolve afterwards. There is such a thing as cough headache, but as the name implies, it is usually more of a general, global headache than a focused pain over one branch of the trigeminal nerve. Of course if their is an inflammatory process within that max sinus, the barotrauma of the cough could cause a sudden sharp pain. If the pain is severe enough you can still treat it with anticonvuslants until it resolves. My favorite for Trigeminal pain is lamotrigine. Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 1, 2011 Moderator Share Posted April 1, 2011 love the fact your partner placed him on abx drops for a hemorrhage and zpak for sinus when sounds like neither one was approapriate life killers - carotid disection - would be veery strange presentation - bruit??? pulsitile mass on temporal region? (TA) I tend to get a HSV 1-2 titres and lyme titre (if endemic or if traveled to somewhere it is) just to make sure Does ha have a big old palpable lymph node in the AC/PC chain on that side? Am I correct that eye is LEFT and cheek pain is RIGHT? thoughts on treatment can d/c zpak and abx drops if no bruit and no findings to support TGN would think watchful waiting is okay with above labs pending (HSV/Lyme and a CBC ?ESR) If any concerns over TA start steroid and bx of artery humm cheek pain - in that it is contralateral to neck pain not sure it is anything to worry about - warn about rah developement and need to be seen immediatly (shingles - have been fooled before), as well sinus congestion in the max sinus could cause this but with out fever and no tenderness to percussion or tooth tenderness then would just do nasal irrigation, hot salt water gargles, ibu 600 TID and d/w him the Dx critera for bacterial sinus infections. f/u 1-2 days Link to comment Share on other sites More sharing options...
hrjames Posted April 3, 2011 Author Share Posted April 3, 2011 I would not call it TN. It may just be more of an "Atypical Face Pain" that is associated with this viral syndrome. Anytime someone is ill or stress nerves can misbehave, but then resolve afterwards. There is such a thing as cough headache, but as the name implies, it is usually more of a general, global headache than a focused pain over one branch of the trigeminal nerve. Of course if their is an inflammatory process within that max sinus, the barotrauma of the cough could cause a sudden sharp pain. If the pain is severe enough you can still treat it with anticonvuslants until it resolves. My favorite for Trigeminal pain is lamotrigine. I was hoping you might respond. I follow your blog some and thought about sending a PM, but you seem way to busy to get pestered by a small-town PA you don't even know. I appreciate the response and value your opinion. I didn't have another name for this, so I went with what I know - TN. Your explanation makes sense. I keep thinking his history makes it sound like the physical trauma of the cough actually caused some nerve irritation or stretch perhaps. I've used tegretol in TN, although my experience is far more limited than yours. Thanks again & good luck in your new venture. I'm rooting for your success from here in Wisconsin, for what it's worth. love the fact your partner placed him on abx drops for a hemorrhage and zpak for sinus when sounds like neither one was approapriate Sorry if I was unclear with the initial history. Not my intent to bash my partner at all, I agreed with her tx plan and the patient said his eyes had been much worse (bilateral redness and drainage) except for the area of the hemorrhage, which had worsened in his mind (I'm thinking the hemorrhage was new). He'd been sick with productive cough x almost 2 weeks when she saw him and dx bronchitis (not sinusitis) and conjunctivitis. Perhaps you could argue the drops are superfluous, but I wasn't trying to here. life killers - carotid disection - would be veery strange presentation - bruit??? pulsitile mass on temporal region? (TA) I thought about dissection. Had a 29 y/o male present to me with what was really a painful Horner's syndrome that had been blown off by the ED NP as "viral ptosis" a few years ago. In her defense, this guy was a total hypochondriac, for real, and one of the most annoying patients I've ever dealt with. But something made me go hmmmm and I found his carotic dissection and got him outta my hands in a hurry. I posted findings on my current patient in my exam section, but to reiterate, no bruit, cranial nerves all normal. I was truly thinking about a dissection and examined him very carefully in that regard. Not something I want to miss, as others have before me. No pain/pulsatile mass on temporal artery. I tend to get a HSV 1-2 titres and lyme titre (if endemic or if traveled to somewhere it is) just to make sure Ineresting thought. Ton of lyme here, but not usually when there's still snow on the ground. Does ha have a big old palpable lymph node in the AC/PC chain on that side? Nope Am I correct that eye is LEFT and cheek pain is RIGHT? Yes. thoughts on treatment can d/c zpak and abx drops if no bruit and no findings to support TGN would think watchful waiting is okay with above labs pending (HSV/Lyme and a CBC ?ESR) If any concerns over TA start steroid and bx of artery humm cheek pain - in that it is contralateral to neck pain not sure it is anything to worry about - warn about rah developement and need to be seen immediatly (shingles - have been fooled before), as well sinus congestion in the max sinus could cause this but with out fever and no tenderness to percussion or tooth tenderness then would just do nasal irrigation, hot salt water gargles, ibu 600 TID and d/w him the Dx critera for bacterial sinus infections. f/u 1-2 days So I felt certain that this was NOT sinus based on his detailed hx and exam. He was a GREAT historian. Better than me, apparently. :) He looked moderately ill. He'd already finished his zpak, so I treated him as a zmax bronchitis failure, as he had continued productive cough and low grade fever with rhonchi on exam. Changed him to Avelox. Also gave him Vicodin 7.5, with goal of cough suppression (as the pain was ONLY with cough) and pain control (also told to use ibuprofen 600 tid). I considered Tegretol (I'll think about the lamictal - thanks!) but decided against it at present. Told him to recheck in 1-2 days if he wasn't reasonably comfortable or getting worse. I have been off since, but will check to see if he came back over the weekend. Thanks for the input again. Link to comment Share on other sites More sharing options...
Joelseff Posted April 3, 2011 Share Posted April 3, 2011 I have nothing really to input but I saw a pt the other day who was being treated by us for C2-3, C3-4, C5-6, C6-7 HNP who had a year of relief s/p CTFESI and now has returning of sx's. One of which is right mandibular branch of CN5 numbness and paresthesias. I asked my SP about it and he says that with cervical HNP's it can refer to the CN5...I haven't really dug into it but it's interesting... Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 3, 2011 Moderator Share Posted April 3, 2011 I was hoping you might respond. I follow your blog some and thought about sending a PM, but you seem way to busy to get pestered by a small-town PA you don't even know. I appreciate the response and value your opinion. I didn't have another name for this, so I went with what I know - TN. Your explanation makes sense. I keep thinking his history makes it sound like the physical trauma of the cough actually caused some nerve irritation or stretch perhaps. I've used tegretol in TN, although my experience is far more limited than yours. Thanks again & good luck in your new venture. I'm rooting for your success from here in Wisconsin, for what it's worth. So I felt certain that this was NOT sinus based on his detailed hx and exam. He was a GREAT historian. Better than me, apparently. :) He looked moderately ill. He'd already finished his zpak, so I treated him as a zmax bronchitis failure, as he had continued productive cough and low grade fever with rhonchi on exam. Changed him to Avelox. Also gave him Vicodin 7.5, with goal of cough suppression (as the pain was ONLY with cough) and pain control (also told to use ibuprofen 600 tid). I considered Tegretol (I'll think about the lamictal - thanks!) but decided against it at present. Told him to recheck in 1-2 days if he wasn't reasonably comfortable or getting worse. I have been off since, but will check to see if he came back over the weekend. Thanks for the input again. humm keep us updated with the results.... sounds like a good choice to step to FQ's.... also to Jeolseff - pretty rare for a CTFESI to be truly transforaminal (correct me if i am wrong) - usally is catheter guided by accessing a little lower in the T-spine - too much imporant stuff and HURTS like heck to do a true TFESI - - - have you been doing (or know people that are doing a true trans foraminal approach?) the above is what two pain doc's always used to tell me but would love to learn if you really can do them Link to comment Share on other sites More sharing options...
Joelseff Posted April 4, 2011 Share Posted April 4, 2011 I always understood the TF approach consisted of an oblique entry vs the old ESI's that went through the middle and were not fluoro-guided. If you mean by "true transforaminal" as actually injecting into where the nerve root exits, then yes my SP does them. It is of course done under live x-ray. I am still new so I dont know ALL the ins and outs but the response rate is for the most part, positive. Especially with TFESI's and selective nerve root blocks for radics. We also do Facet joint RFNA/rhizo which i think is more hit or miss but the LTFESI's and CTFESI's are pretty successful because the pts often report significant improvement of the extremity/radic sx's but dont always have significant relief of their back or neck pain. This is when we have to investigate facets with a diagnostic MBB and so on. I'm still learning but so far its really interesting and seeing a lot of pts have such significant sx relief/improvement just after one procedure that takes less than an hour that is minimally invasive is pretty cool. Link to comment Share on other sites More sharing options...
pagirl82 Posted April 4, 2011 Share Posted April 4, 2011 Could this simply be viral sinusitis and otitis? You said he had a cough and was dx'd with bronchitis last week. Link to comment Share on other sites More sharing options...
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