Atypical facial neuralgia

This can be uni- or bilateral and is of unknown origin. It usually causes a burning sensation, pins and needles, and continuous pain, in cycles of severity: it may occur after dental procedures.

Trigeminal nerve neuritis

This may be encountered in patients of 45–60 years of age. It affects females more often than males and the right side more frequently than the left. The patients complain of unilateral shooting pain, from the ear towards the temporal area and the maxilla, sometimes even in the forehead and towards the pharynx. The cause of the pain may be so obscure that unnecessary dental extraction takes place. Pain is seldom accompanied by diminished sensitivity but characteristic trigger points are often found. Stimulation of these, even sometimes by light touch, results in pain felt elsewhere, which is followed by a refractory period of up to 30 seconds during which stimulation does not lead to new pain. The pain attacks seldom last longer than a few seconds. They may recur at irregular intervals, sometimes on a daily, weekly or even a monthly basis. They are isolated or come on in clusters.²

Herpes zoster oticus infection

This can give rise to dysaesthesia preceding the characteristic vesicles. No true trigger points are present. About 15% of all peripheral facial palsies is caused by this virus.³

Idiopathic peripheral facial palsy (Bell’s palsy)

This is a disorder of the facial nerve, probably the result of a cranial neuritis.4,5

It mainly affects patients between 20 and 50 years of age. It is seldom painful although at the onset some pain around the ear may be felt. It gives rise to a palsy of the facial muscles, characterized by lowering of the ipsilateral side of the mouth. It may also cause diminished pain sensibility, changes in taste, diminished lachrymation and increased salivation.

Peripheral neuropathy

This is usually the result of diabetes, long-standing temporal arteritis or Raynaud’s syndrome. It usually leads to a burning sensation and loss of sensibility on lips, cornea or conjunctivae.

Otitis media, otitis externa and parotitis

These all give rise to pain in the TMJ area. Pain usually remains local and increases on pressure on the tragus (otitis) or parotid gland (parotitis epidemica). These conditions mainly affect children and are usually accompanied by fever.

Paranasal sinusitis

This results in a constant, knocking pain usually felt around the orbits, sometimes radiating towards the cheek and into the teeth.

Infection of the teeth and dental abscess

Tooth infections are followed by pain in the cheek on percussion which is provoked or increased by eating sugary food. An abscess gives rise to local swelling of the gingiva.

Cluster headache (Horton’s neuralgia)

This predominantly affects males, is unilaterally localized, and is associated with increased lachrymation, rhinitis and ipsilateral facial redness. Attacks of severe headache in or around the eyes, usually unilaterally, come on within 5–10 minutes and last from about 45 minutes to a few hours. Attacks occur in clusters.⁶

Temporal arteritis

This is one of the manifestations of a giant-cell arteritis, an autoimmune process.⁷ It is usually seen unilaterally in males over 50 years of age and is frequently associated with polymyalgia rheumatica. It is characterized by a knocking pain around the temporal vessels. The skin overlying the artery is red, swollen and warm. The erythrocyte sedimentation rate is raised.

Leaking cerebral aneurysm