Reflex Sympathetic Dystrophy of the Face

THE CLINICAL SYNDROME

Reflex sympathetic dystrophy (RSD) is an infrequent cause of face and neck pain. Although the symptom complex in this disorder is relatively constant from patient to patient, the diagnosis is often missed. This diagnosis is overlooked despite the fact that RSD of the face and neck presents in a manner that closely parallels its presentation in the upper or lower extremity. This difficulty in diagnosis often results in extensive diagnostic and therapeutic endeavors in an effort to palliate the patient’s pain. The common denominator in all patients suffering from RSD of the face is trauma to tissue. This trauma may take the form of actual injury to the soft tissues, dentition, or bones of the face; infection; cancer; arthritis; or insults to the central nervous system or cranial nerves.

SIGNS AND SYMPTOMS

The hallmark of RSD of the face is pain that is burning in nature. The pain is frequently associated with cutaneous or mucosal allodynia and does not follow the path of either cranial or peripheral nerves. Trigger areas, especially in the oral mucosa, are common, as are trophic skin and mucosal changes in the area affected by the RSD. Sudomotor and vasomotor changes may also e identified but are often less obvious than in patients suffering from RSD of the extremities. Often, patients suffering from RSD of the face will have evidence of previous dental extractions that were performed in an effort to provide the patient with pain relief. Patients suffering from RSD of the face frequently experience significant sleep disturbance and depression.

RSD of the face frequently occurs following trauma such as dental extractions.

TESTING

Although there is no specific test for RSD, a presumptive diagnosis of RSD of the face can be made if the patient experiences significant pain relief after stellate ganglion block with local anesthetic. It should be noted that given the diverse nature of tissue injury that can cause RSD of the face, the clinician must assiduously search for occult pathology that may mimic or coexist with the RSD. Testing is aimed primarily at identifying occult pathology or other diseases that my mimic RSD of the face. All patients with a presumptive diagnosis of RSD of the face should undergo magnetic resonance imaging of the brain and, if significant occipital or nuchal symptoms are present, of the cervical spine. Screening laboratory testing consisting of complete blood count, erythrocyte sedimentation rate, and automated blood chemistry testing should be performed to rule out infection or other inflammatory causes of tissue injury that may serve as the nidus for the RSD.

The clinical symptomatology of RSD of the face may often be confused with pain of dental or sinus origin or may be erroneously characterized as atypical facial pain or trigeminal neuralgia.

Careful questioning and physical examination will usually allow the clinician to distinguish these overlapping pain syndromes. Tumors of the zygoma and mandible as well as posterior fossa tumors and retropharyngeal tumors may produce ill-defined pain that may be attributed to RSD of the face, and these potentially life-threatening diseases must be carefully searched for in any patient with facial pain. The pain of atypical facial pain is constant and dull and aching in character, whereas the pain of trigeminal neuralgia is intermittent and shocklike in nature. Stellate ganglion block may help distinguish it from these two pain syndromes, as the pain of RSD of the face readily responds to this sympathetic nerve block, whereas atypical facial pain does not. The pain of RSD of the face must be distinguished from the pain of jaw claudication associated with temporal arteritis.

TREATMENT

The successful treatment of RSD of the face requires two phases. First, any nidus of tissue trauma that is contributing to the ongoing sympathetic dysfunction responsible for the symptoms of RSD of the face must be identified and removed. Second, interruption of the sympathetic innervation of the face via stellate ganglion block with local anesthetic must be implemented. This may require daily stellate ganglion block for a significant period of time. Occupational therapy consisting of tactile desensitization of the affected skin may also be of value. Underlying depression and sleep disturbance are best treated with a tricyclic antidepressant such as nortriptyline given as a single bedtime dose of 25 mg. Gabapentin may help palliate any component of neuritic pain. Opioid analgesics and benzodiazepines should be avoided to prevent iatrogenic chemical dependence.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue .Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age –related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.