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CASE REPORT Cerebellopontine Angle (CPA) Tumor Mimicking Dental Pain Following Facial Trauma Jutiad Khan, M.D.S., M.P.H.; Gary M. Heir, D.M.D.; Samuel Y.P. Quek, D.M.D.. M.P.H. 0886-9634/2803- 205S05,00/0, THE JOURNAL OF CRANIOMANDIBULûiR PRACTICE, Copyright©2010 by CHROMA, Inc. Manuscripl received February 10, 2010; accepted March 15.2010 Address for correspondence: Dr. Junad Khan Dept. of Diagnostic Scienoes New Jersey Dental School University of Medicine and Dentistry of New Jersey t í o Bergen St., Rm. C880 Newark, NJ 07103 E-mail: junadkhan @ gmail.com ABSTRACT: Facial injuries are common during workplace accidents. These incidents are also associ- ated with an increase in both mortality and morbidity rates. The following case describes a 40 year-old white Hispanic patient with paroxysmal facial pain on the right side, one year in duration. The patient reported facial trauma as a result of a direct fall thought to be related to his pain complaints five months prior to arriving at the New Jersey Dental School emergency unit. The facial pain was progressively worsening ever since the accident. Upon arrival at the emergency unit, a comprehensive intraoral and extraoral examination was performed. Application of a local anesthetic at the site of the pain produced equivocal results. After obfaining a complete history and clinical examination, an MRl was ordered to rule out the possibility of a space-occupying lesion in the brain considered as a possible source of the pain. This case focuses on different aspects relative to dental care: the importance of a complete history and pafient evaluation in order to make an accurate diagnosis; the complexity of orofacial pain; and the train- ing required for dental health care providers who treat unusual oral and facial pain complaints. Dr. Junad Khan is the chief resident at tlie Orofacial Pain Clinic at the University of Medicine and Dentistry of New Jersey, Newark. NJ. He has also completed his Masters in Public Hea¡th and a Masters in Dental Sciences from UMDNJ. He has a fellowship in orofacial pain and TMJ disorders. Currentiy. he is in the second year of his PIt.D. program in oral biology. His major area of focus is pain management. D ental physicians are constantly required to diag- nose odontogenic pain. Identifying the source of a toothache can be challenging. Dentists possess, within their dental armamentarium, an array of devices and procedures that aid them in diagnosing the source of pain. Percussion of the tooth, pulp vitality testing,, ther- mal challenges, and similar tests are often utilized. X- rays may help detect caries and gross apical pathology. Tooth pressure testing may detect potential fractures in the tooth that may contribute to the pain process. Referred pain from the maxillary sinus or from myofascial trigger points must also be suspected if all the above tests result in equivocal findings. If uncertainty remains as to a diagnosis, a diagnostic anesthetic block may provide information that confirms or refutes a local peripheral source of pain. If all odonto- genic sources of pain are eliminated, a central process may be considered. Case Report A 40 year-old white Hispanic male presented lo the Orofacial Pain clinic at the University of Medicine and 205
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CASE REPORT

Cerebellopontine Angle (CPA) Tumor MimickingDental Pain Following Facial Trauma

Jutiad Khan, M.D.S., M.P.H.; Gary M. Heir, D.M.D.;Samuel Y.P. Quek, D.M.D.. M.P.H.

0886-9634/2803-205S05,00/0, THEJOURNAL OFCRANIOMANDIBULûiRPRACTICE,Copyright©2010by CHROMA, Inc.

Manuscripl receivedFebruary 10, 2010; acceptedMarch 15.2010

Address for correspondence:Dr. Junad KhanDept. of Diagnostic ScienœsNew Jersey Dental SchoolUniversity of Medicine andDentistryof New Jerseyt ío Bergen St., Rm. C880Newark, NJ 07103E-mail:junadkhan @ gmail.com

ABSTRACT: Facial injuries are common during workplace accidents. These incidents are also associ-ated with an increase in both mortality and morbidity rates. The following case describes a 40 year-oldwhite Hispanic patient with paroxysmal facial pain on the right side, one year in duration. The patientreported facial trauma as a result of a direct fall thought to be related to his pain complaints five monthsprior to arriving at the New Jersey Dental School emergency unit. The facial pain was progressivelyworsening ever since the accident. Upon arrival at the emergency unit, a comprehensive intraoral andextraoral examination was performed. Application of a local anesthetic at the site of the pain producedequivocal results. After obfaining a complete history and clinical examination, an MRl was ordered to ruleout the possibility of a space-occupying lesion in the brain considered as a possible source of the pain.This case focuses on different aspects relative to dental care: the importance of a complete history andpafient evaluation in order to make an accurate diagnosis; the complexity of orofacial pain; and the train-ing required for dental health care providers who treat unusual oral and facial pain complaints.

Dr. Junad Khan is the chief residentat tlie Orofacial Pain Clinic at theUniversity of Medicine and Dentistry ofNew Jersey, Newark. NJ. He has alsocompleted his Masters in Public Hea¡thand a Masters in Dental Sciences fromUMDNJ. He has a fellowship in orofacialpain and TMJ disorders. Currentiy. he isin the second year of his PIt.D. program inoral biology. His major area of focus ispain management.

Dental physicians are constantly required to diag-nose odontogenic pain. Identifying the source ofa toothache can be challenging. Dentists possess,

within their dental armamentarium, an array of devicesand procedures that aid them in diagnosing the source ofpain. Percussion of the tooth, pulp vitality testing,, ther-mal challenges, and similar tests are often utilized. X-rays may help detect caries and gross apical pathology.Tooth pressure testing may detect potential fractures inthe tooth that may contribute to the pain process. Referredpain from the maxillary sinus or from myofascial triggerpoints must also be suspected if all the above tests resultin equivocal findings.

If uncertainty remains as to a diagnosis, a diagnosticanesthetic block may provide information that confirmsor refutes a local peripheral source of pain. If all odonto-genic sources of pain are eliminated, a central processmay be considered.

Case Report

A 40 year-old white Hispanic male presented lo theOrofacial Pain clinic at the University of Medicine and

205

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CPA TUMOR MIMICKÍNG DENTAL PAIN KHAN ET AL.

Dentistry of New Jersey-New Jersey Dental School toremergency treatment of facial pain that had been presentfor one year. At his first visit, the chief complaint was offacial pain located in the right anterior segment of themaxi I la. The pain extended from the tip of the nose to thecheek. The patient was not able to localize the pain to onearea, but described it as heing in the region of the maxil-lary division of the trigeminal nerve (Figure 1),

The patient mentioned gradual worsening of the painover the past five months following trauma to the rightside of his face after a fall at work, during which he struckhis face. At the time of the falK he was examined at alocal hospital and treated for impact injuries, facialbruise.s, and muscle pain. After the accident, the maxil-lary pain abated. Three weeks later the maxillary painreturned. This time the pain attacks were more frequent,intense, and longer in duration. The patient reported thatthe pain progressively worsened.

Upon physical examination, hlood pressure was 121 /69.Body temperature was 98.4C with a pulse of 73. Thepatient's physical appearance was of a healthy andresponsive individual. His inedical history was negative,and he was not utilizing any medication with the excep-tion of over-the-counter pain medications as needed(acetaminophen and ibuprofen).

After the fall, as pain worsened, the patient consultedwith his private dentist who attempted managing hiscomplaints by first removing tooth #8. As pain persisted.the dentist then decided to remove tooth #7. Both extrac-tions had no effect on the pain. Instead, the pain graduallyworsened. The quality of pain one year prior to his visitwas initially paroxysmal, lasting for only seconds. At thetime of the current evaluation, it had progressed to 2-3

minutes duration. The frequency of the attacks had alsoincreased from two attacks per day to almost sevenattacks per day. The intensity of the attacks was moderateto severe. Pain was spontaneous with no known aggravat-ing factors. The patient reported an increased use of over-the-counter medications (acetaminophen and ibuprofen)that were ineffective in completely eliminating the pain.There was no report of pain awakening the patient duringhis sleep.

Objective findings included a loss of sensatittn of bothlight touch and pinprick in the affected area. This alteredsensation was present in a small region adjacent to theapex of the right maxillary canine extra orally. A palpa-tory examination of the masticatory musculature revealedslight discomfort to the right masseter, but did not repro-duce the chief complaint. TMJ palpation was negative. Adental examination found evidence of the recentlyextracted right central and lateral incisors.

After reviewing the history and examining the patientboth intra- and extraorally, the patient's pain could not bereproduced and no associated intraoral pathology wasfound. Application of topical anesthetic had no effect. Adiagnostic somatic block was than administered at thesite of the pain and had equivocal results.

The negative dental findings prompted considerationof a central mechanism for the patient's pain. Theretbre,he was referred for an MRI of the brain. The objectivewas to rule out any intracranial pathology.

MRI Conclusions

A multiplanar, multi-sequenced MRI was performedon the patient without the administration of intravenous

Areas of Pain

Masseter trigger point tender but unable to produce chief

complaint

Figure tThe patient was tiot able to local-ize the pain to one area, hutdescribed it as being ¡it the regionot the maxillary division <t} thetrigeminal nerve.

206 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2010, VOL. 28, NO. 3

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KHAN ET AL. CPA TUMOR MIMICKING DENTAL PAIN

gadolinium. A large heterogeneous extra-axial masslesion extending from the right cerebellopontine angle(CPA) to involve the right side ofthe perimesencephaliccistern and the posterior aspect of the suprasellar cisternwas tbund. This mass encased the right cranial nerve Vand the basilar artery and caused a severe mass-effect onthe pons. The MRI was negative for any infarct. intracra-nial hemorrhage, or hydrocephalus. Normal llow-relatedvoids were seen within the tnajor intracranial vessels(Figure 2 a-d).

Discussion

The dental practitioner must always consider neuro-pathic pain and trigeminal neuralgia (TN) in a differentialdiagnosis. Clinically. TN is classified as idiopathic orsymptomatic. The presentation and symptoms are typi-cally the same but the underlying pathology is different.The majority of patients fall under the idiopathic cate-gory, where the underlying cause is unknown. In sympto-maticcases, the neuralgic pain issecondarytoapathological

Ki j îure 2 ( a d )Amiws in a-d indicate the lésion. The tumor is compressing major areas of the brain. The compression of rhe trigeminal nerve was considered ihecause ol" the paroxysmal pain experienced by the patient.

JULY 2010, VOL. 28, NO, 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 207

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CPA TUMOR MIMICKING DENTAL PAIN KHAN ET AL.

condition. Examples include meningioma. multiple scle-rosis, and cerebellopontine angle (CPA) tumors. Eventhough the etiology of TN is unclear, the mo.st acceptedtheory i.s that it is due to a compression of the nerve rootby a vessel or tumor. Demyelinization. intrinsic lesionswithin the nerve root, or at the root entry zone (REZ)have also been reported. There is no specific age categoryfor TN. However, it typically affects patients over age of50. When it affects younger patients, suspicions ofintracranial pathology are raised.

This is a case of a cerebellopontine angle tumor. Theimportant message in this case is to consider the atypicaland progressive presentation of the patient's pain and hisage, which is considered too young for the onset of TN.Usually, if an individual has TN-like features and isunder the age of 50, it is necessary to order brain imagingto rule out any possibility of an intracranial lesion.Approximately 0-8% of trigeminal cases are reported tobe secondary to a tumor.'-^ There is very limited docu-mentation of the relationship of TN and CPA tumors.-*-̂ Ithas been established that extra-axial lesions in the poste-rior fossa compressing the nerve root are likely to causeTN. whereas neoplastic compression of the Gasserianganglion may be associated with atypical facial pain.^

CPA tumors resulting in complaints of TN can origi-nate from a variety of tissue types present in the area.Schwannoma (75%), meningioma (13%), and epider-moid cysts (5%) are the most common tumors. Anatom-ically the structures are the CPA borders themselves, theinternal auditory canal, and compartments of CN VII, andVIII. Due to the anatomic diversity, a small percentage ofuncommon tumors have also been

The importance of a thorough history, physical exami-nation, and diagnostic te.sting is illustrated in this case,but can only be successful if the health care provider isaware of the variety of facial pain disorders that maymanifest from intracranial lesions and is prepared to per-form, order, and interpret these tests accurately.

References

Ak.sik I: Mkrcmeural decompression operaiion.s in ihe ircalmenl of someforms of cranial rhizopathy. Acta Neurochir (W\eii) 1993; 125(l-4);(>4-74.

Apfelbaum RI: Surgery for tic JouUiureux. Cliti Neurostirg 1983; 3l:3.'il-368.

Beder.'ion JB, Wilson CB: Evaluation of micro vascular decompression andpartial sensory rhizolomy in 252 cases of trigémina! neuralgia. Neurosurgl989;7l(3);3.59-367.

Pian JH Jr. Wilkins RH: Treatment of tic douloureux and hemifacial spa.smby posterior Ibssa exploration: therapeuiic implications of various neu-rovaseular relationships. A'eiim.iu;-,!' 1984; 14(4);462'471.

Puca A. Miglio M. Tamburritii G, Vari R: Trigeminal involvemeni inintracranial tumours. Anatomical atid clinical observations on 73 piitienls.AaaNet<riKlm\WKn) 1993; 125(l-4):47-51.

Bullitl E. Tew JM. Boyd J: Intracranial tumors in patients with facial pain.Nettmsurg 19S6 4(61:865-87!.

Dr. Gary Heir isa clinical professor at the Department of DiagnosticSciences. University of Medicine and Dentistry of New Jersey. Newark.NJ. He is the clinical director of the Orofaciai Pain Clinic at UMDNJ.

Dr. Samuel Quek is the program director of the General PracticeResidency at the New Jersey Dental School, University of Medicine andDentistiy of New Jersey. Neivark. NJ.

208 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2010, VOL. 28. NO. 3

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