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Neurology (Expert Forum)
Re: Bilateral pain in maxillia in a 2 year old
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Re: Bilateral pain in maxillia in a 2 year old
by CCF Neuro[P] MD RPS, Jan 01, 1995 12:00AM
Posted By CCF Neuro[P] MD. RPS on September 25, 1998 at 16:24:47:
In Reply to: Bilateral pain in maxillia in a 2 year old posted by Lee on September 25, 1998 at 13:42:43:
My daughter who is 2 recently began having pain in her maxilliary area. She was teething her last 2 upper molars when this started. Her pain is out of proportion to teething, requiring codeine and chloral hydrate for sleep.
She has had a CT scan as well as sinus films, she has been seen by an ENT, Oral surgeon, dentist, and pediatric dentist as well as her family practice man. They say this is not teething, nor is there any abnormality of the jaw, cysts, extra teeth, or other anatomical abnormaility. The teeth are through her the bone and free of all soft tissue, yet the pain persists.
The pain comes and goes, and is especially worse at night and seems to get worse after eating. Yesterday she started crying after eating a crispy chinese noodle, biting on the left in the area of her molar. The pain is bilateral. It is unrelieved by NSAIDS. Some days are better than others, but she has not had a pain free day in 6 weeks. You can see her play become more disorganized as the pain comes on, and her affect change. Sometimes she just breaks down to cry. She is very clear what hurts if you ask her she points to each side of her face in the area of her molars. THis isnt TN pain as it is more of a constant pain increasing over minutes to hours. Also it is bilateral. It is poorly realieved by codeine however there is some improvement in her affect following codeine.
She had an aparent viral illness co-incident with the onset of her teething. She had mild fever and hoarseness for about 5 days. She was treated at this time for a red ear drum as well with amoxicillian. She has had no symptoms of other infection, nor recurrent fever at all.
She has an underbite. The new teeth are not yet in occlusion. She is adopted, from China, however she has been home with us for over a year, and was in good health when we got her. She has current vaccinations. I contacted a pediatric practice that works with international adoption, and they felt her problem was not something endemic to her heritage, but specific to her. She does have exema (eczema), which has acted up a bit since this started.
I am at a loss where to go from here. Going to all these doctors and getting the radiology has truamatized her significantly. We started her on tegratol and are awaiting to see how this works. I hesitate to submit her to a full neurologic workup since that would involve lumbar tap MRI etc etc. The oral surgeon suggest that this is a neuritis, however I am unconvinced that it is not her teeth, since eating increases her symptoms and she points to her teeth. She is also tender to touch if you try to explore her mouth with your finger. Has anybody eer seen or heard of something like this? Any clues on what this might be?
Thanks
Lee
Dear Lee:
It sounds like a very thorough workup has been already performed. Did you mention that a sedimentation rate or C-reactive protein level was done? If these are high, it may indicate that an inflammatory process might be occurring. I should add that these tests could also be negative and still have a immunologically induced neuralgia problem. Given that all the structural tests and the clinical exams by multiple clinicians has turned up all negative results it sounds to me like it is virally induced. A sensitive nerve will worsen with use as you describe. The pain is likely throbbing and pretty much unbearable for a youngster. If this is the case, the tegratol will help relieve the pain. I would agree with the therapy. You didn't mention whether she had other symptoms. Is she sensitive to loud noises above what she was before the infection? Does any part of her face droop? If any of these two latter symptoms are present, you might want to get a second opinion from another pediatric neurologist. It might indicate that a treatable virus infection might be present. Although it would be unlikely in a 2 year old, Ramsay Hunt syndrome (varicella virial infection) has been reported in the literature at young ages. Let me know if the tegratol works.
Sincerely,
CCF Neuro[P] MD, RPS
In Reply to: Bilateral pain in maxillia in a 2 year old posted by Lee on September 25, 1998 at 13:42:43:
My daughter who is 2 recently began having pain in her maxilliary area. She was teething her last 2 upper molars when this started. Her pain is out of proportion to teething, requiring codeine and chloral hydrate for sleep.
She has had a CT scan as well as sinus films, she has been seen by an ENT, Oral surgeon, dentist, and pediatric dentist as well as her family practice man. They say this is not teething, nor is there any abnormality of the jaw, cysts, extra teeth, or other anatomical abnormaility. The teeth are through her the bone and free of all soft tissue, yet the pain persists.
The pain comes and goes, and is especially worse at night and seems to get worse after eating. Yesterday she started crying after eating a crispy chinese noodle, biting on the left in the area of her molar. The pain is bilateral. It is unrelieved by NSAIDS. Some days are better than others, but she has not had a pain free day in 6 weeks. You can see her play become more disorganized as the pain comes on, and her affect change. Sometimes she just breaks down to cry. She is very clear what hurts if you ask her she points to each side of her face in the area of her molars. THis isnt TN pain as it is more of a constant pain increasing over minutes to hours. Also it is bilateral. It is poorly realieved by codeine however there is some improvement in her affect following codeine.
She had an aparent viral illness co-incident with the onset of her teething. She had mild fever and hoarseness for about 5 days. She was treated at this time for a red ear drum as well with amoxicillian. She has had no symptoms of other infection, nor recurrent fever at all.
She has an underbite. The new teeth are not yet in occlusion. She is adopted, from China, however she has been home with us for over a year, and was in good health when we got her. She has current vaccinations. I contacted a pediatric practice that works with international adoption, and they felt her problem was not something endemic to her heritage, but specific to her. She does have exema (eczema), which has acted up a bit since this started.
I am at a loss where to go from here. Going to all these doctors and getting the radiology has truamatized her significantly. We started her on tegratol and are awaiting to see how this works. I hesitate to submit her to a full neurologic workup since that would involve lumbar tap MRI etc etc. The oral surgeon suggest that this is a neuritis, however I am unconvinced that it is not her teeth, since eating increases her symptoms and she points to her teeth. She is also tender to touch if you try to explore her mouth with your finger. Has anybody eer seen or heard of something like this? Any clues on what this might be?
Thanks
Lee
Dear Lee:
It sounds like a very thorough workup has been already performed. Did you mention that a sedimentation rate or C-reactive protein level was done? If these are high, it may indicate that an inflammatory process might be occurring. I should add that these tests could also be negative and still have a immunologically induced neuralgia problem. Given that all the structural tests and the clinical exams by multiple clinicians has turned up all negative results it sounds to me like it is virally induced. A sensitive nerve will worsen with use as you describe. The pain is likely throbbing and pretty much unbearable for a youngster. If this is the case, the tegratol will help relieve the pain. I would agree with the therapy. You didn't mention whether she had other symptoms. Is she sensitive to loud noises above what she was before the infection? Does any part of her face droop? If any of these two latter symptoms are present, you might want to get a second opinion from another pediatric neurologist. It might indicate that a treatable virus infection might be present. Although it would be unlikely in a 2 year old, Ramsay Hunt syndrome (varicella virial infection) has been reported in the literature at young ages. Let me know if the tegratol works.
Sincerely,
CCF Neuro[P] MD, RPS
