LETTER TO EDITOR
Year : 2014 | Volume
| Issue : 5 | Page : 120-121
Classical is not that simple: Lesson from trigeminal neuralgia
Chinmoy Roy1, Nilay Chatterjee2
1 Department of Anesthesia and Pain Medicine, Institute of Neurosciences, Kolkata, West Bengal, India
2 Department of Neuroanesthesiology and Pain Medicine, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
Dr. Nilay Chatterjee
NFQ B-10, Sree Chitra Tirunal Institute for Medical Sciences and Technology Faculty Quarters, Kumarapuram, Poonthi Road, P. O. Medical College, Trivandrum - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||6-Nov-2014|
|How to cite this article:|
Roy C, Chatterjee N. Classical is not that simple: Lesson from trigeminal neuralgia. Saudi J Anaesth 2014;8, Suppl S1:120-1
Classical trigeminal neuralgia (cTN) is a pain syndrome consisting of sharp, lancinating pain along the distributions of one or more divisions of the trigeminal nerve. Secondary trigeminal neuralgia (sTN) which often results from head and neck tumors, intracranial infections and multiple sclerosis,  is characterized by constant or persistent, aching, nagging, burning, or throbbing pain, with or without coexisting paroxysmal, triggered, trigeminally distributed pain. Many times the features of cTN and sTN are superimposed and it becomes difficult and challenging to differentiate sTN, which not only mimics cTN, but also dentoalveolar disease and temporomandibular joint disorder. 
A 61-year-old female patient presented with a 3-month history of sudden, severe, sharp, and shooting pain lasting for few seconds over the left cheek. This paroxysmal pain attack was precipitated by touch or even spontaneously with pain free interval in between. Dermatomal distribution suggested involvement of left maxillary and mandibular divisions of trigeminal nerve. There was no neurological deficit, no associated autonomic feature or any tenderness elicited anywhere. Patient was being managed with medicines as a case cTN with minimal effect. Magnetic resonance imaging of the brain did not show any significant neurovascular compression at the root entry zone of the left trigeminal nerve. An irregular polypoid mass lesion was seen in left maxillary region with an extension into the masticator space and involvement of maxillary nerve [Figure 1]a. In computed tomography scan of the posterior nasal space extensive bony destruction maxilla and pterygoid plates were evident, thus favoring a malignant pathology [Figure 1]b. Excisional biopsy from the growth revealed tumor cells in cribriform pattern and focal myxoid and hyaline changes in the stroma with perineural invasion suggesting adenoid-cystic carcinoma [Figure 1]c. Neuralgic pain was completely resolved following surgery and postoperative radiotherapy.
|Figure 1: (a) Magnetic resonance imaging axial postcontrast fat saturated T1-weighted images showing an enhancing mass lesion in the left maxillary region extending into the masticator space. Perineural spread of the lesion is seen extending along the maxillary nerve and infraorbital nerve. Enlargement and enhancement of mandibular nerve is also seen with enlarged foramen ovale. (b) Axial computed tomography scan showing bone destruction of left maxilla and pterygoid plates. (c) Biopsy of the growth shows tumor cells, which are arranged in cribriform pattern with few small tubular acini, trabeculae and small nests. The stroma is showing focal areas of myxoid and hyaline changes. Perineural invasion is seen|
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This case report highlights the difficulties in differentiating classical from sTN through clinical features  and neuroimaging or electrophysiology, although level C+ evidence,  should be considered routinely to identify sTN.
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