面部疼痛的鉴别诊断和治疗指南（三）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013;111(1):95-104.本次学习由杨聪娴副主任医师主讲。

Acute facial pain

The conditions described in this section are rarely seen in painclinics as they are relatively easy to diagnose and are effectively managed by the dental profession or general practitioners.

急性面部疼痛

本节描述的症状很少出现在疼痛诊所中，因为它们相对容易诊断，由牙科专业人员或全科医生管理比较有效。

Dental and oral causes

The majority of dental pain is acute and most are likely to beunilateral and located within the mouth, some very specififically relating to a tooth, but sometimes diffificult to localize.The major features are summarized in Table 1. A good lightis required to examine the teeth, the attached gingiva and then the soft tissues of the oral mucosa. If any dentalcauses are identifified, patients need to be encouraged to seek early dental care. If they have special needs (i.e.complex medical histories or physical disabilities), they mayneed to be treated by dentists specializing in special needs.Diseases of the oral mucosa are painful and will be associated with a lesion (e.g. lichen planus, herpes zoster,herpes simplex, recurrent oral ulceration, and Sjogren’ssyndrome).

牙科和口腔原因

大多数的牙痛是急性的，而且很可能是单侧，位于口腔内，有些可以具体定位到某个牙齿，但有时很难定位，（表1）对其主要特性进行了总结。需要好的光照以检查牙齿、附着的牙龈和口腔黏膜的软组织。如果有牙齿原因确定了，需要鼓励患者尽早就医。如果有特殊需要(如:复杂的病史或身体残疾)，他们可能需要由有特殊需要的牙医治疗。口腔黏膜疾病是痛苦的，并伴随其他病变(如扁平苔藓、带状疱疹、单纯疱疹、复发性口腔溃疡、干燥综合征)。

Maxillary sinusitis

Most sinusitis is acute and the chronic form is less likely to beassociated with pain. The International Headache Society suggests that the diagnostic criteria for all sinusitis is the same—the only difference is location (Table 1). Acute sinusitis is most frequently caused by viruses or bacteria but it canoccur after a dental infection or after treatment to upper premolar or molars, especially extractions. Dental surgical procedures can result in an oral antral fifistula and patients will complain of oral and nasal discharge. Imaging may indicatethe presence of a foreign body in the antrum. The fifistula needs to be closed by oral/maxillofacial surgeons and then managed as for any maxillary sinusitis.

上颌窦炎

大多数鼻窦炎是急性的，慢性鼻窦炎一般不伴疼痛。国际头痛学会提示所有鼻窦炎的诊断标准是相同的---唯一的不同是位置(表1)。急性鼻窦炎最常见的是由病毒或细菌引起，但它可以发生在牙齿感染后或治疗后的上颌前磨牙或臼齿，尤其是拔牙后。牙科手术能导致口腔窦瘘，和患者会有口鼻分泌物的主诉。影像学检查可能表明腔内异物的存在的瘘，需要由口腔/颌面外科医生手术关闭，然后治疗上颌窦炎。

Salivary gland disorders

Tumours, duct blockage and subsequent infection of the salivary glands also elicit pain in the trigeminal nerve. Salivarystones are most frequent in the submandibular gland. The pain is intermittent and characteristically occurs just beforeeating. There may be associated tenderness of the involvedsalivary gland. Bimanual palpation will enable the stone to be palpated. If it is in the duct then salivary flflow from theduct will be slow or absent. Imaging and ultrasound areuseful and referral for further management to oral/maxillofacial surgeons is indicated.

唾液腺疾病

肿瘤、导管堵塞以及随后的唾液腺感染也能引起三叉神经区域的疼痛。唾液腺结石常见于颌下腺。疼痛是间断性的，特征是发生在吃东西之前。可能会有相关的唾液腺压痛。触诊可以触及结石。如果结石在导管里，唾液就会从导管流出减慢或阻塞。影像学检查和超声对进一步治疗口腔/颌面治疗有帮助。

Temporomandibular disorders (TMD)

By far the commonest non-dental cause of facial pain are the TMDs. They affect 5–12% of the population and the peakage is 20–40 yr. Depression, catastrophizing, and other psychological factors increase the risk of chronicity. TMDs are also linked with back pain, fifibromyalgia,and headaches. Schiffman and colleagues have put forward criteria for headache secondary to TMD. The large US OPPERA study confifirms its complexity and that TMD is not just an isolated facial pain.

颞下颌关节功能紊乱(TMD)

到目前为止，引起面部疼痛最常见的非牙齿源性病因是TMD。他们影响5~12%的人口和高峰年龄是20~40岁。抑郁、灾难和其他心理疾病等各种因素增加了慢性化的风险。TMD与背痛、纤维肌痛和头痛相关。Schiffman和他的团队提出了继发于颞下颌关节功能紊乱症的头痛的诊断标准。一项由美国进行的大型研究OPPERA证实了TMD的复杂性，它不是孤立的面部疼痛。