A Case of Painful Trigeminal Neuropathy Attributed to Space-Occupying Lesion Diagnosed Early by Cranial Nerve Examination

Abstract

Purpose: Tumor-associated trigeminal neuralgia is classified under ‘painful trigeminal neuropathy attributed to space-occupying lesion’ according to the International Classification of Headache Disorders, 3rd edition beta version （ICHD3β: 13.1.2.5: hereinafter ‘PTN-SOL’）. Many trigeminal neuralgia patients are diagnosed by dentists. However, some clinicians have reported that PTN-SOL accounts for 10％ of trigeminal neuropathy cases. For this reason, it’s important we have to also consider PTN-SOL when making the diagnosis for early diagnosis. In this paper, we report a case of PTN-SOL diagnosed early by cranial nerve examination.
Case: A female patient in her seventies presented at our hospital department due to pain in her right mandibular tooth. She had consulted a dental practitioner beforehand because she had felt phasic strong pain in her right mandibular premolar teeth region while eating in December 2012 years. The doctor suspected it was trigeminal neuropathy and referred the patient to our hospital, but she did not present because the pain had subsided. However, she came to our hospital on July 2013 years due to recurrence of the pain. The pain was caused by brushing teeth or eating meals, and there were two types of pain resembling numbness. One was a paroxysmal attack with middle to severe intensity and the other was persistent pain for 20 minutes with mild intensity. We conducted a detailed medical interview with the patient because it was not a typical condition for classical trigeminal neuralgia. We determined that the numb-like feeling was hyperesthesia in the right mental region. She had dysfunctional eye movements, diplopia and hyperethesia in the right trigeminal nerve, 3rd branch, by cranial nerve examination. Furthermore, there was a neoplastic lesion around the tuberculum sellae and cavernous sinus on MRI. For this reason, we consulted the neurosurgery department in our hospital.
Results: It was considered a case of painful trigeminal neuropathy attributed to space-occupying lesions by meningioma around the tuberculum sellae and cavernous sinus.
Conclusion: In our report, we have showed the importance of conducting a cranial nerve examination for early diagnosis.