Trigeminal neurelgia_BNS 3rd year.PPTX.CMC

Trigeminal Neurelgia presentation

1. “Trigeminal neuralgia” Prepared by : Samikshya Banjara BNS 3 rd year 14 th batch Chitwan Medical College

2. General Objective: At the end of this session BNS 3rd year students will be able to explain about “trigeminal neuralgia”

3. Specific objectives At the end of this session, students will be able to : define trigeminal neuralgia list the causes of trigeminal neuralgia state the classification of trigeminal neuralgia describe the pathophysiology of trigeminal neuralgia list the sign and symptoms of trigeminal neuralgia

4. Specific objectives (cont..) list the diagnostic evaluation of trigeminal neuralgia explain the management of trigeminal neuralgia describe the nursing management of trigeminal neuralgia state the complication of trigeminal neuralgia

5. Introduction Trigeminal neuralgia is a condition/neuropathic disorder of fifth cranial nerve i.e characterized by paroxysm of the pain in the area innervated by any of the three branches of trigeminal nerve.

6. Introductions (cont..) The pain ends as abruptly as it starts and is describes as a unilateral shooting and stabbing sensation . Associated involuntary contraction of facial muscles can causes sudden closing or twitching of mouth.

7. Introductions (cont..) Pain usually occurs: 𝑣 1 =eye and forehead 𝑣 2 =cheek, upper teeth, upper gums and nose 𝑣 3 =lower jaw, side of tongue, lower teeth, lower gums Thus has been described as the most painful condition known to mankind. Also known as prosopalgia , the suicide disease, tic douloureux , fothergill’s disease, trifacial neuralgia.

8. Definition According to the International Association For Study of Pain “Trigeminal neuralgia is the sudden usually unilateral, severe brief stabbing recurrent pain in the distribution of one or more branches of the fifth cranial nerve”.

9. Definition (cont..) According to International Headache Society “ Painful, unilateral affection of the face, characterized by brief electric shock like pain limited to the distribution of one or more divisions of trigeminal nerve. Pain is commonly evoked by trivial stimuli including washing, shaving, smoking, talking, brushing but may also occur spontaneously. The pain is abrupt in onset and terminations may remit for varying periods”.

10. Incidence It estimated that 5 in every 1,00,000 people Peak incidence is in 50-60 yrs. 90% of the case occurs after age 40. Gender –Female: Male is 2:1. Right sided 56% of the time only 3% people experience pain on both side of the face. Roughly 15,000 new cases annually in U.S Most commonly involves the Maxillary𝑣 2 >Mandibular𝑣 3 >𝑣 1 Opthalmic https ://pubmed.ncbi.nlm.nih

11. Etiology Exact cause is idiopathic but degenerative or viral origin suspected. Sex : female are more affected Intrinsic lesion – gross abnormalities of axon or myelin Multiple sclerosis

12. Etiology (cont..) Extrinsic lesion Mechanical compression by tumors and cyst. Blood vessels anomalies like aneurysms and atrio -venous malformations dental abscess or jaw malformation Inflammatory condition such as Sarcoidosis and Lyme disease Abnormally thickened arachnoid tissue layer of brain Viral etiology – herpes virus infection, syphilis

13. Classification The International Headache Society (IHS) classifies trigeminal neuralgia into two main categories: Classical trigeminal neuralgia Secondary trigeminal neuralgia

14. Classification (cont..) Classical trigeminal neuralgia : It is also known as idiopathic or typical trigeminal neuralgia . This type of neuralgia involves sudden, severe, electric shock like or stabbing pain in the trigeminal nerve’s distribution areas. It’s typically unilateral and often triggered by activities like eating, talking or touching the face.

15. Classification (cont..) Secondary trigeminal neuralgia : It is also known as atypical trigeminal neuralgia . This type of neuralgia typically involves a more constant, burning, aching or squeezing pain, which may not always strictly follow the nerve’s distribution.

16. Classification (cont..) The pain can be more persistent and may not have the same triggers as the typical form. This type is associated with an underlying cause, such as multiple sclerosis, tumors compressing the trigeminal nerve or other structural issues affecting the nerve.

17. Pathophysiology The trigeminal nerve exist in the pons and merges into the gassenar ganglion before it separates into 3 branches. Trigeminal nerve is a largest cranial nerve and has both motor and sensory fibers. It primarily affects the maxilla and mandible branches of the nerve.

18. Pathophysiology (cont..) The pain occurs abruptly and lasts from few seconds to a few minutes and can reoccur at any time. Pain typically described as intense, piercing, burning like lightning bolt; the pain affects only one side of the face and there are no accompanying motor or sensory deficits in the region served by the nerve.

19. Pathophysiology (cont..)

20. Sign and Symptoms In trigeminal neuralgia the specific area on the face where the stimuli can provoke intense pain. Common trigger zones include: V1 (Ophthalmic division) : it supplies sensation to the forehead, upper eyelid and the front of the scalp V2 (Maxillary division): it provides sensation to the cheek, lower eyelid, side of the nose, upper lip, and part of the palate V3 (Mandibular division): it innervates the lower lip, chin, jaw, side of the head and the front part of the ear.

21. Sign and symptoms (cont..) Specific area affected commonly maxillary mandibular branches are affected, causing the symptoms in lips, cheeks, jaw and nose of the affected side and the ophthalmic branches involve the eyes, forehead may be affected Sudden severe, short duration (30 -60 sec to 2 -3 min),excruciating pain, unilateral facial pain in the distribution of one or two branches of trigeminal nerve

22. Sign and symptoms (cont..) A persistent dull ache or burning sensation with occasionally sharp come and go pain Sharp, stabbing or shooting pain on one side of the face that feels series of electric shock and lasts for second to minute. Immediately after the pain transient facial numbness may occur The first episode of pain may last for days, weeks, months and then typically the pains stop for while

23. Sign and symptoms (cont..) Recurrence are unpredictable, may occur several times a day or weeks or month in the same location for each episode. Easily triggered In extreme or chronic cases of trigeminal neuralgia: include frozen face or masked like face arise due to prolonged pain or muscle tension resulting from the continuous discomfort.

24. Diagnostic Evaluation 1) History Taking Collect the information of the patient Ask the past history of the patient Ask for any injury or trauma Ask the patient about the nature of the pain

25. Diagnostic Evaluation (cont..) 2) Physical Examination Assess the condition of the patient Assess the sign and symptoms of the patient Examine the trigeminal nerve Assess the sensory abnormalities such as facial muscle strength Assess the reflexes such as jaw jerk reflex, corneal reflex and other general reflexes

26. Diagnostic Evaluation (cont..) 3)Neurological Examination Assess the GCS of the patient Assess for 12 th cranial nerve Skull X-ray: to rule out the structural changes of the patient 4)CT scan : to assess the structure of skull and identify the abnormalities

27. Diagnostic Evaluation (cont..) 5)MRI scan : it helps to provide more detail information than CT scan 6)Angiography : to evaluate the blood vessels 7)MRA scan : to evaluate the blood vessels in the area and determine if any vascular compression

28. Management The goal of managing the trigeminal neuralgia are: To alleviate pain and improve the quality of life To reduce the frequency and intensity of painful episode

29. A. Medical Management 1. Drug Therapy Anti-seizure drugs- carbamazepine, gabapentin, lamotrigine phenyton , valproate and pregablin . Muscle relaxants –baclofen, clonazepam. Tricyclic antidepressants- amitriptyline , norptyline or carbamazepine . Analgesic or opioids are usually not effective in controlling pain

30. Drug Therapy (cont..) 1st line therapy Anti convulsant drugs Carbamazepine: 400- 800 mg/day Oxcarbazepine : 900-1200 mg/day 2 nd line therapy Lamotrigine : 150-400 mg/day Baclofen: 40-80 mg/day Phenytoin: 300-500 mg/day 3 rd line therapy Clonazepam Valporic acid : 500-1500 mg/day

31. Conservative Therapy Nerve Blocking with Local Anesthesia Relief of pain is temporary, lasting from 6-18 months Complications include bruising, swelling at the site of injection

32. Conservative Therapy (cont..) 2. Biofeedback : It is a non-invasive approach that may be helpful with the patient with trigeminal neuralgia 3. Reduce stress: L earning relaxation technique might help individual to manage stress, potentially reducing the intensity and frequency of trigeminal neuralgia pain episodes

33. Conservative Therapy (cont..) 4. Developing coping strategies: It helps individual in understanding how their body responds to pain and teach the method to control physiological responses

34. Surgical Management Microvascular decompression ( Jannetta procedure) Gamma Knife Surgery Percutaneous Radiofrequency Rhizotomy Glycerol Rhizotomy Balloon Compression Radiofrequency Thermal Lesioning

35. Surgical Management (cont..) 1.Microvascular decompression ( Jannetta procedure) Cranial surgery performed to find and fix an offending blood vessel that is injuring or compressing the trigeminal nerve.

36. Surgical Management (cont..) This procedure involves making a small opening in the lower back portion of the skull, locating the blood vessel, and inserting a small pad (Teflon sponge or shredded Teflon) to keep the blood vessel and nerve apart. In most cases, the causative blood vessel is an artery.

37. Surgical Management (cont..) 2.Gamma Knife Surgery Gamma knife surgery is a radiosurgery and no actual incision is made, making it the least invasive surgical option. Gamma knife surgery is a common procedure for patients who cannot tolerate surgery and/or those who have unsuccessful treatments with medications.

38. Surgical Management (cont..) Focused beams of cobalt-60 radiation are directed on a particular area of the brain to cut off the trigeminal nerve’s blood supply, causing scarring and death of the nerve tissue.

39. Surgical Management (cont..) 3.Percutaneous Radiofrequency Rhizotomy It is known as radiofrequency ablation or rhizolysis It is an invasive surgical procedure used to alleviate pain in certain cases of trigeminal neuralgia. It’s aim is to reduce or block pain signals transmitted by the trigeminal nerve by selectively damaging the nerve fibers responsible for transmitting pain sensation.

40. Surgical Management (cont..) 3. Glycerol Rhizotomy This is a procedure in which pure anhydrous glycerol injection is administered in the trigeminal ganglion. Glycerol causes nerve damage by disintegration of the nerve’s myelin sheath. This nerve injury in turn prevents the nerve from sending pain signals to the brain. The goal is to damage the nerve selectively in order to interfere with the transmission of the pain signals to the brain.

41. Surgical Management (cont..) 4.Balloon Compression A large needle is inserted into the trigeminal ganglion, and a tiny balloon is inflated at its tip with a small amount of liquid. The goal is to squeeze the nerve against the bony tissue and cause enough damage to disrupt the pain signals. The balloon is then deflated, and the needle is removed.

42. Surgical Management (cont..) 5.Radiofrequency Thermal Lesioning An electrode inserted through the cheek is used to heat the nerve and cause selective damage to stop pain signals from traveling to the brain. The treatment provides immediate pain relief in up to 90% of patients, but can cause more facial numbness than the other procedures and has a pain recurrence rate of 40% at 2 to 3 years post-surgery. If necessary, the procedure can be repeated.

43. Nursing Management Nursing assessment: Take complete history of the patient, of pain, including duration, severity, and aggravating factors. Perform physical examination including neurological examination. Assess for nutritional status and hydration. Assess for anxiety and depression, including problems with sleep, social interaction, coping ability/skills.

44. Nursing Management (cont..) Nursing Diagnosis Chronic pain related to trigeminal nerve compression Imbalanced body nutrition related to pain during chewing and eating. Powerlessness related to lack of control over painful episodes.

45. Nursing Diagnosis (cont..) Ineffective individual coping related to severe pain. Anxiety related to prognosis of disease and change in health Self- care deficit related to pain and discomfort. Fear related to treatment or invasive procedures

46. Nursing Diagnosis (cont..) Deficit knowledge related to disease condition as evidenced by frequently asked questions Risk for injury to the eyes related to possible reduction in corneal sensation Ineffective therapeutic regimen management related to lack of knowledge about triggering stimulus as evidenced by patient verbalization

47. Nursing Interventions 1.To relieve pain To minimize the pain episodes, review with patient potential triggering factors and develop individual coping methods. Encourage patient to take medicine regularly. Instruct patient to avoid exposure of affected area to cold.

48. Nursing Interventions (cont..) Help in communication methods without pain while talking. Improve the quality of sleep. Encourage patient to keep a pain diary noting the severity and frequency of pain. Serum levels must be monitored to avoid toxicity in patients who require high doses to control the pain

49. Nursing Interventions (cont..) 2.Monitor Adequate Nutrition Monitor daily intake and output. Instruct the patient to take food and fluids at room temperature. Avoid foods that are too cold or hot. Encourage to chew with the help of unaffected side.

50. Nursing Interventions (cont..) Have the patient consult with dietician for appropriate meal, texture and composition. Encourage small frequent meals to avoid fatigue and pain. Advice about use of nutritional supplements as needed. In severe cases NG Tube feeding can be done

51. Nursing Interventions (cont..) 3.To control pain Teach relaxation exercises such as breathing, progressive muscle relaxation and guided imagery to relief muscle tension Instruct patient to share his/her fears with family or with nurses for relief and assurance.

52. Nursing Interventions (cont..) Teach patient about the disease process and it’s treatment methods. Instruct patients the methods to prevent environment stimulation of pain. Instruct patient to inspect eye for redness and foreign body if corneal sensation is impaired and use of eye drops as prescribed.

53. Nursing Interventions (cont..) 4.To maintain health Teach them about follow up visit, regular medication, and consult if any changes in sensation on face like numb. Refer the patient to physiotherapy and speech therapy for facial exercise and to improve communication

54. Nursing Interventions (cont..) 5.To maintain Hygiene Provide cotton pads and room temperature water for washing the face. Instruct the patient to rinse mouth with mouthwash after eating if toothbrush causes pain.

55. Nursing Interventions (cont..) Instruct to perform personal hygiene during pain free intervals. Schedule routine dental care to prevent extensive dental treatment. Warm normal saline irrigation of the affected eye 2/3 times a day is helpful in preventing corneal infection.

56. Nursing Interventions (cont..) 6.To increase control Support patient through treatment trials. Teach relaxation exercises, such as guided imagery to relieve tension. Encourage participation in support groups, and facilitate a therapeutic relationship with the health care provider

57. Nursing Interventions (cont..) 7.Post- operative management Postoperative neurologic assessments are conducted to evaluate the patient for facial motor and sensory deficits in each of the three branches of the trigeminal nerve. If the surgery results in sensory deficits to the affected side of the face, the patient is instructed not to rub the eye, because pain will not be felt if there is injury.

58. Nursing Interventions (cont..) The eye is assessed for irritation or redness. Artificial tears may be prescribed to prevent dryness in the affected eye. The patient is cautioned not to chew on the affected side until numbness has diminished. The patient is observed carefully for any difficulty in eating and swallowing foods of different consistency.

59. Nursing Interventions (cont..) 8.To provide education Explain what is TN using the simple terms Discuss about the common triggers like chewing, speaking and ask patient to note down the activities that precede their pain Explain about the prescribed medications and their side effects Demonstrate the relaxation techniques like deep breathing or gentle facial massage

60. Nursing Interventions (cont..) 9.To prevent from eye injury Educate the patient about the importance of protecting their eyes due to reduce sensation Advise them to avoid rubbing their eyes Encourage foe regular eye check up by ophthalmologist to monitor eye health, especially due to potential corneal sensation reduction

61. Nursing Interventions (cont..) Instruct patient to use lubricating eye drops as prescribed Instruct patient to use eye patch or shield Ø Maintain the hygiene of the patient

62. Nursing Interventions (cont..) 10.To implement strategies to avoid or minimize triggers Explain the common triggers of trigeminal pain such as eating, talking, cold air exposure Collaborate with the patient to identify the specific triggers that seem to consistently precede their TN pain episodes.

63. Nursing Interventions (cont..) Teach the patient about the relaxation techniques and stress management which helps to reduce the impact of triggers Ensure that the patient understand their prescribed medication for TN

64. Complications Morbidity associated with trigeminal nerve decompression stems from hemorrhage, infection, and possible damage to the brainstem around the area of decompression. Adverse effects of surgery include : corneal anesthesia, facial numbness outside of the trigger zone, new facial pain, facial dysesthesias , and intracranial hemorrhage (rare).

65. Complications (cont..) Anesthesia dolorosa Facial dysesthesia F acial numbness Blurred vision or chewing problems are usually temporary

66. Prognosis After the initial attack, the disorder may become inactive for months or even years. Over time, the attacks may become more frequent, more easily triggered, disabling, and may eventually require long-term medication.

67. Prognosis (cont..) Overall, the prognosis depends on the cause of the problem. If there is no underlying disease, some people find that treatment provides at least partial relief. In some patients, however, the pain may become constant and severe.

68. References Black, J.M., & Hinkle, J.L. (2009). Medical Surgical Nursing; (8 th ed.). volume-2 Reed Elsevier India Pvt. Ltd. Mandal G.N., (2016) Text book of medical surgical nursing (5 th ed.). Makalu publication house Dillibazzar , Kathmandu. Shrestha, H., Paudyal , P., & Giri , S. (2072). A textbook of Medical Surgical Nursing I & II. 2nd (ed.), Kathmandu, Nepal: Heritage Publishers & distributors Pvt. Ltd. 368-370.

69. References Smeltzer , C.S., Bare, G.B, Hinkle, L.J., & Cheever, H.K (2011). Brunner & suddarth’s Textbook of Medical – Surgical Nursing. 12th (ed.). Wolters Kluwer Pvt. Ltd; 1973-1975 https:// www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/trigeminal-neuralgia-factsheet https ://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Trigeminal-Neuralgia