面部疼痛的鉴别诊断和治疗指南（二）

 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。

Approach to facial pain diagnosis

History and examination

To make an accurate diagnosis it is essential to listen to thehistory and allow time for the patient to complete theiropening statement. The pain history needs to includedetails on:

• Timing: onset, duration, and periodicity.

• Location and radiation (e.g. within nerve distribution).

• Quality and severity.

• Relieving and aggravating factors (e.g. effect of hot,cold sweet foods, prolonged chewing, eating, brushingof teeth, touching the face, weather, physical activity,posture, stress, and tiredness).

• Associated factors (e.g. taste, salivary flflow, clenching,bruxing habits, locking or clicking of jaw joint, alteredsensation, nasal, eye, or ear symptoms).

• Other pain conditions (e.g. headaches, migraines,chronic widespread pain, and fifibromyalgia).

• Impact of pain (e.g. sleep, mood, concentration, fatigue,beliefs, and quality of life).

面部疼痛的诊断方法

病史和体检

要做出准确的诊断，必须听取病史，并留出时间让病人完成他们的完整陈述。病史需要包括以下细节：

• 时间方面:发病时间、持续时间和周期性

• 位置和放射（如神经分布）

• 严重程度

• 缓解和加重的因素(例如热的、冷的甜的食物、长时间咀嚼、进食、刷牙、摸脸、天气、身体活动、姿势、压力及疲倦)。

• 相关因素(如味觉、唾液、咬合、摩擦习惯、下颌关节绞索或弹响、感觉改变、鼻、眼或耳症状)。

• 其他疼痛情况(如头痛、偏头痛、慢性广泛性疼痛和纤维肌痛)。

• 对疼痛的影响因素(如睡眠、情绪、注意力、疲劳、信念和生活质量)。

As with all chronic pain, psychological assessment, familyhistory (e.g. TMDs have a genetic predisposition), socialhistory, and signifificant life events need to be determined.It is useful to ascertain the healthcare professionals theyhave accessed including complementary and alternativemedicine practitioners. A full drug history is important anda past and present medical history.

与所有慢性疼痛一样，需要心理评估、家族史(例如TMD有遗传倾向)、社会关系和重要的生活事件。需要了解患者就诊过的科室。完整的用药史以及过去和现在的病史都很重要。

Extraoral examination is confifined generally to the headand neck region. Visual inspection will show up any colourchanges, swellings, and skin lesions. Palpation of lumps orsalivary glands may be indicated in some circumstances.Examination includes the muscles of mastication, head andneck muscles for tenderness and trigger points, musclehypertrophy, and movement of the temporomandibularjoint including crepitus. The cranial nerves need to be examined. Intraoral examination includes the hard tissues andteeth for obvious dental pathology including decay, mobileteeth, excessive wear facets (indicating bruxism), occlusion,ability to open and fifixed, and removal appliances. The oralmucosa is examined for soft tissue lesions.

口外检查一般局限于头颈部。肉眼检查可以发现皮肤颜色变化、肿胀和皮肤损伤。在某些情况下可触及肿块或唾液腺。体格检查包括咀嚼肌、头颈部肌肉有无压痛和触发点、肌肉肥大、颞下颌关节的运动情况，包括捻发音。需要检查颅神经。口腔内检查包括牙齿的问题，包括龋齿、可移动的牙齿、过度磨损的小面(表明磨牙症)、咬合、张口和保持张口的能力和咬东西。检查口腔黏膜是否有软组织损伤。

Investigations

As pain is subjective, it is useful to use questionnaires to helpin assessment and monitoring of effects of therapy. Questionnaires such as the Brief Pain Inventory, Beck DepressionInventory, Hospital Anxiety and Depression Scale, McGillPain Questionnaire, and Oral Impacts on Daily Performance(OHIP) have all been well validated and are sensitive. Laboratory investigations are not of great importance, except in thepotential diagnosis of cranial arteritis and for auto-immunedisorders such as Sjogren’s syndrome. Imaging is especiallyimportant for dental pain and consists mainly of localX-rays which can be carried out in every dental practice.Dental panoramic tomographs are very useful for bonylesions or cysts and are available in most hospitals butalso in larger dental practices (for further details, see e.g. Zakrzewska4). Salivary gland diseases are best investigated usingultra sound. Magnetic resonance imaging (MRIs) and computerized tomography (CTs) are indicated in some conditions.

检查

由于疼痛是主观的，所以使用问卷来帮助评估和监测治疗效果是有用的。问卷调查，如简明疼痛量表、贝克抑郁量表、医院焦虑和抑郁量表、McGill疼痛问卷，以及口腔对日常表现的影响(OHIP)，都是有效的和敏感的。实验室检查并不重要，除了对颅动脉炎和自身免疫疾病如干燥综合征的潜在诊断。影像对牙痛尤为重要，主要由局部X光片组成，可在口腔科实践中进行。牙科全景断层摄影对骨性病变或囊肿非常有用，在大多数医院都可以使用，但在大型牙科诊所也可以使用(详情见Zakrzewska4)。唾液腺疾病最好的研究是使用超声检查。磁共振成像(MRI)和计算机断层扫描(CT)可以用于某些疾病。