Recently I had the opportunity to evaluate a 55-year old woman who complained of right side facial pain that by its description seemingly had a nerve-related origin. Her pain was daily and was most intense during the first few bites of a meal. In addition, as she brought food to her lips, (which initiates salivation), her pain greatly intensified. The pain was described as bright, sharp, and debilitating during eating and lingered even after the meal was over.
Prior to her consultation in my office she had seen a number of ENT doctors whose evaluation did not lead to a diagnosis or an effective course of treatment. All dental exams and X-rays were also negative. What then could be causing this pain problem characterized by nerves that were firing abnormally essentially sparking when stimulated? Trauma and disease had been ruled out as the source of the pain based on the patient’s pain history and complete MRI scanning.
How did I approach this mystery? There was a risk factor that needed consideration: the patient was diabetic! While many patients with diabetes experience no nerve symptoms, others have pain, tingling, and even numbness. This condition is called diabetic neuropathy. Diabetic neuropathy in fact can impact every organ in the body. Some studies have shown that 60% to 70% of patients with diabetes have some form of neuropathy and the highest rates are in those who have had diabetes for more than 25 years.
The causes of diabetic neuropathy are multiple and researchers are now studying how prolonged exposure to high blood glucose causes nerve damage. Nerve damage, however, is likely due to a combination of factors:
- Metabolic factors: high blood glucose levels, and possibly low levels of insulin
- Neurovascular factors: lead to damage of the blood vessels that carry oxygen and nutrients to nerves
- Autoimmune factors: can cause inflammation in nerves
- Lifestyle factors: smoking or alcohol use (in this case, the patient also smoked!)
So my patient’s intense facial pain was most likely glossopharyngeal neuralgia, a type of neuropathy that individuals with diabetes may develop, particularly when aggravated by chronic smoking! Glossopharyngeal neuralgia causes sudden, intense pain in the throat, mouth, tongue, jaw, ear, and neck and may be brought on by swallowing, sneezing, chewing, clearing the throat, eating spicy foods, drinking cold liquids, speaking, laughing, or coughing.
As with other neuralgic pain, the course of treatment has been to use medications to reduce the spontaneous firing of nerves in the presence of normal stimuli, in this case eating. Though glossopharyngeal neuralgias are often quite receptive to medications, my patient’s history of diabetes and long-term smoking will likely be complicating factors that will influence her ability to respond to treatment.
For more information about neuropathy and diabetes, link here.
Dr. Donald Tanenbaum is a specialist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat facial pain associated with jaw problems, TMJ, referred pain, nerve pain, and migraines. Find out more at www.tanenbaumtmj.com.