M2 ANATOMY

As a third year medical student, you are working at a rural clinic in northern Michigan. One morning while you are seeing patients, a dentist who is working at the same clinic asks you if you would like to see an interesting case with him. You readily agree, and the two of you proceed to a treatment room where a patient is seated in the dental chair. After the dentist introduces you to the patient, the dentist tells you that the patient is 54 years old and that she has been a patient of his for nearly 20 years. The woman smiles, but immediately groans and puts her hand to her left cheek. “Oh, I’m so sorry!” she apologizes. “I can’t seem to even smile or talk anymore without having this terrible pain.” You tell the patient that you are sorry for the pain she is experiencing. The dentist you are with nods, and then he asks the patient if she would be willing to give you a brief history of her present illness.

The patient generously agrees to give a detailed account of her illness. As you listen to her recount the course of her medical challenges, you learn that 3 years ago she started to experience short episodes of intense, shooting, electrical pain in her lower left face. Initially the pain only lasted a few brief seconds and seemed to come on randomly. Over time, however, the painful episodes lasted longer, sometimes for several minutes or even an hour. These longer episodes of attack eventually would end up persisting for weeks at a time. Early on, her dentist and physician suspected that she might be experiencing a herpes zoster infection, but no herpetic lesions ever appeared. For the first couple years the painful episodes were very intermittent with long periods of no symptoms between episodes. For the past 6 months, however, the patient’s symptoms have returned and have not gone away. Instead, they have intensified. New triggers have begun to elicit the pain, including makeup application and removal, face washing, teeth brushing, and even eating and speaking. 

When the patient has finished giving you her history, the dentist tells you that a complete head and neck exam was performed upon the patient’s initial presentation with symptoms. No dental or medical pathologies were discovered, and eventually it was determined that infectious causes, including herpes zoster, were unlikely. An MRI was performed, and it showed venous compression of the trigeminal nerve at the base of the brain. The dentist tells you that he and the patient’s physician work together to manage her symptoms, but the anticonvulsant therapy (carbamazepine) she has been taking has not been adequately controlling her pain as of late. 

The dentist then asks you what the next steps of treatment might be for his patient. You tell him that it sounds like she might need to explore more invasive options such as microvascular decompression surgery. He nods in agreement and tells you that you are correct. He tells you that both he and the patient’s physician have spoken with her about the procedure and have explained the potential benefits and risks (including stroke, hearing loss, and facial numbness). As the dentist is speaking to you, the patient is nodding her head in agreement. She interrupts the dentist to tell you that she has been getting excellent care, but she is definitely at the point where she needs something more in order to maintain her quality of life.