Learning Objectives
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Learn the common causes of facial pain.
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Learn the common types of painful rashes.
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Develop an understanding of varicella zoster infection.
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Learn the clinical presentation of shingles.
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Develop an understanding of the treatment options for shingles.
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Learn the appropriate testing options to help diagnose shingles.
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Learn to identify red flags in patients who present with acute facial pain.
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Develop an understanding of postherpetic neuralgia.
Renaldo Saldana
I asked Renaldo about any antecedent trauma to the forehead and he just shook his head. “Doc, this kind of snuck up on me. Like I said, at first, my forehead began aching and then I woke up with this crazy rash. But, like I also said, I gotta work.” I asked Renaldo what made his pain worse and he said, “Anytime I forget and touch my forehead, it really hurts.” He added, “You know, Doc, the other crazy thing is that if the fan in my room blows on my forehead, I get these sharp pains. What the hell is that about?”
I asked Renaldo to point with one finger to show me where it hurts the most. He pointed to the rash over his left eye, taking care not to touch the area. “Doc, I can’t really point to one place. It kind of hurts all around my left eye and my forehead, and another crazy thing is, sometimes I feel like my hair hurts.” I asked if he had any fever or chills and he shook his head no. I then asked, “What about steroids? Did you ever take any cortisone or drugs like that?” Renaldo again shook his head no. He denied any cancer or human immunodeficiency virus (HIV). Renaldo said, “Doc, you know me, I am happy and healthy,” but with a worried look, he added, “This really has me freaked out. I really need your help!”
On physical examination, Renaldo was afebrile. His respirations were 18 and his pulse was 84 and regular. His blood pressure (BP) was slightly elevated at 144/88. I made a note to recheck it again before he left because he was pretty anxious. He had obvious vesicular lesions over the left eye. He had no lesions in his ear and both his eyes looked normal. His cardiopulmonary examination was unremarkable other than the mild hypertension. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema or adenopathy. His low back examination was unremarkable. I did a rectal exam, which revealed no mass and a normal prostate. The remainder of Renaldo’s physical examination was within normal limits.
Key Clinical Points—What’s Important and What’s Not
The History
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A history of left forehead pain, which occurred prior to the onset of vesicular rash
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No history of acute trauma
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No history of previous significant facial pain
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No fever or chills
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Acute onset of vesicular pain in the distribution of the left ophthalmic branch of the trigeminal nerve (V1) following the onset of forehead pain
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Allodynia when the affected area is blown on by a fan
The Physical Examination
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The patient is afebrile
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Obvious vesicular rash in the distribution of the left ophthalmic branch of the trigeminal nerve (V1) (see photo of Renaldo Saldana)
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No auricular lesions bilaterally
Other Findings of Note
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Slightly elevated BP
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Normal head, eyes, ears, nose, throat (HEENT) examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal prostate examination
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No adenopathy
What Tests Would You Like to Order?
The following tests were ordered:
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Complete blood count
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Chemistry profile
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Enzyme-linked immunosorbent assay (ELISA) test for HIV
Test Results
All testing was within normal limits.
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Acute herpes zoster of the first division of the trigeminal nerve on the left
The Science Behind the Diagnosis
Anatomy of the Trigeminal Nerve
The trigeminal nerve is the fifth cranial nerve and is denoted by the Roman numeral V. The trigeminal nerve has three divisions and provides sensory innervation for the forehead and eye (V1, ophthalmic), cheek (V2, maxillary), and lower face and jaw (V3, mandibular), as well as motor innervation for the muscles of mastication ( Fig. 1.1 ). The fibers of the trigeminal nerve arise in the trigeminal nerve nucleus, which is the largest of the cranial nerve nuclei. Extending from the midbrain to the upper cervical spinal cord, the trigeminal nerve nucleus is divided into three parts: (1) the mesencephalic trigeminal nucleus, which receives proprioceptive and mechanoreceptor fibers from the mandible and teeth; (2) the main trigeminal nucleus, which receives the majority of the touch and position fibers; and (3) the spinal trigeminal nucleus, which receives pain and temperature fibers.
The sensory fibers of the trigeminal nerve exit the brainstem at the level of the midpons with a smaller motor root emerging from the midpons at the same level. These roots pass in a forward and lateral direction in the posterior cranial fossa across the border of the petrous bone. They then enter a recess called Meckel’s cave, which is formed by an invagination of the surrounding dura mater into the middle cranial fossa. The dural pouch that lies just behind the ganglion is called the trigeminal cistern and contains cerebrospinal fluid.
The gasserian ganglion is canoe shaped, with three sensory divisions: (1) the ophthalmic division (V1), which exits the cranium via the superior orbital fissure; (2) the maxillary division (V2), which exits the cranium via the foramen rotundum into the pterygopalatine fossa, where it travels anteriorly to enter the infraorbital canal to exit through the infraorbital foramen; and the mandibular division (V3), which exits the cranium via the foramen ovale anterior convex aspect of the ganglion ( Fig. 1.2 ). A small motor root joins the mandibular division as it exits the cranial cavity via the foramen ovale. Three major branches emerge from the trigeminal ganglion (see Fig. 1.2 ). Each branch innervates a different dermatome. Each branch exits the cranium through a different site. The first division (V1; ophthalmic nerve) exits the cranium through the superior orbital fissure, entering the orbit to innervate the globe and skin in the area above the eye and forehead.
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