Infraorbital Neuralgia: Clinical Presentation and Management
Infraorbital neuralgia presents with electric shock-like, throbbing, or stabbing pain localized to the cheek, nasal wing, and upper teeth (lateral incisor, canine, first premolar) in the distribution of the infraorbital nerve, with tenderness over the infraorbital foramen being pathognomonic. 1, 2
Signs and Symptoms
Pain Characteristics
- Electric shock-like, throbbing, or stabbing pain in the mid-face region, specifically affecting the cheek, nasal wing, and upper anterior teeth 1
- Pain typically scores 8-9/10 on numeric rating scales in untreated cases 1
- Can present with chronic or intermittent patterns 2
- Pain is localized to the distribution of the infraorbital nerve (V2 branch of trigeminal nerve) 3, 1
Physical Examination Findings
- Tenderness on palpation of the infraorbital foramen is a hallmark finding 2
- The infraorbital foramen can be located by palpating the cheek just lateral to the nose in the horizontal plane 3
- Hypoesthesia to touch and pain in the infraorbital region may develop after nerve blocks 3
Diagnostic Confirmation
- Absolute but transitory relief of symptoms upon infraorbital nerve blockade with local anesthetic confirms the diagnosis 2
- A diagnostic block with 1% lidocaine should provide immediate pain relief if the diagnosis is correct 1
- Persistence of protracted unilateral facial pain with tenderness over the nerve and response to blockade strongly suggests infraorbital neuralgia 2
Treatment Approach
First-Line Treatment
Ultrasound-guided infraorbital nerve block with steroid and local anesthetic combination is the recommended initial interventional treatment. 1, 4
- Perform diagnostic block first with 1% lidocaine (0.5-1.5 mL) to confirm diagnosis 1
- If successful, proceed with therapeutic block using 15 mg lidocaine plus 1.5 mg dexamethasone in 1.5 mL total volume 1
- Repeat the therapeutic block twice within one month for optimal results 1
- This approach can provide pain relief lasting 21 months or longer 1
Ultrasound-Guided Technique
- Position patient supine with face sterilized and draped 3
- Use 6-13 MHz linear ultrasound probe with sterile cover 3
- Place probe horizontally on cheek beside nose and slide cranially to identify the infraorbital foramen dimple 3
- Insert 25G 25mm needle from caudal side using out-of-plane approach 3
- Confirm needle placement and medication spread around nerve with real-time ultrasound visualization 3
Alternative Treatment for Refractory Cases
For patients who fail conservative nerve blocks, pulsed radiofrequency (PRF) treatment under CT guidance is effective and safe. 5
- PRF achieves 69% effectiveness at one month, with 50% maintaining relief at two years 5
- Higher output voltage during PRF correlates with better outcomes 5
- CT guidance ensures precise needle placement at the infraorbital foramen 5
When Medical Management Fails
- Surgical treatment can be considered only after medical and interventional treatments have failed 2
- Results are better in previously untreated patients compared to those who have undergone prior surgery 4
- Transcutaneous nerve stimulation or tricyclic antidepressants may be added for incomplete relief 4
Common Pitfalls and Caveats
Avoid These Mistakes
- Do not proceed directly to surgery without attempting nerve blocks first - results are significantly worse in patients with prior surgical attempts 4
- Do not use carbamazepine as sole therapy if side effects develop; proceed to interventional treatment 3, 1
- Ensure adequate follow-up as pain may recur in new trigger points outside the infraorbital distribution within one week 3
Expected Side Effects
- Small hematomas in the cheek may occur but resolve within one week 3
- Mild numbness lasting up to one month is common but not concerning 5
- Serious complications (paresthesia, hyperpathia, dysesthesia, double vision) are rare with proper technique 3