Sir, an 83-year-old gentleman recently attended our OMFS department with intractable facial pain of presumed dental origin. He initially reported a 6-month history of gradually worsening pain in the upper left quadrant. This became increasingly severe and he eventually visited his dentist who assumed a dental causes and extracted 25, 26 and 27 (Fig 1.)

Figure 1
figure 1

An OPT showing 25 heavily filled, 26 distal radiolucent lesion and 37 apical radiolucent lesion

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However, following these extractions, the pain became increasingly relentless and he attended the accident and emergency department with referral to OMFS. His pain was now severe left sided pain radiating from the upper lip to the left ear. The pain was scored 10/10 and described as a sharp, electric shock like, episodic pain with a trigger point around 23, 24 region. An MRI scan was ordered which demonstrated a solid, space occupying lesion in the left cerebellopontine angle (CPA). This was reported to be causing distortion on the left trigeminal nerve. The definitive diagnosis was a meningioma1 which was impinging on the left V2 trigeminal nerve resulting in neuralgia.2 Initial management was medical treatment with carbamazepine and a neurosurgical consult was also arranged.

This case serves to highlight the importance of a thorough history and clinical examination in all cases of facial pain, together with reassessment of those patients in whom clinical symptoms do not resolve following initial treatment. In these cases, a prompt referral to the appropriate specialist (in this case OMFS) is advised for further investigations and management.

Figure 2
figure 2

Axial MRI images showing lesion in left CPA

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