Facial pain after thyroidectomy
Short summary
A 47 years old female underwent total thyroidectomy for papillary carcinoma of the thyroid, followed by treatment with radioactive Iodine (I131).
Since then, the patient has been suffering from severe facial pain (left>right), dry mouth and recurrent local infections. She was diagnosed with bilateral sialadenitis, and was repeatedly treated with endoscopy and repeat washing. Medical treatment for neurogenic pain wasn't helpfull, as well as visits to different salivary gland specialists.
Patient's questions
1. What is the reason of the pain?
2. What are the possible treatments for this disorder?
2. Does salivary gland excision is an option?
Medical Background
A 47 years old female.
Current list of diagnoses:
S/P Papillary Carcinoma of thyroid.
S/P Total Thyroidectomy.
S/P Radioactive Iodine Treatment.
Bilateral Sialadenitis.
Facial Pain.
18 months ago, the patient underwent total thyroidectomy for papillary carcinoma of the thyroid, followed by treatment with radioactive Iodine (I131).
Since then, the patient has been suffering from severe facial pain (left>right) due to salivary gland damage (bilateral sialadenitis). Dry mouth and recurrent local infections was repeatedly treated with endoscopy and repeat washing.
Medical treatment with Carbamazepine (200mg/day) was initially helpful but was stopped due to an allergic reaction. Treatment with Amitriptyline (10mg/day) and Baclofen (10mg/day) were not effective. Recently treatment with Gabapentin was initiated, but it is too early to say if it helpful.
According to the patient, neurological examination was uninformative and repeated visits to different salivary gland specialists were not helpful.
Medical opinion
Summary of clinical presentation:
The patient complains of bilateral facial pain 18 months following thyroidectomy for papillary thyroid cancer. The thyroidectomy was followed by radioactive iodine treatment. According to the note included in this review, the patient was diagnosed with chronic sialadenitis. The pain persisted despite medical therapy. In addition, the patient mentioned that she consulted several salivary gland specialists who told her that "nothing can be done to help her".
Diagnosis:
Bilateral facial pain following thyroidectomy and radioactive iodine therapy for papillary thyroid cancer.
Recommendation:
The etiology of the pain cannot be determined from the short history provided in this review. The differential diagnosis included muscular pain, neurogenic pain, carotidynia, and sialadenitis. It is not likely for papillary thyroid cancer to cause neuropathic pain or lead to perineural metastasis. However, if metastatic or loco-regional cancer is ruled out, then the diagnosis can be focused on neuralgia, muscular pain, carotidynia and sialadenitis. The patient was tried on medical therapy for neurogenic pain but symptoms persisted. I am unsure on how the diagnosis of sialadenitis was established: did the patient complain of recurrent parotid and / or submandibular gland swelling? Was she noted to have sialolith? Are the salivary glands enlarged on physical examination? Are the salivary glands tender? What is the location and distribution of the pain? Is the pain constant or episodic? And if episodic, how long does it last and what precipitates it? Is the pain dull, throbbing, or sharp shooting?
In summary, definite treatment recommendation cannot be provided based on the limited information in this review. A more detailed work-up is needed. Treatment is dictated by the diagnosis and the severity of the pain. Salivary gland excision should be the last resort and only considered if there are definite localized findings in one salivary gland.
