OVERVIEW
- A careful history is essential for an accurate diagnosis
- In the absence of any nasal symptoms or signs, facial pain is unlikely to be due to sinus disease
- Patients with a normal CT scan are unlikely to have pain due to rhinosinusitis (NB CT changes on their own are not diagnostic of rhinosinusitis)
- If it is not possible to make a diagnosis at the first consultation, it is helpful to ask the patient to keep a diary of their symptoms, carry out a trial of medical treatment and review
- If a patient has facial pain as well as nasal obstruction and a loss of sense of smell, which is worse with the common cold or flying, then he or she is likely to be helped by nasal medical or, if that fails, surgical treatment
- Patients with purulent secretions and facial pain are likely to benefit from treatment directed at rhinosinusitis
In patients with facial pain it is important to get the diagnosis right in order to prevent the unnecessary prescription of medication or surgery. Most people are aware that the sinuses lie behind the facial bones; therefore, it is not surprising that many believe that the cause of their facial pain is their sinuses. However, rhinosinusitis is often not the cause of facial pain.
A structured approach is essential; this can be aided by using an anatomical or pathological surgical sieve. An anatomical approach would focus the history on the site of pain, for example nose, sinus, teeth, temporomandibular joint or eyes. An alternative would be a pathological sieve, for example see Table 10.1.
Table 10.1 Pathological surgical sieve.
| Example | |
| Infection | Dental abscess, acute rhinosinusitis |
| Inflammation | Acute rhinosinusitis |
| Trauma | Fractured nose |
| Tumour | Intracranial tumours |
| Vascular | Migraine |
| Neurological | Trigeminal autonomic cephalgia, trigeminal neuralgia, tension-type headache, midfacial segment pain |
| Iatrogenic | Surgery |
| Idiopathic | Atypical facial pain |
A combination of both approaches gives the seven key catagories of facial pain; rhinological pain, dental pain, vascular pain, neruralgias, midfacial pain, atypical facial pain and pain secondary to neoplasia. A careful history is essential for correct diagnosis.
Eight questions form the basis of an algorithm that will help towards a diagnosis.
Facial pain often has some emotional significance. For some patients, facial pain may be greatly affected by emotional distress, anxiety or the psychological harm the patient associates with disease, trauma or surgery. It may sometimes be the means by which they obtain secondary gain. The presence of marked psychological overlay does not mean that there is no underlying organic problem, but it is a relative contraindication to surgical treatment. If there is a big discrepancy between the patient’s affect and the description of the pain, the organic component of the illness may be of relatively minor importance. Should the diagnosis be elusive, re-taking the history at a further consultation may be helpful, as well as asking the patient to keep a symptom diary.
Examination
This should include anterior rhinoscopy as well as endoscopic assessment of the nasal cavity, sinus ostia and postnasal space. This is frequently normal. Examination of the eyes, ears, oral cavity and face should be included as indicated from the history.
Investigations
Incidental radiological findings are common and limit the usefulness of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of facial pain. Note that a third of asymptomatic patients have incidental mucosal changes on CT, and so radiographic changes are not diagnostic of rhinosinusitis. If they are performed, any positive findings should be interpreted with caution in the light of the history and endoscopic findings.
Making the diagnosis
Infection
Nose and sinus infection
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