Sinusitis is characterized by headache, nasal obstruction, rhinorrhea, fever, and malaise (Table 16-1). In children headache is an uncommon presentation. The sinuses most frequently involved are the maxillary sinuses in children and adults. Their involvement, however, usually is associated with ethmoid sinusitis or even with pansinusitis. The disease can be acute, subacute, or chronic in presentation.

Frontal sinus barotrauma most commonly presents with pain following an airplane flight, diving, or use of a high-speed, highrise elevator. Other sinuses are less commonly affected by barotrauma. The pain of barotrauma often radiates to the maxillary sinus. Treatment is directed at relief of the obstruction and management of any superimposed infection.

Mucocele of the paranasal sinuses is an uncommon entity that sometimes causes maxillofacial pain. It is a benign, encapsulated, mucus-filled mass that produces pain by impinging on or displacing contiguous structures. Headache is the most common symptom. Infection of a mucocele (pyocele) often gives the same distribution of pain as occurs with acute sinusitis.

Paranasal sinus neoplasms do not consistently cause pain. Neoplasms of the frontal, ethmoidal, and sphenoidal sinuses are
uncommon, and the symptoms tend to resemble those of chronic infection. The most common malignant tumor is squamous cell carcinoma of the maxillary antrum. This lesion has a high propensity for invasion and destruction of surrounding tissues. Hypesthesia over the infraorbital nerve is more common with carcinoma of the maxillary antrum. Pain or hypesthesia usually is caused by direct compression of the nerve or infection within the sinus. Neural symptoms occur in the distribution of the affected nerve (infraorbital symptoms with involvement of the orbital floor and nasal or retrobulbar symptoms with high lateral nasal wall involvement or posterior wall invasion).

Trigeminal neuralgia (tic douloureux) is essentially a sharp, shooting, or needlelike pain in a persistent or recurrent form. It is usually induced by means of palpation of one or more trigger zones, such as brushing the teeth or touching the cheek. It may affect one or several divisions of the trigeminal nerve, but the second (maxillary) and third (mandibular) division are most commonly involved. Most cases are unilateral. The condition typically begins in the fourth to sixth decades of life and occurs more commonly among women. If there is sensory alteration in association with the severe pain, a destructive or neoplastic lesion must be considered.

At present, most patients are successfully treated pharmacologically, usually with carbamazepine alone or in combination with baclofen. Regional nerve extirpation (peripheral), cryosurgery of the peripheral nerve, and glycerol ganglion injection are all effective for refractory cases. Patients aged <40 years with presumptive tic should be evaluated for multiple sclerosis.

Sphenopalatine neuralgia (Sluder’s syndrome) is unilateral facial pain associated with vasomotor abnormalities such as lacrimation, rhinorrhea, and salivation. It may radiate to the eye, nose, palate, maxillary teeth, ear, temple, and zygoma. In describing the distribution of pain, most patients place the heel of the palm over the orbit with the fingers extending back over the temple to indicate the path of radiating pain. A useful diagnostic test involves topical application or local infiltration of an anesthetic in the area of the sphenopalatine ganglion (near the posterior end of the middle turbinate). Relief of symptoms confirms the diagnosis. Management of the condition is controversial, although sphenopalatine ganglion neurectomy offers symptomatic relief.

Glossopharyngeal neuralgia presents with unilateral throat pain with radiation to the ear, posterior tongue, or soft palate. The pain is usually severe and paroxysmal, but it may be constant. Pharyngeal or aural trigger zones may be present. Associated symptoms include ipsilateral rhinorrhea, salivation, coughing, and facial burning. The diagnosis is confirmed by means of topical application of an anesthetic to the lateral pharyngeal wall during an attack. Among patients aged <30 years, an organic cause such as viral infection, arachnoiditis, or styloid elongation (Eagle syndrome) is a distinct possibility. Among older patients, oropharyngeal tumors must be considered. Treatment is usually palliative, but in severe cases alcohol injection or nerve resection may be successful.

Postherpetic neuralgia is a painful condition that occurs after attacks of herpes zoster. The symptoms are similar to those of trigeminal neuralgia. Although any sensory nerve may be affected, the pain is usually along the ophthalmic division of the trigeminal nerve, which is the division least commonly affected by tic douloureux. Symptoms usually last 2 to 3 weeks but can persist longer, especially among older patients. A history of vesicular skin lesions before the onset of the neuralgia confirms the diagnosis.

Trotter’s syndrome, also referred to as the sinus pain of Morgagni’s syndrome, is usually caused by neoplastic invasion of the lateral nasopharyngeal wall. Symptoms include unilateral deafness, pain of the mandibular division of the trigeminal nerve, ipsilateral palate hypomotility, and subsequent trismus.

Pterygopalatine fossa syndrome is caused by metastasis to the pterygopalatine fossa, and involves the maxillary division of the fifth cranial nerve. The patient reports pain in the maxillary teeth and infraorbital and palatal anesthesia. Signs of the syndrome may include blindness and neuromuscular paralysis of the pterygoid muscles.