To be able to differentiate pain caused by sinus disease from pain caused by other diseases
To know the correct investigation and management of non-sinus facial pain
One of the common challenges for primary care doctors and ENT Surgeons alike is to differentiate between patients with facial pain due to sinus disease and that caused by a number of other muscular and neurological causes.
The job is made harder for a few reasons: patients are often convinced that the problem is in their sinuses and may start the consultation by saying so; and the symptoms of rhinitis are so common in the general public that the doctor may be led to assume, because the patient has a runny and blocked nose and facial pain, that they have sinus disease when they have two problems – rhinitis and facial pain. Occam’s razor does not always apply.
Causes of non-sinus related facial pain
There are many of these but the common and important ones are:
Facial arthromyalgia (temporomandibular joint associated pain)
Mid-facial segment pain
Other causes not dealt with here include:
This is a condition of the temporomandibular joint and its associated muscles: temporalis, masseter, and the medial and lateral pterygoids. Pain can radiate out from these sites to include the ear, and the face and forehead.
The patient will usually have a history of some of the following:
Bruxism – grinding the teeth often at night and causing increased pain first thing in the morning
Clenching the jaw during the day
Excessive use of chewing gum
Recent dental work
Facial and jaw trauma
Signs and symptoms of facial arthromyalgia:
Pain and tenderness around the TMJ
Tenderness in any of the associated muscles
Pain on movement of the jaw
Deviation of the jaw on opening and closing
Joint crepitus may be present but in isolation is not significant.
Some of the stranger symptoms that facial arthromyalgia can cause are tinnitus and dizziness.
Facial arthromyalgia is usually managed by conservative measures. Soft diet, localised heat and massage and non-steroidal pain relief will usually ease the problem. Jaw exercises can also be useful as can management of the underlying triggers for bruxism. There are surgical options for a few patients but they are outside our remit here.
This is a tension or pressure over the forehead, temples and sub-occipital areas that should be present for more than 15 days per month and for more than three months.
Patients also complain of hyperaesthesia of the skin over the same area and some tenderness.
It is a diagnosis of exclusion and treated with low dose Amitriptyline or Gabapentin.
Mid facial segment pain
This is analogous to tension headache but is in a different distribution. The diagram below shows where patients indicate their pain is. If a patient points to these areas it is important to consider the condition.
X-ray / CT images of sinus
The nose can feel blocked and the sensation lasts for hours or is continuous.
Examination of the nose will be normal and the condition does not improve with standard treatments for sinus disease.
It is treated in the same way as tension headaches.
I mention this only to say that it is difficult to confuse this disease with any of the above. Trigeminal neuralgia causes an intense, agonising, lancinating pain and is induced by a trigger point. It is commoner in the middle and lower face.
Investigation of facial pain
The majority of patient can be diagnosed from their history and examination alone. Investigation rarely helps and scanning is usually reserved for when surgery is being planned for sinus disease.
Investigating non-sinogenic pain is usually unnecessary as the diagnosis, once considered, will present itself.
MRI scan of the trigeminal cave is commonly used in cases of possible trigeminal neuralgia to look for surgically amenable vascular loops. Radiology of the temporomandibular joint and teeth is also done but is outside the scope of this course.
The non-sinus causes of facial pain are described above. The key thing to consider here is whether the patient has sinus disease or not. This can be difficult.
For example, what if the patient has rhinitis and mid-facial segment pain? This is a common occurrence as about 35% of the population have rhinitis at any one time. It follows that 35% of mid-facial pain patients also have rhinitis.
This is one reason why patients with facial pain are misdiagnosed as having sinusitis – and why they don’t respond to standard treatments for sinus disease.
Try out a short quiz on facial pain here.