Sinogenic Facial Pain: Diagnosis and Management

Facial pain: sinus or not?

Facial pain remains a diagnostic and therapeutic challenge for both clinicians and patients. In clinical practice, patients suffering from facial pain generally undergo multiple repeated consultations with different specialists and receive various treatments, including surgery. Many patients, as well as their primary care physicians, mistakenly attribute their pain as being due to rhinosinusitis when this is not the case. It is important to exclude non-sinus-related causes of facial pain before considering sinus surgery to avoid inappropriate treatment. Unfortunately, a significant proportion of patients have persistent facial pain after endoscopic sinus surgery (ESS) due to erroneous considerations on aetiology of facial pain by physicians. It should be taken into account that neurological and sinus diseases may share overlapping symptoms, but they frequently co-exist as comorbidities. The aim of this review was to clarify the diagnostic criteria of facial pain in order to improve discrimination between sinogenic and non-sinogenic facial pain and provide some clinical and diagnostic criteria that may help clinicians in addressing differential diagnosis.

Clinical and 22-item Sino-Nasal Outcome Test symptom patterns in primary headache disorder patients presenting to otolaryngologists with "sinus" headaches, pain or pressure

BACKGROUND

The objective of this work was to study patient and 22-item Sino-Nasal Outcome Test (SNOT-22) characteristics in primary headache disorders (PHDs).

METHODS

Retrospective chart review of "sinus" headache/pressure/pain patients was conducted. Patients that had rhinosinusitis excluded (negative endoscopy/computed tomography [CT]), and neurologist-confirmed PHD were studied. Patterns in symptom and SNOT-22 items were analyzed by network visualization and cluster analysis.

RESULTS

Forty-six patients met study criteria. Forty-three (93.5%) reported "need to blow nose" and 40 (86.9%) reported postnasal drainage. Sneezing was reported by 37 (80.4%) patients, "blockage/congestion of nose" by 33 (71.8%), and "runny nose by 32 (69.6%) patients. The median SNOT-22 score was 54 (interquartile range [IQR], 40 to 63). Past history included neurological diagnoses (60%), rhinologic disease (39%; chronic rhinosinusitis [CRS], rhinitis, recurrent acute sinusitis), asthma (28%), and allergen-sensitivity (26%). Previous sinonasal surgery had been performed in 41%. Network layout and cluster analysis identified 2 patient clusters and 2 symptom clusters. Two-thirds (31) of patients formed a tight cluster (cluster 1) linking to a symptom cluster of psychosocial items wrapped tightly with "facial pain/pressure." The remaining one-third of patients (cluster 2) linked to rhinologic symptoms loosely grouped away from "facial pressure/pain." In contrast to patients in cluster 2, patients in cluster 1 were predominantly female (p < 0.04), had significantly higher (p < 0.0001) median SNOT-22 scores (60 vs 34; IQR, 53 to 67 vs 17 to 42), were more likely to have migraine history (p = 0.058), and reported being "sad" (p < 0.0001) or "embarrassed" (p < 0.006).

CONCLUSION

Prominent rhinologic symptoms can be present in PHD patients in the absence of rhinosinusitis. In particular, high symptom-burden/SNOT-22 scores and high psychosocial symptoms should raise suspicion of PHD when endoscopy and/or CT results do not correlate with symptoms.

Comprehensive management of patients presenting to the otolaryngologist for sinus pressure, pain, or headache

OBJECTIVES/HYPOTHESIS

To study differential diagnosis and efficacy of management strategies in patients presenting to an otolaryngologist for sinus pressure, pain, or headache.

STUDY DESIGN

Retrospective analysis at an academic medical center.

METHODS

Patients were seen in the clinic (2010-2012) for sinus-related headache, pressure, pain or fullness (study symptoms) by a rhinologist. A retrospective chart review of patients with study symptoms was conducted.

RESULTS

Of 211 patients with study symptoms, 70.62% met American Academy of Otolaryngology-Head and Neck Surgery criteria for sinusitis or had rhinologic disease. Otolaryngic therapy alone (medical or surgical) relieved study symptoms in 51.66%; combined neurology intervention helped another 15.17%. Nearly half of the patients (48.82%) were diagnosed with primary headache disorders. Comorbid rhinologic-neurologic disease was present in 27.96% and odontogenic disease in 7%. Initial otolaryngology referral was likely unnecessary for 36.49% of the study patients. Sinus computed tomography (CT) was available for 91% of 211 patients, and 80% of scans were positive. Endoscopic sinus surgery (ESS) was used in only 80/211 patients (37.69%) and was effective in 66/211 (31.28%). ESS was most successful in patients receiving concurrent neurological intervention. The Lund-Mackay CT score did not predict outcomes from ESS. Interdisciplinary otolaryngology-neurology efforts resulted in a positive outcome for 92.4% of patients.

CONCLUSIONS

We present the first series detailing management of patients with sinus-headache pain in an otolaryngology practice. Such symptoms have multifactorial etiologies. Positive sinus CT results require cautious interpretation. ESS should be judiciously used. Interdisciplinary care is critical for success: approximately 50% of patients benefited from otolaryngic management, 50% needed neurological treatment, and 7% required dental disease management.

LEVEL OF EVIDENCE

4.

Solitary chemosensory cells and bitter taste receptor signaling in human sinonasal mucosa

BACKGROUND

Solitary chemosensory cells (SCCs) are specialized cells in the respiratory epithelium that respond to noxious chemicals including bacterial signaling molecules. SCCs express components of bitter taste transduction including the taste receptor type 2 (TAS2R) bitter taste receptors and downstream signaling effectors: α-Gustducin, phospholipase Cβ2 (PLCβ2), and transient receptor potential cation channel subfamily M member 5 (TRPM5). When activated, SCCs evoke neurogenic reflexes, resulting in local inflammation. The purpose of this study was to test for the presence SCCs in human sinonasal epithelium, and to test for a correlation with inflammatory disease processes such as allergic rhinitis and chronic rhinosinusitis.

METHODS

Patient demographics and biopsies of human sinonasal mucosa were obtained from control patients (n = 7) and those with allergic rhinitis and/or chronic rhinosinusitis (n = 15). Reverse transcription polymerase chain reaction (RT-PCR), quantitative PCR (qPCR), and immunohistochemistry were used to determine whether expression of signaling effectors was altered in diseased patients.

RESULTS

RT-PCR demonstrated that bitter taste receptors TAS2R4, TAS2R14, and TAS2R46, and downstream signaling effectors α-Gustducin, PLCβ2, and TRPM5 are expressed in the inferior turbinate, middle turbinate, septum, and uncinate of both control and diseased patients. PLCβ2/TRPM5-immunoreactive SCCs were identified in the sinonasal mucosa of both control and diseased patients. qPCR showed similar expression of α-Gustducin and TRPM5 in the uncinate process of control and diseased groups, and there was no correlation between level of expression and 22-item Sino-Nasal Outcomes Test (SNOT-22) or pain scores.

CONCLUSION

SCCs are present in human sinonasal mucosa in functionally relevant areas. Expression level of signaling effectors was similar in control and diseased patients and did not correlate with measures of pain and inflammation. Further study into these pathways may provide insight into nasal inflammatory diseases and may offer potential therapeutic targets.

The aetiology underlying sinus headaches

OBJECTIVE

Patients with sinus headaches usually complain of pain and pressure sensation around the sinuses and periorbital area; most are misdiagnosed with sinusitis and receive unnecessary treatment. This prospective study investigated the aetiology of sinus headache in patients with negative endoscopic or computed tomography (CT) scan findings.

METHODS

This multicentre study included patients who could be followed regularly after being admitted to otorhinolaryngology outpatient or emergency units due to sinus headache, in whom endoscopic and radiological examinations did not show sinonasal pathology. The study group comprised patients with primary headache, according to International Headache Society criteria. Participants were followed monthly for 3 months and treatment response was evaluated as complete remission, partial remission or no response.

RESULTS

The study included 98 patients. The main reason for diagnosing and treating sinus headaches that arose from neurovascular events was attributed to the accompanying symptoms, e.g. nasal obstruction, nasal discharge and sinus sensitivity.

CONCLUSIONS

A better understanding of vascular event-derived headaches (especially migraine) and a detailed examination of patients via endoscopy and CT scanning are expected to minimize misdiagnosis rates, in patients with sinus headaches.

Causes of headache in patients with a primary diagnosis of sinus headache

Headache is a common occurrence among the general population. Although the pain could be a symptom of acute sinusitis, chronic sinusitis is not considered as a usual cause of headache. In addition, autonomic-related symptoms in the sinonasal region may be associated with vascular pain. Confusion regarding these symptoms could lead to an incorrect diagnosis of sinusitis. A prospective cross-sectional study was conducted at two tertiary referral centers with residency programs in otorhinolaryngology, head and neck surgery and neurology. The study included 58 patients with a diagnosis of "sinus headache" made by a primary care physician. Exclusion criteria were as follows: previous diagnosis of migraine or tension-type headache; evidence of sinus infection during the past 6 months; and the presence of mucopurulent secretions. After comprehensive otorhinolaryngologic and neurologic evaluation, appropriate treatment was started according to the final diagnosis and the patient was assessed monthly for 6 months. The final diagnoses were migraine, tension-type headache and chronic sinusitis with recurrent acute episodes in 68, 27 and 5% of the patients, respectively. Recurrent antibiotic therapy was received by 73% of patients with tension-type headache and 66% with migraine. Sinus endoscopy was performed in 26% of the patients. Therapeutic nasal septoplasty was performed in 16% of the patients with a final diagnosis of migraine, and 13% with tension-type headache. Many patients with self-described or primary care physician labeled "sinus headache" have no sinonasal abnormalities. Instead, most of them meet the IHS criteria for migraine or tension-type headache.

Sinus headaches: avoiding over- and mis-diagnosis

'Sinus headache' is a term used by many patients and primary-care physicians and, contrary to popular belief, sinus headaches are uncommon. Headaches that are due to sinusitis are confined to a minority of patients who have acute frontal sinusitis or sphenoiditis. The International Headache Society classification is robust in qualifying the term sinus headache and says that "chronic sinusitis is not validated as a cause of headache and facial pain unless relapsing into an acute stage". The vast majority of people who present with a symmetrical frontal or temporal headache, sometimes with an occipital component, have tension-type headache. Unilateral, episodic headaches are often vascular in origin. The idea that sinusitis can trigger migraine is misplaced, as the whole symptom complex is vascular and coexisting nasal congestion is due to vasodilation of the nasal mucosa that is sometimes part of the vascular event. The use of nasal endoscopy and imaging of the paranasal sinuses have advanced our appreciation that these patients are suffering from a vascular event. When these patients are asked to attend a clinic when they are symptomatic, the vast majority are found not to have a sinus infection. Sinusitis rarely causes headache, let alone facial pain, except when there is an acute bacterial infection when the sinus in question cannot drain, and it is usually unilateral due to increased pressure and inflammation caused by pus trapped within the sinus cavity. These patients usually have a history of a viral upper respiratory infection immediately before this and they have pyrexia with unilateral nasal obstruction. The vast majority of patients with acute sinusitis respond to antibiotics. Recurrent bacterial sinusitis is rare and anyone with more than two episodes of genuine bacterial sinusitis in 1 year should be investigated for evidence of poor immunity. Patients with chronic bacterial sinusitis rarely have any pain unless the sinus ostia are blocked and their symptoms are then the same as in acute sinusitis. Within the medical literature, there are texts that report that sphenoid sinusitis can cause headaches and, as with other acute sinus infections, intracranial or ophthalmolgical complications can occur. First, acute sphenoid sinusitis is rare and second, most of these patients respond to antibiotics. Batotrauma can cause short-lived pain in the sinus involved but there is always a clear history associated with diving or flying and, as the pressure within the sinus equalizes, the pain resolves within a few hours. Headaches are rarely due to sinusitis.

Chronic daily headache: when to suspect sinus disease

Migraine may be responsible for many headaches thought to be caused by the sinuses. Patients complaining of "sinus headache" must have a complete ear, nose, and throat examination. Occasionally, chronic headaches may arise from the sinuses; a thorough history is important to search for symptoms of facial pain and pressure along with other nasal sinus symptoms.