Facial pressure and sinus pain

Facial pressure and sinus pain is pressure, fullness or pain over the cheeks, forehead, around the eyes or the bridge of the nose. Most cases are not bacterial sinusitis: migraine, tension type headache, rhinitis and dental disease are more frequent causes of facial pain labelled as sinus pain.

Anatomy. The paranasal sinuses (maxillary, ethmoid, frontal, sphenoid) drain through the ostiomeatal complex. Obstruction of drainage with mucosal inflammation produces pressure and pain, with pain referred by the trigeminal nerve.

Classification. Acute rhinosinusitis (under 4 weeks; viral or bacterial), subacute (4 to 12 weeks), chronic rhinosinusitis (over 12 weeks; with or without polyps), and recurrent acute rhinosinusitis (4 or more episodes each year).

Diagnostic criteria for rhinosinusitis. Nasal obstruction or discharge (anterior or posterior) plus facial pain or pressure or reduced smell, for the appropriate duration, with endoscopic or CT evidence for chronic disease.

Features favouring bacterial infection. Symptoms persisting over 10 days without improvement, worsening after initial improvement (double sickening), severe onset (fever over 39 degrees Celsius with purulent discharge and facial pain for 3 to 4 days), or unilateral maxillary pain with purulent discharge.

History. Site and character of pain, duration, course, discharge, obstruction, smell, fever, tooth pain, relation to bending forward, triggers, headache features (photophobia, nausea, aura), jaw symptoms, previous sinus disease or surgery, asthma, allergies, immunosuppression, diabetes, and dental work.

Examination. Facial tenderness (percussion over sinuses; limited specificity), nasal endoscopy (mucopus in the middle meatus, oedema, polyps), teeth (percussion tenderness), eyes (swelling, redness, proptosis, visual acuity, eye movements), cranial nerves, temporal arteries in older adults, and neck.

Red flags

• Periorbital swelling, redness, proptosis, diplopia, reduced vision or painful eye movement (orbital complication)
• Severe headache, neck stiffness, drowsiness, seizures or focal signs (intracranial complication)
• Frontal swelling or Pott puffy tumour
• Unilateral symptoms with bleeding, mass, cranial nerve palsy or numbness
• Diabetes or immunosuppression with black necrotic mucosa (mucormycosis)
• Jaw claudication, scalp tenderness or visual symptoms (giant cell arteritis)
• Persistent unilateral symptoms in a patient over 40 with weight loss

Special groups. Children: orbital complications are more frequent and adenoiditis can mimic sinusitis. Pregnancy: avoid doxycycline and fluoroquinolones. Older adults: giant cell arteritis, cancer. Region specific: fungal sinusitis and mucormycosis in poorly controlled diabetes.

Sinonasal

• Acute viral rhinosinusitis, acute bacterial rhinosinusitis
• Chronic rhinosinusitis with and without polyps
• Allergic fungal sinusitis, invasive fungal sinusitis (mucormycosis), fungal ball
• Odontogenic sinusitis
• Allergic and non-allergic rhinitis
• Sinus barotrauma, mucocele
• Sinonasal tumours, nasopharyngeal carcinoma

Complications

• Orbital cellulitis and abscess, subperiosteal abscess
• Cavernous sinus thrombosis
• Meningitis, subdural empyema, brain abscess, osteomyelitis of the frontal bone

Non-sinogenic mimics

• Migraine, tension type headache, cluster headache
• Trigeminal neuralgia, post-herpetic neuralgia
• Dental abscess and periodontal disease, temporomandibular disorder
• Giant cell arteritis, acute angle closure glaucoma
• Granulomatosis with polyangiitis, sarcoidosis
• Atypical facial pain and depression

Reasoning. Diagnose acute rhinosinusitis clinically and treat conservatively unless features indicate bacterial disease or complications. Reserve imaging for chronic disease, complications, unilateral or atypical features, and surgical planning. Consider headache disorders when sinus findings are absent.

First line. Nasal endoscopy and examination of teeth and eyes. Blood tests are not needed for uncomplicated disease.

Targeted tests.

• CT sinuses without contrast for chronic disease after medical treatment, recurrent acute sinusitis, surgical planning, or suspected anatomical disease. CT is non-specific and often abnormal in asymptomatic adults; a normal CT excludes sinus disease as a cause of symptoms.
• CT with contrast and MRI orbits and brain urgently for orbital or intracranial complications. CT with venography or MR venography for cavernous sinus thrombosis.
• Nasal swab or sinus aspirate for culture in complications, immunosuppression or failure of treatment. Fungal stains and histology for suspected fungal disease.
• Full blood count, C reactive protein and blood cultures in suspected complications.
• ESR and C reactive protein for suspected giant cell arteritis. ANCA and angiotensin converting enzyme for suspected granulomatous disease. Biopsy for any mass.
• Dental assessment with panoramic radiograph or cone beam CT for suspected odontogenic disease. Intraocular pressure measurement for suspected angle closure.

Limitations. Facial tenderness and discharge colour are poor predictors of bacterial infection. Plain sinus radiographs add little.

Emergency conditions.

• Orbital or intracranial complication: admit. Give ceftriaxone 2 g IV every 12 hours (children 50 mg/kg every 12 hours, maximum 2 g) plus metronidazole 500 mg IV every 8 hours (children 7.5 mg/kg every 8 hours).
• Add vancomycin when resistant staphylococci are possible: 25 to 30 mg/kg IV loading dose, maximum 3 g, then 15 to 20 mg/kg every 8 to 12 hours adjusted to creatinine clearance and levels.
• Arrange urgent ophthalmology, ENT and neurosurgical review for drainage.
• Meningitis: dexamethasone 10 mg IV every 6 hours for 4 days, with the first dose before or with the antibiotic.
• Cavernous sinus thrombosis: IV ceftriaxone 2 g every 12 hours plus metronidazole 500 mg every 8 hours. Anticoagulation by specialist decision (enoxaparin 1 mg/kg subcutaneously every 12 hours, adjusted when creatinine clearance is under 30 mL/min).
• Mucormycosis: immediate ENT, ophthalmology and infectious disease referral; liposomal amphotericin B 5 mg/kg IV daily (up to 10 mg/kg with CNS disease), glycaemic control and urgent surgical debridement.
• Acute angle closure glaucoma: same day ophthalmology.

Acute rhinosinusitis, general measures.

Analgesia is with paracetamol 1 g orally every 4 to 6 hours, or ibuprofen 400 mg orally every 6 to 8 hours with food (maximum 2.4 g in 24 hours). The paracetamol maximum is 4 g in 24 hours; 2 g in 24 hours with weight under 50 kg, chronic alcohol use or liver disease.

Other measures are saline irrigation and an intranasal corticosteroid, with evidence of modest benefit (mometasone 50 micrograms, 2 sprays to each nostril once daily, maximum 200 micrograms daily).

A short term topical decongestant may be used (oxymetazoline 0.05 percent, 2 sprays to each nostril twice daily for no more than 3 days).

Most viral cases resolve within 10 to 14 days. Antibiotics are not needed in the first 10 days of mild illness.

Acute bacterial rhinosinusitis. Treat symptoms persisting over 10 days, double sickening or severe onset with amoxicillin 500 mg orally three times daily for 5 days (maximum 3 g daily; children 40 to 90 mg/kg daily in 2 or 3 divided doses, maximum 3 g daily).

Penicillin allergy: doxycycline 200 mg orally on day 1 then 100 mg daily for 5 days (avoid in pregnancy and under 12 years). Treatment failure at 48 to 72 hours: amoxicillin with clavulanic acid 625 mg orally three times daily for 5 to 7 days. Odontogenic sinusitis: dental treatment with antibiotics.

Chronic rhinosinusitis. Saline irrigation, intranasal corticosteroid (mometasone 50 micrograms, 2 sprays to each nostril once daily, maximum 200 micrograms daily), and allergy treatment.

For refractory disease, specialists may use high volume irrigation with budesonide 0.5 mg in 240 mL daily. For polyps, give prednisolone 30 mg orally daily for 7 to 14 days (monitor glucose, blood pressure and mood).

Doxycycline 100 mg orally twice daily for 3 weeks only by specialist decision. ENT referral for surgery after 3 months of adequate medical treatment. Biologic therapy (dupilumab, omalizumab, mepolizumab) by specialists for refractory polyp disease.

Non-sinogenic causes.

Migraine: sumatriptan 50 to 100 mg orally at onset, repeated after at least 2 hours (maximum 300 mg in 24 hours). Contraindications are ischaemic heart disease, uncontrolled hypertension, and use of ergot or monoamine oxidase inhibitors.

• Tension type headache: paracetamol or ibuprofen.
• Giant cell arteritis: prednisolone 40 to 60 mg orally each morning, aspirin 75 mg daily, and same day specialist review.
• Temporomandibular disorder: ibuprofen 400 mg orally three times daily with food for up to 2 weeks and dental review.
• Trigeminal neuralgia: carbamazepine 100 mg orally twice daily increased by 100 to 200 mg every 2 to 3 days to a usual 400 to 800 mg daily (maximum 1.6 g daily) with sodium, blood count and liver function monitoring.

Monitoring. Review at 3 to 5 days if worsening, and at 2 weeks for persistent symptoms. Reassess chronic disease at 3 months.

Referral and escalation. Same day for orbital or intracranial complications, mucormycosis, suspected giant cell arteritis with visual symptoms, or angle closure. ENT within 2 weeks for unilateral persistent symptoms, mass, bleeding or cranial nerve signs. ENT routine for chronic disease refractory after 3 months and for recurrent acute sinusitis (4 or more episodes each year).

Admission criteria. Orbital or intracranial complications, immunosuppressed or diabetic patients with suspected invasive fungal disease, severe systemic illness, or failure of oral therapy.

Discharge and safety netting. Return for eye swelling, redness, double vision or reduced vision, severe headache, fever with stiff neck, forehead swelling, drowsiness, seizure, or symptoms not improving after 2 weeks.