CBD: Facial Pain

cASE STUDY

Clinical scenario

A 45-year-old woman presents with a year’s history of what she refers to as “sinus pain”.  She describes a heaviness and pressure that is felt across her nasal bridge and around her eyes.  It is present for a large proportion of the day and does not vary a great deal.  She finds it uncomfortable but otherwise feels well.  She takes amlodipine for hypertension and is otherwise fit and well. 

On further questioning by her GP, she has no nasal blockage, rhinorrhoea or hyposmia.  She does not smoke or drink excessive amounts of alcohol.  She drinks 8-10 cups of coffee or tea a day.  A trial of a nasal steroid spray has little effect, so the patient is referred to ENT for further assessment.

Examination with nasendoscopy shows no evidence of chronic rhinosinusitis.  The patient is diagnosed with midfacial segment pain; she is asked to decrease her caffeine consumption, and commenced on low-dose amitriptyline.  After 8 weeks of dose titration her symptoms are well controlled.

Pathology

There is a widespread misconception that facial pain is generally due to sinus pathology.  With the exception of acute or acute-on-chronic rhinosinusitis, where facial pain may accompany the acute febrile illness, this is almost always false.  The vast majority of cases of facial pain in the absence of convincing sinonasal symptoms (blockage, hyposmia, rhinorrhoea) are a variant of a headache disorder.  Similarly, most patients with moderate-to-severe chronic rhinosinusitis do not typically complain of facial pain, outside of acute infective exacerbations.  Where facial pain and chronic rhinosinusitis do co-exist, patients are warned that improvement of their facial pain is not guaranteed.

Clinical features

General Practitioners will be quite familiar with the clinical features and management of most common headache syndromes.  The commonest neurological diagnosis that causes supposed “sinus pain” is midfacial segment pain, which is similar to chronic tension headache.

Severe constant unilateral facial pain, in the absence of dental pathology, should raise suspicion of malignancy.

Midfacial segment pain/chronic tension headache

Midfacial segment pain is symmetrical, constant and non-disabling (similarly to chronic tension headache, and in contrast to migraine).  It is typically described as a dull ache or pressure, centred around the bridge of the nose, across the cheeks and/or behind the eyes. There may be an occipital or cervical component to the pain.

Migraine

Pain due to migraine is typically asymmetrical, episodic and disabling. Patients will often complain of concurrent nausea, lethargy, or dizziness. Confusingly, migraine attacks can be accompanied by nasal congestion, lending weight to the patient’s assertion that their symptoms are sinonasal in origin.  However, sinonasal symptoms rarely fluctuate in the same way, and are not generally accompanied by systemic features.

Atypical facial pain

Pain in this disorder is migratory, and variable in severity and character.  This is a diagnosis of exclusion and is frequently associated with psychological morbidity.

Cluster headache

The typical patient is a young to middle-aged man, with clusters of episodes of extremely intense headache / retro-orbital pain, characteristically accompanied by autonomic features such as conjunctival injection or rhinorrhoea.  There are no symptoms between attacks.

Management

Patients with midfacial pressure and pain should first be asked whether they have nasal symptoms (blockage, rhinorrhoea, hyposmia).  Examine the nose for features of CRS/rhinitis.  Sinus palpation is not performed, as tenderness of palpated sinuses is not a useful sign of sinus disease.

In the absence of nasal symptoms or signs, treat for the most likely headache syndrome, as per applicable guidelines.  The management of headache is beyond the scope of this article, but brief details are given below.

·      In suspected midfacial segment pain / chronic tension headache, commence amitriptyline, escalating from a low night-time dose.

·      In migraine, consider a trial of symptomatic or prophylactic treatment, depending on episode severity and frequency.

·      In suspected atypical facial pain, consider neurological referral as appropriate.

If nasal symptoms are present, or the patient is adamant that the problems is in their sinuses, ENT referral may be helpful for clarification of the diagnosis.

NB: CT of the sinuses has a high negative predictive value for excluding sinonasal disease.  However, incidental mucosal thickening/sinus opacification is seen in as much as 30% of asymptomatic patients.  Clinicians should therefore be wary of using this investigation in the diagnosis of facial pain, as a radiologically opacified sinus is very unlikely to represent the cause of the patient’s pain.

Further reading

Kamani T, Jones NS. 12 minute consultation: evidence based management of a patient with facial pain. Clin Otolaryngol. 2012 Jun;37(3):207-12.

Author: Mr Thomas Jacques, Consultant Rhinologist/ENT Surgeon, St. George’s Hospital, London