12 minute consultation: Evidence based management of a patient with facial pain

Clin. Otolaryngol. 2012, 37, 207212 Background: There is a common misconception that facial pain and headache are mainly caused by sinusitis. The findings of nasal endoscopy, computer tomography (CT) and the results of observational studies reveal that this is not the case. Moreover, when sinus surgery is performed in patients where headache/facial pain has been a feature, it has been found that these symptoms persist after sinus surgery, particularly where there had been no nasal symptoms or endoscopic signs of paranasal sinusitis. Methods: This review was based on a literature search performed on 30 November 2011. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading of facial pain, that is, rhinosinusitis, migraine, cluster headaches, midsegment facial pain, trigeminal neuralgia, paroxysmal hemicrania, hemicrania continua and drug-dependent headache. The search was limited to English language articles. Relevant references from selected articles were reviewed after reading the abstract. Results: A review of the literature shows that headaches are rarely caused by sinusitis. Similarly, only a small proportion of patients with facial pain have sinusitis, and these patients have either acute sinusitis or an acute exacerbation of chronic purulent sinusitis. Importantly, most patients with chronic rhinosinusitis rarely have facial pain unless they develop an acute infection or suffer barotrauma. CT scans should not routinely be performed for facial pain because of the prevalence of incidental changes in asymptomatic patients. Surgery is very rarely indicated in the treatment for chronic facial pain. Conclusion: A structured history of the pain and its associated symptoms, nasendoscopy and relevant targeted investigations should lead to a correct diagnosis and the appropriate treatment.