What are the differential diagnoses and efficacy of management strategies in patients presenting to an otolaryngologist for sinus pressure, pain, or headache?
Background: The management of patients with sinus pressure, pain, fullness, or headache is problematic, because although sinus headaches can result from sinusitis, neurogenic causes, or both, this knowledge is poorly disseminated among patients and physicians. Migraines are commonly misdiagnosed as sinusitis. Symptom-based criteria can be overly sensitive in diagnosing sinusitis and may ignore culpable neurogenic factors.
Explore this issue:April 2015
Study design: Retrospective analysis of 211 patients between 2010 and 2012 at an academic medical center.
Setting: Department of Otolaryngology and the Department of Neurology, Mayo Clinic, Phoenix, Ariz.
Synopsis: True prevalence of sinonasal disease among patients was 70.62%; chronic rhinosinusitis (CRS) was suspected in 55.92%, acute sinusitis in 12.80%, mucoceles in 1.99%, tumor in 0.95%, and odontogenic disease in 7.11%. Comorbid rhinologic-neurologic disease was present in 59 patients. Although septal contact point was seen in 26 patients, contact point headache was diagnosed in only two. Thirty-six patients had pre-existing neurological disorders. CT scan was performed or available for 192 patients; 154 were positive, and 149 of these had Lund-Mackay (LM) scores of ≥4; 38 showed fluid levels, 15 had odontogenic disease, and 90 had one or more completely/near-completely opacified sinuses. Medical therapy (MT) targeting sinonasal disease was used in 153 patients, either up front or subsequently. A purely otolaryngic intervention was successful in study-symptom improvement in 109 patients, and a combined otolaryngology-neurology approach was helpful in an additional 32 patients. Based on any positive response to any otolaryngic therapy, rhinologic disorder was estimated to be culpable in causing study symptoms in 141 patients. Neurological disorder contributory to study symptoms was confirmed in 103 patients. Combined neurology-otolaryngology effort was successful in 42 patients, and otolaryngic intervention was critical in 43.75% of these. MT was less likely to succeed with an LM score ≥10 versus those in the four to nine range. Endoscopic sinus surgery (ESS), which was used for 80 patients, was effective for only 66.
Bottom line: Symptoms were found to have multifactorial etiologies, positive sinus CT results require cautious interpretation, and ESS should be used judiciously. Interdisciplinary care is critical for success.
Citation: Lal D, Rounds A, Dodick DW. Comprehensive management of patients presenting to the otolaryngologist for sinus pressure, pain, or headache. Laryngoscope. 2015;125:303-310.
—Reviewed by Amy Hamaker