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American Pain Society
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Glenview, IL 60025
Ronald Kulich, PhD, Department Editor
Salah D. Salman, MD FACS; Biljana MiIjanovic, MD MPH
Sinusitis is one of the most common diseases in the United States, and its costs are staggering. The number of days of restricted activity as a result of sinusitis has been estimated at 73 million per year, and as many as 200,000 sinus surgeries are performed each year, with $2.4 billion in direct medical costs, not including surgery (Geiger, 1997).
Misdiagnosis and overtreatment of chronic sinusitis may account for a substantial portion of patients’ suffering and cost. In the absence of empirically based algorithms for patients suffering from chronic facial pain, managed care organizations have often funded unnecessary surgical procedures that made the situation worse.
The facial pressure or pain (these two terms are used interchangeably throughout this article) of acute sinusitis is easily recognizable. It involves the forehead in frontal sinusitis, the cheeks in maxillary sinusitis, and the intercanthal areas in ethmoid sinusitis. Sphenoid sinusitis usually produces occipital, vertex, retroorbital, and/or interorbital pain. The diagnosis of acute sinusitis is not difficult, because typically patients have had a history of prior upper-respiratory-tract infections, nasal allergies, nasal symptoms, or a worsening of old nasal symptoms (e.g., blockage, anterior and/or posterior discharge, alteration in the senses of smell and taste). The findings on clinical evaluation include some toxicity, facial tenderness, and signs of inflammation seen on nasal endoscopy.
Chronic sinus pain, on the other hand, may be caused by conditions other than chronic sinusitis; therefore, it is very important to be confident about the diagnosis of chronic sinusitis before medical or surgical treatments are initiated. The advent of outpatient procedures such as nasal endoscopy and high resolution sinus computed tomography (CT) scanning have helped tremendously in confirming or ruling out the diagnosis of chronic sinusitis. Acquadro and Montgomery (1996) have reported that many patients with severe, persistent, and often debilitating sinus pain are not found to suffer from chronic sinusitis.
The pain of chronic sinusitis is usually described by patients as pressure, congestion, dull aches, or a general discomfort throughout the face. Patients may feel a pulsating sensation when bending down. Salman and Rebeiz (1994) followed a series of 207 patients who underwent endoscopic sinus surgery for chronic sinusitis. They reported that 69% of the patients had facial pain along with other symptoms; in 9% of the patients, pain was the only symptom, but positive endoscopic and CT findings helped form the diagnosis of sinusitis.
Examination of patients with chronic sinusitis may elicit tenderness, and purulence, congestion, polyps, and/or ostiomeatal blockages are seen on nasal endoscopy. CT sinus scans confirm the diagnosis by revealing mucosal thickenings, blocked ostiomeatal complexes, polyps, bone sclerosis, and even air fluid levels, despite the absence of acute symptoms or signs.
With the availability of broad-spectrum antibiotics, cultures are no longer routinely recommended or taken before the diagnosis is made and the treatment initiated. The medical treatment usually consists of antibiotics, antiallergics, decongestants, and, if necessary, analgesics. When medical treatment fails or its effect is only temporary, surgical options should be considered. Endoscopic sinus surgery is the most frequently performed surgery at present. The concept of functional endoscopic sinus surgery assumes that blockages in the ostiomeatal complex are major contributors to the pathogenesis of chronic sinusitis and hence surgically removing these blockages and enlarging the sinus ostium constitute the aims of the surgical treatment.
As Acquadro and Montgomery (1996) have found, many patients subjected to antibiotic or surgical treatments may not suffer from chronic sinusitis. Experience has taught us that not all patients with facial pressure that is sometimes accompanied by nasal congestion and postnasal drip suffer from sinusitis, even if they respond to antibiotics and/or decongestants. This lesson is further enhanced by the large number of patients who undergo one or more sinus procedures and who emerge with their pain intact or worsened. These patients’ responses to antibiotics, even when nasal endoscopy, the CT, and the cultures are negative, raise the possibility that antibiotics, in addition to their antimicrobial effect, may also have an analgesic or anti-inflammatory effect. Patients’ responses to local or oral decongestants suggest the possibility that their pain may be attributable to a vasomotor reaction in the sinonasal mucosa, rather than to an inflammatory or infectious process (1996). It is already known that the pain of migraine headache and its variants is the result of a vasomotor reaction.
Other conditions that may be associated with facial pressure or pain include allergies, dental disease, temporomandibular joint disorders, myofascial pain, and neuralgia that may be idiopathic, postsurgical, posttraumatic, or postinfectious. For these conditions, a variety of treatment strategies need to be developed (Acquandro, Salman, & Joseph, 1997).
In a series of 252 patients with chronic sinusitis who underwent surgery and were followed for 6 to 12 months (Acquandro et al., 1997), the surgery itself was not found to be a cause of new pain postoperatively in patients who did not have preoperative pain. However, among patients who did have preoperative pain, 7% developed new pain, and in 2% of the patients, surgery made the preoperative pain worse.
It is unfortunate that more interest has been generated about the medical and surgical treatment of chronic sinusitis than in the definition of the term. Various medical disciplines handle the diagnosis and treatment of sinusitis very differently. The term rhinosinusitis seems to be a better appellation than sinusitis. In 1997 an International Advisory Board published a monograph on infectious rhinosinusitis in adults (Lund et al. & International Rhinosinusitis Advisory Board, 1997) that contains a timely and serious attempt at classifying the important, complex, and controversial issue of sinusitis.
A closer cooperation between different specialties is needed, because in the final analysis, we all serve the same purpose. Medical doctors should be considered neither adversaries nor competitors, but colleagues. The collective experiences of otolaryngologists, internists, pediatricians, allergists and immunologists, pulmonary and infectious disease specialists, radiologists, and even pathologists should be pooled, explored, and built upon. The formation of multidisciplinary clinics to evaluate patients with resistant chronic facial pains is a step in the right direction. The common incidental sinus CT (Havas, Motbey, & Guillane, 1988) or magnetic resonance imaging (Iwabuchi, Hanamure, Ueno, Fukuda, & Furuta, 1997) abnormalities noted in asymptomatic patients, and the fact that patients with upper- respiratory-tract infections do have CT abnormalities, further complicate the issue of the diagnosis of chronic sinusitis. This raises doubts about the weight sometimes given to imaging evidence of abnormalities in making the diagnosis, even when no endoscopic abnormalities are noted. In a recent report, many patients with the common cold were shown to have CT evidence of “sinusitis” that disappeared or improved spontaneously within 2 weeks without the use of antibiotics (Gwaltney, Phillips, Miller, & Riker, 1994).
Finally, it is the authors’ impression that the potent broad-spectrum antibiotics prescribed empirically are overused. The impact of this overuse on healthcare cost and the possibility of the emergence of resistant bacteria are great.
When a diagnosis is unclear or repeat surgical procedures are recommended, a closer cooperation between different specialties is needed. Multidisciplinary clinics that evaluate patients with resistant chronic facial pain offer the optimum standard of care, and we have had some success by integrating specialties including otolaryngology, neurology, anesthesiology, oral surgery, physical therapy, and psychology. Rather than offering treatment, our focus provides assessment and treatment recommendations with each case we present to the interdisciplinary pain team. Reasonable clinical management of the case can then occur.
Acquadro M.A., & Montgomery, W.W. (1996). Treatment of chronic paranasal sinus pain with minimal sinus disease. Annals of Otology, Rhinology, and Laryngology, 105, 607-614.
Acquadro, M.A., Salman, S.D., & Joseph, M.P. (1997). Analysis of pain and endoscopic sinus surgery for sinusitis. Annals of Otology, Rhinology, and Laryngology,106, 305-309.
Geiger, J. (1997). Sinusitis: Bench to bedside– current findings, future directions. Journal of Allergy and Clinical Immunology, 99(6), Part 3, S829-S849.
Gwaltney, J.M., Phillips, C.D., Miller, R.D., & Riker, R.K. (1994). Computed tomographic study of the common cold? New England Journal of Medicine, 330, 25-30.
Havas, T.E., Motbey, J.A., & Guillane, P.J. (1988). Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses. Archives of Otolaryngology-Head and Neck Surgery, 114, 856-859.
Iwabuchi, Y., Hanamure, Y., Ueno, K., Fukuda, K., & Furuta, S. (1997). Clinical significance of asymptomatic sinus abnormalities on magnetic resonance imaging. Archives of Otolaryngology-Head and Neck Surgery, 123, 602-604.
Lund, V.L. et al., & International Rhinosinusitis Advisory Board (1997). Infectious rhinosinusitis in adults: Classification, etiology and management. ENT Journal, 12 (Suppl. 76), 1-22.
Salman, S.D., & Rebeiz, E.E. (1994). Sinusitis and headache. Lebanese Medical Journal, 42, 200-202.
