Nasal Disease & Facial Pain
Junaid Hanif
Consultant ENT Surgeon
Norfok & Norwich University Hospital
Honorary Senior Lecturer UEA Medical School
GP seminar snh March 2012
Common Scenarios
6 yr old child with recurrent epistaxis
occurring X 3 / week
GP seminar snh March 2012
Epistaxis: Children
Hx:
URTI (does it only happen with a cold)
Nose-picking
Rhinitis
Bleeding disorders (rare)
Exam: Lift tip of nose and shine light
? Infection (pus, mucus, excoriation)
Little’s area
Tx: Naseptin (b.d 1/52), AgNO3 cautery
Refer if no improvement after trial of both of above
GP seminar snh March 2012
Scenario
64 yr old with recurrent epistaxis
GP seminar snh March 2012
Epistaxis: Adults
Hx:
Side, duration, frequency
Nose picking or other trauma
Bleeding disorder
Anticoagulants
Exam: Lift tip and shine light (if hairy, trim!)
Deviated septum
Little’s area (? evidence of nose picking)
Tx: AgNO3 cautery and vaseline. Refer if no
improvement after X 2 cautery (4/52 apart)
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
Scenario
43 yr old female:
“Doctor, I can’t shift my sinuses. If only they would
just drain. Do something”
OR
“My sinuses feel all congested and blocked and
they hurt. Do something”
OR
“My face and head hurt. I think it’s my sinuses.
Can you help. Do something!”
(Or something similar)
GP seminar snh March 2012
Sinusitis and Facial Pain
Hx:
Frequency & duration: “Most days”, “all of
the time”, “most weeks”, “lasts most of the
day” Think non-sinogenic pain
“When I get a cold (URTI)”, “every few
weeks”, “lasts a few days to a week or
two” Think sinogenic pain
GP seminar snh March 2012
Sinusitis and facial pain
Distribution:
“All over my head and face”, “all the way back to
my neck and back of head”, “pressure on top of
my head”, “keeps changing and moving around”
(differing distribution when asked at differing
consultations) Think non-sinogenic pain
“Over my cheeks and around my eyes” could
be either
GP seminar snh March 2012
Sinusitis and facial pain
Character:
“Like a sharp pain”, “my face feels very
sensitive”, “as if someone has punched me”,
“very sensitive to touching and pressure” Think non-sinogenic pain
“Very congested feeling”, “mild discomfort, not
too bad a pain” Possible sinusitis
Dull ache Could be either
GP seminar snh March 2012
Sinusitis and facial pain
Associated features (may need to ask leading
questions):
Lacrimation, feeling sleepy most of the time, tired all the
time, pressure feeling all over head, hx of
anxiety/depression, nasal sprays/simple
analgesics/antibiotics unhelpful Think non-sinogenic
pain
With a URTI, blocked nose, discoloured rhinorrhoea,
cacosmia, postnasal drip, hx of rhinitis (allergic, nonallergic, nasal polyps, atopy), hx of bronchiectasis Probably sinogenic pain
GP seminar snh March 2012
Sinusitis and facial pain
Examination:
Difficult without endoscope
Try otoscope (can get misted)
May get some idea by simply shining a torch
Sinusitis: Nasal mucosa: Pale, pale blue, moist
looking, obvious pus, polyps, obvious mucopus
or thick mucoid seen in throat coming from
nasopharynx
GP seminar snh March 2012
Chronic sinusitis and facial pain
Definitive diagnosis by nasendoscopy.
If nasendoscopy normal then almost
certainly no sinus disease. Unfortunately,
tools and expertise not available in GP
surgeries (? yet!)
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
GP seminar snh March 2012
Nasal polyps
GP seminar snh March 2012
Facial pain and sinusitis
80% patients referred to ENT clinic with
facial pain/headaches do not have sinus
disease
Majority have non-sinogenic pain
Often impossible to distinguish without
endoscopic nasal examination (and
sometimes CT scanning)
GP seminar snh March 2012
General symptoms of chronic
sinusitis
Nasal blockage
Rhinorrhoea
Sneezing
Post nasal drip
Tiredness
Facial pain
uncommon
(As if the patient has
a cold, chronically)
GP seminar snh March 2012
Chronic sinusitis: types
Allergic
Non-allergic
Infective
Anatomical abnormalities causing
drainage pathway obstruction
As part of systemic chronic conditions:
Wegener’s, SLE, Cystic fibrosis etc.)
GP seminar snh March 2012
Allergic sinusitis
Atopic
Type 1 asthma
Known allergies (HDM, grasses, molds, trees,
pollen, animal dander…………; also ingested
allergens: dairy products, fishes,
wheat…………….)
Often other allergic symptoms: itchy eyes,
sneezing, eczema, dermatitis, FH
Diagnosis: skin prick testing, RAST
GP seminar snh March 2012
Non-allergic chronic sinusitis
Very similar symptoms
No allergens detected
Associated with type 2 asthma (30% have
nasal polyps)
Associated with nasal polyps
GP seminar snh March 2012
Chronic sinusitis
Management of chronic sinusitis:
Antihistamines if allergic
Steroid nasal sprays (Nasonex, Avamys,
Flixonase, Beconase if it works), long term
Steroid drops: Betnesol (betamethasone) for
6 weeks in “head down” position
Oral steroids (reducing dose of Prednisolone
starting with 30mg, over 3weeks if no
contraindications)
GP seminar snh March 2012
Chronis sinusitis
Surgery if medical treatment fails and
patients still symptomatic
If chronic sinusitis due to allergic/nonallergic/nasal polyps then will need postop nasal sprays; long term
Nasal polyps often require removal on
several occasions for symptomatic relief,
esp. if asthmatic
Facial pain & chronic sinusitis: Summary
Common problem
Chronic sinusitis and nasal polyps are usually painless
Sinogenic pain usually occurs with a URTI
Majority of patients referred with possible ch. Sinusitis do
not have sinogenic pain
Longstanding constant facial pain/headache without
nasal symptoms, sensitive/tender to touch is unlikely to
be caused by sinus disease, esp. if vague hx and pain
distribution seems to change
Chest disease and atopy is associated with sinusitis
Discoloured rhinorrhoea is due to sinusitis
Definitive diagnosis cannot be made without
nasendoscopy or CT scan of sinuses
Facial pain
Common problem
Often mimics sinusitis and can be difficult to
distinguish without nasendoscopy
Some well described entities within this group,
e.g. Trigeminal neuralgia, cluster headaches
Commonest group is probably “mid-facial pain”
or “mid-segment facial pain”
GP seminar snh March 2012
Mid-segment facial pain
Symmetrical sensation of pressure/tightness
Subjective nasal blockage
Nasal bridge / periorbital
May be hyperaesthesia of skin
Nasal endoscopy and CT normal
Symptoms may be intermittent or persistent (for
days)
No consistent exacerbating or relieving factors
(analgesics and antibiotics often unhelpful)
GP seminar snh March 2012
Mid-segment facial pain: Management
Difficult
Anti-migrainous / anti-neuralgic therapy,
e.g. Amitriptyline, Gabapentin, Pregablin
Sometimes clinical psychologist
involvement helpful
GP seminar snh March 2012
When to refer
Obvious chronic sinusitis not responding to
conservative treatment
Obvious unilateral polyp (use an otoscope, may
be smaller one on the other side)
Known atopic pt. with poorly controlled hay fever
Known chronic chest disease with unresponsive
sinusitis
Complication of sinusitis (orbital cellulitis,
neurological symptoms or obvious frontal lump
GP seminar snh March 2012