Treatment of chronic paranasal sinus pain with minimal sinus disease

A common problem for otolaryngologists are patients who present with recurrent, persistent sinus pain that appears out of proportion to the findings on physical examination. Often these patients have a history of recurrent sinusitis that required antibiotics or surgical intervention. Many have had repeated surgical procedures because of this pain. Other common past medical histories may include allergic rhinitis, facial trauma, or dental disease. Patients who have experienced documented acute sinusitis in the past will often present de novo with similar symptoms, but lack any objective evidence of a new active sinus infection. However, the diagnosis of sinusitis is not clearly removed from the patient's or clinician's mind, and the patient is further frustrated by the lack of adequate diagnosis, treatment, and resolution of symptoms. These patients may or may not be experiencing an upper respiratory tract infection or allergy with nasal drainage. Often, they are emotionally distraught from recurrent and persistent pain, the lack of resolution of their symptoms, dependency on narcotics and other analgesics, multiple consultations with a variety of clinicians, and the impingement of their symptoms on employment, interpersonal relationships, and societal and family obligations. If sinusitis is not found to be present, the otolaryngologist must help the patient understand this point, reassure him or her that the otolaryngologist will still be vigilant for the development of sinusitis, and refocus the history and workup for some other cause of the recurrent and persistent paranasal pain. We review various treatment approaches to paranasal pains that are not the result of sinusitis.