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Ministry of Health Agentina, University of Buenos Aires, Europe
Submission: July 30, 2018; Published: August 03, 2018
*Corresponding author: Dra Mirta D’ambra, Public Health Specialist Ministry of Health Agentina, University of Buenos Aires, Chairman Wams in Argentina Headquarters in Nedherlands, Email: email@example.com
How to cite this article: Dra Mirta D’ambra. How to Diagnose Orofacial Pain?. Glob J Oto, 2018; 17(1): 555954. DOI: 10.19080/GJO.2017.17.555954
It is usually incorrectly attributed to rhinosinusitis. Some patients describe pain as sinus. In a series of 973 patients with suspected rhinosinusitis, only 1 in 10 confirmed paranasal sinus disease by endoscopy and computed tomography (CT). Therefore, the correct diagnosis can be lost or delayed and result in inadequate treatment and prolonged symptoms. Chronic orofacial pain, which lasts more than 12 weeks and could have already received treatment in primary care, leading to the reconsideration of the diagnosis before the persistence of symptoms. What are the common causes of orofacial pain? Although there is no solid evidence on the prevalence of different conditions, migraine and middle facial segment pain are among the most common causes of orofacial pain. However, they are often misdiagnosed as rhinosinusitis due to the accompanying nasal symptoms.
a) Orofacial pain is not a hallmark of rhinosinusitis and affects only 10% of patients with rhinosinusitis.
b) Consider alternative diagnoses such as migraine, pain in the middle facial segment and the group of headaches that may present with facial pain and nasal symptoms, such as rhinorrhea and nasal congestion.
c) Start a therapeutic trial for 4 weeks for the most probable diagnosis and ask the patient to return if the symptoms do not improve.
Orofacial pain is not a hallmark of rhinosinusitis Rhinosinusitis is an inflammation of the lining of the nasal cavity and sinuses, with or without formation of nasal polyps. Symptoms can be acute (<12 weeks) or chronic (> 12 weeks). It is estimated that it affects 2-10% of the population. A study based on the population of Canada (n = 73,000 patients) reported a prevalence of 3.4% in men and 5.7% in women. Orofacial pain is not a hallmark of rhinosinusitis. The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) defines rhinosinusitis and nasal polyps by the presence of 4
symptoms, of which, the presence of nasal block, congestion,
obstruction nasal discharge (anterior rhinorrhea or postnasal drip) They are essential to support the diagnosis. So it is unlikely that patients with orofacial pain without congestion or anterior or posterior nasal obstruction have rhinosinusitis. The data from cohort studies show that orofacial pain is a poor predictor of chronic rhinosinusitis and it is more likely that, if pain is used as a criterion to evaluate patients with rhinosinusitis, an erroneous diagnosis is made . A prospective observational study of 108 patients with confirmed chronic rhinosinusitis found that less than one third of patients had orofacial pain. When there are nasal polyps, the ratio drops to 1 in 10 patients, which indicates that orofacial pain is even less common in patients with chronic rhinosinusitis who have nasal polyps.
The International Headache Society states that «rhinosinusitis is not validated as a cause of headache or facial pain, unless it has an acute relapse.» Patients with acute rhinosinusitis are more likely to have orofacial pain, caused by irritation of the sensory nerves, through inflammatory mediators, changes in pressure and a sinus without drainage, blocked . The pain is intense and is usually unilateral.
It is associated with fever and nasal obstruction, and in the case of acute maxillary rhinosinusitis, there may be dental pain. Recurrent true acute rhinosinusitis is rare, and the etiology of pain is often vascular, as in migraines or cluster headaches. As some patients with chronic orofacial pain may complain of associated nasal symptoms, it can be difficult to assess whether the pain is related to sinusitis, especially if the patient points out the pain clearly, at the anatomical sites of the sinuses, such as the cheeks or the front. Good and bad predictors of syngenic facial pain. Good predictive value Poor predictive value Increase in pain intensity when the patient moves from sitting to supine, or during a flight, or skiing Increases intensity when leaning forward Reduction of smell Normal smell. Improvement with antibiotic or corticosteroid treatment No improvement with antibiotic or corticosteroid treatment. Purulent, malodorous rhinorrhea Severe facial pain affects the activities of daily life Worse with upper respiratory tract infections Sensitivity or swelling on the skin of the face Symptoms of rhinosinusitis .
a) Nasal blockage, congestion, nasal obstruction: essential
b) Nasal discharge (rhinorrhea or anterior or retronasal
drip): essential for diagnosis
Often, migraine is misdiagnosed as sinus headache or
rhinosinusitis. Chronic incapacitating headaches are more likely
to be related to migraines than to rhinosinusitis. EPOS states:
«most sinus headaches can be classified as migraines.» For
this reason, in patients presenting in primary care with «sinus
headache», the diagnosis of migraine should be explored before
considering rhinosinusitis. A recent systematic review of studies
of migraine (> 6 million participants) reported a prevalence of 1
in 10. While patients with migraine commonly report hemicrania,
a subgroup of patients may be located on the face but with pain.
characteristic symptoms of migraine, such as nausea, vomiting,
sensitivity to light and sound. In a study of 517 patients with
migraine, almost 9% had pain in the head and lower half of the
face; these patients were also more likely to have associated
trigeminal autonomic symptoms, such as rhinorrhea and nasal
blockage. Often, migraine is misdiagnosed as sinus headache
or rhinosinusitis, due to certain associated symptoms such as
nasal congestion, rhinorrhea, lacrimation or inflammation of the
cheeks, which appear during migraine attacks. In a prospective
cohort study of 2,991 patients with a history of self-medication
or of the International Headache Society. Of these patients,
more than 80% of those who reported pain or sinus pressure,
63% reported nasal congestion and 40%, rhinorrhea. How to
make a diagnosis? The characteristics and site of pain can help
distinguish these conditions through history and semiology.
It is more likely that the intense pain that interferes with the
activities of the patient’s daily life is motivated by a migraine or
other headaches, unlike temporomandibular pain, middle facial
segment pain and tension headache, which do not interfere. In
general, the associated nasal symptoms are compatible with
rhinosinusitis, but the authors recommend taking into account
the autonomic trigeminal symptoms that appear in migraines,
and the possibility that there is a coinciding rhinitis, given its
high prevalence in the adult population. The history or family
history of migraine are important. During the examination, the
skin covering the breasts should be felt. If there is tenderness
about the breasts, the suspicion of pain of the middle facial
segment should be greater. It is necessary to feel on the
temporomandibular joint and the neighboring areas, to detect
sensitivity, reaching the temple and the line of the jaw, the
mastoid area and the cheek, since within these areas are the
trigger points for temporomandibular disorders. While the
temporomandibular joint is palpated, the patient is asked to
open and close the mouth to feel the click and laxity of the jaw.
The laxity reflects a greater joint mobility and the protrusion of
the joint laterally during the opening of the mouth. The laxity
and the click of the jaw are signs of temporomandibular joint
abnormality. The anterior rhinoscopy can be performed with an
otoscope, to investigate the presence of purulent mucus in the
nasal cavities (which supports the diagnosis of rhinosinusitis)
or enlarged lower turbinates (suggesting rhinitis). The authors
recommend a complete examination of the cranial nerves in
all patients with chronic orofacial pain, to exclude intracranial
tumors that may present with orofacial pain. In general, no
studies are required to confirm the diagnosis.
Often, and due to overlapping symptoms, ≥2 diagnoses
are possible. You can start with a trial treatment for 4 weeks
for the most likely diagnosis. If there is no improvement, said
treatment is suspended and other diagnoses and alternative
treatments are considered. If the patient has doubts about
the diagnosis, it is important to explain the complex nature of
orofacial pain, which can create diagnostic difficulties, because
patients can find it reassuring to know that this situation is not
rare. It is recommended to emphasize the need to follow up if
the symptoms do not improve. The aforementioned symptoms
nasal blockage, congestion, nasal obstruction, nasal discharge
(rhinorrhea or anterior or retronasal drip) are sufficient to
support the diagnosis of rhinosinusitis and begin treatment
in primary care. The management of chronic rhinosinusitis
depends on the severity of the symptoms and the presence of
polyps. The EPOS guidelines recommend treatment with a
steroid nasal spray and nasal spray, and then retest the patient
at 4 weeks. If the symptoms have improved, then the treatment
can be continued in the long term.
If it is a question of migraine or tension headache, advise
patients to follow a daily routine, sleep hygiene, exercises, diet
and periods of relaxation and, that reduce the consumption of
caffeine. Patients with an acute episode of tension headache
can be treated with 1 g of paracetamol or 400 mg of ibuprofen.
If the probable diagnosis is pain of the middle facial segment,
low doses of amitriptyline (10 mg at night for at least 6
weeks) are recommended. This should be continued for a
minimum of 6 months; If the condition has disappeared,
treatment can be suspended as of this moment. The treatment
of temporomandibular disorder is multifaceted, and includes
lifestyle changes, relaxation techniques, simple analgesia
with paracetamol or NSAIDs, low doses of benzodiazepines
and neuropathic agents. Specialized treatment involves the
use of temporomandibular joint injections, arthroscopies,
arthroplasties, and joint replacement surgery.
Cluster headache is the only condition that guarantees
immediate referral to the neurologist. In most cases, only
the referral of the patient is required when the symptoms are
refractory to medical treatment initiated in primary care or, if there are associated alarm symptoms. Cluster headache is
the only condition that guarantees immediate referral to the
neurologist, due to the potential need for neuroimaging and
specialized treatment. If the diagnosis is in doubt, or there are