Primary headaches

For patients who only have sinus pain and no other nasal symptoms, it sometimes turns out that no specific sinus problem can be found to explain the pain. Doctors may have treated you for sinus infections, allergies, and other sinus problems but with little success. At some point a doctor will probably get a CT scan to know about those places that you can't see into on physical exam. In many such patients (those with no other nasal symptoms), a definite answer isn't found.

When this becomes the case, the sinus pain is best treated like a headache. All too often, a specialist will tell such a patient "you see, the CT scan is normal, you don't have sinus problems." Well, I personally don't think that that is the right approach. So, does a normal brain MRI mean you don't have headaches? Of course not. The same logic goes towards sinus pain in my opinion. Much of this is semantics, but it is important for the doctor to avoid saying things that really aren't accurate or that make the patient feel like their problems (pain) is being dismissed.

The way I put it in these cases is "The CT scan doesn't show any areas of infection, obstruction, or anatomic anomaly. I don't think you will get any benefit from antibiotics or allergy medicines. Let's try treating this with the medicine used for headaches and see if we can get some relief from the pain." At this point I usually try a couple of the migraine medicines and refer the patient to a neurologist for a headache workup. Such patients have invariable had many sinus medicines already anyway.

The explanation for how your sinuses can hurt when there is no obvious anatomic or structural explanation is that the nerves that supplies the sinus and nasal lining can become irritated or inflamed, for reasons that are often unclear. Perhaps it is the same process that can make the nerves that innervate the meninges of the brain hurt and cause tension and migraine headaches. 

Sinusitis

People often think of sinusitis as a cause of sinus pain, and of course it is one of the more common causes. It is uncommon for sinus pain to be the only symptom from sinusitis, but it is not unheard of. If an isolated ethmoid sinus or frontal sinus or spenoid sinus becomes obstructed or infected, it can cause pain without causing nasal congestion or drainage.

The clues that a blocked or infected sinus is the cause of sinus pain, even when there are no other symptoms are:

One sided pain
Pain that is worse when you lean your head down low
Pain that began after a cold or sinus infection, eventhough other symptoms cleared
Pain that clearly responds to antibiotics

It is usually necessary to obtain a CT scan to clearly diagnose such a problem. Plain X-Rays don't often reveal such problems. If blockage and infection was extensive enought to show up on a plain X-Ray, there would almost always be some congestion, airway obstruction, or drainage. 

TMJ syndrome (Temporo-mandibular joint dysfunction)

I'm not a big believer in initially blaming symptoms on TMJ syndrome. Some doctors believe that most temple region and ear region pain is from TMJ syndrome. Certainly there are patients with this problem, but I don't think it should be the default diagnosis for lateral facial pain of uncertain origin.

Certainly if you have pain directly over the jaw joint, if you are a habitual tooth grinder at night, or if you have had recent significant dental work, then this diagnosis should come to mind. If chewing worsens of elicits the pain or if you have had all other options investigated, then it makes sense to entertain TMJ problems as a source for headaches and sinus type pain.

The pain from TMJ syndrom is usually around the ear, temple, or the angle of the jaw bone. It is best evaluated by a dentist who has special interest in this subject. It is treated with simple measures first, and then with a splint that can be purchased OTC or through your dentist.

Nasal septal deviations

The bone and cartilage that separates the left and right side of your nasal passage is called the nasal septum. This structure is almost never perfectly straight. When the nasal septum is excessively crooked, it can have sharp spurs of bone that poke into the side wall of the nasal cavity; this is not a rare problem at all. In other cases, a broad area of deviation can touch the side wall. Often there is no history of injury or fracture to explain the deviation. Nasal septal deviations often cause airway obstruction, but not always.

Especially when there is a sharp spur of bone, this can cause pain. the pain is usually one sided, it often feels like it is on the side of the face or ear, and it worsens with any causes of nasal congestion. One somewhat helpful diagnostic test that you can do at home is to spray decongestant nasal spray (Afrin®)on the side of the pain. If that pain is significantly reduced shortly after spraying, this provides additional evidence of such a abnormality. There is a specific form of para-nasal pain caused by a sharp bone spur called Sluder's Neuralgia.

This type of sinus pain can come and go in severity. The usual first treatment is with steroid nasal sprays and the occasional use of decongestant sprays and oral decongestants. If such treatment is not adequate, you should see a sinus specialist to help confirm the diagnosis and to recommend treatment. A CT scan, X-Ray, or endoscopic exam may be helpful to finalize the diagnosis. Chronic pain from this type of source often benefits from surgical intervention.  

Concha bullosa and other anatomic abnormalities

This structure is a fairly common normal variant. It is the variant when a normally thin plate of bone, the middle turbinate, develops a bubble or small sinus inside the plate. When this occurs, it causes the middle turbinate to be larger than it is supposed to be. The increase in size permits the middle turbinate to forcefully press on surrounding structures and cause pain. It is sort of like 10 pounds in a 5 pound sack.

Pain from a concha bullosa usually presents between the eyes. The pain can be on one side or both. There is probably a correlation between the size of the concha bullosa and its propensity to cause pain. Many small concha bullosa do not cause any problems.

There are other similar anatomic abnormalities that can cause sinus pain. In all cases, it seems like they are misshapen in a fashion that would have two two adjacent structures apposing when they would normally have an air gap between them. Club shaped middle turbinate, large agger nasi cells, and large ethmoid bullae are some examples.

It takes a CT scan to delineate a concha bullosa and to help give some insight into the likely hood that it is a source of sinus pain. Many smaller concha bullosa are totally without problems. Concha bullosa can be treated with steroid nasal sprays and decongestants, or if the symptoms are difficult to control, a minor surgical procedure.

When no other nasal symptoms are present, it may be most efficient to pursue other causes first. It is uncommon, but not unheard of, for problems that are truly sinus in origin to cause sinus pain and no other nasal symptoms.

For example, if pain is in the upper teeth, a dentist might be considered first. Pain in the ear can be an ear problem or TMJ syndromes. Pain between the eyes or over the eyes can often be a type of headache, even when it feels like the pain originates in the sinuses. In patients with few other symptoms besides pain, I feel that early CT scanning is helpful, so that other options can be considered if the sinuses don't provide an explanation for the pain.

A quick home test can help clear things up somewhat. If 2 squirts of decongestant spray seem to relieve sinus pain, this would point more towards a sinus origin problem. If the decongestant spray is of no benefit, this does not rule out a primary sinus problem. This is a test, not a treatments. Decongestants sprays can only be used for a few days in a row.