Neuralgia-related pains that mimic sinusitis

Welcome to Sinus411.com, a blog about sinusitis and sinus surgery.

One of the most common reasons that patients see me in clinic is for facial pain.  Some of these patients have sinusitis, but the vast majority of some other facial pain syndrome.   Of these “non sinusitis patients” with facial pain, migraines are the most common.

However, we do occassionally see patients that have neuralgia pains, and its important to identify these patients, because the treatments are different than for other headaches.   And the pain is often severe.  So making the correct diagnosis is important to treating the patient.

Neuralgia-related pains that mimic sinusitis

There are several neuralgia types of pain that occur in the head and face that mimic sinusitis and for that matter may mimic migraines or other severe headaches.  It is important to identify these because the workup and treatment of these disorders  is substantially different and because these headaches are typically quite severe and incapacitating.  The two most common types of neuralgia, or nerve related pains, are trigeminal neuralgia and atypical facial pain.  Although they share many similar characteristics, each of them have particular features that usually make it possible to discriminate between them.

Trigeminal neuralgia.

The pain of trigeminal neuralgia is a severe sharp, shooting, or electrical shock type a sensation that lasts seconds to a couple of minutes and is almost always unilateral.  The pain arises over the trigeminal nerve, which has three branches.  The trigeminal nerve has a branch over the eye (frontal division), a branch between the eye in the upper lip (maxillary division), and a branch near the chin (mandibular division).  The maxillary or mandibular nerves are more frequently involved than the frontal division.  Of course pain in the lower jaw does not typically make one suspicious of the sinus infection.  However pain over the cheek and brow is frequently confused for sinus-related disease as well as dental-related disorders.  In about 90% of patients with trigeminal neuralgia, there is a trigger zone in the face were a light touch type of stimulation will trigger the severe, lancinating in any pain.  The light touch stimulus could include chewing, talking, washing one’s face, brushing teeth, facial movement, cold air or when.  After the sharp, Lance many pain, there may be a dull ache for a few minutes.

A physician’s workup for trigeminal neuralgia will entail a search for any disease along the course of the trigeminal nerve or the division of the trigeminal nerve that is involved.  This will often entail an evaluation of the skin, cheek, nose, cranial nerves, head, and neck as well as focused general and neurologic examination.    Usually a CT scan or MRI is also helpful to rule out a lesion along the nerve that cannot be assessed by direct physical examination, for instance a tumor at the base of skull or deep within the maxillary sinus.  MRI scans have the advantage of assessing being able to identify very fine, discrete lesions near the nerve as well as assessing for abnormalities of the soft tissues of the face and skull.   A substantial number of patients with classic findings of trigeminal neuralgia are found to have a small vascular loop, that is a small blood vessel, that compresses or pulsates against the trigeminal nerve in the region of the brain which is just prior to its exit from the skull. In less than 5% a cases, a tumor on or near the trigeminal nerve is identified.  An MRI scan also will identify an occasional patient with multiple sclerosis.

Treatment of Trigeminal neuralgia

Treatment of trigeminal neuralgia is is often successful once the correct diagnosis is made.  Patients with vascular loops causing compression of the nerve are candidates for nerves surgical evaluation and possible decompression of the nerve.  Otherwise medications are often effective for management of the pain.  Similar to treatment of migraines, this prophylactic medication is usually initially taken at low doses, with gradual increasing doses, week by week, until pain relief is accomplished or side effects occur. Intolerable side effects may necessitate trial of an alternative drug.   For patients who cannot get relief from many medical therapy, surgical approaches to the nerve are possible but each of the surgical approaches are invasive and are associated risks of side effects or failure that require thoughtful consideration on the part of the patient and surgeon  alike.    Some of the more commonly used medications to control our trigeminal neuralgia include tricyclic antidepressants, carbamazepine, oxcarbamazaepine, gabapentin, phenytoin, baclofen, clonazepam, valproate, and pimozide.   While some of the medications require little or no monitoring long-term, others require monitoring for blood or liver side effects, which the patient should discuss with his or her physician.  Once properly identified, these conditions are frequently treated by our neurologists or by one primary care physician.

Atypical facial pain

Patients and their fourth or fifth decades of life in a described as a steady deep ache, boring, pain that can last hours or days at a time or longer.  The most common location is over the second branch of the trigeminal nerve, below the eye or along the side of the nose or the nasal labial region (the cheek fold).  Atypical facial pain often begins after a dental procedure or after significant facial trauma.  When specifically questioned, patients will admit to numbness over the cheek after a procedure or injury that precedes the onset of the pain.  The painful region will often be sensitive to light touch, which is quite characteristic of neuralgia pains or nerve-type of pains.  Gently brushing the area with a finger or even a cotton ball will cause discomfort far out of proportion to the stimulus.  Gently touching the area will sometimes be associated with a tingling or “ants crawling on my skin” feeling.  In fact, after the initial injury that causes a numbness, patients will sometimes recall a period of tingling sensations which subsequently may be replaced by the facial pain or occur intermittently with the facial pain.

Patients with atypical facial pain will usually seek care from primary physicians, dentists, neurologists, or otolaryngologists.  It is not unusual for patients to undergo multiple dental extractions searching for a tooth root that may be infected in causing the pain, but usually to no avail.

Treatment of atypical facial pain is similar to that of trigeminal neuralgia.  Low doses of tricyclic antidepressants, increasing in dosage slowly on a weekly basis until pain is controlled or side effects become intolerable, are often effective.

When I diagnose patients with trigeminal neuralgia or atypical facial pain, I usually refer them back to a local neurologist for long term management and potentially further workup for a “cause”.

Jeffrey E. Terrell, MD

Michigan Sinus Center

4 comments to Neuralgia-related pains that mimic sinusitis

  • KS

    Atypical Facial Pain–

    I have suffered from this for over 15 years – a chronic aching boring pain on the side of my cheek. I have been to countless doctors and dentists to no avail and have been basically diagnosed as a chronic sinus sufferer. However, I recently self-diagnosed after realizing that my pain always goes away briefly after yoga. I began thinking about the role of relaxation and my pain and began to realize that perhaps I was unconsciously clenching my jaw and cheek at night and triggering the trigeminal nerve. I recently had acupuncture for this and my “Sinus pain” aka Atypical facial pain went away completely after one treatment. I am a little in shock. As someone who has had chronic pain for most of my adult life… I am vexed that not one doctor ever suggested this to me.

    The only way, I figured it out was because once while flying I had a bout of Trigeminal Neuralgia and learned about Trigeminal nerve while googling the pain. It took about 8 months later to make the clenching connection….

    I hope you are able to publish something in journals that both dentists and doctors might read!!!!

  • Bryan Bowe

    KS, I have lived in utter misery the past three years after having a botched root canal and Apicoectomy(tooth root surgery). I have went from specialist to specialist including all of the ones listed above and have prayed for some sort of relief. I feel as if someone has a vooodoo doll of me and are pricking it daily in the facial area. The teeth that were affected were my front top right side teeth #7 and #8 thus the area that was affected is my right side behind my nose. Every day I get pains and numbness in that area that casues me pain similiar to a horrible sinus infection. Pain in cheek, pain behind the right eye, leads to horrible headaches on the right side of my face. I feel as if the pain is directly in the bones of the right side of my face next to my nose and below my eye. What also drives me crazy is the fact that just the iar traveling through my right nostril and sinus cavity create major discomfort and shooting pains especially when it is cold. I would give my right arm for relief from this! I am 41 years old and it has truly taken the joy out of my life to the point where it makes me feel suicidal at times. I have 6 beautiful children and I want to feel healthy and happy for them again. Where was the acupunturist you went to? Please help with any suggestions. Thank you so much, Bryan

    • admin

      Hi,

      In the blog, I wrote: Treatment of atypical facial pain is similar to that of trigeminal neuralgia. Low doses of tricyclic antidepressants, increasing in dosage slowly on a weekly basis until pain is controlled or side effects become intolerable, are often effective.

      When I diagnose patients with trigeminal neuralgia or atypical facial pain, I usually refer them back to a local neurologist for long term management and potentially further workup for a “cause”.

      Here is some more general information (not to be confused with medical advice in your case) . I have seen cases like yours, and it sounds exactly like a neuralgia after a tooth extraction. Numbness, pricking feeling, shooting pain, sensitivity to cold in nose (same nerve covers both areas) are pretty classic. Maybe consider writing down the symptoms you describe, some points from the blog, and this response, and taking it to a neurologist or pain specialist. Amitryptaline, neurontin, and Tegretol have been used on this type of neuralgia. People may respond better to one than to another. Ask your doctor if they would consider trying one of these drugs. Or maybe go to the nearest academic medical center, if your healthcare providers have not put this together for you. Good luck.

  • Minna

    Dear Dr Terrell,
    Two years ago I was diagnosed with brain tumor and I underwent brain tumor surgery. It was a tennis ball sized benign tumor on the left frontal cortex. The surgeon was able to remove nearly all of it. As I woke up from surgery I had these weird symptoms of numbness and tingling under my left eye and cheek Pain and swelling on the upper left teeth and bone; (all good in good shape according to my dentist). These symptoms are still existing today.
    While recovering for about five months , I was taking Keppra 1000 mg 2x daily. The side effects were so bad that I could not take them when going to work 18 months ago. I also suffered a grand mal seizure a year after the surgery and a petit mal seizure near the second anniversary of the surgery. After the recent petit mal seizure I returned to Keppra, to be safe, at a lower dose.
    Lately I have had increased pain in the left sinus and tooth section, paired with nausea and vertigo. It is difficult to breathe in through left nostril and yes, I do have a cyst in the left sinus cavity… What to do next…?
    I would so greatly appreciate your advice.
    Thank you kindly,
    Minna

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