Facial pain and sinonasal surgery

To examine the causes of facial pain that persists after endoscopic and other sinonasal surgery.

A study of a cohort of 973 patients presenting in the outpatient clinic with symptoms of facial pain and/or rhinosinusitis. The study subgroup consisted of 75 patients with facial pain persisting after sinus surgery (endoscopic procedure n = 48, other intranasal procedures n = 27). The patients in the subgroup were studied with particular reference to their original presenting symptoms, endoscopic signs, and findings at CT as well as their symptoms when they presented to this unit and, importantly, these were analysed in the context of their response to treatment and follow-up after a mean of 2 years 7 months.

Of the 75 patients who had persistent pain after surgery, 40 had no evidence of disease at endoscopy or CT at their initial presentation, whilst 35 had preoperative evidence of sinonasal disease. However, after surgery and re-evaluation, as well as neurological medical treatment, it was found that sinonasal disease was not the cause of these patients pain. The causes of their facial pain that persisted after sinonasal surgery were tension-type headache, atypical facial pain, migraine, paroxysmal hemicrania, cluster headache but the most common cause was 'midfacial segment pain', which has all the characteristics of tension-type headache but primarily affects the midface.

Some patients with facial pain are undergoing endoscopic sinus surgery in the mistaken belief that rhinosinusitis is the cause of their facial pain. All surgeons dealing with facial pain should be familiar with non-sinonasal diagnoses. A new category of facial pain, 'midfacial segment pain', is described and proposed.