Nose- and Sinus-related Neuralgia Syndromes: a Narrative Review with Proposed Diagnostic and Management Algorithm

Nose- and sinus-related neuralgia syndromes (NSNS) constitute a constellation of clinical entities characterized by persistent pain in the distribution of nerves from the nasal cavity and paranasal sinuses. Various characterizations and management approaches have been reported in the literature, yet no universally accepted definition exists. The aim of this study is to provide a narrative synthesis of relevant studies and to propose a structured algorithm for the diagnosis and management of this intriguing clinical entity.

A narrative review informed by a structured database search was conducted using Medline (via PubMed), Scopus and manual searching, with no restrictions on publication date.

Since Sluder's first description in 1908, a number of related syndromes have been reported in the literature, each with partially overlapping clinical features and diagnostic criteria, including anterior ethmoidal nerve syndrome, anterior ethmoidal neuralgia, sphenopalatine neuralgia, syndrome of the olfactory fissure, nasociliary neuralgia (Charlin's syndrome), collectively reflecting the complex and ambiguous nature of these disorders. While the anterior ethmoidal nerve is central to the syndrome, other nerves innervating the lateral nasal wall and nasal pyramid skin are also implicated in the associated headache. Complex pathophysiological mechanisms contribute to the chronic pain. Clinically, the syndrome is characterized by the absence of a specific sinonasal disease; pain may vary in localization, be uni- or bilateral, and can be associated with mucosal engorgement, intranasal contact points, or a history of facial trauma. A thorough history, clinical examination, nasal endoscopy, imaging of the nasal cavity and paranasal sinuses, recognition of the frequent association with endonasal contact points and the topical anesthetic test remain fundamental to the diagnosis of NSNS. Management options include conservative and surgical approaches.

The existing literature on NSNS consists exclusively of small, uncontrolled case series and expert opinion spanning over a century, with no randomized controlled trials or prospective comparative studies, reflecting a persistent evidence gap that limits definitive conclusions about diagnosis and treatment. In this review, a practice-oriented diagnostic and management algorithm is proposed. Prospective controlled studies are needed to validate and refine these recommendations.