Neurologic diagnosis and treatment in patients with computed tomography and nasal endoscopy negative facial pain

Objective: To determine the helpfulness of specialist neurology referral for patients with facial pain, a normal sinus computed tomography (CT) scan, and normal nasal endoscopy findings. Study Design: Prospective identification of patients and analysis of data approved by the Institutional Review Board. Methods: The data of 104 consecutive patients presenting with facial pain, a normal sinus CT scan, and normal nasal endoscopy findings were reviewed. The patients presented to a single rhinologist in a tertiary care institution. All patients were referred for specialist neurologic evaluation and potential treatment. Further information was obtained from a patient survey. Results: Of the 104 patients, 81 were women and 23 were men. The average age was 46 years (range, 22-85). Fifty-six had clear CT scans, 48 had minimal change, and all had negative endoscopies. Twenty-nine had previous unsuccessful sinus surgery. The average follow-up period was 10.5 months. Forty of 75 patients seeing a neurologist were seen on multiple occasions. Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis. The most common diagnoses were migraine (37%), rebound headache (17%), chronic daily headache (17%), and obstructive sleep apnea. (16%). Overall, 58% improved on medical therapy; 60% of those with a clear CT scan improved, and 53% of those with minimal change on CT scan improved (P =.749). Conclusions: Facial pain remains a difficult symptom to diagnose and treat in rhinologic practice. Patients often undergo surgery without help. Most patients with facial pain, a normal sinus CT scan, and normal endoscopy findings benefit from neurologic consultation. Serious intracranial pathologic conditions can be excluded and diagnosis-specific pharmacogenetic therapy instituted with improvement in more than 50%.