Eli: I have a question about sinus pain. I’ve been having sinus pain since March. I‘m not sure if it’s allergy-related. I’ve had some in the past during the summer, but this is the first time it’s lasted this long, and I’m having it every day. I don’t have congestion really, maybe a little bit, but mostly just a dull pressure, and sometimes it’s more severe.
Dr. Reh: So, this is a topic and problem that I see often in my office. What makes the pressure worse, generally?
Eli: The only thing I’ve noticed is that it gets worse as the day progresses. I saw it in the summertime as the weather got warmer, that’s when it got worse.
Dr. Reh: Okay. Does it get worse on bad weather days, or depending on the weather?
Eli: I think when it’s warmer outside it seems a little worse.
Dr. Reh: Okay. And you said you don’t have a lot of nasal congestion, runny nose, loss of smell or taste?
Eli: Not that much maybe a little bit of congestion, but nothing. I don’t’ have any green mucus, it’s clear, so it’s nothing too bad.
Dr. Reh: So, I see a lot of patients who come to me with – I say this in quotes – “Sinus pressure” or “facial pressure”. What I’ll tell you is, when it happens frequently or daily like in your case, a typical thing I’ll do for that patient is look at that patient with an endoscope just to see if I see anything that looks like infection or inflammation that would need to be treated.
Then, I would typically order a CT of the sinuses, which is an x-ray of CAT scan. What that will tell me is one of two things. It’s either gonna come back as a scan that shows that you have blockage in your sinuses, obstruction, which is potentially a fixable problem with topical medications. Or, if that doesn’t work, you can do different types of procedures, both in the office, say balloon dilation, or in the OR to open up and drain the sinuses.
But, a not-insignificant number of my patients have a normal CT scan, which means it’s totally clear. What I’ll tell them is that they have facial pressure or issues with headaches or pressure, but it’s not your sinuses because they’re normal sinuses. And I won’t do surgery on normal sinuses because I can’t make a normal sinus more normal.
So, there are a lot of causes for the symptoms you might have. One of them could be a blocked sinus, but a lot of my patients don’t have blocked sinuses. Allergies can certainly cause you to feel pressure or headaches, but typically you’d also have nasal congestion with that. Allergy medications can sometimes help with this, over-the-counter meds like an antihistamine or a topical nasal steroid.
And then, if that doesn’t work, I would typically send the patient to a neurologist to see if they have a migraine or headache disorder. And I will say that in patients with normal CAT scans who don’t have allergies or respond to allergy medications, a lot of them will end up with a diagnoses of some type of headache or migraine disorder when they see the neurologist.
Shawn: What sort of work-up have you had done, Eli?
Eli: I actually have not had that much done recently. I know I did have some headaches when I was younger. They did a CT scan and they found some polyps, but nothing else. I have actually tried Flonase and a saline solution.
Shawn: Are you currently working with your nose and throat doc?
Eli: No. I was gonna make an appointment, I just wanted to ask you.
Shawn: Yeah, I think that’s definitely your first step, especially if you tell me you’ve had a history of polyps. Right, doc?
Dr. Reh: 100%. If you’ve had a CAT scan that showed that you have inflammation in your sinuses, or obstruction, seeing an otorhinolaryngologist and EMT doctor getting a CAT scan would be the best next step.
Shawn: And you could even maybe start pretreating with – if you can tolerate them – some nasal steroids, so that when you get there you can tell the doc that you’ve been on it for a month so they can see what you look like under the best circumstances, maybe not the worst.
Eli: Is that Flonase?
Shawn: Yeah. There’s several over-the-counter nasal steroids. Some people tolerate one more than the other. Do you have a version that you prefer, doc?
Dr. Reh: Yeah, I like the Flonase Sensimist. It’s a different drug. The old Flonase is called Fluticasone propionate, and in the old Flonase, which comes in the green top, or the generic, it causes drying and it actually causes headaches. So, when I was a resident, we would prescribe it all the time and patients would call in all the time with headaches from it.
But, the new one which is called Flonase Sensimist, it’s Fluticasone furoate, and it’s a lot better tolerated. When we started prescribing that, the number of calls I got for headaches came way down. So, that’s the one I like, especially for patents like you who already have facial pressure, pain or headaches. Sensimist is over-the-counter it’ll just be in the aisles. It has a blue top. So, giving that a 2-3 week trial would be helpful.
If that doesn’t help, 100%, getting a CAT scan is the next step.
Shawn: I think that’s really good advice for a lot of people. I don’t think people commonly know the difference between the two, or the common downside to the green top. Eli, give us a call back. Are you there?
Eli: Yeah, thank you.
Shawn: You bet. Try that out, and get in to see an ear, nose and throat doc. They’re gonna wanna put a little tiny scope ion your nose. It’s painless. Probably do a CAT scan as Doctor Reh said, and hopefully they’ll come up with some answers for you. When they do that, give us a call back and let us know.