What is the workup for unilateral nasal bone pain?

Workup for Unilateral Nasal Bone Pain

The optimal workup for unilateral nasal bone pain should include nasal endoscopy and CT imaging of the paranasal sinuses without contrast as the primary diagnostic approach. 1

Initial Evaluation

• Nasal Endoscopy: Essential first-line examination to directly visualize:

  • Purulent discharge or edema in the middle meatus
  • Presence of nasal polyps or masses
  • Mucosal changes or ulceration
  • Septal deviation or perforation
  • Signs of fungal disease

• Physical Examination should specifically assess for:

  • Facial asymmetry or swelling
  • Tenderness over the nasal bones
  • Evidence of trauma
  • Palpable masses
  • Neurological symptoms (facial numbness or paresthesia)

Imaging Studies

CT Scan (Primary Imaging Modality)

• Non-contrast CT of the paranasal sinuses is the imaging modality of choice 1
  • Provides excellent bone detail and soft tissue visualization
  • Can detect subtle fractures, bone erosion, or destruction
  • Identifies anatomical variants and structural abnormalities
  • Coronal and axial views are essential for complete evaluation

When to Consider Additional Imaging:

• CT with contrast should be added when:

  • Complications of sinusitis are suspected (periorbital edema, abscess)
  • Sinonasal tumor is suspected
  • Unilateral opacification with bone erosion is present 1

• MRI with contrast should be considered when:

  • Soft tissue mass is suspected
  • Need to differentiate between tumor and retained fluid
  • Concern for orbital or intracranial extension
  • Suspicion for fungal sinusitis 1

Special Considerations for Unilateral Complaints

Unilateral nasal bone pain requires careful evaluation as it may indicate serious pathology:

• Neoplastic disease should be suspected with:

  • Epistaxis
  • Facial neuralgia or paresthesia
  • Visible mass on endoscopy
  • Bone remodeling or erosion on CT 2

• Fungal sinusitis should be considered when CT shows:

  • Unilateral lesions
  • Nodular mucoperiosteal thickening
  • Focal bone destruction
  • Dense intrasinus concretions 1

Laboratory Testing

• Nasal cytology may be useful to evaluate for:

  • Eosinophilic inflammation (allergic etiology)
  • Neutrophilic inflammation (infectious etiology)
  • Fungal elements 1

• Biopsy is indicated when:

  • Mass or polyp is visualized on endoscopy
  • Neoplastic process is suspected
  • Fungal disease is suspected
  • Granulomatous disease is suspected 1, 2

Common Pitfalls to Avoid

1. Relying on plain radiographs: These are inaccurate and have been largely replaced by CT for sinonasal evaluation 1

2. Missing unilateral disease: Unilateral complaints, especially with bone pain, should raise suspicion for neoplasm even when inflammatory disease is more common 2, 3

3. Inadequate timing of imaging: CT should be performed >2 weeks after an upper respiratory infection and >4 weeks after acute bacterial sinusitis to avoid confounding findings 1

4. Overlooking odontogenic causes: Maxillary sinus pain may originate from dental pathology, which requires specific evaluation 1

By following this systematic approach to evaluating unilateral nasal bone pain, clinicians can effectively diagnose the underlying cause and initiate appropriate treatment to reduce morbidity and improve quality of life.