What is the treatment for a patient with sinus pressure and toothache?

Treatment for Sinus Pressure and Toothache

For patients with sinus pressure and toothache, treatment should include analgesics, nasal saline irrigation, decongestants, and intranasal corticosteroids, with antibiotics reserved for cases meeting criteria for bacterial sinusitis. 1

Initial Assessment

• Determine if symptoms suggest viral rhinosinusitis (VRS) or acute bacterial rhinosinusitis (ABRS) based on duration, pattern, and severity 1
• Consider dental origin if pain is localized to maxillary teeth, as maxillary sinusitis can present with toothache in 39% of cases 2
• Evaluate for purulent nasal discharge, sinus tenderness, and lack of improvement with decongestants, which suggest bacterial sinusitis 3
• Assess for complicating factors such as facial swelling, visual changes, or neurological signs that would require urgent care 1

First-Line Treatment for Symptomatic Relief

• Analgesics: Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for pain relief, including facial and dental pain 1
• Nasal saline irrigation: Use isotonic or hypertonic (3-5%) saline to improve mucociliary clearance, thin mucus, and reduce inflammation 1
• Decongestants:
  • Oral pseudoephedrine for temporary relief of sinus congestion and pressure 4
  • Topical decongestants (e.g., xylometazoline) for short-term use (not exceeding 3-5 days) to reduce nasal and sinus mucosal congestion 1
• Intranasal corticosteroids: Recommended for reducing inflammation and improving symptoms, particularly when congestion is prominent 1
• Comfort measures: Adequate hydration, warm facial compresses, steamy showers, and sleeping with head elevated 1, 5

Antibiotic Therapy (Only for Bacterial Sinusitis)

• When to use antibiotics: Only if symptoms persist beyond 10 days, or worsen after initial improvement 1, 5
• First-line antibiotic: Amoxicillin (1.5-4g/day divided doses) for 10-14 days 1, 5
• If no improvement after 3-5 days: Switch to high-dose amoxicillin-clavulanate or cefuroxime axetil 1, 5
• For penicillin-allergic patients: Consider cephalosporins (if no anaphylaxis history), macrolides, or quinolones 1, 5

Special Considerations

• Dental vs. Sinus Pain:
  • Sinus-related tooth pain typically affects multiple upper teeth rather than a single tooth 2, 6
  • If dental examination is negative and pain is unilateral, suspect maxillary sinusitis of dental origin 2, 7
• Antihistamines:
  • Not recommended for non-allergic patients as they may worsen congestion by drying nasal mucosa 1
  • May be helpful only in patients with concurrent allergies 1
• Oral corticosteroids: Limited evidence supports their use in combination with antibiotics for short-term symptom relief in severe cases 1

When to Refer to a Specialist

• Symptoms persisting despite appropriate medical therapy 1, 5
• Recurrent episodes of sinusitis (3 or more episodes per year) 1, 5
• Presence of nasal polyps or anatomical abnormalities 1
• Suspected complications such as orbital or intracranial involvement 1
• When dental origin is suspected but dental examination is negative 2, 7

Prevention of Recurrence

• Appropriate treatment of underlying allergies and rhinitis 1, 5
• Avoidance of environmental irritants and allergens 1, 5
• Regular dental care to prevent odontogenic sources of infection 2, 8