Specific Areas to Test for Sinus Tenderness
The specific areas to test for sinus tenderness include the maxillary sinuses below the cheeks, frontal sinuses above the eyebrows, ethmoid sinuses between the eyes, and sphenoid sinuses behind the ethmoids. 1
Anatomical Locations for Testing Sinus Tenderness
Maxillary sinuses: Located beneath the cheeks on either side of the nose. Apply gentle pressure with fingertips to the area below the cheekbones to assess tenderness. This is the most common site of sinusitis and should be routinely evaluated. 1
Frontal sinuses: Located in the forehead above the eyebrows. Apply gentle pressure to the supraorbital ridge area to assess tenderness. Frontal sinus tenderness may indicate frontal sinusitis, which can lead to serious complications if untreated. 1
Ethmoid sinuses: Located between the eyes on either side of the nasal bridge. Apply gentle pressure to the medial canthal area (inner corner of the eyes) to assess tenderness. Ethmoid involvement occurs in approximately 20% of patients without maxillary sinus infection. 1
Sphenoid sinuses: Located deep in the skull behind the ethmoid sinuses. These are difficult to directly palpate but may cause referred pain to the vertex or occiput of the head. 1
Technique for Assessment
Use fingertip pressure applied gradually to each area, noting patient's response. 2
Quantitative studies show that normal pressure threshold for non-sinusitis patients is approximately 1.59 kg/cm², while patients with acute sinusitis have lower thresholds (1.10 kg/cm²), indicating increased sensitivity. 2
Decongestion of the nasal mucosa with a vasoconstrictor prior to examination may improve visualization of purulent secretions in the middle meatus, which is highly predictive of bacterial sinusitis. 1
Clinical Correlation
Sinus tenderness should be correlated with other clinical findings such as purulent nasal discharge, nasal congestion, and facial pain to increase diagnostic accuracy. 1, 3
In one prospective study, abnormal transillumination combined with purulent nasal secretions and a history of maxillary pain, poor response to decongestants, and colored rhinorrhea was the best predictor of acute bacterial sinusitis. 1
Purulent exudates in the middle meatus are highly predictive of bacterial sinusitis but might be difficult to visualize without proper decongestion. 1
Important Caveats
Sinus tenderness alone is not diagnostic of sinusitis. Some patients with chronic fatigue syndrome may have sinus tenderness without sinusitis due to systemic hyperalgesia. 2
Children rarely present with headache or facial tenderness, even with confirmed sinusitis. 4
Dental pain may indicate maxillary sinusitis as the roots of the teeth project into the floor of the maxillary sinus. Examine for dental tenderness when maxillary sinusitis is suspected. 1
Any patient with orbital swelling or pain, swelling of the forehead, and/or diplopia should be urgently evaluated as these may indicate serious complications. 1
When to Consider Imaging
When symptoms are vague, physical findings are equivocal, or clinical disease persists despite optimal medical therapy, imaging techniques can provide confirmatory evidence. 1
CT is the optimal technique for evaluating the ethmoid sinuses and for preoperative evaluation of the nose and paranasal sinuses. 1
Standard radiographs might be used to detect acute sinusitis but are not sensitive, particularly for ethmoid disease. 1