What could be causing the pressure, stiffness, and throbbing sensation in my nasal septum?

Nasal and Facial Pressure: Understanding Your Symptoms

Your nasal septum pressure, stiffness, and throbbing sensation extending to your front teeth is most likely caused by acute or chronic sinusitis, with the differential diagnosis including septal deviation, allergic rhinitis, or vascular headaches/migraines. 1

Primary Diagnostic Considerations

Acute or Chronic Sinusitis

The combination of facial-dental pain, nasal congestion, and pressure localized to the nasal septum and upper teeth strongly suggests sinusitis as the primary diagnosis. 1

• Facial-dental pain is a prominent symptom of acute bacterial sinusitis in adults, along with nasal congestion, purulent rhinorrhea, postnasal drainage, headache, and cough 1
• The throbbing quality you describe occurs because obstruction of the sinus ostia causes pressure changes within the sinus cavity, with pressure decreasing by 20-30 mm H2O, which directly causes pain symptoms, particularly in the frontal region 1
• Acute bacterial sinusitis is suspected when upper respiratory tract infection symptoms persist beyond 10-14 days, with persistent purulent rhinorrhea and facial pain having the strongest correlation with bacterial disease 1
• Chronic sinusitis symptoms are similar to acute sinusitis but may be more subtle, with patients experiencing mild increases in congestion and fatigue rather than dramatic new symptoms 1

Anatomical Factors Contributing to Pressure

Septal deviation can contribute to your symptoms by obstructing the ostiomeatal complex, which impairs sinus ventilation and drainage. 2

• Approximately 80% of the general population has some degree of septal asymmetry, but only 26% have clinically significant deviation causing symptoms 2, 3
• Anterior septal deviation is more clinically significant than posterior deviation because it affects the nasal valve area responsible for more than 2/3 of airflow resistance 2
• Severe septal deviation with increased angles is significantly linked to specific disease patterns in the osteomeatal complex, which can predispose to chronic rhinosinusitis 4

Differential Diagnosis to Consider

Allergic and Nonallergic Rhinitis

The differential diagnosis of sinusitis includes allergic rhinitis (AR), eosinophilic nonallergic rhinitis (NAR), vasomotor rhinitis (VMR), and vascular headaches-migraines. 1

• Red, swollen nasal tissue indicates infectious rhinitis and sinusitis, while pale boggy turbinates suggest allergic rhinitis 1
• Environmental exposures, genetic predisposition, nasal polyps, and other causes of ostiomeatal obstruction are predisposing factors for sinusitis 1

Vascular Headaches

It is probable that headache attributed to chronic sinusitis could be a migraine equivalent, particularly when facial pain is the predominant symptom without other clear signs of infection 1

• Migraines, tension headaches, cluster headaches, and temporomandibular joint disorder are common causes of facial pain that can be mistaken for sinusitis 1

Recommended Diagnostic Approach

The diagnosis of sinusitis is based on a combination of clinical history, physical examination, imaging studies, and/or laboratory tests. 1

Clinical Examination Findings to Assess

• Sinus tenderness on palpation, mucosal erythema, purulent nasal secretions, increased pharyngeal secretions, and periorbital edema are clinical signs of acute sinusitis 1
• Purulent exudates in the middle meatus are believed to be highly predictive of bacterial sinusitis, appearing yellow-green, green, or gray 1
• Assess the quality and color of nasal secretions: clear and watery suggests viral or allergic causes, while thick, colored (yellow-green), and opaque secretions suggest bacterial infection 1

When Imaging Is Appropriate

Imaging studies are not indicated for uncomplicated sinusitis but may be appropriate to rule out misdiagnosis if symptoms do not respond to therapy. 1

• CT imaging with fine-cut protocol should be obtained for surgical planning if medical management fails 2
• The most common imaging finding is mucosal thickening, usually bilateral, with acutely infected sinuses demonstrating air-fluid levels 1

Initial Management Strategy

If symptoms have persisted beyond 10-14 days, you should be evaluated for acute bacterial sinusitis and consider antibiotic therapy along with supportive measures. 1

Medical Management

• A complete medical management trial should include intranasal corticosteroids, saline irrigations, appropriate antibiotics for bacterial sinusitis, and treatment of any underlying allergic component 2
• A minimum of 4 weeks of documented medical therapy is required before considering surgical intervention, including intranasal corticosteroids, saline irrigations, and mechanical treatments 2, 5

When to Reassess

If the diagnosis of sinusitis is confirmed and treatment failure occurs within 7 days after initial diagnosis, antibiotic therapy should be adjusted or initiated. 1

• Between 7-12 days after treatment enrollment, 73% of patients randomized to placebo have clinical improvement, rising to 85% with antibiotics 1

Common Pitfalls to Avoid

• Do not assume all septal deviations require surgical correction, as only 26% are clinically significant 2
• Typical "colds" last 5-7 days and rarely as long as 10 days—persistence of purulent secretions beyond 10 days in the middle meatus area is characteristic of sinusitis 1
• Patients with rhinitis might not perceive they have chronic sinusitis, instead sensing only a mild increase in congestion and fatigue, or complaining that usual rhinitis medications are not effective 1
• Examine for complications if symptoms worsen, including proptosis, visual changes, severe headache, abnormal extraocular movements, changes in mental status, and periorbital inflammation 1