What are the next steps for managing persistent sinus pressure after normal CT (Computed Tomography) scans, MRI (Magnetic Resonance Imaging), and sinus surgery?

Management of Persistent Sinus Pressure After Normal Imaging and Surgery

Your persistent sinus pressure with normal CT scans, MRI, and failed sinus surgery most likely represents non-rhinogenic facial pain or vasomotor rhinitis rather than true chronic rhinosinusitis, and you should be evaluated for alternative diagnoses before considering any further sinus interventions.

Understanding Your Situation

When multiple imaging studies are normal and sinus surgery has failed to relieve pressure symptoms, the problem is almost certainly not structural sinus disease. The American Academy of Otolaryngology guidelines emphasize that surgery should not be performed on patients with normal sinus CT scans 1. Your case suggests either:

• Non-sinus sources of facial pressure (neurologic, dental, temporomandibular joint disorders, migraine variants)
• Vasomotor rhinitis causing pressure sensations without true sinusitis
• Post-surgical complications that may paradoxically worsen symptoms

Immediate Next Steps

1. Reassess the Diagnosis

Stop pursuing sinus-directed treatments and investigate alternative causes of facial pressure:

• Neurologic evaluation: Migrainous facial pain, trigeminal neuralgia, and atypical facial pain commonly mimic sinus pressure but show normal imaging 1
• Dental examination: Dental pathology and temporomandibular joint dysfunction frequently present as "sinus pressure" 1
• Medication review: Rhinitis medicamentosa from overuse of topical decongestants can cause persistent pressure symptoms 2

2. Evaluate for Post-Surgical Complications

Even with "clear" imaging, endoscopic examination by an experienced rhinologist should assess for 1:

• Synechiae (scar tissue): Bridging between the middle turbinate and lateral nasal wall can cause obstruction despite normal-appearing mucosa 1
• Recirculation of mucus: Multiple ostia can cause mucus to drain and re-enter the sinus, perpetuating symptoms 1
• Frontal recess scarring: This is difficult to visualize even for experienced endoscopists and may not show clearly on imaging 1
• Excessive turbinate resection: Paradoxically causes increased sensation of obstruction and pressure despite patent airways 1

3. Trial of Medical Management for Vasomotor Rhinitis

If structural problems are excluded, your symptoms may represent vasomotor (non-allergic) rhinitis 2, 3:

First-line treatment:

• Intranasal corticosteroids (fluticasone, mometasone) at regular dosing for at least 4-6 weeks 2
• Add ipratropium bromide 0.03% nasal spray if rhinorrhea is prominent—this combination is more effective than either alone 2, 3

Adjunctive measures:

• Regular saline irrigation (twice daily) to reduce irritant exposure 2
• Identify and avoid triggers: Temperature changes, strong odors, irritants 3

What NOT to do:

• Never use topical decongestants beyond 3 days—they cause rebound congestion (rhinitis medicamentosa) 2
• Avoid oral antihistamines for vasomotor rhinitis—they are ineffective for non-allergic causes 2

Critical Pitfalls to Avoid

Do Not Pursue Additional Sinus Surgery

The 2025 American Academy of Otolaryngology guidelines explicitly state that surgery on sinuses without radiologic evidence of disease is inappropriate 1. With five normal imaging studies, further surgical intervention would be:

• Unlikely to provide benefit
• Associated with risks of complications (0.5% severe complication rate) 1
• Potentially harmful through creation of additional scarring 1

Recognize That Normal Imaging Rules Out Chronic Rhinosinusitis

Chronic rhinosinusitis requires both clinical symptoms AND objective evidence of inflammation on CT imaging for at least 12 weeks 1. Your normal imaging definitively excludes this diagnosis, regardless of symptoms 1.

Consider That Surgery May Have Worsened Your Condition

Post-surgical changes can paradoxically increase pressure sensations through 1:

• Scarring and synechiae formation
• Altered nasal airflow patterns
• Excessive tissue removal creating "empty nose syndrome"

Recommended Evaluation Algorithm

Step 1: Obtain nasal endoscopy by experienced rhinologist to identify subtle post-surgical complications not visible on imaging 1

Step 2: If endoscopy is normal, pursue non-rhinologic evaluation:

• Neurology consultation for facial pain syndromes
• Dental/TMJ evaluation
• Consider trial of migraine prophylaxis if headache features present

Step 3: If vasomotor rhinitis suspected, trial intranasal corticosteroids + ipratropium for 6-8 weeks 2, 3

Step 4: If no improvement, consider multidisciplinary pain management rather than additional sinus interventions

When Imaging Might Be Misleading

In rare cases, frontal recess disease can be difficult to visualize even on high-quality CT scans, and evaluation requires specialized expertise 1. However, after five imaging studies and surgery, this is extremely unlikely to be your issue.

The key insight is that persistent symptoms with consistently normal imaging almost never represent surgically correctable sinus disease 1. Further sinus-directed interventions risk harm without benefit.