What's the best treatment for unilateral facial pain without nasal congestion, possibly indicating acute bacterial rhinosinusitis or other conditions like trigeminal neuralgia?

Unilateral Facial Pain Without Nasal Congestion

Unilateral facial pain without nasal congestion does NOT meet diagnostic criteria for acute rhinosinusitis and should prompt consideration of alternative diagnoses, particularly trigeminal neuralgia, dental pathology, or other neurologic conditions. 1, 2

Why This Is Not Rhinosinusitis

Acute rhinosinusitis requires purulent nasal discharge PLUS at least one additional cardinal symptom (nasal obstruction, facial pain/pressure, or loss of smell). 1, 2 Facial pain alone—even if unilateral—is explicitly excluded from the diagnosis of acute rhinosinusitis. 1

• The American Academy of Otolaryngology-Head and Neck Surgery states clearly: "facial pain without purulent nasal drainage is not consistent with ARS, even though many patients present with a history of self-reported or physician-diagnosed 'sinus.'" 1
• Nasal obstruction without purulent drainage also does not meet criteria for rhinosinusitis. 1

Alternative Diagnoses to Consider

Unilateral facial pain without rhinologic symptoms should trigger evaluation for:

• Trigeminal neuralgia: Sharp, electric shock-like pain in trigeminal nerve distribution, often triggered by touch or movement 1
• Dental pathology: Maxillary tooth abscess, periodontitis, or referred dental pain 1, 3
• Temporal arteritis: If age >50 years, consider ESR/CRP 1
• Cluster headache or migraine: Vascular headaches can present with unilateral facial pain 1
• Temporomandibular joint disorder: Pain with jaw movement 1
• Atypical facial pain: Diagnosis of exclusion after ruling out structural causes 1

When Bacterial Rhinosinusitis IS the Diagnosis

If the patient actually has purulent nasal discharge (which you stated is absent), then acute bacterial rhinosinusitis requires one of three patterns: 1, 2

1. Persistent symptoms ≥10 days without improvement (purulent discharge, nasal obstruction, facial pain) 1, 2
2. Severe symptoms for ≥3 consecutive days: fever >39°C (102.2°F), purulent discharge, and severe unilateral facial pain 1, 2
3. "Double sickening": Initial improvement followed by worsening within 10 days 1, 2

Management for True ABRS (If Criteria Were Met)

First-line treatment would be amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days, with watchful waiting as an equally appropriate option if reliable follow-up exists. 4, 5

• Plain amoxicillin 500-875 mg twice daily is acceptable only for uncomplicated cases without recent antibiotic exposure. 4, 5
• For penicillin allergy: respiratory fluoroquinolones (levofloxacin, moxifloxacin) for severe Type I allergy, or cephalosporins (cefuroxime, cefpodoxime, cefdinir) for non-severe allergy. 4, 5
• Essential adjunctive therapy: intranasal corticosteroids (mometasone, fluticasone), saline irrigation, and analgesics for all patients. 4, 5

Critical Clinical Pitfall

Do not prescribe antibiotics for isolated facial pain without purulent nasal discharge. 1, 2 This represents inappropriate antibiotic use that:

• Exposes patients to unnecessary adverse effects (28% increased risk vs. placebo) 2
• Contributes to antibiotic resistance that persists up to 12 months 2
• Delays appropriate diagnosis and treatment of the actual underlying condition 1

Recommended Approach for Your Patient

Perform a focused examination looking for:

• Dental tenderness, percussion sensitivity, or visible dental pathology 1, 3
• Trigger points for trigeminal neuralgia (light touch to face) 1
• Temporal artery tenderness if age >50 years 1
• TMJ tenderness or crepitus with jaw movement 1
• Actual presence of purulent nasal discharge on examination (not just patient-reported) 1, 2

If no purulent discharge is confirmed on examination, refer to neurology or dentistry as appropriate rather than treating empirically for sinusitis. 1