Do Not Order CT Head With and Without Contrast for Sinus Pressure and Ear Pressure
For uncomplicated sinus congestion and eustachian tube dysfunction causing insomnia, you should not order any CT imaging at all—this is not an appropriate indication for CT scanning. 1, 2
Why CT Head Is Inappropriate
CT head does not adequately cover the paranasal sinuses and is explicitly not recommended for evaluation of chronic rhinosinusitis (CRS) or sinus-related symptoms 1
Contrast (with or without) adds no diagnostic value for uncomplicated sinus disease—the ACR states there is "no relevant literature to support the use of combined pre- and postcontrast CT imaging" for inflammatory sinus disease 1
CT imaging for uncomplicated acute rhinosinusitis is rated only 4/9 ("may be appropriate") by the American Academy of Otolaryngology, meaning it's generally not indicated 2
CT findings of chronic sinusitis on brain imaging are incidental and not associated with acute headaches or symptoms—a study of 500 patients found equal prevalence (22.2% vs 17.7%) of sinus findings in headache patients versus controls with minor head injury 3
When CT Sinus Imaging IS Appropriate
If you were considering imaging at all, the correct study would be CT maxillofacial (paranasal sinuses) WITHOUT contrast, but only in these specific scenarios:
Appropriate Indications for CT Sinus (Without Contrast):
- Surgical planning for chronic rhinosinusitis after failed medical management (rated 9/9 "usually appropriate") 1, 2
- Suspected orbital complications such as periorbital cellulitis or subperiosteal abscess (rated 8/9 with contrast) 1, 2
- Suspected intracranial complications such as meningitis, epidural abscess, or subdural empyema (requires contrast) 1, 2
- Recurrent acute rhinosinusitis being considered for surgical intervention 2
Management of Your Patient's Symptoms
For simple sinus pressure and eustachian tube dysfunction causing sleep disturbance:
Medical management is first-line: nasal saline irrigation, intranasal corticosteroids, and potentially oral decongestants 4, 5
ETD symptoms are extremely common in rhinology patients—43.3% of patients in rhinology clinics report symptoms consistent with ETD 5
Topical decongestants have limited evidence for improving eustachian tube function, though they may increase duration of tube opening 4
Document failed medical management if you later need to justify imaging for surgical planning 2
Critical Pitfalls to Avoid
Do not use diagnosis code J01.x0 (acute uncomplicated sinusitis) to justify CT imaging—insurers will deny these claims 2
CT cannot distinguish bacterial from viral acute rhinosinusitis, making it unhelpful for acute management decisions 2
"Fear of missing something" is not a valid indication—studies show this psychological factor drives 50% of unnecessary head CTs, but guidelines should prevail 6
Radiation exposure matters: CT sinus delivers 0.1-1 mSv and must be clinically justified 2