What are the possible causes of pain over the bridge of the nose?

Causes of Pain Over the Bridge of the Nose

Pain over the bridge of the nose most commonly results from acute rhinosinusitis (particularly maxillary sinusitis), post-traumatic external nasal neuralgia, or temporomandibular disorders, with the specific cause determined by associated symptoms, trauma history, and response to diagnostic nerve blocks.

Primary Diagnostic Considerations

Acute Rhinosinusitis

• Maxillary sinusitis is the most frequent cause of nasal bridge pain in general practice, characterized by unilateral facial pain, purulent nasal discharge, and pain worsening when bending forward 1.
• The pain typically follows upper respiratory infection symptoms and may be accompanied by nasal obstruction, fever above 38°C, and malaise 1.
• Diagnostic criteria include symptoms lasting >7 days with at least two of the following: purulent discharge, facial pain over the maxillary sinus, and pain on bending 1.
• CT imaging may show mucosal thickening ≥5mm, air-fluid levels, or opacification, though clinical diagnosis is often sufficient 1.

Post-Traumatic External Nasal Neuralgia

• This is a frequently missed diagnosis that presents after nasal trauma with a characteristic latent interval before pain onset 2, 3.
• The external nasal nerve (branch of the anterior ethmoidal nerve from the ophthalmic division of the trigeminal nerve) becomes injured during nasal impact 4, 3.
• Pain can be episodic with tingling sensations lasting up to 30 minutes, occurring 2-3 times daily, or constant with a bruised sensation of mild-to-moderate intensity 4.
• Diagnostic confirmation is achieved through temporary relief with local anesthetic nerve blocks to the external nasal nerve 2, 4.
• MRI brain and CT sinuses are typically negative, distinguishing this from structural pathology 4.

Temporomandibular Disorders (TMD)

• TMD affects 5-12% of the population with peak incidence at ages 20-40 years and can refer pain to the nasal bridge region 1.
• Associated features include jaw dysfunction, headaches, and often coexisting fibromyalgia or back pain 1.
• Depression and catastrophizing increase chronicity risk 1.

Less Common but Important Causes

Dental-Related Pain

• Upper premolar or molar pathology can refer pain to the nasal bridge, particularly after extractions that create oral-antral fistulas 1.
• Look for oral and nasal discharge suggesting communication between oral cavity and maxillary sinus 1.

Pressure-Related Injury

• Non-invasive ventilation masks, eyeglasses, or other external pressure sources can cause nasal bridge pain and even pressure sores 5.

Idiopathic External Nasal Neuralgia

• Rare cases occur without trauma history, likely representing central sensitization given poor response to intranasal anesthetics 4.

Diagnostic Algorithm

1. Assess for recent trauma history: If positive with latent pain onset → consider post-traumatic external nasal neuralgia 2, 3
2. Evaluate for rhinosinusitis features: Purulent discharge, fever, pain on bending, post-URI symptoms → likely acute sinusitis 1
3. Check for jaw dysfunction: TMD often coexists with facial pain and requires specific examination 1
4. Examine oral cavity: Dental pathology or oral-antral fistula may be causative 1
5. Consider external pressure sources: Masks, glasses, or other devices 5

Treatment Approach by Etiology

For Acute Rhinosinusitis

• Antibiotics (amoxicillin 500mg three times daily for 10 days) show benefit in patients with confirmed acute bacterial rhinosinusitis 1.
• However, many cases are viral and self-limiting 1.

For Post-Traumatic External Nasal Neuralgia

• First-line pharmacologic treatment: Pregabalin or amitriptyline for prevention 4
• Most effective intervention: Nerve blockade with local anesthetic to the external nasal nerve, with some patients requiring radiofrequency ablation 4
• Surgical division of the anterior ethmoidal nerve provides definitive cure in refractory cases 2
• Sphenopalatine ganglion blocks also show efficacy 4

For TMD

• Management aims to decrease pain through conservative measures initially, with psychological factors addressed concurrently 1.

Critical Pitfalls to Avoid

• Do not dismiss nasal bridge pain after trauma as simple bruising—external nasal neuralgia develops after a latent period and requires specific treatment 2, 3.
• Do not over-prescribe antibiotics for viral rhinosinusitis—confirm bacterial infection criteria before treatment 1.
• Do not overlook dental causes—always examine the oral cavity and upper teeth 1.
• Do not assume imaging is always necessary—clinical diagnosis is often sufficient for rhinosinusitis, while imaging is typically negative in external nasal neuralgia 1, 4.