The sinusitis that is not sinusitis

One of the most frustrating scenarios in clinical practice: the patient arrives with face and forehead pain — pressure in the sinuses, a sensation of frontal heaviness, pain that worsens on bending the head — and has already gone through two or three antibiotic courses without improvement. The CT of the sinuses is normal. The otorhinolaryngologist rules out sinusitis. But the pain persists, and the patient feels left without answers.

What frequently explains this picture are trigger points in the sternocleidomastoid (SCM), temporalis, masseter, and medial pterygoid muscles. These muscles have referred-pain patterns that project precisely over the sinuses — frontal, maxillary, and periorbital — creating a picture clinically indistinguishable from sinusitis on physical examination alone. Differential diagnosis depends on a clean image and reproduction of the pain on muscle palpation.

How cervical and facial muscles simulate sinusitis

  1. SCM — sternal belly and frontal pain

    The sternal belly of the sternocleidomastoid refers pain to the ipsilateral supraorbital and frontal region. This projection over the frontal sinus explains the diagnostic confusion — the patient points exactly to where the "sinusitis" hurts, but the origin is in the neck.

  2. Temporalis — pressure on the temple and forehead

    Trigger points in the temporalis muscle generate referred pain in the temporal and frontal regions and even in the upper teeth. The "pressure" sensation that the patient describes as sinus congestion is frequently the referred tension of the temporalis.

  3. Masseter — maxillary and infraorbital pain

    Trigger points in the deep masseter refer pain to the maxillary region and to the ear — simulating maxillary sinusitis or otitis. The superficial masseter refers to the mandible and the eyebrow, expanding the territory of facial pain.

  4. Medial pterygoid — deep facial pain

    The medial pterygoid, when activated by bruxism or TMD, refers deep pain to the palate, pharynx, and back of the face — pain that the patient frequently describes as "inside the head" or "behind the nose", consistent with sphenoid sinusitis.

Numbers that reveal the problem

30–40%
OF "CHRONIC SINUSITIS"
estimate in clinical series — proportion of cases that do not respond to antibiotics with a myofascial component as the main or significantly contributing cause of facial pain
~5
MEDICAL VISITS
average number reported in clinical series before myofascial facial pain is recognized as the diagnosis — patients see ENT specialists, neurologists, and allergists before muscular evaluation
Most
WITH ASSOCIATED BRUXISM
of patients with chronic myofascial facial pain present sleep bruxism or daytime clenching as an identifiable perpetuating factor — recurrent clinical observation
6–8
SESSIONS (TYPICAL RANGE)
in clinical experience, of medical acupuncture with needling of facial and cervical trigger points are usually necessary for significant relief of referred facial pain — individual response variable

Recognizing false sinusitis

Critérios clínicos
08 itens

Myofascial facial pain — typical pattern

  1. 01

    Face and forehead pain without purulent nasal discharge

  2. 02

    Sinus CT normal or with nonspecific mucosal thickening

  3. 03

    Pain that does not improve with antibiotics or nasal corticosteroids

  4. 04

    Facial pressure that worsens with stress or tooth clenching

  5. 05

    Associated periauricular or mandibular pain

  6. 06

    Reproduction of pain on pressing the SCM, temporalis, or masseter

  7. 07

    Cervical stiffness associated with facial pain

  8. 08

    History of bruxism, TMD, or tension-type headache

Myths and facts about chronic facial pain

Myth vs. Fact

MYTH

Facial pain is always sinusitis

FACT

Sinusitis is just one of the causes of facial pain. Trigger points in the SCM, temporalis, masseter, and pterygoids produce referred-pain patterns that overlap exactly with the sinuses — frontal, maxillary, and sphenoidal. When the CT is normal and antibiotics fail, myofascial assessment is the next diagnostic step.

MYTH

If the CT is normal, the pain is psychological

FACT

A normal CT excludes sinusitis but does not exclude myofascial pain. Trigger points do not appear on imaging — the diagnosis is clinical, by muscle palpation. The pain is real, measurable, and treatable with dry needling and medical acupuncture.

MYTH

Bruxism splints resolve facial pain

FACT

Occlusal splints protect the teeth and TMJ but do not deactivate trigger points already formed in the masticatory muscles. They are complementary to treatment — they do not replace needling of trigger points in the temporalis, masseter, and pterygoids that maintain facial pain.

The diagnosis that changes treatment

Treatment protocol

Complete differential assessment
1st visit

Review of prior tests (sinus CT). Systematic palpation of the SCM, temporalis, masseter, and pterygoids for pain reproduction. Assessment of bruxism and TMD. If warning signs present, referral for additional investigation.

SCM and temporalis needling
Sessions 1–3

Dry needling of the sternal belly of the SCM (referred frontal pain) and of the taut bands of the anterior and middle temporalis. 2 Hz electroacupuncture to enhance analgesia. Twitch response reproduces and relieves the referred facial pain.

Deep masseter and pterygoids
Sessions 3–6

Needling of the deep masseter by extraoral approach. Needling technique for the medial pterygoid when indicated — requires experience with the anatomy of the infratemporal fossa. Concomitant management of bruxism with an occlusal splint if necessary.

Maintenance and prevention
Sessions 7–10

Spacing of sessions to biweekly. Guidance on parafunctional habits (daytime clenching, cervical posture). Mandibular relaxation exercises. Monitoring for recurrence in periods of stress.

Clinical pearl: the clenching test

Frequently asked questions

FREQUENTLY ASKED QUESTIONS · 04

Frequently Asked Questions

If the sinus CT is normal (or shows only nonspecific mucosal thickening) and facial pain has not improved with antibiotics, a myofascial cause should be investigated. Reproduction of pain on palpation of the SCM, temporalis, or masseter confirms the muscular component. A medical acupuncturist can perform this assessment.

Needling of the temporalis and masseter is generally well tolerated — the needle is thin and the twitch response is brief. Needling of the medial pterygoid may generate greater transient discomfort but lasts only a few seconds. Most patients report immediate partial relief after the session, accumulating over the course of treatment.

Yes, and this combination is more common than imagined. Acute sinusitis can activate facial trigger points by reflex pain and muscle tension. Even after the infection resolves, the trigger points remain active, maintaining pain. In these cases, treating only the infection does not resolve it — it is necessary to deactivate the residual trigger points.

Most patients note partial improvement of facial pain after the first or second needling session. Chronic cases with associated bruxism may take 4–6 weeks for significant relief, since the perpetuating factor needs to be controlled simultaneously. The medical acupuncturist evaluates the response and adjusts the protocol individually.