A 14-year-old male presents with a history of seasonal allergies and headache since the age of 12. Initially, headaches were sporadic, but recently pain has been frequent and intense. The pain is located on the forehead and eyes without radiation. It is not associated with any food intake, and patient denies visual aura. Pain is oppressive and can reach an intensity of 8/10, worse if the patient leans forward. Pain does not clearly change when lying down, coughing, or performing other Valsalva maneuvers. There is no history of photophobia, phonophobia, nausea, or vomiting. Mother comments that sometimes his eyelids and forehead are swollen. He has no history of fever, trauma, or toxic exposures. Patient was previously seen by his pediatrician, who prescribed nasal drops and fluticasone propionate inhaler. As the headaches did not improve, the patient was referred to neurology.

Systems review is positive for frequent nasal congestion on the left. Patient is not taking vitamins, hormones, antibiotics, or other medicines. He also denies the use of recreational drugs including cocaine. There is no history of significant weight gain in the past year, anxiety, or depression. He has no allergies to medications. Vaccinations are complete.

There is no family history of migraine headaches, aneurysms, or brain tumors. Maternal grandfather with meningioma treated by surgery, maternal aunt with pituitary adenoma, younger brother with ADHD.

Physical examination shows weight 70 kg, height 175 cm, head circumference 55 cm, blood pressure 110/70, pulse 88, temperature 37.8°C. On general head examination, patient is normocephalic, without neck stiffness or lymphadenopathy. Current headache level is 6/10, with mild pain on percussion of frontal bone and left maxillary sinus. Nasal examination shows mucosal edema and hyperemia in addition to yellowish discharge on the left side. Cardiorespiratory and abdominal examinations are normal.

Neurological examination shows normal mental status for age. Cranial nerves and fundoscopy are normal. Motor, sensory, cerebellar, and gait examinations are normal.

Paranasal sinus X-ray reveals opacification of the left maxillary sinus.

CT scan confirms maxillary and ethmoid sinus inflammatory disease without associated bone alterations.

MRI shows air-fluid level in the left maxillary sinus indicative of acute inflammation ( Fig. 1.1 ).

Acute left maxillary and ethmoid sinusitis. Paranasal sinus x-ray (A): opacification of left maxillary sinus ( arrow ). Paranasal sinus CT (B): fluid and soft tissue density in the left maxillary sinus and ethmoid air cells. MRI, axial T2 (C): left maxillary sinus mucosal thickening with air-fluid level ( arrowhead ).

Incidental sinonasal mucosal disease. Paranasal sinus CT: patchy mucosal thickening and retention cysts in both maxillary sinuses ( arrowheads ).

Migraine, cluster headache, chronic paroxysmal hemicrania, SUNCT/SUNA (short-lasting, unilateral, neuralgiform headaches with conjunctival tearing and injection/cranial autonomic features), and hemicrania continua. Headaches are distinguished by duration, stereotyped circadian cycles, and response to indomethacin.

Tension headache can cause pain in the forehead and back of neck.

“Salt-and-pepper pains” of the eyes may indicate an evolving brainstem infarction.

Purulent nasal discharge and sinonasal inflammation are suggestive of acute rhinosinusitis.

Mucocele is caused by obstruction of sinus exit foramina with sinus expansion and wall thinning/remodeling ( Fig. 1.2 ). Infection (mucopyocele) is a dreaded complication.

Sinusitis with secretions can demonstrate varying MRI signals depending on fluid, protein, and fungal contents.

Benign and malignant paranasal sinus masses can be characterized by imaging features, including calcifications, expansion, contrast enhancement, bone erosion, and spread (direct extension, perineural spread, satellite lymphadenopathy).

Sinusitis.

Diagnosis of sinusitis is clinical. Imaging can help confirm the diagnosis or further evaluate disease severity,response to treatment, or complications. Sinus radiograph is sufficient for basic diagnosis. For rapid screening and surgical planning, CT helps evaluate bony sinonasal anatomy. MRI can be considered in the setting of suspected intracranial complications or invasive fungal sinusitis requiring soft tissue detail.

A large percentage of children with imaging tests done for other indications show incidental sinonasal abnormalities, including mucosal thickening and retention cysts. These abnormalities can be caused by chronic upper respiratory infection or allergic inflammation, which may not require treatment if asymptomatic ( Fig. 1.3 ). However, the presence of air-fluid levels or aerosolized bubbly secretions suggests an acute infectious process that is more commonly associated with headache. Chronic sinusitis can manifest with paranasal sinus atelectasis (decreased size) and/or wall thickening (hyperostosis) ( Fig. 1.4 ).