Abstract
Nasal endoscopy is one of the common out-patient diagnostic procedures in ENT practice. Patients suffering from persistent rhinosinogenic headache which is not responding to standard medical management demand a thorough evaluation that incorporates diagnostic nasal endoscopy (DNE). Rhinosinogenic headache is multifactorial which includes contact point, deviated nasal septum, inferior turbinate hypertrophy, nasal polyposis and sinusitis. To identify the particular cause of the headache is necessary for appropriate management. We conducted a prospective observational study to assess the role of nasal endocopy in diagnosis and management of rhinosinogenic headache persisting for at least 3 months, over a period of one and half year. Thirty patients fulfilling the inclusion criteria were enrolled in the study. We categorized the headache as mild, moderate and severe. After DNE, we found that 93.33% (n = 28) had deviated nasal septum (DNS), 40% (n = 12) had septal spur, 10% (n = 3) had polyp, 50% (n = 15) had contact point, 67% (n = 20) had inferior turbinate hypertrophy (ITH), 26.67% (n = 8) had pneumatised middle turbinate or concha bullosa and 50% (n = 15) patients of sinusitis. After computed tomographic evaluation, 30% (n = 9) patients underwent septoplasty, 20% (n = 6) underwent endoseptoplasty, 40% (n = 12) underwent middle turbinate lateralisation (MTL), 16.67% (n = 5) underwent FESS, 30% (n = 9) underwent FESS with endoseptoplasty, 3.33% (n = 1) Caldwell Luc’s operation for unilateral maxillary polyp with sinusitis. Postoperatively we found that, 86.67% (n = 26) had total relief, 6.67% (n = 2) had partial improvement and 6.67% (n = 2) had no improvement of headache. Our study demonstrates that nasal endoscopy has significant role in diagnosis and management of rhinosinogenic headache.
Keywords: Headache, Nasal endoscopy, Contact point, Deviated nasal septum, Rhinosinogenic, Inferior turbinate hypertrophy
Introduction
Rhinosinogenic headache is one of the common symptoms encountered by otolaryngologists. Rhinogenic headache is due to mucosal contact points in absence of inflammation of mucosa, sinonasal polyp or mass, nasal discharge. It is also described in literature as four finger headache, contact point headache and Sluder headache [1]. There are various types of headache that can mimic rhinosinogenic headache like migraine, tension headache, neuralgia, cervical spine disorder, temporomandibular joint disorder, ophthalmic disorder, intracranial pathologies and vascular type headache. Acute and chronic sinus headache is usually associated with sinus and nasal symptoms like nasal discharge, post-nasal drip, cough, pressure in face and tenderness over paranasal sinuses. Contact point has been attributed to intranasal contact between opposing mucosal surfaces resulting in referred pain in distribution of trigeminal nerve [2–4].Wolf described that referred facial pain may occur due to contact between turbinate or other region in the nasal cavity [5]. Contact point headache is described as intermittent pain in periorbital, medial canthal or temporomandibular area, associated with nasal endoscopic or computed tomographic evidence of mucosal contact point. Various intranasal abnormalities including enlarged ethmoid bulla, septal deviations and spurs, middle turbinate anomalies attribute to mucosal contact. The pathogenesis of headache is diverse and mucosal contact point is not the sole cause of refractory headache [6]. Hence, the diagnosis and management of headache needs assessment by multiple specialised practitioner including neurologist, orthopaedician, dental surgeon as well as otorhinolaryngologist.. Patients with rhinosinogenic headache are treated first by endoscopic sinus surgery if medical management fails. The present study evaluated the role of nasal endoscopy in diagnosis and management of rhinosinogenic headache.
Materials and Methods
We conducted a study at Vardhman Mahavir Medical College and Safdarjung Hospital New Delhi, on 30 patients suffering from headache for minimum period of 3 months, with symptoms of sinusitis and other sinonasal problems or having contact point as seen on either nasal endoscopy or computed tomography scan or both, over the period of one and a half year. Selected patients were categorized into mild, moderate and severe patient. The severity was based on the descriptor viz activity, mild-may inhibit activities, moderate-inhibits daily activities but doesn’t prohibit activities, severe-prohibits daily activities [7]. We excluded the patients suffering from headache due to non-sinus conditions like migraine, neuralgia, cervical spine disorder, temporomandibular joint disorder, ophthalmic problem and trauma. We also excluded any other cause of headache after thorough evaluation by neurologist, ophthalmologist and dental surgeon. This was a prospective observational study that evaluated headache using nasal endoscopy and compared preoperative and postoperative severity of headache among selected patients who underwent endoscopic surgery.
Diagnostic nasal endoscopy using 0° and 30° endoscope was done to evaluate patients suffering from chronic sinusitis (not responding to medication), allergy, nasal obstruction, contact point(s) and foreign body. We did functional endoscopic sinus surgery (FESS) for patients with chronic sinusitis not responding to steroid nasal spray and oral antihistaminics. We also did endoscopic septoplasty, excision of polyp, turbinate reduction surgery, middle turbinate lateralisation among patients with contact point headache. Patients were given intravenous antibiotics (ampicillin and cloxacillin), analgesics and oral antihistaminic postoperatively. Post-op FESS patients were given steroid nasal spray and alkaline nasal douching. Patients were followed up weekly for first 1 month and monthly for three consecutive months. We assessed the patients for complete or partial relief of headache postoperatively. Anterior rhinoscopy was done for persistent contact point, synechiae and incision site healing.
Observations and Results
A total of 30 patients of headache fulfilling inclusion criteria were enrolled for the study. Pre-operatively we found 73.3% (n = 22) complaining of nasal obstruction, 60% (n = 18) with rhinorrhoea, 26.67% (n = 8) with nasal bleeding, 36.67% (n = 11) with anosmia or hyposmia, 80% (n = 24) with nasal discharge, 23.33% (n = 7) with nasal mass, 30% (n = 9) with postnasal drip and 26.67% (n = 8) with ophthalmologic symptoms (Table 1, Fig. 1). Intensity, frequency and duration of headache was analysed by questionnaire method pre and postoperatively. Intensity of headache was classified as mild (20%, n = 6), moderate (70%, n = 21) and severe (10%, n = 3). We found that 86.67% (n = 26) patients had headache every day, whereas 13.33% (n = 4) patients had headache intermittently. Duration of headache ranged from 3 to 96 months (Table 2, Fig. 2).
Table 1.
Symptoms among the patients
| Symptoms | Number of patients (percentage of total number of patients) |
|---|---|
| Headache | 30 (100%) |
| Nasal obstruction | 22 (73.33%) |
| Rhinorrhoea | 18 (60%) |
| Nasal bleeding | 8 (26.67%) |
| Anosmia/hyposmia | 11 (36.67%) |
| Nasal discharge | 24 (80%) |
| Nasal mass- | 7 (23.33%) |
| Eye symptoms | 8 (26.67%) |
| Post nasal drip | 9 (30%) |
Fig. 1.
Symptoms among the patients
Table 2.
Headache duration (pre-operative)
| Duration in months | 3–22 months | 23–42 months | 43–62 months | 63–82 months | 83–102 months |
|---|---|---|---|---|---|
| Number of patients | 14 (46.67%) | 8 (26.67%) | 7 (23.33%) | 0 (0%) | 1 (3.33%) |
Fig. 2.
Headache duration (pre-operative)
We assessed each patient by using diagnostic nasal endoscopy. We found that 93.33% (n = 28) had deviated nasal septum (DNS) (Fig. 3), 40% (n = 12) had septal spur (Fig. 4), 10% (n = 3) had polyp, 50% (n = 15) had contact point, 66.67% (n = 20) had inferior turbinate hypertrophy (ITH), 26.67% (n = 8) had pneumatised middle turbinate or concha bullosa and 50% (n = 15) patients of sinusitis (Table 3, Fig. 5).
Fig. 3.
Deviated nasal septum (left side)
Fig. 4.
Septal spur in contact with inferior turbinate
Table 3.
Diagnostic nasal endoscopy findings
| Diagnostic Nasal endoscopic findings | Deviated nasal septum | Spur | Polyp | Sinusitis features | Contact point | Inferior terminate hypertrophy | Pneumatised middle turbinate | |
|---|---|---|---|---|---|---|---|---|
| With IT | With MT | |||||||
| Number of patients | 28 (93.33%) | 12 (40%) | 3 (10%) | 15 (50%) | 6 (20%) | 9 (30%) | 20 (66.67%) | 8 (26.67%) |
Fig. 5.
Diagnostic nasal endoscopy findings
Each patient underwent non-contrast enhanced computed tomography scan. We found that 93.33% (n = 28) patients had DNS, 30% (n = 9) had septal spur (Fig. 6), 10% (n = 3) had a polyp, 30% (n = 9) had septum/spur in contact with middle turbinate (MT), 20% (n = 6) had septum/spur in contact with inferior turbinate (IT), 60% (n = 18) had ITH, 53.33% (n = 16) had pneumatised MT and 50% (n = 15) had features of sinusitis (Table 4, Fig. 7).
Fig. 6.
Septal spur (left side) in contact with lateral nasal wall
Table 4.
Computed tomography findings
| Computed tomography findings | Deviated nasal septum | Spur | Polyp | Sinusitis features | Contact point | Inferior terminate hypertrophy | Pneumatised middle turbinate | |
|---|---|---|---|---|---|---|---|---|
| With IT | With MT | |||||||
| Number of patients | 28 (93.33%) | 10 (33.33%) | 3 (10%) | 15 (50%) | 6 (20%) | 9 (30%) | 18 (60%) | 16 (53.33%) |
Fig. 7.
Computed tomography findings
After endoscopic and computed tomographic evaluation, patients were selected to undergo surgical management accordingly. 30% (n = 9) patients underwent septoplasty, 20% (n = 6) underwent endoseptoplasty, 40% (n = 12) underwent middle turbinate lateralisation (MTL), 16.67% (n = 5) underwent FESS, 30% (n = 9) underwent FESS with endoseptoplasty, 3.33% (n = 1) Caldwell Luc’s operation for unilateral maxillary polyp with sinusitis (Table 5, Fig. 8).
Table 5.
Surgical procedures
| Surgical procedures | Septoplasty | Endoseptoplasty | MTL with other procedures | FESS | FESS with endoseptoplasty | Caldwell Luc’s operation |
|---|---|---|---|---|---|---|
| Number of patients | 9 (30%) | 6 (20%) | 12 (40%) | 5 (16.67%) | 9 (30%) | 1 (3.33%) |
Fig. 8.
Surgical procedures
We evaluated whether headache improved partially or completely or no improvement at all postoperatively. We found that, 86.67% (n = 26) had total relief, 6.67% (n = 2) had partial improvement and 6.67% (n = 2) had no improvement of headache (Table 6, Fig. 9). Follow up of the patients was done by questionnaire method. We found that only 13.33% (n = 4) patients had persistent headache at the end of 3 months follow up, rests showed relief of headache either complete or partial.
Table 6.
Post-operative headache
| Post-operative headache | Total relief | Partial relief or incomplete relief | No improvement |
|---|---|---|---|
| Number of patients | 26 (86.67%) | 2 (6.67%) | 2 (6.67%) |
Fig. 9.
Post-operative headache
Discussion
Headache is the 9th most common symptom arising concern among both the patients and physicians [8]. It is a multifactorial symptom that should be investigated by neurologist, ophthalmologist, orthopaedic surgeon, dental surgeon as well as otorhinolaryngologist. We assessed the role of nasal endoscopy in diagnosis and management of rhinosinogenic headache excluding other common causes of headache like migraine, tension headache, cluster headache, refractive error, vasogenic headache, intra-cranial space occupying lesions etc. In 1988, International headache society (IHS)proposed classification of headache to maintain uniform diagnostic criteria. The simplest way to classify headache is to categorizes acute, sub-acute, and chronic headache into primary and secondary [9]. We questioned each patient about headache and analysed its duration, frequency and intensity. Most patients had duration of headache between 3 and 22 months. 86.67% patients reported headache everyday and 70% of patients had moderate intensity of headache. We found that nasal endoscopy has significant impact in diagnosis of rhinosinogenic headache with or without contact point. Mucosal contact point headache was constituted by IHS [10] as
-
A.
Intermittent pain localised to the periorbital or medial canthal or temporozygomatic region fulfilling criteria C and D
-
B.
Clinical, nasal endoscope and/or CT imaging evidence of mucosal contact point without acute sinusitis.
-
C.Evidence that the pain can be attributed to mucosal contact based on at least one of the following:
- Pain corresponds to gravitational variations in mucosal congestion as the patients moves between upright and recumbent positions
- Abolition of pain within 5 min after diagnostic topical application of local anaesthesia to the middle turbinate using placebo or other controls
-
D.
Pain resolves within 7 days, and does not recur, after surgical removal of mucosal contact point(s).
The nasal mucosa contains nociceptors which are responsible for conveying information of noxious stimuli, mechanoreceptors which are responsible for non-noxious stimuli and dynamic range receptors which are stimulated by both noxious and non-noxious stimuli [9]. Wolfe, Dalessian and Greenfield showed release of vasoactive amines responding to tissue injury, triggering headache. Blumenthal suggested that substance P is a neuropeptide, synthesis of which is triggered by chemicals, infections, thermal irritants and mechanical pressure (contact point);mediates pain through unmyelinated C fibres to cortex [11]. Bakra and Jones [12] found prevalence of contact point in patients with facial pain 42% (n = 407) and those without facial pain 58% (n = 566). In our study, the incidence of contact point headache was 11.90% and headache due to rhinosinusitis was 23.80%. According to our study, maximum number of patients had deviated nasal septum (93.33%, n = 28), followed by inferior turbinate hypertrophy, as observed in both nasal endoscopy (66.67%, n = 20) as well as computed tomography (60%, n = 18). Jia Wang MS et al found that most common anatomic abnormality was deviated nasal septum (41.1%), followed by pneumatized middle turbinate (32.4%), whereas we found only 53.33% (n = 16) cases with pneumatized middle turbinate [6].
Ostiomeatal complex (OMC) is a key area where maxillary, frontal and anterior group of ethmoid air cells drain. Anatomical or pathological blockage of OMC impairs sinus drainage and causes contact point of opposing mucosal surface in narrow spaces as well as malventilation of sinuses. Subsequently mucociliary functions of mucosa become impaired and stagnant mucus acts as nidus for infection. Malventilation of sinuses leads to local hypoxia, reduced pH, reduced ciliary beat, thick mucus and predisposes to infection. Polyp exerts pressure over mucosa. These factors attribute to the development of sinus headache [9]. We found 50% (n = 15) patients had features of sinusitis endoscopically with or without associated abnormality.
Mokbel K.M. et al studied role of nasal endoscopy for both diagnosis and localized excision of intranasal contact point. They found 98.75% patients got benefit from surgery [13]. Devrim Baktas evaluated the role of FESS to alleviate rhinosinogenic headache including contact point. They showed statistically significant improvement of headache post surgically [14]. We did FESS on selected patients of sinusitis who were not responding to medical management. The basic principal of various surgeries was correcting mucosal contact point, preserving normal mucosa. Maximum number of patients underwent middle turbinate lateralisation (40%, n = 12). We did not encounter any intra or post-operative complication requiring blood transfusion, re-exploration or treatment in intensive care unit (ICU). In our study, 93.33% (n = 14) patients of sinusitis and 80% (n = 26) of contact headache showed complete relief postoperatively. Likewise, Mohebbiet al reported 83% improvement of headache post surgery after correction ofcontact point(s), which is comparable to outcome of our study [15].
Conclusion
Headache is one of the common symptoms faced in day to day life, that has a potential impact on quality of life. As already discussed that headache is multifactorial. We studied the role of nasal endoscopy in diagnosis and management of rhinosinogenic headache in selected group of patients. We found that nasal endoscopy had significant impact in diagnosis as well as management of such headache. To identify the exact cause of headache in these cases is critical as there could be various types of etiology of headache in same patients and mode of management may not yield favourable outcome. We did an observational study that showed improvement of headache in majority of patients following surgery. Only 13.33% patients had persistent headache which may attribute to undiagnosed cause of headache or incomplete clearance of disease. To conclude, we must say that nasal endoscopy has significant role in diagnosingas well asdecision making for surgical intervention to manage rhinosinogenic headache. There could be significant improvement of headache post-surgery in carefully selected patients.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
All procedures involving human participants were in accordance with the ethical standards of the institution.
Informed Consent
Informed consent was obtained from all individuals participants included in the study.
Footnotes
Publisher's Note
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