Underestimation of Rhinogenic Causes in Patients Presenting to the Emergency Department with Acute Headache

OBJECTIVES

Differential diagnosis is essential, since secondary headache due to paranasal sinus lesions are similar in headache characteristics to primary headache. However, since patients visiting the emergency department due to acute severe headache are primarily treated by neurologists, paranasal sinuses lesions and anatomical variations of the nasal cavity causing the headache are commonly overlooked because of the clinician's lack of knowledge about rhinosinugenic headache. This study investigated the prevalence of paranasal sinus lesions and anatomical variations that may cause secondary headaches in patients who were diagnosed as primary headache and treated by neurologists in the emergency room.

METHODS

A retrospective study was done involving 1235 patients who visited the emergency department from January 2008 to December 2012 and who were diagnosed with primary headache. From the axial view of brain computed tomography, examination of sinusitis, mucosal contact points, concha bullosa, isolated sphenoid lesion, and osteoma were done, and location and morphology was analyzed.

METHODS

Three hundred fifty-five of 1235 (28.7%) patients had sinusitis, mucosal contact points, concha bullosa, isolated sphenoid lesion, and osteoma as possible causes for secondary headaches.

CONCLUSION

Differential diagnosis of primary headaches requires knowledge of paranasal sinus lesions including rhinosinusitis or anatomical variations. Also, interdisciplinary evaluation of acute headache presenting to the emergency room is necessary for accurate diagnosis and proper management.

Prosthetic rehabilitation of an edentulous patient with an oronasal fistula

The presence of an oronasal fistula presents a challenge to maxillary complete denture fabrication because leakage of air from the nasal cavity through the fistula prevents the formation of an adequate border seal. Although surgical repair or dental implants are possible solutions, these options are invasive and sometimes not feasible. This clinical report illustrates an alternative prosthetic solution by integrating a small retentive component into a maxillary complete denture.

Giant nasolabial cyst

Nasolabial (nasoalveolar) cysts are nonodontogenic soft tissue lesions derived from epithelial remanant of the nasolacrimal duct. These are generally slow-growing painless lesions. Additionally, they can cause obstruction, facial deformity and pain. This case report evaluates the facial deformity and boat-shaped resorption demonstrated on computerized tomography (CT) in a 28 years-old patient presenting with facial swelling and pain as a result of a nasolabial cyst. Nasolabial cysts must be kept in mind in patients suffering from facial deformity and infection as an underlying predisposing factor. Recurrences may be seen in cases not amenable to treatment by surgical excision.

Pyoderma Gangrenosum Associated with Nasal Septal Perforation, Oropharyngeal Ulcers and IgA Paraproteinemia

We report a case of pyoderma gangrenosum (PG) associated with nasal septal perforation, pharyngeal ulcers and IgA paraproteinemia. A 28-year-old woman first developed painful undermined ulcers on her perianal, inguinal and axillary areas when she was 22 years old. Histological findings from the cutaneous ulcers showed dermal and epidermal infiltrate of neutrophils, which was compatible with PG. Laboratory examinations did not detect any associations of systemic diseases other than polyclonal IgA paraproteinemia. Nasal fiberscopy revealed septal perforation and multiple ulcers on her pharynx. The biopsy specimen from the pharyngeal ulcers showed a polymorphous cellular infiltrate without necrotizing vasculitis or granuloma. However, there were no atypical lymphocytes that are typically seen in nasal NK/T lymphoma. By immunohistochemical analysis, the infiltrated lymphocytes were proved to be T cells and Epstein-Barr virus encoded RNA (EBER) was not detected. No pulmonary or renal lesions resembling Wegener's granulomatosis were found. Taken together, the nasal septal perforation was considered as nasal involvement of PG.

[Clinical analysis of nasogenic brain abscess]

OBJECTIVE

To investigate the clinical features of nasogenic brain abscess.

METHOD

Four patients with nasogenic brain abscess diagnosed in Tianjin huanhu hospital between June 2007 and January 2013 were reported and the relevant literatures reviewed.

RESULTS

All four patients were frontal abscess, however, the pathogeny of frontal abscess were different. These four patients were treated by different methods and followed up from 12-28 months, no recurrence was found. All four patients were cured.

CONCLUSIONS

The clinical manifestation of nasogenic brain abscess was hiding and was easy to misdiagnosis. Enhanced MRI is the key of the diagnosis. According to the pathogeny of brain abscess, it was important to cure nasogenic brain abscess with different ways.

Concha bullosa, nasal septal deviation and paranasal sinusitis; a computed tomographic evaluation

PROBLEMS/OBJECTIVES

Although concha bullosa, nasal septal deviation (NSD) and paranasal sinusitis are apparently three independent entities, some studies suggest that they are interconnected. Computed tomography (CT) is a useful and accurate imaging modality for examining this interconnection. The objective of this study is to use CT imaging to investigate the possible association between concha bullosa, NSD and paranasal sinusitis.

METHODOLOGY

We reviewed 206 nasal and paranasal CT images of individuals with sinonasal symptoms/cosmetic issues and investigated the association between the presence of concha bullosa and NSD with paranasal sinusitis.

RESULTS

There was no significant relation between the presence of concha bullosa and paranasal sinusitis. The mean NSD was significantly higher in the cases with frontal, maxillary, ethmoid and sphenoid sinusitis than in unaffected subjects. Similar findings were found in the patients with any involved paranasal sinus and the controls (6.49 +/- 3.060 vs. 3.31 +/- 1.99 degrees; p<0.001). An NSD > or =3.5% differentiated between the presence and absence of paranasal sinusitis, with a sensitivity and specificity of 77.8% and 76.5%, respectively. A significant positive correlation was found between NSD and the number of involved sinuses (Pearson's r=0.58, p<0.001). The laterality of sinusitis was not associated with NSD or concha bullosa.

CONCLUSIONS

Nasal septal deviation, but possibly not concha bullosa, is associated with paranasal sinusitis and its extent. An NSD > or = 3.5 degrees is a useful predictor of paranasal sinusitis.

[Clinical analysis of nasal mucosa contact headache]

OBJECTIVE

To investigate the efficacy of nasal mucosa contact point headache with the treatment of endoscopic sinus surgery.

METHOD

Clinical data of 75 cases with nasal mucosa contact point headache treated in our department from Jan 2008 to Nov 2011 were retrospectively analyzed. These patients were performed with endoscopic sinus surgery.

RESULT

All patients were followed up for more than six months. They all achieved significant efficacy and no complications occurred.

CONCLUSION

Nasal mucosa contact point headache and primary headache had different clinical features and different treatment. Misdiagnosis were easily made if not being carefully analyzed. Three lines tension relaxing septorhinoplasty combined with nasal bone fracture correction can achieve satisfactory curative effect and can effectively prevent the occurrence of complications. Therefore, it is necessary to strengthen the awareness of this disease. Nasal structure abnormality is the main reason of nasal mucosa contact point headache. The implementation of individualized nasal endoscopic sinus surgery can achieve satisfactory curative effect.

Rock, paper, endoscopy: a baffling case of rhinolith

A 60-year-old woman presented with a bulky nasal mass. The mass was accidentally discovered during examination following a head injury. The patient, suffering from severe mental retardation, did not complain of any nasal symptoms, though her relatives, upon direct questioning, reported a two year history of fetid rhinorrhoea and occasional epistaxis. The CT scan showed a large inhomogeneous calcified mass in left nasal cavity, impacted on the choanal border. The patient underwent endoscopic nasal surgery under general anaesthesia in order to remove the mass. A transnasal approach granted a successful and complete removal. The patient was discharged the following day without any complication and no sign of recurrence or symptoms relapse was reported during a two year follow-up.

A rare cause of nasal septal abscess

We describe a patient with mid-facial pain and nasal obstruction due to a nasal septal abscess (NSA) complicating an occult fungal ball of the sphenoid sinus. We highlight the importance of suspecting unusual pathology in patients with NSA and no trauma history.

Headache pain of ear, nose, throat, and sinus origin

Pain of the ear, nose, sinuses, and throat is commonly encountered in clinical practice. For the most part, the pathologic process responsible for the patient's symptoms is easily identifiable after the physician performs a targeted history and physical examination. Unfortunately, the nature of this anatomic region makes it possible for the most thorough physician to miss pathologic factors that may ultimately harm the patient. For this reason, the following rules for the treatment of ear, nose, sinus, and throat pain serve both the patient and the clinician well: (1) take a targeted history; (2) perform a careful, targeted physical examination; (3) heed the warning signs of serious disease, such as fever, constitutional symptoms, or weight loss; (4) image early and frequently if the diagnosis remains elusive; (5) perform laboratory tests that help identify "sick from well," such as erythrocyte sedimentation rate, hematology, and blood tests; (6) avoid attributing the patient's pain to idiopathic or psychogenic causes; and (7) always assume that you have missed the diagnosis.

Intranasal tooth and associated rhinolith in a patient with cleft lip and palate

We report the case of a 9-year-old girl who presented with a complaint of a malodorous bloody discharge from the left naris. The patient had previously undergone a complete repair of left-sided cleft lip and palate. Clinical examination revealed hyperplasia of the nasal mucosa on the left side. X-ray examination of the nasal cavity demonstrated a radiopaque structure that resembled a tooth and a radiopaque mass similar to an odontoma that was adherent to the root of the suspected tooth. With the patient under general anesthesia, the structure was removed. On gross inspection, the structure was identified as a tooth with a rhinolith attached to the surface of its root. Microscopic examination revealed normal dentin and pulp tissue. A nonspecific inflammatory infiltrate was observed around the rhinolith, and areas of regular and irregular mineralization were seen. Some mineralized areas exhibited melanin-like brownish pigmentation. Areas of mucus with deposits of mineral salts were also observed. Rare cases of an intranasal tooth associated with a rhinolith have been described in the literature. We believe that this case represents only the second published report of an intranasal tooth associated with a rhinolith in a patient with cleft lip and palate.

[A case of rhinolith and actinomycosis]

The patient presented with right nasal obstruction, purulent secretion in nasal meatus and dull headache for 3 years. A dark brown mass, irregular in shape, surface roughness and purulent secretion adherent, was seen in the nose, touched as coal tar stone. CT examination showed high density in the right nasal meatus. Postoperative pathological examination proved to be rhinolith and actinomycosis.

A different placement of the stone; rhinolithiasis

INTRODUCTION

Rhinolithiasis is a rare disease and formed by mineralization in the nasal cavity. Precipitated calcareous material on intranasal foreign substances forms the rhinoliths. It is start time could have since childhood.

MATERIALS AND METHODS

In this article, we present eight cases of rhinolithiasis who admitted to our Clinic between January 2001 and December 2010 with unilateral chronic nasal discharge, nasal obstruction and oral malodor.

CONCLUSIONS

Rhinolithiasis mostly manifests itself with unilateral purulent rhinorrhea, nasal obstruction and facial pain symptoms. We aimed to discuss these entity with similar cases in the literature.

Spontaneous cerebrospinal fluid rhinorrhea with pneumocephalus: an unusual manifestation of nasal tuberculosis

An unusual case of spontaneous cerebrospinal fluid (CSF) rhinorrhea with a pneumocephalus is described in a middle-aged woman who presented with a watery nasal discharge for 1 week and headache, vomiting, and fever for 1 day. The neurological examination revealed meningeal signs and bilateral papilledema. The CSF picture suggested pyogenic meningitis, and computed tomography of the brain revealed pneumocephalus. Diagnostic nasal endoscopy showed outpouching of the dura from the left olfactory cleft with a CSF leak and granular nasal mucosa. The defect was repaired surgically, and a biopsy of that area revealed granulomatous changes suggestive of tuberculosis. The patient recovered completely with standard four-drug antitubercular therapy. To our knowledge spontaneous CSF rhinorrhea with pneumocephalus occurring secondary to nasal tuberculosis has not been previously reported.

[One-step rhinootosurgery. Clinical, economic and social aspects]

The objective of this work was to estimate from the clinical, economic, and social standpoints the efficacy of medical aid provided to the patients with chronic suppurative otitis media (CSOM) and concomitant pathology of the nasal cavity by means of the one-step surgical intervention. The study included a total of 208 patients presenting with CSOM of whom 108 ones were treated by the traditional multistage method and the remaining 108 by simultaneous rhinootosurgery. The latter approach was shown to be much more efficacious in terms of clinical, economic, and social considerations.

Complications of nose and paranasal sinus disease

BACKGROUND

Diseases of nose and paranasal sinuses can complicate to involve the orbit and other surrounding structures because of their close proximity. These diseases are usually infective or can be neoplastic in origin.

METHOD

All the patients presenting in ENT or Eye Departments of Ayub Teaching Hospital during the one year study period who had complicated nose or paranasal sinus disease were included in the study. A detailed history and examination followed by CT scanning and laboratory investigations to assess the type and extent of the disease, was carried out.

RESULTS

Infections were the most common cause of complicated sinus disease 11 (75%). The rest of the 4 (25%) cases were tumours. 12 (80%) of the cases presented with proptosis. In I of these 12 cases. there was complete blindness. In 2 (13%) of the cases there was only orbital cellulitis. Two of these patients had facial swelling and 2 had nasal obstruction and presented as snoring. Two patients presented with history of weight loss and these patients had malignant tumour of the paranasal sinuses. One patient presented with early signs of meningitis. In 1 case subperiosteal scalp abscess (Pott's puffy tumour) was the only complication noted.

CONCLUSION

Nose and paranasal sinus diseases can complicate to involve mostly the orbit, but sometimes brain, meninges and skull bones can also get involved.

Rhino-cerebral zygomycosis after allogeneic transplant: case report and literature review

The proportion of patients with hematological malignancies (HM) who develop rare invasive fungal infections (IFI) has increased worldwide over the past few decades. Zygomycosis is an opportunistic fungal infection, which begins in the nose and paranasal sinuses due to inhalation of fungal spores. Rhino-cerebral zygomycosis is the most common form of the disease, it typically develops in diabetic or immunocompromised patients and presents as an acute fulminate infection, which is often lethal. We report a case of rhino-cerebral zygomycosis in an allotransplanted patient to emphasize early diagnosis and treatment of this potentially fatal fungal infection. We discuss different risk factors, specific diagnosis procedures and review the current concepts in management of zygomycosis.

Sinonasal sarcoidosis. A case report

INTRODUCTION

Sarcoidosis is a granulomatous disease of unknown etiology, which in the majority of cases affects the lower respiratory tract. Although neck mass, parotid swelling and facial nerve palsy are considered the primary complaints in cases of head and neck sarcoidosis, sinonasal localization of the disease is also uncommonly reported.

CASE

A 46 year old woman presented in our clinic with complaints of nasal congestion over a six month period. The patient reported increasing symptom severity in the last month with occasional purulent discharge. No other symptoms were reported. The patient's medical record was significant only for sarcoidosis localized to the lower respiratory tract. On anterior rhinoscopy, the nasal mucosa presented marked hypertrophy, purplish discoloration and granulomatous appearance of the inferior turbinates on the left side. The diagnosis of sinonasal sarcoidosis was made based on histopathologic examination of biopsy specimens.

CONCLUSION

Sinonasal sarcoidosis presents a challenging issue for the clinicial as its mimicking features may be misleading and delay diagnosis. In the present paper we present a case of sinonasal sarcoidosis presenting as chronic rhinosinusitis.

Outcomes of septoplasty in young adults: the Nasal Obstruction Septoplasty Effectiveness study

The goal of this study was to compare the outcome of septoplasty in our patients with previous reports. We found some different outcomes of septoplasty at our center compared with the reports in the literature. One of the major differences between this and previous studies is in the mean age of patients undergoing surgery, 22.44 years in our study vs more than 40 years in most studies. In this study, 86 patients with septal deviation were asked using an outcomes instrument (the Nasal Obstruction Symptom Evaluation scale) before and 3 and 6 months after septoplasty. Seventy-seven patients (89.5%) reported a subjective improvement in their nasal obstruction, which is more than the experience of most authors. There was a significant improvement in mean Nasal Obstruction Symptom Evaluation score at 3 months after septoplasty, and some symptom improvement continued to 6 months. We conclude that younger patients who have nasal obstruction with septal deviation benefit more from septoplasty.

Rhinolithiasis: an unusual cause of sinusitis complicated with frontal osteomyelitis and epidural abscess

Rhinoliths are rare foreign bodies of the nose formed by in situ mineralization of endogenous or exogenous foreign material. They are often asymptomatic but may have various clinical presentations, with purulent rhinorrhea and nasal obstruction being the most common. They may go unnoticed for a long period and be diagnosed accidentally during a routine examination. We report a 6.5-year-old girl with rhinolithiasis complicated with sinusitis, frontal osteomyelitis and epidural abscess; she had a history dating back four years.

Nasal septal abscess complicating isolated acute sphenoiditis: case report and literature review

This report presents an extremely rare case of nasal septal abscess complicating acute sphenoiditis in a non-immunocompromised adult patient. A 56-year-old woman came to our emergency service with a 2 wk history of nasal obstruction, headache, and facial pain. A nontraumatic nasal septal abscess complicating acute isolated sphenoiditis was diagnosed. Under general anaesthesia, we drained the septal abscess and performed an endoscopic transnasal sphenoidotomy. Bacteriological cultures revealed viridans streptococci in the septal abscess and sphenoid cavity. We discuss the patient's diagnosis, possible complications, and treatment. There are limited reports in the literature on this subject. Our report emphasizes the need to determine whether an infection is associated with a non-traumatic nasal septal abscess. The incidence of severe complications is directly related to delays in diagnosis and treatment. Therefore, a prompt and correct diagnosis immediately followed by appropriate treatment is necessary.

Evaluation of non-viral risk factors for nasopharyngeal carcinoma in Thailand: results from a case-control study

Nasopharyngeal cancer (NPC) is rare in most populations but common in Southern China and Southeast Asia. To understand the role of environmental exposures on risk of NPC, a case-control study was conducted among 327 newly diagnosed case of NPC and 327 controls matched to case on sex, age and geographic residence. Information was collected by interviewer about demographic variables, cigarette smoking, alcohol drinking, eating habits, past history of disease, family history of cancer and a lifetime history of every job that was held for one year or longer. The result indicates that cigarette smoking was associated with an increased risk of NPC (OR=2.41, 95% CI 1.61-3.6). There was indication of increased risk with a history chronic ear or nose disease (OR=2.71, 95% CI 1.45-5.06). Occupational exposure to wood dust was also associated with a higher risk (OR=1.63, 95% CI 1.02-2.61). Furthermore, lower education was found to be positively associated with NPC (OR=2.71, 95% CI 1.45-5.06). There was no association between NPC and salted fish intake (OR=1.38, 95% CI 0.84-2.25) or alcohol consumption (OR=0.88, 95% CI 0.58-1.33). Our results suggest that cigarette smoking, past history of ear or nose disease and occupational exposure to wood dust may play a role in the development of NPC in the Thai population.