Surgical Treatment of Rhinogenic Contact Point Headache: An Experience from a Tertiary Care Hospital

Effectiveness of the Treatment of Rhinogenic Headache Caused by Intranasal Contact

OBJECTIVES

The aim of the study is to evaluate the effectiveness of the surgical and nonsurgical treatment of headache caused by contact points (CPs) between the nasal septum and inferior or middle turbinate.

METHODS

The research was designed as a prospective clinical case-series study. The patients with CP headaches were offered to choose between 2 treatment options, surgery and medical treatment. Two groups of surgically treated patients (surgery groups 1 and 2, depending on whether there is a contact between nasal septum and inferior turbinate or middle turbinate) were evaluated and compared for headache intensity and frequency. Headache intensity was measured using a visual analog scale value from 0 to 10; the frequency of headache was expressed as the number of days during 1 month with a headache (before surgery, 1 month, and 6 months after surgery). A comparison was also made between surgically and nonsurgically treated patients.

RESULTS

We found more intensive and frequent headache in patients who had CP between the nasal septum and the middle turbinate (P = .038 and P = .003, respectively). A significant reduction in headache intensity and frequency was found in both groups of surgically treated patients 6 months after surgery; however, this reduction was more significant in patients with mucosal contact between nasal septum and middle turbinate. The nonsurgical treatment made a significant reduction of headache intensity and frequency at 1-month follow-up (P = .012 and P = .031, respectively), but not at 6-month follow-up (P = .114 and P = .088, respectively).

CONCLUSION

Surgery gave a statistically significant reduction in the intensity and frequency of headache, which was assessed 6 months after surgery. Surgery was found as superior to nonsurgical treatment in the therapy of CP headache.

A CBCT Study for Anatomic Variations of Osteomeatal complex in Patients With Cleft Lip and Palate

OBJECTIVE

To evaluate the anatomy and variations of osteomeatal complex (OMC) by comparing patients with nonsyndromic cleft lip and palate (CLP) and control group.

DESIGN

This case-control study was retrospectively analyzed using cone-beam computed tomography data.

SETTING

Istanbul University Faculty of Dentistry Department of Dentomaxillofacial Radiology.

PATIENTS

The study was conducted with 100 patients (44 females, 56 males) with CLP and 100 patients in the control group, which matched gender and age (with a maximum difference of 3 years).

VARIABLES

OMC variations are grouped as follows: ethmoidal, conchal, uncinate process, and septal variations. Then, we evaluated the presence of these OMC variations and compared them between the two groups.

STATISTICAL ANALYSIS

The McNemar's test was used to determine any significant differences between the groups for all indices at the 95% confidence level.

RESULTS

The most common anatomic variation in this study was Agger nasi cell (97%) and concha bullosa (97%) in the patients with CLP, while Agger nasi cell was the most common variation (99%) in the controls. Moreover, the atelectatic uncinate process was the least observed variation in both groups (1%). The incidences of paradoxical concha (58%;42%), bifid concha (29%;11%), deviated nasal septum (92%;80%) were significantly higher in the CLP group (p < 0.05).

CONCLUSIONS

The statistically significant results found when comparing OMC anatomy between the two groups reveal the importance of three-dimensional evaluation before functional endoscopic sinus surgery in patients with CLP.

A Comparative Study of CT Scan and Nasal Endoscopic Findings of Lateral Wall of Nose, in Headache of Rhinogenic Origin

Headache disorders are rated among the ten most disabling conditions worldwide. Contact points like septal spur, septal deviation, concha bullosa and bulla ethmoidalis can cause rhinogenic headache (RH). Diagnostic nasal endoscopy (DNE) is an essential part of evaluation of sinonasal disease and is the key to understanding anatomical variations. As compared to CT paranasal sinus (CT PNS), DNE is cheaper and has wider availability, being part of the basic training of present ENT curriculum. We conducted a prospective observational study from September 2018 to June 2020 on 202 patients who were diagnosed to have RH. The aim of this study was to the define the role of DNE as the primary examination for early and accurate diagnosis of rhinogenic headache as compared to CT PNS. RH patients were evaluated with DNE followed by CT PNS. Evaluation of the findings of anatomical variations of lateral wall of nose on DNE and CT PNS was done. In our study the most common anatomic variations in order of frequency in both DNE and CT PNS was deviated nasal septum, impacting spur and unilateral concha bullosa. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of DNE for the various anatomical variations was statistically better than CT PNS findings. We conclude that DNE is a better than CT PNS as a diagnostic technique to detect various anatomical variations, thus initiating early management of RH.

Clinical Outcome Following Endoscopic Septoturbinal Surgeries for Rhinogenic Contact Point Headache: A Retrospective Analysis

To assess the clinical outcome of endoscopic septoturbinal surgeries in patients with rhinogenic contact point headache. Retrospective audit of medical records. Retrospective audit of medical records of patients having undergone endoscopic surgical management for contact point headache between a period of May 2017 to May 2018 were included in the study. Patients who underwent functional endoscopic sinus surgery were excluded from the study. Pre operative pain score were compared with post operative pain score at interval of 1 month for 3 months consequently and at 1 year interval using Visual Analog scale (VAS). The difference between preoperative (mean 6.82) and post operative VAS pain scores after 1 month (mean 3.36), 2 months (mean 4.50), 3 months (mean 5.48), 1 year (mean 5.01) was statistically significant (p < 0.001). Contact point headache is an important clinical entity that might be missed during evaluation and management of refractory headache. Surgical management under endoscopic guidance can help to ensure removal of mucosal contact point and aid in the treatment of refractory headache as noted in our study.

Rhinogenic and sinus headache - Literature review

BACKGROUND

Headache is a common, yet challenging symptom to evaluate given its wide range of clinical presentations and different etiologies. For centuries, conceptual understanding of headache causation has been attributed to anatomic abnormalities of the nose and paranasal sinuses.

METHODS

Structured literature review.

RESULTS

The number of cases, categorized as migraines or other primary headaches, misdiagnosed as a "sinus headache" is high in the literature, ranging from 50 to 80%. The potential mechanisms for rhinogenic headaches were classically described as pain secondary to prolonged mucosal contact points, hypoxia in the paranasal sinuses secondary to poor ventilation, or pressure caused by the growth of nasal polyps. Additionally, other mechanisms were described and are still being studied. Corrective surgery for mucosal contact points in the nasal cavity is deemed necessary for relieving the headache, although patient outcomes are variable.

CONCLUSION

Delay in proper diagnosis and treatment negatively impact patient quality of life. Most cases of "sinus headache" or "rhinogenic headache" seen in clinical practice are in fact misdiagnosed as either primary headaches or migraines. Because of increased misdiagnoses, Otolaryngologists should establish a direct and precise diagnosis congruent with a chief complaint being a headache. Vital information such as a good clinical history, well-performed nasal endoscopy, and occasional CT scan may decrease misdiagnosis probability.

Endoscopic surgical treatment for rhinogenic contact point headache: systematic review and meta-analysis

Purpose

This meta-analysis study was designed to analyze endoscopic surgery’s role in treating rhinogenic contact point headache.

Methods

We performed a comprehensive review of the last 20 years’ English language regarding Rhinogenic contact point headache and endoscopic surgery. We included the analysis papers reporting post-operative outcomes through the Visual Analogue Scale or the Migraine Disability Assessment scale.

Results

We provided 18 articles for a total of 978 RCPH patients. While 777 (81.1%) subjects underwent functional nasal surgery for RCPH, 201 patients (20.9%) were medically treated. A significant decrease from the VAS score of 7.3 ± 1.5 to 2.7 ± 1.8 was recorded (p < 0.0001). At quantitative analysis on 660 patients (11 papers), surgical treatment demonstrated significantly better post-operative scores than medical (p < 0.0001).

Conclusion

At comparison, surgical treatment in patients with rhinogenic contact points exhibited significantly better values at short-term, medium-term, and long term follow up. Endoscopic surgery should be proposed as the choice method in approaching the symptomatic patient.

Nasal cavities and the nasal septum: Anatomical variants and assessment of features with computed tomography

The nasal cavities are complex anatomical structures with high inter-individual variability that relates to different functions. Different anatomic variants may manifest at this site, mainly belonging to the nasal septum and turbinates. Precise knowledge of the anatomy and variants is fundamental for both radiologists and ENT surgeons. This article provides an overview of the main anatomic variants and their frequency, according to the existing literature, as well as ongoing research on nasal cavity segmentation in order to obtain personal 3D models and to predict post-surgical results.

Sino-Nasal Anatomical Variations in Rhinogenic Headache Pathogenesis

Rhinogenic headache (RH) is a widespread pain syndrome but its pathogenesis and treatment are still unclear. Some authors recognize a correlation between RH and mucosal contact points or some other sinonasal anatomical variations. The authors conducted a retrospective case-control study to analyze the correlation between radiological findings and clinical symptoms.One hundred-nineteen adults with Para-Nasal Sinuses Computed Tomography (PNS-CT) scans were included: 64 patients who have originally undergone PNS-CT scan as part of rhinogenic headache workup (Group A), and 55 controls in whom PNS-CT scans were obtained for other purposes (Group B). All subjects were asked to report their symptoms using a headache scoring system. PNS-CT scans of all subjects were analyzed for presence of mucosal contact points, middle turbinate concha bullosa (MTCB) and frontoethmoidal cells.The most common anatomical abnormality found in our series was MTCB, reported in 60.9% of patients in Group A and 41.8% of those in Group B. A statistically significant prevalence was found in Group A compared to Group B regarding the presence of MTCB (P = 0.037) and Type II (P = 0.016) and Type III (P = 0.039) frontoethmoidal cells. No statistically significant difference (P >0.05) was found between Group A and Group B regarding the presence of mucosal contact points at each site.Multiple anatomical variations in nasal and paranasal sinuses may cause a rhinogenic headache with different characteristics. Some of these, such as concha bullosa of middle turbinate or type II and III Kuhn cells, have shown a significant association with rhinogenic headache. No statistically significant association was found between presence of headache and mucosal contact points and type I and IV frontal cells. These findings can be very helpful for the surgeons that want to deal with the treatment of RH.

Is septoplasty effective rhinogenic headache in patients with isolated contact point between inferior turbinate and septal spur?

BACKGROUND

Rhinogenic headache is a painful sensation in the head and face due to intranasal contact point without any mass or inflammatory findings. Surgery is recommended in patients with nasal obstruction; however the approach in case of isolated mucosal contact point that does not cause obstruction is controversial. Our aim is to observe changes in the severity of headache in patients with isolated mucosal contact point and headache who do not complain of nasal obstruction.

METHODS

Our study included patients with unilateral headache without any nasal and/or paranasal sinus pathology. We confirmed the presence of mucosal contact by nasal endoscopy and by computed tomography (CT). One hundred patients with isolated mucosal contact point without any problem in breathing were included in this study. All participants were treated by topical nasal corticosteroid for a month. Surgery was recommended to the patients with no satisfactory relieve of headache. Visual Analog Scales (VAS) were used to evaluate the severity of headache in patients at time of diagnosis (0 month), after a medical treatment (1st month) and after a surgical or medical treatment (6th month). The results were compared with each other statistically.

RESULTS

There was a decrease in VAS values after a month of medical treatment in all patients with isolated contact point (Z = -8.352; p = 0.0). VAS values significantly improved after surgical treatment group (Z = -4.97; p = 0.0). However, VAS values of patients increased at 6th month in medical treatment group (Z = -5341 p = 0.0). After a successful surgical removal of mucosal contacts, the decrease of headache severity was more intense in patients with surgical treatment group than in the patients with medical treatment group (Z = -8.441; p = 0.0).

CONCLUSION

Surgical correction provides a more effective outcome in patients with rhinogenic headache. However, it is difficult to convince that headache may improve with surgery in these patients especially with isolated mucosal contact point and without nasal obstruction. In order to prove the benefit of surgery, we believe that medical treatment can be used as a guide.

Can Functional Nasal Surgery Treat Chronic Headaches? A Systematic Review

BACKGROUND

Nasal surgery is one of the most common operations performed by plastic surgeons. The link between functional nasal surgery and improvement in nasal breathing is well established, but there are other metrics that have been shown to improve as a result of anatomical correction of the nose. Current literature suggests that surgery to remove nasal mucosal contact points can reduce symptoms in chronic headache patients. The authors conducted a systematic literature review to determine the validity of this hypothesis.

METHODS

A systematic search of the literature was performed using the terms "headache," "rhinogenic headache," "contact point," "migraine," and "surgery/endoscopy."

RESULTS

The authors identified 39 articles encompassing a total of 1577 patients who underwent surgery to treat mucosal contact point headaches. Septoplasty and turbinate reduction were the most commonly performed procedures, often in combination with endoscopic sinus surgery. Analysis of the combined data demonstrated improvement in the reported severity of patient symptoms, with 1289 patients (85 percent) reporting partial or complete resolution of headaches postoperatively. Average visual analogue scale scores and number of headache days in patients undergoing nasal surgery were reduced from 7.4 ± 0.9 to 2.6 ± 1.2 (p < 0.001) and 22 ± 4.3 days to 6.4 ± 4.2 days (p = 0.016), respectively. Improvement in headache symptoms was significantly associated with a positive response to preoperative anesthetic testing, and with inclusion of endoscopic sinus surgery as part of the surgery.

CONCLUSION

Functional nasal surgery is a viable option to improve headache symptoms in appropriately selected patients.

Nasal Septal Spur Associated with Rhinogenic Contact Point Otalgia and Tinnitus

Rhinogenic contact point otalgia is a new term in medicine and it represents earache as a form of facial pain that is caused by intranasal mucosal contact points between the nasal septal spur or septal deviation and lateral nasal wall. It is a referred otalgia without any signs of inflammation. The author reports an unusual case of a 19-year-old male who complained of a 5-year history of right-sided otalgia and tinnitus. On physical exam, a big, right-sided nasal septal spur was seen in contact with the right lateral nasal wall. Other findings are unremarkable. Placement of anesthetic and vasoconstrictor solution provided relief of symptoms. After the exclusion of other causes of otalgia, and after surgical removal of septal spur, the patient experienced a significant relief of symptoms.

Headaches and facial pain in rhinology

"Sinus headache" is a common chief complaint that often leads patients to an otolaryngologist's office. Because facial pain may or may not be sinogenic in origin, the otolaryngologist should be equipped to evaluate and treat or to appropriately refer these patients. Analysis of current data indicates that the majority of patients who present with sinus headaches actually have migraines. Furthermore, the downstream effect of the cytokine cascade initiated in migraine physiology can cause rhinologic symptoms, including rhinorrhea, congestion, and lacrimation, which may also confound diagnosis. Other causes of sinus headache include the following: cluster headaches, Sluder neuralgia, trigeminal neuralgia, myofascial trigger point pain (tension headaches, temporomandibular joint dysfunction), and contact point headaches. The diagnostic dilemma for an otolaryngologist occurs when a patient has facial pain and symptoms that may indicate chronic rhinosinusitis but with nondiagnostic endoscopy. Traditionally, these patients have been primarily managed with empiric antibiotics. An alternative strategy is to first screen these patients with an upfront computed tomography. This algorithm may ultimately decrease cost; avert unnecessary antibiotics prescriptions; and prompt more timely referrals to other, more appropriate, disciplines, such as neurology, dentistry, and/or pain management specialists.