Endoscopy-negative, computed tomography-negative facial pain in a nasal clinic

A minireview of the anatomical and pathological factors pertaining to Costen's syndrome symptoms

Objective: Interest in the symptoms pertaining to Costen's syndrome has revived in recent years. The aim of this work is to address the symptoms of Costen's syndrome from the basic science perspectiveMethods: A minireview of the literature related to Costen's syndrome symptoms was performed by retrieving relevant articles from the PubMed database from 1980 until 2021.Results: The validity of Costen's syndrome symptoms has been confirmed by a multitude of articles. Conclusion: Maladaptive plasticity in the central nervous system pathways probably accounts for the incidence and severity of Costen's syndrome symptoms.

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.

Clinical Features and Headache Diagnoses in Patients With Chief Complaint of Craniofacial Pain

OBJECTIVES

Investigate the use of nasal endoscopy, sinus imaging, and neurologic evaluation in patients presenting to a rhinologist primarily for craniofacial pain.

METHODS

This was a retrospective analysis of consecutive outpatients presenting to a rhinologist between 2016 and 2019 with chief complaints of craniofacial pain with or without other sinonasal symptoms, who were then referred to and evaluated by headache specialists. Data analyzed included sinusitis symptoms, Sino-Nasal Outcome Test (SNOT-22) scores (and facial pain subscores), pain location, nasal endoscopy, computed tomography (CT) findings, and headache diagnoses made by headache specialists.

RESULTS

Of the 134 patients with prominent craniofacial pain, the majority of patients were diagnosed with migraine (50%) or tension-type (22%) headache, followed by multiple other non-sinogenic headache disorders. Approximately 5% of patients had headaches attributed to sinusitis. Amongst all patients, 90% had negative nasal endoscopies. Patients with negative endoscopies were significantly less likely to report smell loss (P = .003) compared to those with positive endoscopies. Poor agreement was demonstrated between self-reported pain locations and sinus findings on CT (kappa values < 0.20). Negative nasal endoscopy showed high concurrence with negative CT findings (80%-97%).

CONCLUSIONS

Patients presenting with chief complaints of craniofacial pain generally met criteria for various non-sinogenic headache disorders. Nasal endoscopy was negative in 90% of patients, and CT demonstrated poor agreement with pain locations. Nasal endoscopy and CT shared high concurrence rates for negative sinus findings. The value of nasal endoscopy over sinus imaging in craniofacial pain evaluation should be explored in future studies.

Surgical management of mucosal contact headache

BACKGROUND

Most research on mucosal contact headache has focused on mucosal contact between the nasal septum and middle or inferior turbinate. However, rarely have any studies explored how headache is related to the only one contact point between superior turbinate and nasal septum.

OBJECTIVE

To explore how headache is related to the only one contact point between superior turbinate and nasal septum.

METHODS

80 patients with headache were selected. The mucosal contact between superior turbinate and nasal septum was removed to study the relationship between the contact point and headache, with a follow-up of 12 months.

RESULTS

Headache symptoms in 56 cases disappeared entirely. Significant relief was observed in 20 patients, and unsatisfactory results in only 4 patients, with the success rate being 95%.

CONCLUSION

Some patients with headaches who had intranasal mucosal contact areas benefitted from the surgery. Satisfactory results were achieved by endonasal surgery in 95% of our patients in whom intranasal contact points were believed to be the cause of their headaches who had a mucosal contact point between the superior turbinate and the septum.

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.

Etiology of 'Sinus Headache'-Moving the Focus from Rhinology to Neurology. A Systematic Review

'Sinus headache and/or facial pain' (SH) is a common complaint encountered by otorhinolaryngologists, neurologists and general practitioners. However, several studies suggested that the majority of those cases may be attributed to primary headaches (i.e., migraine and tension-type headache (TTH). The purpose of this review is to evaluate the etiology of SH. The first part includes cross-sectional studies analyzing the prevalence of respective diagnoses in subjects with SH. The majority of these publications indicate that migraine and TTH are the most prevalent causes of SH, although most of these studies were conducted in a clinical setting. The second part of this review included treatment trials in subjects with SH. The findings from this part of the review show that SH without rhinosinusitis responds well to pharmacotherapy targeted at primary headaches. This observation further supports a neurologic etiology of the majority of SH cases.

Sinus Headache: Differential Diagnosis and an Evidence-Based Approach

The diagnosis "sinus headache" has been reclassified as "headache attributed to disorder of the nose or paranasal sinuses" by the International Headache Society, but the term is still commonly used by patients and primary care doctors alike. Rhinologic symptoms and headache disorders are common, and they may coexist without a causative relationship. Patients may undergo unnecessary medical interventions because of inadequate understanding of the classifications and management of various headache disorders. Otolaryngologists frequently treat patients with these complaints, and a systematic approach to the differential diagnosis and utilization of a multidisciplinary approach are critical in providing optimal patient care.

Symptom Profile of Chronic Rhinosinusitis Versus Obstructive Sleep Apnea in a Tertiary Rhinology Clinic

Objectives:

Patients with undiagnosed obstructive sleep apnea (OSA) often present to an otolaryngologist with symptoms of chronic rhinosinusitis (CRS). This study analyzes symptom profiles of such patients to help identify those who may benefit from polysomnography.

Methods:

This is a 2-year retrospective analysis of adult patients at an academic practice with a rhinologic chief complaint. Results of the 22-Item Sinonasal Outcomes Test (SNOT-22) were compared between patients with untreated OSA without CRS (OSA group) and a control group of CRS patients (CRS group). Univariate analysis with Bonferroni correction and multiple logistic regression were used.

Results:

Forty-one patients were included in the OSA group (mean apnea-hypopnea index = 28.8, SD = 21.0) and 124 patients in the CRS group. CRS group demonstrated higher scores in nasal, extra-nasal, and ear/facial symptom domains ( P < .001), while OSA group displayed higher psychological ( P = .020) and sleep domain scores ( P = .048). Nasal discharge ( P < .001) and loss of smell/taste ( P = .004) scores were higher in CRS group, whereas facial pain ( P = .285) and nasal obstruction ( P = .822) were not significantly different. On logistic regression, thick nasal discharge, loss of smell/taste, and ear pain were predictive of CRS, while waking up tired was predictive of OSA. Finally, OSA group was more likely to choose a sleep-related issue as a most important symptom (MIS) ( P < .001).

Conclusions:

OSA and CRS have significant overlap in symptom profiles. The SNOT-22 can help identify those with undiagnosed OSA. OSA should be suspected in patients who report a sleep-related item as a MIS and display higher psychological and sleep domain scores.

A comparative clinical and radiographic study on patients with chronic facial pain with and without temporomandibular disorder presenting to an otolaryngology clinic

Objective: Facial pain associated with temporomandibular disorder (TMD) is considered a component of Costen's syndrome. However, prior to the current study, no previous clinical and radiographic studies have addressed facial pain in patients with TMD. Methods: The study included 212 patients with chronic facial pain examined in an otolaryngology clinic. These were stratified into 132 patients with TMD and 80 patients without TMD. Clinical and radiographic findings were documented in both groups. Results: Forty-eight patients in the TMD group had normal endoscopic findings and clear CT scans and had their facial pain directly attributable to TMD. Conclusion: In patients presenting with facial pain, where nasal endoscopy reveals no abnormality, TMD should be specifically addressed, especially if CT scans of the paranasal sinuses are clear.

Facial pain: sinus or not?

Facial pain remains a diagnostic and therapeutic challenge for both clinicians and patients. In clinical practice, patients suffering from facial pain generally undergo multiple repeated consultations with different specialists and receive various treatments, including surgery. Many patients, as well as their primary care physicians, mistakenly attribute their pain as being due to rhinosinusitis when this is not the case. It is important to exclude non-sinus-related causes of facial pain before considering sinus surgery to avoid inappropriate treatment. Unfortunately, a significant proportion of patients have persistent facial pain after endoscopic sinus surgery (ESS) due to erroneous considerations on aetiology of facial pain by physicians. It should be taken into account that neurological and sinus diseases may share overlapping symptoms, but they frequently co-exist as comorbidities. The aim of this review was to clarify the diagnostic criteria of facial pain in order to improve discrimination between sinogenic and non-sinogenic facial pain and provide some clinical and diagnostic criteria that may help clinicians in addressing differential diagnosis.

Rhinogenic Contact Point Headache: Surgical Treatment Versus Medical Treatment

Rhinogenic contact point headache (RCPH) is a headache syndrome secondary to mucosal contact points in the sinonasal cavities, in the absence of inflammatory signs, hyperplastic mucosa, purulent discharge, sinonasal polyps, or masses. It may result from pressure on the nasal mucosa due to anatomic variations among which the septal deviation, septal spur, and concha bullosa, are the most commonly observed. In recent years, RCPH has remained a subject of controversy regarding both its pathogenesis and treatment. This study aimed to investigate the effect of surgical and medical treatment of pain relief in patients with RCPH, evaluating the intensity, duration, and frequency of headaches, and the impact of different treatments on quality of life. Ninety-four patients with headache, no symptoms or signs of acute and chronic sinonasal inflammation and who present with intranasal mucosal contact points positive to the lidocaine test were randomized into 2 equal groups and given medical or surgical treatment. The authors used visual analog scale, number of hours, and days with pain to characterize the headache and Migraine Disability Assessment score (MIDAS) to assess the migraine disability score before and 3 to 6 months after treatment. After treatment the severity, duration, and frequency of the headache decreased significantly (P < 0.001, P < 0.001, and P = 0.031, respectively) as well as the MIDAS in the surgical group compared with medical group. Our results suggest that surgical removal of mucosal contact points is more effective than local medical treatment improving the therapeutic outcomes in patients with contact point headache.

The price of pain in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with productivity losses exceeding US$13 billion annually. Although pain is well known to significantly affect patient productivity in other diseases, its economic impact on CRS-related lost productivity has not been examined. The objective of this study was to determine whether CRS-related facial pain correlates with lost productivity in patients with CRS.

METHODS

Seventy patients with CRS were enrolled in a cross-sectional investigation. Patients with a history of systemic inflammatory disease, ciliary dysfunction, chronic pain syndromes, migraines, and fibromyalgia were excluded. Pain was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short-Form McGill Pain Questionnaire (SF-MPQ). Presenteeism, absenteeism and lost work, and household and overall productivity were assessed. Regression analysis was performed to assess potential confounders, including depression.

RESULTS

Pain as measured with BPI-SF and SF-MPQ total scores correlated with all domains of productivity losses. Overall, lost productivity was significantly correlated with pain (R range, 0.354-0.485; p < 0.001). Presenteeism (reduced work efficiency) had the highest correlation with all of the overall pain scores (R range, -0.366 to -0.515; p < 0.001). Lost household productivity time was the least affected by pain (R range, 0.267-0.389; p < 0.05). These correlations remained statistically significant after regression analysis, which accounted for depression (p < 0.05).

CONCLUSION

A significant correlation exists between CRS-related facial pain and productivity losses in patients with CRS that is independent of depression. Facial pain has the strongest correlation with presenteeism, which is the main driver of productivity losses and indirect costs associated with CRS.

Clinical Outcomes of Chronic Rhinosinusitis in Response to Medical Therapy: Results of a Prospective Study

Background

Little information exists regarding the outcome of medical management of chronic rhinosinusitis (CRS) in adults. The aim of this study was to examine whether baseline patient demographics, symptoms, objective findings, or treatment strategies were associated with improved CRS outcomes over time.

Methods

Eighty-four new patients with CRS were evaluated and medically treated for up to 12 months. Patients completed monthly health status questionnaires. The average change of symptom scores using the Sino-Nasal Outcome Test plus one additional symptom–-sense of smell (SNOT-20+1)–-was the primary outcome measure.

Results

Overall, patients experienced a modest improvement in SNOT-20+1 scores (Δ = -0.61; p< 0.0001), but this did not reach the predetermined level of a clinically meaningful effect (Δ = -0.80). Baseline facial pain or facial pressure was negatively associated with outcome (p = 0.048 and 0.029, respectively) and did not correlate with extent of disease by sinus CT scoring. Other factors, including nasal discharge, hyposmia, cough, nasal polyps, and sinus CT severity, did not predict outcomes. The use of either oral antibiotics or oral steroids was associated with trends toward improved outcomes only when sinus-specific symptoms alone were considered.

Conclusion

The majority of CRS patients receiving medical treatment show modest improvement over time in SNOT-20+1 scores. Facial pain or facial pressure at entry are negatively associated with outcomes and may reflect causes other than CRS. These findings highlight the limitations of current medical treatment for CRS and the need for novel treatment strategies.

The Economic Burden and Symptom Manifestations of Chronic Rhinosinusitis

Background

The aim of this study was to delineate patient symptoms and economic burdens of chronic rhinosinusitis (CRS).

Methods

Adult patients with CRS were assessed prospectively with a survey instrument. Symptom scores for major and minor symptoms of CRS, medication use, physician visits for CRS, and work days missed were determined. Cost analyses were conducted.

Results

Three hundred twenty-two patients were studied prospectively (mean age, 42.3 years). Nasal obstruction and facial congestion were the most common and severe major symptoms, and headache and fatigue were the most common and severe minor symptoms. Patients received an average of 2.7 antibiotic courses and used nasal steroids and prescription antihistamines 18.3 and 16.3 weeks, respectively, in a 12-month period. Mean medical resource costs were $921 per patient-year. CRS caused an average of 4.8 days of missed work per 12-month period. The overall yearly economic cost of CRS was $1539 per patient.

Conclusion

Nasal and facial symptoms prevail over systemic and oropharyngeal symptoms in CRS. Significant medical resource expenditures and global economic costs accompany CRS.

Lack of Significant Correlation between Rhinosinusitis Symptoms and Specific Regions of Sinus Computer Tomography Scans

Background

The sinonasal computer tomography (CT) scan is frequently used to help confirm the diagnosis of rhinosinusitis. However, little data exist correlating patient symptoms with CT findings.

Methods

Immediately preceding CT of the sinuses, 94 subjects without evidence of trauma, nasal tumors, or previous sinus surgery completed the Rhinosinusitis Outcome Measure 31 symptom questionnaire and were asked to locate areas of facial pain or pressure. CT scans were graded according to the Lund-MacKay system, and agger nasi and ethmoid bulla cells were measured. Data from CT scans and symptom/pain questionnaire responses were analyzed for significant correlations.

Results

No correlation was identified when comparing total Lund-MacKay scores, opacification of individual sinuses, and size of the agger nasi and ethmoid bulla cells with the Rhinosinusitis Outcome Measure 31 subset scores and areas of facial pain or pressure.

Conclusion

The sinus CT scan is a necessary tool for preoperative planning; however, it should not be used to predict symptoms or to localize areas responsible for facial pain or pressure.

Clinical Predictors of Chronic Rhinosinusitis

Background

Chronic rhinosinusitis (CRS) is diagnosed by the presence of signs and symptoms of CRS in conjunction with physical evidence of mucosal inflammation. We sought to identify symptoms that predict CRS.

Methods

We performed a retrospective review of patients referred to a tertiary care rhinology clinic for evaluation of CRS. Symptom survey data and diagnoses were reviewed.

Results

Of 187 patients who met inclusion criteria, 112 (60%) were diagnosed with CRS and 75 (40%) were not. Chronic purulent rhinorrhea (odds ratio [OR], 2.2) and hyposmia (OR, 2.3) individually and in combination (OR, 3.8) were significant predictors of CRS. The major criteria of the 1997 Task Force in Rhinology (TFR) also predicted CRS (OR, 1.9) but the minor criteria did not (OR, 0.3).

Conclusion

In this preliminary study, purulent rhinorrhea and hyposmia are strong predictors of CRS. The major criteria of the TFR also predict CRS but the minor criteria do not.

An Analysis of Neuropeptides at Nasal Contact Points of Patients With Secondary Headache

OBJECTIVES

This prospective research study was designed to analyze the surgical outcomes and the intensity of substance P (SP), neurokinin A (NA), and calcitonin gene-related peptide (CGRP) in contact and noncontact nasal mucosa of patients with headache.

METHODS

Twenty adults with secondary headache and correctible nasal obstruction were included in this study. The patients had nasal contact points between the nasal septum and the middle or inferior turbinates on nasal endoscopy and computed tomography scan. During surgical procedures, sample tissues were obtained from the nasal contact point and the noncontact area of the lateral nasal wall of these patients. Fluorescein staining intensity for antibodies against SP, NA, and CGRP was analyzed using image J software. Headaches were evaluated using a visual analog scale preoperatively and postoperatively.

RESULTS

The differences between the preoperative and the postoperative 3rd month (P < 0.001) and 12th month (P < 0.001) visual analog scale scores were statistically significant. However, fluorescein staining intensity for SP (P = 0.631), NA (P = 0.546), and CGRP (P = 0.683) did not show statistically significant differences between the contact mucosa and the noncontact mucosa groups.

CONCLUSIONS

Although in selected patients significant relief of headache can be obtained by surgery, there is no evidence from this study that SP, NA, and CGRP are responsible for the initiation of headache.

[Headache: Otorhinolaryngological aspects]

Headache is the main symptom in a wide variety of diseases of which ear, nose and throat (ENT) entities are only a small fraction but are not reflected in the number of patients. Comprehensive knowledge of the clinical signs of the most common primary headaches, e. g. migraine, is therefore essential for the ENT specialist because the few patients with secondary headache from ENT-related causes must be identified. Reasons for confusing primary headache with e. g. sinusitis are mostly symptoms mediated by the trigeminal nerve, such as nasal obstruction and rhinorrhea because branches of the trigeminal nerve also innervate the meninges. The ENT-specific origin of headaches is characterized by clinical findings of physical organ disease; therefore, from an ENT perspective imaging should be part of the diagnostic procedure as normal imaging findings are indicative of primary headache, which would not normally be treated by an ENT specialist.

A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists

BACKGROUND

Ambulatory care visits for chronic sinusitis outnumber visits for acute sinusitis. The majority of these visits are with non-otolaryngologists. In order to better understand patients diagnosed with chronic sinusitis by non-otolaryngologists, we sought to determine if incident cases of chronic sinusitis diagnosed by primary care (PC) or emergency medicine (EM) providers meet diagnostic criteria.

METHODS

This was a retrospective cohort study. Patients were identified using administrative data from 2005 to 2006. The dataset was then clinically annotated based on chart review. We excluded prevalent cases.

RESULTS

We identified 114 patients with newly diagnosed chronic sinusitis in EM (75) or PC settings (39). Rhinorrhea (EM 61%, PC 59%) and nasal obstruction (EM 67%, PC 64%) were common in both settings but facial fullness (EM 80%, PC 39%) and pain (EM 40%, PC 18%) were more common in the EM setting. Few patients reported symptoms of 90 days or longer (EM 6.0%, PC 24%) and no patient had evidence of inflammation on physical examination. A minority of patients received a sinus computed tomography (CT) scan (22.8%) or nasal endoscopy (1.8%). In total, only 1 patient diagnosed with chronic sinusitis met the diagnostic criteria.

CONCLUSION

Most patients diagnosed with chronic sinusitis by non-otolaryngologists do not have the condition. Caution should be used in studying chronic sinusitis using administrative data from non-otolaryngology providers because a large proportion of the patients may not actually have the disease.

Rhinogenic and nonrhinogenic headaches

PURPOSE OF REVIEW

To review the present knowledge and the recent publications on the cause, characteristics, course and treatment of chronic and recurring facial pain and headaches. Facial pain is amongst the commonest complaints in ear, nose and throat clinics. Recent articles have presented important evidence-based approach to this common problem.

RECENT FINDINGS

Recent publications in the fields of otolaryngology and neurology have better defined the differences between rhinogenic and nonrhinogenic facial pain, and place this symptom in the context of rhinosinusitis. Although chronic facial pain has conventionally been considered to be due to sinusitis because of anatomical proximity, there is increasing evidence to support the contrary. Published literature has identified that only 16-20% of patients with sinusitis (purulent or with polyposis) confirmed by nasal endoscopy actually declared symptoms of facial pain. More pertinently, surgical series have shown that up to 40% of patients had persistent postoperative facial pain despite resolution of sinusitis on nasal endoscopy and computed tomography (CT). Rhinogenic pain is generally unilateral, severe, located on the same side and related to rhinogenic symptoms, and almost always accompanied by endoscopic and CT abnormalities. Incidental CT mucosal disease can be noted in 30% of asymptomatic patients.

SUMMARY

Traditionally, facial pain has often been considered to be caused by chronic rhinosinusitis. Increasing evidence has shown that the commonest cause for chronic facial pain is of nonrhinogenic origin. As otorhinolaryngologists, we deal with facial pain on a daily basis and therefore need to be aware of the different causes for this common symptom.

Impact of corrective rhinologic surgery on rhinogenic headache

OBJECTIVE

In this study, the localization of the headache, mucosal contact points, sinonasal anatomic variations and the incidence of mucosal abnormalities were determined in patients with rhinogenic headache, and the efficacy of the corrective surgery on the severity of the headache and the rate of improvement on that localization were investigated.

STUDY DESIGN

Conducted in a prospective manner.

LEVEL OF EVIDENCE

Level 2b.

METHODS

Sixty-five patients who were admitted with sinonasal symptoms and headache and had septoplasty, endoscopic sinus surgery, or surgical procedures involving the nasal turbinates were included in this study. The quality and the severity of the headache were investigated preoperatively as well as in the 3rd and 12th postoperative months.

RESULTS

Headache was most frequently localized the frontal region. The mucosal contact points were most frequently localized between the nasal septum and the middle or inferior turbinates. Differences between preoperative headache and headache in postoperative 3rd month and postoperative 12th month were statistically significant (P < 0.05). Improvement in headache after surgery was statistically significant in cases with Haller cell and paradoxical middle turbinate and in patients with contact points between the nasal septum and the middle or inferior turbinates (P < 0.05).

CONCLUSIONS

We have shown the importance of surgery in the treatment of rhinogenic headache. We have also shown the reliability of the decongestion test for determining the indication for surgery. We suggest that the rhinologic surgery may have a great contribution to the treatment of headache.

Is 'sinus' pain really sinusitis?

So-called 'sinus pain' is a common complaint in GP and ear, nose and throat clinics, and patients often receive treatment with antibiotics and decongestants. Recent evidence suggests that facial pain may not be related to the sinuses at all and that doctors may have to rethink their prescribing strategy.

Prospective three-year follow up of a cohort study of 240 patients with chronic facial pain

Background:

Patients often present with facial pain ascribed to sinusitis, despite normal nasal endoscopy and sinus computed tomography. Facial pain is increasingly recognised to be of neurological origin.

Method:

A cohort of 240 patients with chronic facial pain was followed up for 36 months at an otolaryngological practice in Malta. The types of facial pain were classified according to International Headache Classification criteria. The body mass index, occupation and educational level of patients were compared with the general population.

Results:

Tension-type mid-facial pain and facial migraine without aura were the most common types of chronic facial pain. The sites of pain, symptoms, treatment and outcomes for these principal pain types are discussed. Patients with mid-facial pain were treated with low-dose amitriptyline for eight weeks. After three years, nearly half of the patients were symptom free, and in a third the pain changed from being chronic to being episodic. The treatment of patients with facial migraine was more varied but the length of time until recurrence of pain was similar.

Conclusion:

The most effective long-term treatments for tension-type mid-facial pain and facial migraine were low-dose amitriptyline and low-dose amitriptyline and triptans, respectively.

Intranasal contact points as a cause of facial pain or headache: a systematic review

BACKGROUND

There is a body of opinion in the clinical literature advocating the removal of intranasal contact points to treat facial pain.

OBJECTIVES

To review the evidence that intranasal mucosal contact points cause facial pain or headache and their removal is therapeutic.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A systematic search of the available literature was performed using MEDLINE, EMBASE, Cochrane library and NHS Evidence from inception to September 2011. Terms used include facial pain and contact point (3628), rhinologic headache (6) contact point and surgery/endoscopy (38).

EVALUATION METHOD

Inclusion criteria applied. Assessment of papers were undertaken by one reviewer and checked by the second. A narrative review of each study was performed and results recorded in tables.

RESULTS

In one study, 973 consecutive patients with a provisional diagnosis of rhinosinusitis were divided into groups with (42%) and without facial pain. There was a 4% prevalence of nasal contact in both groups, which was unrelated to the presence of facial pain. In another study of 100 patient's coronal paranasal sinus CT scans, 29% had headache and 55% had a contact point but their presence was inversely related to the presence of pain.(1) In a further study, ten healthy volunteers had palpation, adrenaline, substance P and placebo applied to different areas throughout the nasal cavity and none of these stimuli caused facial pain. Nineteen studies were identified where nasal mucosal contact points had been removed surgically for the treatment of facial pain. They were small case series, not randomised and subject to selection bias, had no control group, a limited follow-up and were open to observer bias with level IV evidence. Seven studies had a statistically significant improvement in pain postoperatively compared with preoperative questionnaire results but the majority had residual facial pain.

CONCLUSION

The majority of people with contact points experience no facial pain. The presence of a contact point is not a good predictor of facial pain. The removal of a contact point rarely results in the total elimination of facial pain making the theory that a contact point is responsible unlikely. The improvement in postoperative symptoms following the removal of contact points in some patients may be explained by cognitive dissonance or neuroplasticity. A randomised, controlled and blinded trial with a followed up period of over 12 months is needed to assess the place of surgery in the removal of a contact point for the treatment of facial pain.

The aetiology underlying sinus headaches

OBJECTIVE

Patients with sinus headaches usually complain of pain and pressure sensation around the sinuses and periorbital area; most are misdiagnosed with sinusitis and receive unnecessary treatment. This prospective study investigated the aetiology of sinus headache in patients with negative endoscopic or computed tomography (CT) scan findings.

METHODS

This multicentre study included patients who could be followed regularly after being admitted to otorhinolaryngology outpatient or emergency units due to sinus headache, in whom endoscopic and radiological examinations did not show sinonasal pathology. The study group comprised patients with primary headache, according to International Headache Society criteria. Participants were followed monthly for 3 months and treatment response was evaluated as complete remission, partial remission or no response.

RESULTS

The study included 98 patients. The main reason for diagnosing and treating sinus headaches that arose from neurovascular events was attributed to the accompanying symptoms, e.g. nasal obstruction, nasal discharge and sinus sensitivity.

CONCLUSIONS

A better understanding of vascular event-derived headaches (especially migraine) and a detailed examination of patients via endoscopy and CT scanning are expected to minimize misdiagnosis rates, in patients with sinus headaches.

Impact of posttraumatic stress disorder on sinonasal symptoms and quality of life in patients with chronic rhinosinusitis

BACKGROUND

Severity of chronic rhinosinusitis (CRS), measured by disease-specific health-related quality-of-life questionnaires, is expected to increase in patients who also suffer from posttraumatic stress disorder (PTSD). Altered pain perception, sleep disorders, and fatigue may be associated with this comorbidity.

METHODS

Severity of CRS was compared between a group of 28 patients with CRS and a group of 28 patients with CRS and concomitant PTSD using different disease-specific and generic instruments, such as visual analog scale (VAS), Short Form-36 test (SF-36), and Sino-Nasal Outcome Test-22 (SNOT 22).

RESULTS

SNOT-22 test showed significantly higher CRS severity in patients with CRS and PTSD, compared to patients with CRS without PTSD.

CONCLUSION

Patients with less severe CRS, measured by objective outcome measures, due to the impact of comorbid PTSP, are classified as having severe rhinosinusitis, and are exposed to the risk of unnecessary diagnostic and therapeutic procedures. In patients with difficult-to-treat rhinosinusitis, diagnosis should be revised, and one item that should be evaluated is whether they suffer from PTSD.

Causes of headache in patients with a primary diagnosis of sinus headache

Headache is a common occurrence among the general population. Although the pain could be a symptom of acute sinusitis, chronic sinusitis is not considered as a usual cause of headache. In addition, autonomic-related symptoms in the sinonasal region may be associated with vascular pain. Confusion regarding these symptoms could lead to an incorrect diagnosis of sinusitis. A prospective cross-sectional study was conducted at two tertiary referral centers with residency programs in otorhinolaryngology, head and neck surgery and neurology. The study included 58 patients with a diagnosis of "sinus headache" made by a primary care physician. Exclusion criteria were as follows: previous diagnosis of migraine or tension-type headache; evidence of sinus infection during the past 6 months; and the presence of mucopurulent secretions. After comprehensive otorhinolaryngologic and neurologic evaluation, appropriate treatment was started according to the final diagnosis and the patient was assessed monthly for 6 months. The final diagnoses were migraine, tension-type headache and chronic sinusitis with recurrent acute episodes in 68, 27 and 5% of the patients, respectively. Recurrent antibiotic therapy was received by 73% of patients with tension-type headache and 66% with migraine. Sinus endoscopy was performed in 26% of the patients. Therapeutic nasal septoplasty was performed in 16% of the patients with a final diagnosis of migraine, and 13% with tension-type headache. Many patients with self-described or primary care physician labeled "sinus headache" have no sinonasal abnormalities. Instead, most of them meet the IHS criteria for migraine or tension-type headache.

[The influence of endoscopic treatment of isolated, small inflammatory lesions of sphenoid sinus on headache sensation]

One of the most frequent complaint in patients with isolated sphenoiditis is headache. In large proportion of these patients no pathologic findings are revealed in sphenoethmoidal recess endoscopicaly thus discrimination between sinus originated and primary headache in such cases may be especially difficult.

THE AIM OF THIS STUDY

Was the assessment of the influence of endoscopic treatment of isolated, small inflammatory sphenoid sinus lesions on headache sensation.

MATERIAL AND METHOD

13 patients suffering from headache, with CT-diagnosed isolated, small inflammatory lesions of sphenoid sinus such as mucosal thickening, polypoid tissue and cysts were treated endoscopicaly. Headache was assessed on the basis of five-grade scale before surgery, 1 month after surgery and after the observation period that varied between 5 to 40 months.

RESULTS

In the first postoperative month the improvement in their headache was declared by 84.6% of patients, but after longer observation the success rate lowered to 61.5%. The improvement was observed both in patient whose the only complaint was headache and in patients with negative endoscopic findings.

CONCLUSIONS

Small isolated sphenoid sinus lesions constitute a group of specific pathologies of paranasal sinuses, which is still difficult to diagnose despite of technological advancement. The treatment of these lesions remains controversial. Decision as to operative treatment should be taken cautiously since headache in great proportion of these patient is not sinus originated. Further multicenter studies on the basis of larger group of patients are necessary to delineate the indications for surgical intervention in patients with small isolated inflammatory sphenoid sinus lesions.

Symptomatic maxillary sinus retention cysts: should they be removed?

OBJECTIVES/HYPOTHESIS

Recently, endoscopic sinus surgery (ESS) endoscopic sinus surgery (ESS) okay? has become the surgical procedure of choice for removing retention cysts from the maxillary sinus. The aim of our study was to determine the relationship between symptomatic relief and ESS with or without endoscopic excision of maxillary cysts.

STUDY DESIGN

Prospective, randomized study.

METHODS

Inclusion criteria were symptomatic maxillary cysts filling at least 50% of the sinus space. We conducted a prospective, randomized study comprising 80 patients. Of the patients, 41 underwent endoscopic ethmoidectomy, middle meatus antrostomy, and excision of the cysts (group A); and 39 underwent ethmoidectomy and antrostomy without cyst detachment (group B). During follow-up an attempt was made to correlate symptomatic failure with type of surgery, computed tomography (CT) score, cyst size, and ratio of cyst size/antral size.

RESULTS

Symptomatic failure occurred in nine cases: four in the group A and five in group B. There was no relationship between success rates and type of surgery, CT score, cyst size, and ratio of cyst size/antral size.

CONCLUSIONS

Endoscopic ethmoidectomy and middle meatus antrostomy without cyst detachment yielded similar outcomes with cyst extirpation through the antrostomy. Our treatment should be aimed in restoring ventilation and drainage of the dependent maxillary sinus.

The sinus headache explained

The concept of a sinus headache is problematic from neurology, allergology, and rhinology perspectives. It may be considered the final neurological diagnosis of exclusion when criteria for other craniofacial pain syndromes are not met. The International Headache Society definition implicates the presence of acute sinusitis, but this requirement is often not met in practice or with a patient's perception of the term. Otorhinolaryngologists have a similar exasperation with this cephalgia but tend to attribute idiopathic, nonallergic rhinopathy as the cause. Allergists often see patients who claim to have a sinus headache but instead have perennial allergic rhinitis or nonallergic rhinitis. A fresh perspective is required to determine the characteristics, differential diagnosis, and veracity of the sinus headache. We recommend using the term with caution only if the clinical picture meets the criteria for acute sinusitis-induced headache.

Endonasal endoscopic management of contact point headache and diagnostic criteria

BACKGROUND

Some types of headaches with sinonasal origin may be present in the absence of inflammation and infection. The contact points between the lateral nasal wall and the septum could be the cause of triggering and sustained pain via trigeminovascular system.

OBJECTIVE

The aim of this study was to evaluate the feasibility and effectiveness of endoscopic surgery in the sinonasal region for treatment of headache with special attention paid to specific diagnostic methods and patient selection.

METHODS

This was a prospective, non-randomized and semi-quasi experimental research study. Thirty-six patients with chronic headaches who had not previously responded to conventional treatments were evaluated by rhinoscopy and/or endoscopy, local anesthetic tests and computed tomography scans as diagnostic criteria. These patients were divided into 4 groups based on the diagnostic methods utilized. The intensity of headaches pre- and post-operatively were recorded by utilizing the visual analog scale scale and performing analysis with analysis of variance test comparison and Statistical Package for Social Sciences. Average follow-up was 30 months.

RESULTS

Our overall success rate approximated 83% while the complete cure rate was 11%. Patients in group 4 achieved the best results. In this group all diagnostic criteria were positive. In addition, patient responses were statistically significant in groups with more than one positive criteria compared with group 1 who only had positive examination. The positive response of 14 migrainous patients diagnosed with migraine prior to treatment was 64%.

CONCLUSION

Surgery in specific cases of headaches with more positive evidence of contact point could be successful, particularly if medical therapy has failed.

Sinus headaches: avoiding over- and mis-diagnosis

'Sinus headache' is a term used by many patients and primary-care physicians and, contrary to popular belief, sinus headaches are uncommon. Headaches that are due to sinusitis are confined to a minority of patients who have acute frontal sinusitis or sphenoiditis. The International Headache Society classification is robust in qualifying the term sinus headache and says that "chronic sinusitis is not validated as a cause of headache and facial pain unless relapsing into an acute stage". The vast majority of people who present with a symmetrical frontal or temporal headache, sometimes with an occipital component, have tension-type headache. Unilateral, episodic headaches are often vascular in origin. The idea that sinusitis can trigger migraine is misplaced, as the whole symptom complex is vascular and coexisting nasal congestion is due to vasodilation of the nasal mucosa that is sometimes part of the vascular event. The use of nasal endoscopy and imaging of the paranasal sinuses have advanced our appreciation that these patients are suffering from a vascular event. When these patients are asked to attend a clinic when they are symptomatic, the vast majority are found not to have a sinus infection. Sinusitis rarely causes headache, let alone facial pain, except when there is an acute bacterial infection when the sinus in question cannot drain, and it is usually unilateral due to increased pressure and inflammation caused by pus trapped within the sinus cavity. These patients usually have a history of a viral upper respiratory infection immediately before this and they have pyrexia with unilateral nasal obstruction. The vast majority of patients with acute sinusitis respond to antibiotics. Recurrent bacterial sinusitis is rare and anyone with more than two episodes of genuine bacterial sinusitis in 1 year should be investigated for evidence of poor immunity. Patients with chronic bacterial sinusitis rarely have any pain unless the sinus ostia are blocked and their symptoms are then the same as in acute sinusitis. Within the medical literature, there are texts that report that sphenoid sinusitis can cause headaches and, as with other acute sinus infections, intracranial or ophthalmolgical complications can occur. First, acute sphenoid sinusitis is rare and second, most of these patients respond to antibiotics. Batotrauma can cause short-lived pain in the sinus involved but there is always a clear history associated with diving or flying and, as the pressure within the sinus equalizes, the pain resolves within a few hours. Headaches are rarely due to sinusitis.

Revisiting the interpretation of positive sinus CT findings: a radiological and symptom-based review

OBJECTIVE

It is widely believed that a high percentage of normal, healthy patients without sinusitis symptoms have abnormal findings on sinus CT. Experiences of the authors of this study suggest otherwise.

STUDY DESIGN

Cross-sectional survey.

SUBJECTS AND METHODS

Head/sinus CT scans of 50 consecutive patients from each of three study groups were reviewed. Group 1 consisted of patients without any sinus symptoms. Group 2 consisted of patients with acute headache symptoms. Group 3 consisted of patients with complaints consistent with chronic sinusitis. CT scans were evaluated with the Lund-Mackay scoring system.

RESULTS

In the asymptomatic patient group (group 1), six (3%) patients had positive sinus CT scan findings, compared with 11 (5.5%) in the acutely symptomatic group (group 2), and 32 (64%) in the chronically symptomatic group (group 3). In the chronically symptomatic group (group 3), 64 percent of patients were allergic compared with 18% of the acute headache group (group 2) and 8 percent of the asymptomatic patient group (group 1).

CONCLUSION

Results of this study suggest that symptomatic sinus patients are much more likely to have positive sinus CT scan findings than asymptomatic patients. Conversely, normal healthy patients should not be expected to have abnormal sinus CT scans.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

[Pain as a symptom in otolaryngology conditions]

Pain is very frequent in otolaryngology disease: headaches, facial pain, earaches, and neck pain. The search for nasal pathology with maxillary sinus, sphenoidal, or ethmoidal involvement is part of the workup for headache. Facial pain should first suggest symptomatic neuralgia through involvement of the cranial nerves - trigeminal, glossopharyngeal, superior laryngeal - even if asymptomatic neuralgia are the most frequent. Earaches should be investigated through a search for involvement of the ear at the pinna, the external acoustic conduit, and the tympanic membrane. If the ear examination is normal, pain irradiating from the masticatory apparatus, the parotid, or the oropharynx is undertaken, with a systematic search for a tumoral cause.