- Email: [email protected]
Rhinogenic contact point headache – Frequently missed clinical entity
apollo medicine 13 (2016) 169–173
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Review Article
Rhinogenic contact point headache – Frequently missed clinical entity Santosh Kumar Swain a,*, Ishwar Chandra Behera b, Sidharth Mohanty c, Mahesh Chandra Sahu d a
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India b Department of Community Medicine, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India c Department of Anesthesia, Apollo Hospital, Bhubaneswar, Odisha, India d Directorate of Medical Research, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India
article info
abstract
Article history:
Background: There are different anatomical situations inside the nasal cavity leading to
Received 11 June 2016
rhinogenic contact point headache (RCPH), where each contact point has its own character-
Accepted 4 August 2016
istics. The precise excision of contact points by endoscopic approach in patients with RCPH
Available online 21 August 2016
is very effective and could be done carefully in selected patients. This review presents an overview of the current aspects in pathophysiology, clinical profile, and management of
Keywords:
RCPH.
Anatomical variations
Method: Relevant literature was searched from PubMed, Science direct, and Scopus data-
Headache
bases.
Contact point headache
Results: Headache is a common clinical entity and is nearly universal in the course of
Computed tomography
everyone's life. Pressure of two opposing mucosa in the nasal cavity without evidence of inflammation can be a cause of headache or facial pain. Minor intranasal anatomical variation leading to mucosal contact point may be an etiological factor for causing headache and often misdiagnosed and forgotten by clinician during evaluation of headache patients and sometimes considered as headache of unknown etiology. # 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Headache is a common complaint by the patients in day-today clinical practice and creates a distressing situation for both patient and the physician. There are myriads of causes for
headache varying from simple tension headache, migraine, refractory errors in eye, temperomandibular joint arthralgia, myofacial spasm to severe brain tumors. Headaches may be classified into primary and secondary types, where primary headache does not have specific etiology and include migraine, tension headache and cluster headache. Secondary
* Corresponding author. Tel.: +91 9556524887. E-mail address: [email protected] (S.K. Swain). http://dx.doi.org/10.1016/j.apme.2016.08.001 0976-0016/# 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
170
apollo medicine 13 (2016) 169–173
Table 1 – Anatomic variations noted on diagnostic nasal endoscopy and CT scan anatomic variations. Serial no.
Anatomical variations of nose
1 2 3 4 5 6 7 8 9
Deviated nasal septum Septal spur Concha bullosa Hypertrophied superior turbinate Overpneumatised ethmoidal bulla Hypertrophied agger nasi cells Malformed uncinate process Paradoxical middle turbinate Hypertrophied inferior turbinate
headache may arise owing to infections, trauma, tumor, vascular lesions, and metabolic diseases.1 It needs a multidisciplinary approach to diagnose the causative factors for headache. Often the rhinogenic cause of headache is undiagnosed; even worse, this cause is not suspected on preliminary evaluation. Headache together with facial pain owing to nasal origin in the absence of inflammatory sinonasal pathology is a new clinical entity that has received attention in medicine. This is called as rhinogenic contact point headache (RCPH), which is a new terminology in medicine. Even without the presence of sinusitis, the referred headache often due to pressure on the nasal mucosa because of the anatomical variations in the nose.2 Contact point headache is a new type of headache in the International Classification of Headache Disorders (ICHD), supported by limited evidence. RCPH is defined as intermittent pain localized in the periorbital and medial canthal or temporozygomatic regions; evidence of mucosal contact points with postural movements; cessation of headache within 5 min following topical use of local anesthesia at contact area and significantly resolution of headache in less than 7 days following removal of contact points.3 Intranasal contact points denote to a contact between two opposing intranasal mucosal surfaces. Intranasal contact points are present in about 4% of noses.4 Different intranasal anatomical variations causing RCPH are given in Table 1. Stammberger and Wolf documented the role of substance P (SP) in RCPH. They also described that this kind of headache is not only because of abnormal middle turbinate but also by abnormal mucosal contact causing referred pain.5 This review article describes the role of anatomical variations in nose leading to headache, which is a prudent evaluation with diagnostic nasal endoscopy and computed tomography (CT) scan before accurate diagnosis of rhinogenic cause of headache. It also describes details of pathophysiology, clinical profile, and management.
2.
Pathophysiology
The pathogenesis of RCPH is still the subject of controversy by some authors. The mechanical irritants such as pressure on the nasal mucosa may cause release of neuropeptides through the central orthodromic impulse and peripheral local, antidromic impulse. Neuropeptides like SP and calcitonin gene related peptide (CGRP) cause vasodilatation and edema of mucosal membrane, which again intensifies the pressure of contact area. The release of neuropeptides from central
nervous system causes the pain sensation, which is almost similar to migraine without aura. The duration and onset of pain coincide with duration and beginning of the nasal cycle.6 The middle turbinate is covered with mucosa on the lateral nasal wall. Its anterior wall and nasal septum are supplied by anterior ethmoidal nerve. RCPH is usually a referred pain where two different afferent sensory neurons, one with its receptor in the nasal cavity mucosa and other in the skin of forehead, zygomatic, temple and medial canthal area synapse on the same sensory neuron of sensory nucleus of trigeminal nerve. If the receptors in the nasal mucosa are stimulated, leading to the misinterpretation by the sensory cortex as originated from the skin, causing referred pain to the supraorbital or glabellar region. The cause of RCPH is multifactorial. RCPH may result from nociceptors in the nasal mucosa, which ends up in the sensory nucleus of the trigeminal nerve. Pressure effect on the nasal mucosa is associated with changes in micro vascular supply, followed by release of biologic substances, induces pain or decreasing the pain threshold. The contact between mucosal lining of concha bullosa and nasal septum or the lateral wall of nose results in release of SP, CGRP,7 and neurokinin A.8 These chemicals are found in nociceptive fibers in the central nervous system and trigeminovascular system. So the contact point between intranasal mucosa may be a cause of secondary headache or triggering factor to primary headache.9 This phenomenon is also called as middle turbinate syndrome.10 SP has a known role in pathophysiology of contact point headache.5 SP is a neuropeptide that can be identified in the mucosa of the nasal cavity. When SP is released around vascular area, vasodilatation, plasma extravasation and perivascular inflammation, causing headache similar to clinical manifestations of migraine without aura.9 Normal nasal mucosa has a higher concentration of SP than chronic hyper-plastic mucosa or polypoidal tissue. This explains why contact point headaches are almost always seen in patients without rhinosinusitis.
3.
Clinical profile
Headache is a very commonly encountered clinical symptom seen in everyone's life. Facial pain and headache due to sinus and nasal origin in the absence of inflammatory sinonasal pathology is a clinical presentation which has received attention in both otorhinolaryngology and neurology. Different types of intranasal anatomical variations with mucosal contact points can lead to RCPH. The characteristic headache may be different in each type of intranasal anatomical variation. Many clinicians are not well versed with these types of clinical condition with headache. Intranasal mucosal contact headache was added as a secondary headache disorder in the ICHD.11 Most relevant etiology concerned for otolaryngologists includes anatomical variations of nose causing secondary headache, which includes septal deviation, septal spur, and concha bullosa.12 Wolf and Tosum et al. documented that nasal septal deviation and spur are causing referred headache in the absence of inflammation.2 There are different types of septal deviations including cartilaginous deviation, bony deviation, bony spur, and high septal deviation. The significant RCPH is seen in septal spur (Fig. 1). Concha
[(Fig._1)TD$IG]
apollo medicine 13 (2016) 169–173
[(Fig._2)TD$IG]
171
Fig. 2 – Endoscopic picture showing concha bullosa of middle turbinate.
Fig. 1 – Endoscopic picture showing septal spur.
needed. Hypertrophied bulla ethmoidalis pushing the middle turbinate leading to contact between nasal septum and middle turbinate causing contact point headache. In RCPH, no features of sinusitis like purulent nasal discharge, postnasal drip, and foul smelling are seen.
bullosa is hypertrophied pneumatized middle turbinate and rarely seen in superior and inferior turbinates. The compression of middle turbinate because of congestion of nasal mucosa or concha bullosa may cause periorbital or ocular pain through anterior ethmoidal nerve, a branch of ophthalmic division of fifth cranial nerve.2 The superior turbinate is often forgotten turbinate during assessing the nasal pathology. Superior turbinate is innervated by maxillary and ophthalmic branches of trigeminal nerve. The facial area supplied by V1 and V2 affected with referred pain due to concha bullosa of superior turbinate. RCPH is a referred pain which arises owing to intranasal mucosal contact points, where a patient presents with facial pain and headache. The intranasal mucosal points which are seen in case of septal deviation, septal spur, concha bullosa of middle turbinate (Fig. 2), large ethmoidal bullosa and nasal septal bullosa (Fig. 3). If no other findings of inflammation for headache are seen, intranasal mucosal contact points should be given due importance. RCPH is frequently seen in septal deviations/spur followed by concha bullosa of middle turbinates in many cases. Hypertrophied superior turbinate is rarely seen and is often mistaken with a posterior ethmoidal cell. The contact point between upper septum and medial lamella of hypertrophied superior turbinate leads to headache. The contact point headache due to hypertrophied pneumatised superior turbinate usually causes pain over forehead, medial, and lateral canthus. Sometimes medialized middle turbinate causes mucosal contact with nasal septum. Creating a space between middle turbinate and septum is needed for reversing this situation. This is done by trimming the parts of middle turbinate. Bulla ethmoidalis is the large anterior ethmoidal air cells and when it is larger than normal; its medial surface may push the middle turbinate and may cause a contact with nasal septum. To reverse this situation, anterior ethmoidectomy and lateralization of middle turbinate are
4.
Management
Headaches are the most frequent causes for patients to seek medical attention and one of the largest factors for disability in the community. Early management of headache helps a patient to protect from disability. Multidisciplinary approach is always a need for diagnosis and treatment of headache. Headache without evidence of inflammation in nose and
[(Fig._3)TD$IG]
Fig. 3 – CT scan of paranasal sinus showing nasal septal bullosa.
172
apollo medicine 13 (2016) 169–173
paranasal sinuses is usually examined by neurophyscians, ophthalmologist, otolaryngologists, dentist, and internist to exclude other causes of headache such as neuralgia, temporal arteritis, and vascular headache.13 Evaluation of intranasal contact points should be thoroughly done by otolaryngologists. The combination of diagnostic nasal endoscopy and CT scan provides maximum information for the diagnosis of RCPH.14 Diagnostic nasal endoscopy in conjunction with CT scan has proven to be ideal combination for diagnosis of sinonasal pathology. Anatomical variations such as septal deviation, septal spurs, concha bullosa (Fig. 4), hypertrophied inferior turbinate, medialized middle turbinate, uncinate bulla, medially or laterally bent uncinate process, paradoxically middle turbinate, and large ethmoidal bulla are best assessed by CT scan and diagnostic nasal endoscopy which are often cause for contact headache. However, there exist limitations in diagnosis, as characteristic headache should be relieved after application of local anesthetics, which is usually not done in all cases of headaches. In one study of 30 patients with applications of local anesthetic agents, 43% showed complete recovery, 47% showed slight improvement, and 10% showed no improvement.2 This is why RCPH are properly diagnosed by endoscopic examination and CT scan to rule out differential diagnosis. Different anatomical variations of nose causing contact point headaches are given in Table 1. After identification of contact points, RCPH can be treated with surgical management.13 After evolution of endoscopic sinus surgery, many authors described different techniques such as partial turbinectomy and turbinoplasty aiming to decrease contact point headache and minimize postoperative synechia.15 The limited endoscopic sinus surgery is a useful surgical technique which helps to remove the contact points (Table 2). Patients with deviated nasal septum (DNS) or septal spur need septoplasty or spurectomy, which causes removal of mucosal contact points. In case of concha bullosa, conchoplasty is done by resecting the lateral wall of superior or middle turbinate. In case of large bulla ethmoidalis, anterior ethmoidectomy is usually a best option to remove the contact
[(Fig._4)TD$IG]
Table 2 – Mini functional endoscopic sinus surgery procedures applied to patients with RCPH. Serial no. 1 2 3 4
Surgical procedure Septoplasty Septal spur resection (spurectomy) Lateral resection of concha bullosa Subtotal resection of concha bullosa Segmental resection of concha bullosa Submucosal resection of hypertrophied inferior turbinate Excision of overpneumatised bulla (anterior ethmoidectomy)
5 6 7
points. For inferior turbinate hypertrophy, turbinoplasty or conservative partial turbinectomy are done to release the nasal obstruction and helping to remove the intranasal mucosal contact points. Few authors described treatment of contact point headaches using transaction of fifth cranial nerve or injection of Gasserian ganglion by alcohol or novocaine.3 Before the era of endoscopic sinus surgery, complete removal of middle turbinate was done to manage concha bullosa. After evolution of endoscopic sinus surgery, techniques such as partial turbinectomy and turbinoplasty are practiced aiming to relieve the contact point headaches.16 Septal spur has a significant relation with headache in case RCPH. Other than septal spur and hypertrophied middle turbinate, contact point headache may also cause by the contact between the septum and superior turbinate or medial wall of the ethmoidal sinus.13 Nose has a diverse anatomical variation. Relation between these anatomical variations and contact point headache was confirmed in septal spur, septal deviations, concha bullosa, and large ethmoidal bulla. So above lesions should not be ignored from mind during evaluation of headache and their respective treatment helps to relief the symptoms. Some anatomical variations of nose, which cause RCPH, are given below with its treatment.
4.1.
DNS
DNS is the most common anatomical variation of nose.17 It has been reported that DNS and septal spur may cause referred headache and facial pain in absence of inflammation.2 DNS along with variation of middle turbinate is a major contributor for contact point headache.2 DNS along with hypertrophic rhinitis is also a major concern for nasal obstruction, leading to headache. Patient will get maximum benefit from septoplasty surgery.
4.2.
Fig. 4 – CT scan of paranasal sinus showing bilateral concha bullosa showing contact points.
Concha bullosa
Concha bullosa is the hypertrophied pneumatized middle turbinate. Concha bullosa occupies the space between the lateral wall of nose and nasal septum, cause large areas of extensive mucosal contact. Intranasal mucosal contact between enlarged middle turbinate or superior turbinate and nasal septum may lead to stimulation of sensory component of trigeminal nerve, causing RCPH. Concha bullosa causes impairment of ventilation of sinuses if it
apollo medicine 13 (2016) 169–173
blocks the osteomeatal complex area leading to vaccum headache and often predisposes sinusitis. Concha bullosa of middle turbinate results in periorbital or ocular pain through anterior ethmoidal nerve, which is a branch of ophthalmic division of trigeminal nerve.2
4.3.
Prominent ethmoid bulla
This is the largest, anterior most, and consistent ethmoid air cells. The ethmoid bulla can be extensively pneumatized and hypertrophied causing contact to the middle turbinate. This is treated surgically with the help of endoscope. The endoscopic conchoplasty can be done for removing contact point between two apposing nasal mucosa.
4.4.
Agger nasi cells
These are the most anterior extramural ethmoid air cells, seen anterior superior to the attachment of middle turbinate at the lateral wall of nose. Hyperpneumatised agger nasi cells may cause contact to nasal septal mucosa, followed by contact headache. This is treated surgically by an endoscopic approach.
5.
Conclusion
Headache due to contact of nasal mucosa is often considered as an exclusion of diagnosis. RCPH should be included in the list of differential diagnosis of headache, and it should be properly investigated so that the management will be effective and appropriate. The outcome of this study highlights that diagnostic nasal study and CT scan are important tools in the diagnosis of anatomical variations of nose causing contact point headache. Anatomical variations such as DNS, nasal spur, concha bullosa, hypertrophied inferior turbinate, medialized middle turbinate, and septal bullosa are important causes for a headache. Nose has a diverse anatomical variation. DNS and/or septal spur are common anatomical variations of the nose causing contact point headache followed by concha bullosa and enlarged bulla ethmoidalis. Relation of anatomical variations with headache should not be ignored during decision making for headache management.
Conflicts of interest The authors have none to declare.
173
references
1. Cady RK, Schreiber CP. Sinus headache: a clinical conundrum. Otolaryngol Clin N Am. 2004;37:267–288. 2. Tosun F, Gerek M, Ozkaptan Y. Nasal surgery for contact point headaches. Headache. 2000;40:237–240. 3. Albirmawy OA, Elsherif HS, Shehata EM, Younes A. Middle turbinate evacuation conchoplasty in management of contact-point rhinogenic headache in children. Int J Clin Pediatr. 2010;1(4–5):115–123. 4. Peric A, Baletic N, Sotirovic J. A case of an uncommon anatomic variation of the middle turbinate associated with headache. Acta Otorhinolaryngol Ital. 2010;30:156–159. 5. Roozbahany NA, Nasri S. Nasal and paranasal sinus anatomical variations in patients with rhinogenic contact point headache. Auris Nasus Larynx. 2013;40:177–183. 6. Stammberger H, Wolf G. Headaches and sinus disease: the endoscopic approach. Ann Otol Rhinol Laryngol Suppl. 1988;134:3–23. 7. Durham PL. Calcitonin gene-related peptide (CGRP) and migraine. Headache. 2006;46(suppl 1):3–8. 8. Goadsby PJ, Hoskin KL, Storer RJ, Edvinsson L, Connor HE. Adenosine A1 receptor agonists inhibit trigeminovascular nociceptive transmission. Brain. 2002;125(Pt 6):1392–1401. 9. Behin F, Lipton RB, Bigal M. Migraine and intranasal contact point headache: is there any connection? Curr Pain Headache Rep. 2006;10(4):312–315. 10. Anselmo-Lima WT, De Oliveira JA, Speciali JG, et al. Middle turbinate headache syndrome. Headache. 1997;37:102–106. 11. Headache Classification Committee of the International Headache Society: the international classification of headache disorders. Cephalalgia. 2004;24(suppl 1):1–160. 12. Cady RK, Schreiber CP. Sinus problems as a cause of headache refractoriness and migraine chronification. Curr Pain Headache Rep. 2009;13:319–325. 13. Behin F, Behin B, Behin D, Baredes S. Surgical management of contact point headaches. Headache. 2005;45:204–210. 14. Huang HH, Lee TJ, Huang CC, Chang PH. Non-sinusitis related rhinogenous headache: a ten-year experience. Am J Otolaryngol. 2008;29:326–332. 15. Sigston EA, Iseli CE, Iseli TA. Concha bullosa: reducing middle meatal adhesions by preserving the lateral mucosa as a posterior pedicle flap. J Laryngol Otol. 2004;118 (10):799–803. 16. Behin F, Behin B, Bigal ME, Lipton RB. Surgical treatment of patients with refractory migraine headaches and intranasal contact points. Cephalalgia. 2005;25(6):439–443. 17. Gerbe RW, Fry TL, Fischer ND. Headache of nasal spur origin: an easily diagnosed and surgically correctable cause of facial pain. Headache. 1984;24:329–330.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Review Article
Rhinogenic contact point headache – Frequently missed clinical entity Santosh Kumar Swain a,*, Ishwar Chandra Behera b, Sidharth Mohanty c, Mahesh Chandra Sahu d a
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India b Department of Community Medicine, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India c Department of Anesthesia, Apollo Hospital, Bhubaneswar, Odisha, India d Directorate of Medical Research, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India
article info
abstract
Article history:
Background: There are different anatomical situations inside the nasal cavity leading to
Received 11 June 2016
rhinogenic contact point headache (RCPH), where each contact point has its own character-
Accepted 4 August 2016
istics. The precise excision of contact points by endoscopic approach in patients with RCPH
Available online 21 August 2016
is very effective and could be done carefully in selected patients. This review presents an overview of the current aspects in pathophysiology, clinical profile, and management of
Keywords:
RCPH.
Anatomical variations
Method: Relevant literature was searched from PubMed, Science direct, and Scopus data-
Headache
bases.
Contact point headache
Results: Headache is a common clinical entity and is nearly universal in the course of
Computed tomography
everyone's life. Pressure of two opposing mucosa in the nasal cavity without evidence of inflammation can be a cause of headache or facial pain. Minor intranasal anatomical variation leading to mucosal contact point may be an etiological factor for causing headache and often misdiagnosed and forgotten by clinician during evaluation of headache patients and sometimes considered as headache of unknown etiology. # 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Headache is a common complaint by the patients in day-today clinical practice and creates a distressing situation for both patient and the physician. There are myriads of causes for
headache varying from simple tension headache, migraine, refractory errors in eye, temperomandibular joint arthralgia, myofacial spasm to severe brain tumors. Headaches may be classified into primary and secondary types, where primary headache does not have specific etiology and include migraine, tension headache and cluster headache. Secondary
* Corresponding author. Tel.: +91 9556524887. E-mail address: [email protected] (S.K. Swain). http://dx.doi.org/10.1016/j.apme.2016.08.001 0976-0016/# 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
170
apollo medicine 13 (2016) 169–173
Table 1 – Anatomic variations noted on diagnostic nasal endoscopy and CT scan anatomic variations. Serial no.
Anatomical variations of nose
1 2 3 4 5 6 7 8 9
Deviated nasal septum Septal spur Concha bullosa Hypertrophied superior turbinate Overpneumatised ethmoidal bulla Hypertrophied agger nasi cells Malformed uncinate process Paradoxical middle turbinate Hypertrophied inferior turbinate
headache may arise owing to infections, trauma, tumor, vascular lesions, and metabolic diseases.1 It needs a multidisciplinary approach to diagnose the causative factors for headache. Often the rhinogenic cause of headache is undiagnosed; even worse, this cause is not suspected on preliminary evaluation. Headache together with facial pain owing to nasal origin in the absence of inflammatory sinonasal pathology is a new clinical entity that has received attention in medicine. This is called as rhinogenic contact point headache (RCPH), which is a new terminology in medicine. Even without the presence of sinusitis, the referred headache often due to pressure on the nasal mucosa because of the anatomical variations in the nose.2 Contact point headache is a new type of headache in the International Classification of Headache Disorders (ICHD), supported by limited evidence. RCPH is defined as intermittent pain localized in the periorbital and medial canthal or temporozygomatic regions; evidence of mucosal contact points with postural movements; cessation of headache within 5 min following topical use of local anesthesia at contact area and significantly resolution of headache in less than 7 days following removal of contact points.3 Intranasal contact points denote to a contact between two opposing intranasal mucosal surfaces. Intranasal contact points are present in about 4% of noses.4 Different intranasal anatomical variations causing RCPH are given in Table 1. Stammberger and Wolf documented the role of substance P (SP) in RCPH. They also described that this kind of headache is not only because of abnormal middle turbinate but also by abnormal mucosal contact causing referred pain.5 This review article describes the role of anatomical variations in nose leading to headache, which is a prudent evaluation with diagnostic nasal endoscopy and computed tomography (CT) scan before accurate diagnosis of rhinogenic cause of headache. It also describes details of pathophysiology, clinical profile, and management.
2.
Pathophysiology
The pathogenesis of RCPH is still the subject of controversy by some authors. The mechanical irritants such as pressure on the nasal mucosa may cause release of neuropeptides through the central orthodromic impulse and peripheral local, antidromic impulse. Neuropeptides like SP and calcitonin gene related peptide (CGRP) cause vasodilatation and edema of mucosal membrane, which again intensifies the pressure of contact area. The release of neuropeptides from central
nervous system causes the pain sensation, which is almost similar to migraine without aura. The duration and onset of pain coincide with duration and beginning of the nasal cycle.6 The middle turbinate is covered with mucosa on the lateral nasal wall. Its anterior wall and nasal septum are supplied by anterior ethmoidal nerve. RCPH is usually a referred pain where two different afferent sensory neurons, one with its receptor in the nasal cavity mucosa and other in the skin of forehead, zygomatic, temple and medial canthal area synapse on the same sensory neuron of sensory nucleus of trigeminal nerve. If the receptors in the nasal mucosa are stimulated, leading to the misinterpretation by the sensory cortex as originated from the skin, causing referred pain to the supraorbital or glabellar region. The cause of RCPH is multifactorial. RCPH may result from nociceptors in the nasal mucosa, which ends up in the sensory nucleus of the trigeminal nerve. Pressure effect on the nasal mucosa is associated with changes in micro vascular supply, followed by release of biologic substances, induces pain or decreasing the pain threshold. The contact between mucosal lining of concha bullosa and nasal septum or the lateral wall of nose results in release of SP, CGRP,7 and neurokinin A.8 These chemicals are found in nociceptive fibers in the central nervous system and trigeminovascular system. So the contact point between intranasal mucosa may be a cause of secondary headache or triggering factor to primary headache.9 This phenomenon is also called as middle turbinate syndrome.10 SP has a known role in pathophysiology of contact point headache.5 SP is a neuropeptide that can be identified in the mucosa of the nasal cavity. When SP is released around vascular area, vasodilatation, plasma extravasation and perivascular inflammation, causing headache similar to clinical manifestations of migraine without aura.9 Normal nasal mucosa has a higher concentration of SP than chronic hyper-plastic mucosa or polypoidal tissue. This explains why contact point headaches are almost always seen in patients without rhinosinusitis.
3.
Clinical profile
Headache is a very commonly encountered clinical symptom seen in everyone's life. Facial pain and headache due to sinus and nasal origin in the absence of inflammatory sinonasal pathology is a clinical presentation which has received attention in both otorhinolaryngology and neurology. Different types of intranasal anatomical variations with mucosal contact points can lead to RCPH. The characteristic headache may be different in each type of intranasal anatomical variation. Many clinicians are not well versed with these types of clinical condition with headache. Intranasal mucosal contact headache was added as a secondary headache disorder in the ICHD.11 Most relevant etiology concerned for otolaryngologists includes anatomical variations of nose causing secondary headache, which includes septal deviation, septal spur, and concha bullosa.12 Wolf and Tosum et al. documented that nasal septal deviation and spur are causing referred headache in the absence of inflammation.2 There are different types of septal deviations including cartilaginous deviation, bony deviation, bony spur, and high septal deviation. The significant RCPH is seen in septal spur (Fig. 1). Concha
[(Fig._1)TD$IG]
apollo medicine 13 (2016) 169–173
[(Fig._2)TD$IG]
171
Fig. 2 – Endoscopic picture showing concha bullosa of middle turbinate.
Fig. 1 – Endoscopic picture showing septal spur.
needed. Hypertrophied bulla ethmoidalis pushing the middle turbinate leading to contact between nasal septum and middle turbinate causing contact point headache. In RCPH, no features of sinusitis like purulent nasal discharge, postnasal drip, and foul smelling are seen.
bullosa is hypertrophied pneumatized middle turbinate and rarely seen in superior and inferior turbinates. The compression of middle turbinate because of congestion of nasal mucosa or concha bullosa may cause periorbital or ocular pain through anterior ethmoidal nerve, a branch of ophthalmic division of fifth cranial nerve.2 The superior turbinate is often forgotten turbinate during assessing the nasal pathology. Superior turbinate is innervated by maxillary and ophthalmic branches of trigeminal nerve. The facial area supplied by V1 and V2 affected with referred pain due to concha bullosa of superior turbinate. RCPH is a referred pain which arises owing to intranasal mucosal contact points, where a patient presents with facial pain and headache. The intranasal mucosal points which are seen in case of septal deviation, septal spur, concha bullosa of middle turbinate (Fig. 2), large ethmoidal bullosa and nasal septal bullosa (Fig. 3). If no other findings of inflammation for headache are seen, intranasal mucosal contact points should be given due importance. RCPH is frequently seen in septal deviations/spur followed by concha bullosa of middle turbinates in many cases. Hypertrophied superior turbinate is rarely seen and is often mistaken with a posterior ethmoidal cell. The contact point between upper septum and medial lamella of hypertrophied superior turbinate leads to headache. The contact point headache due to hypertrophied pneumatised superior turbinate usually causes pain over forehead, medial, and lateral canthus. Sometimes medialized middle turbinate causes mucosal contact with nasal septum. Creating a space between middle turbinate and septum is needed for reversing this situation. This is done by trimming the parts of middle turbinate. Bulla ethmoidalis is the large anterior ethmoidal air cells and when it is larger than normal; its medial surface may push the middle turbinate and may cause a contact with nasal septum. To reverse this situation, anterior ethmoidectomy and lateralization of middle turbinate are
4.
Management
Headaches are the most frequent causes for patients to seek medical attention and one of the largest factors for disability in the community. Early management of headache helps a patient to protect from disability. Multidisciplinary approach is always a need for diagnosis and treatment of headache. Headache without evidence of inflammation in nose and
[(Fig._3)TD$IG]
Fig. 3 – CT scan of paranasal sinus showing nasal septal bullosa.
172
apollo medicine 13 (2016) 169–173
paranasal sinuses is usually examined by neurophyscians, ophthalmologist, otolaryngologists, dentist, and internist to exclude other causes of headache such as neuralgia, temporal arteritis, and vascular headache.13 Evaluation of intranasal contact points should be thoroughly done by otolaryngologists. The combination of diagnostic nasal endoscopy and CT scan provides maximum information for the diagnosis of RCPH.14 Diagnostic nasal endoscopy in conjunction with CT scan has proven to be ideal combination for diagnosis of sinonasal pathology. Anatomical variations such as septal deviation, septal spurs, concha bullosa (Fig. 4), hypertrophied inferior turbinate, medialized middle turbinate, uncinate bulla, medially or laterally bent uncinate process, paradoxically middle turbinate, and large ethmoidal bulla are best assessed by CT scan and diagnostic nasal endoscopy which are often cause for contact headache. However, there exist limitations in diagnosis, as characteristic headache should be relieved after application of local anesthetics, which is usually not done in all cases of headaches. In one study of 30 patients with applications of local anesthetic agents, 43% showed complete recovery, 47% showed slight improvement, and 10% showed no improvement.2 This is why RCPH are properly diagnosed by endoscopic examination and CT scan to rule out differential diagnosis. Different anatomical variations of nose causing contact point headaches are given in Table 1. After identification of contact points, RCPH can be treated with surgical management.13 After evolution of endoscopic sinus surgery, many authors described different techniques such as partial turbinectomy and turbinoplasty aiming to decrease contact point headache and minimize postoperative synechia.15 The limited endoscopic sinus surgery is a useful surgical technique which helps to remove the contact points (Table 2). Patients with deviated nasal septum (DNS) or septal spur need septoplasty or spurectomy, which causes removal of mucosal contact points. In case of concha bullosa, conchoplasty is done by resecting the lateral wall of superior or middle turbinate. In case of large bulla ethmoidalis, anterior ethmoidectomy is usually a best option to remove the contact
[(Fig._4)TD$IG]
Table 2 – Mini functional endoscopic sinus surgery procedures applied to patients with RCPH. Serial no. 1 2 3 4
Surgical procedure Septoplasty Septal spur resection (spurectomy) Lateral resection of concha bullosa Subtotal resection of concha bullosa Segmental resection of concha bullosa Submucosal resection of hypertrophied inferior turbinate Excision of overpneumatised bulla (anterior ethmoidectomy)
5 6 7
points. For inferior turbinate hypertrophy, turbinoplasty or conservative partial turbinectomy are done to release the nasal obstruction and helping to remove the intranasal mucosal contact points. Few authors described treatment of contact point headaches using transaction of fifth cranial nerve or injection of Gasserian ganglion by alcohol or novocaine.3 Before the era of endoscopic sinus surgery, complete removal of middle turbinate was done to manage concha bullosa. After evolution of endoscopic sinus surgery, techniques such as partial turbinectomy and turbinoplasty are practiced aiming to relieve the contact point headaches.16 Septal spur has a significant relation with headache in case RCPH. Other than septal spur and hypertrophied middle turbinate, contact point headache may also cause by the contact between the septum and superior turbinate or medial wall of the ethmoidal sinus.13 Nose has a diverse anatomical variation. Relation between these anatomical variations and contact point headache was confirmed in septal spur, septal deviations, concha bullosa, and large ethmoidal bulla. So above lesions should not be ignored from mind during evaluation of headache and their respective treatment helps to relief the symptoms. Some anatomical variations of nose, which cause RCPH, are given below with its treatment.
4.1.
DNS
DNS is the most common anatomical variation of nose.17 It has been reported that DNS and septal spur may cause referred headache and facial pain in absence of inflammation.2 DNS along with variation of middle turbinate is a major contributor for contact point headache.2 DNS along with hypertrophic rhinitis is also a major concern for nasal obstruction, leading to headache. Patient will get maximum benefit from septoplasty surgery.
4.2.
Fig. 4 – CT scan of paranasal sinus showing bilateral concha bullosa showing contact points.
Concha bullosa
Concha bullosa is the hypertrophied pneumatized middle turbinate. Concha bullosa occupies the space between the lateral wall of nose and nasal septum, cause large areas of extensive mucosal contact. Intranasal mucosal contact between enlarged middle turbinate or superior turbinate and nasal septum may lead to stimulation of sensory component of trigeminal nerve, causing RCPH. Concha bullosa causes impairment of ventilation of sinuses if it
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blocks the osteomeatal complex area leading to vaccum headache and often predisposes sinusitis. Concha bullosa of middle turbinate results in periorbital or ocular pain through anterior ethmoidal nerve, which is a branch of ophthalmic division of trigeminal nerve.2
4.3.
Prominent ethmoid bulla
This is the largest, anterior most, and consistent ethmoid air cells. The ethmoid bulla can be extensively pneumatized and hypertrophied causing contact to the middle turbinate. This is treated surgically with the help of endoscope. The endoscopic conchoplasty can be done for removing contact point between two apposing nasal mucosa.
4.4.
Agger nasi cells
These are the most anterior extramural ethmoid air cells, seen anterior superior to the attachment of middle turbinate at the lateral wall of nose. Hyperpneumatised agger nasi cells may cause contact to nasal septal mucosa, followed by contact headache. This is treated surgically by an endoscopic approach.
5.
Conclusion
Headache due to contact of nasal mucosa is often considered as an exclusion of diagnosis. RCPH should be included in the list of differential diagnosis of headache, and it should be properly investigated so that the management will be effective and appropriate. The outcome of this study highlights that diagnostic nasal study and CT scan are important tools in the diagnosis of anatomical variations of nose causing contact point headache. Anatomical variations such as DNS, nasal spur, concha bullosa, hypertrophied inferior turbinate, medialized middle turbinate, and septal bullosa are important causes for a headache. Nose has a diverse anatomical variation. DNS and/or septal spur are common anatomical variations of the nose causing contact point headache followed by concha bullosa and enlarged bulla ethmoidalis. Relation of anatomical variations with headache should not be ignored during decision making for headache management.
Conflicts of interest The authors have none to declare.
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