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Headache--A Sinonasal Symptom and More… a Review Article

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Headache--A Sinonasal Symptom and More… a Review Article Indonesian Journal of Biomedical Sciences Volume 7, Number 1, January-June 2013: 1-6 Print-ISSN: 2085-4773, E-ISSN: 2302-2906. HEADACHE--A SINONASAL SYMPTOM AND MORE… A REVIEW ARTICLE 1Kaur, A., and 2Singh, A. 1Assistant Professor at Departement of Physiology, M. M Institute of Medical Sciences and Research, Mullana, Ambala, India. 2Assistant Professor at Departement of E. N. T., M. M Institute of Medical Sciences and Research, Mullana, Ambala, India ABSTRACT Headaches and facial pain are common complaints. In many cases, patients are referred to an otolaryngologist to determine if head pain is sinus related. In the absence of other nasal or sinus symptoms, some rhinogenic headaches can be overlooked or misdiagnosed. A complete history and thorough ENT examination, including nasal endoscopy with or without coronal CT scans is key to the correct diagnosis.1 Headache resulting from disease of the nose or paranasal sinuses are usually associated with symptoms (congestion, fullness, discharge, obstruction) that point to the site of origin. Occasionally, however nasal or sinus disease can be manifested solely as headache. Key words: Headache; Sinusitis; FESS. INTRODUCTION Patients with chronic headache pain often Headache is nearly a universal human present to a variety of specialists, including their experience. The lifetime incidence of headache is primary care physician, neurologist, dentist, estimated to be at least 90%. Moskowitz has otolaryngologist and even psychiatrist. They present described headache as the symptom produced by the to otolaryngologist because they or their physician nervous system when it perceives threat and as such is believe the headache to be related to underlying sinus considered part of the protective physiology of the pathology. The primary focus of the otolaryngologist nervous system. When the cause of headache is a is to exclude this possibility. The diagnosis of headache definable underlying pathologic process, the headache secondary to acute-sinusitis can be relatively is diagnosed as a secondary headache. Causes straightforward. Diagnosing headache related to include metabolic, infectious, inflammatory, chronic sinus disease can be much more difficult traumatic, neoplastic, immunologic, endocrinologic depending on patients presentation.4 This article will and vascular entities. help us in understanding and refresh our knowledge When no clear pathologic condition can be regarding headache and sinusitis. identified, headache is considered to be a manifestation of a primary headache syndrome. The DISCUSSION common primary headache disorders as defined by The knowledge of the presence of the paranasal the International Headache Society, are migraine, sinuses dates back to early mankind as well as probable migraine, tension type and cluster attempts to treat their disease. In ancient times, the headache.2 paranasal sinuses, were thought to be a system of The term ‘sinusitis’ refers to a group of disorders hollow spaces through which mucus produced by characterized by inflammation of the mucosa of the brain was drained. Leonardo da Vinci in Milano in paranasal sinuses. Because the inflammation nearly 1489 was the first to prepare and draw anatomical always also involves the nose, it is now generally specimens of the paranasal sinuses. Highmore N in accepted that ‘rhinosinusitis’ is the preferred term to England in 1651, presented the first detailed describe the inflammation of the nose and paranasal description and drawing of the maxillary sinus and 3 sinuses. hence it is named Highmore’s antrum. Drake J. and Cooper W in England in 1707 reported that in some Correspondence: Kaur, A. cases ozaena was due to suppuration in the maxillary Departement of Physiology, M. M Institute of Medical Sciences and Research, Mullana, Ambala, India sinus and could be cured by extraction of a tooth and Email: [email protected] opening the sinus via the alveolus. 1 www.ojs.unud.ac.id and www.balimedicaljournal.com Indonesian Journal of Biomedical Sciences Volume 7, Number 1, January-June 2013: 1-6 Print-ISSN: 2085-4773, E-ISSN: 2302-2906. Caldwell GW in New York in 1893 published his mucosa. It mediates pain impulses to the cortex via method, opening the canine fossa wall, removal of the afferent C-fibers.12 mucous membrane and opening a window in the Sinus infections are much less common today lateral wall of inferior nasal meatus.5 than they were in the pre-antibiotic era, but they still Hippocrates was the first to describe lesions that are over diagnosed. Acute sinusitis, a relatively obstruct the nasal passages. Andreas Vesalius uncommon cause of headache is the result of described the maxillary, frontal and sphenoid sinuses. infection of one or more of the cranial sinuses. Acute Siebenmann was apparently the first to recommend sinusitis usually is characterized by purulent discharge supranasal antrostomy in the middle meatus which is in the nasal passages and a pain profile determined by now fashionable again.6 The maxillary sinus has been site of infection. Sinusitis is over diagnosed as a cause the focus of surgical attention from the 17th century of headache because of the belief that pain over the onwards largely as a result of its size and accessibility, sinuses must be related to the sinuses. Paradoxically, initially reinforced by plain X-ray.7 sinus disease also tends to be under-diagnosed, as The surgical treatment of chronic inflammatory sphenoid sinus infection frequently is missed.13 frontal sinus disease over the past century has varied Headache associated with acute sinusitis is a well between intranasal and external procedures. recognized entity, the diagnosis is easily made due to However, a single approach that will lead to relief of the associated nasal and sinus symptoms. However, symptoms, eradication of disease with preservation of the phenomenon of referred headache from chronic function, and a minimum of deformity has not yet sinusitis or intranasal abnormalities or both without been attained.8 upper respiratory symptoms is not well understood[14]. From the otolaryngologist’s point of view, there Headache can be caused by a multitude of factors, but are multiple causes for the frequent symptoms of experienced physicians accustomed to treating facial and head pain, headaches due to ear disease, patients with headache are adept at making an pain extending to the ear region, with special regard accurate diagnosis. Occasionally, however a patient to “referred otalgia” involving the cranial nerves V, IX, has an unusual presentation of headache or facial X, facial pain due to temporomandibular dysfunction, pain.15 rhinological causes of facial and head pain, including There is a frequent coincidence of headache and post-traumatic trigeminal neuralgia and “facial sinusitis. In acute sinusitis, the localization of the sympathalgies”, the syndrome of the elongated styloid headache can yield good diagnostic clues, while process.9 chronic inflammations do not offer reliable diagnostic Recent studies have demonstrated that a indications. Further characteristics of rhinogenous neuropeptide (substance P) is likely to be a mediator headache are typical periodicity during the day, of pain arising in the nose or paranasal sinuses.10 occasional distributions of sensitivity in a specific Headache due to pressure on nasal mucosa of cutaneous area and certain typical pressure points in anatomical variations, nasal polyps or mucosal the facial region.16 swelling in the absence of inflammation of the Nasal signs and symptoms commonly accompany paranasal sinuses is a clinical entity that has gained cephalgia in some headache syndromes. Head pain wide acceptance. In the absence of any other associated with sinusitis is also fairly well recognized. identifiable etiological factors, intranasal mucosal However, referred cephalgia of rhinogenic origin in contact must be kept in mind as a cause of the absence of sinonasal symptoms is poorly headache.11 understood.17 Headache can be of sinugenic origin even if this Long neglected as a clinical entity, sinus cause may not be suspected from the case history. headache has become a common complaint of Endoscopy of the lateral wall with rigid cold light patients with facial pain. Although pain is associated endoscopes in combination with polytomography or with some sinus disease, many experts feel the computed tomography usually will reveal the magnitude and instances of sinus headache have been underlying causes hidden from the unaided eye, the exaggerated to the public.18 Intranasal and sinus operating microscope and standard X-ray disease may result in disabling head and facial pain examination. Small lesions in the lesser cells of the and serious complications. Awareness of the ethmoid complex may give rise to headaches, symptoms of acute and chronic sinusitis and their especially when located in key areas of the ethmoid various presentations will enhance diagnostic accuracy infundibulum or frontal recess. and improve patient outcome. It is important to The neuropeptides recently were newly remember that nasal mucosa is under autonomic identified as a group of mediator besides the control. Sinus symptomatology, whether from neurotransmitter noradrenaline and acetylcholine. anatomic abnormality or chronic inflammation, may Substance P is one of the most important occur with and will typically be exacerbated by neuropeptides that we can identify in human nasal increased parasympathetic outflow or reduced sympathetic tone.19 2 www.ojs.unud.ac.id and www.balimedicaljournal.com
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