|Year : 2022 | Volume
| Issue : 1 | Page : 35-39
Endoscopic treatment of rhinogenic contact point headache-our experiences at a tertiary care teaching hospital of Eastern India
Santosh Kumar Swain, Rohit Agrawala
Departments of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “o” Anusandhan University, Bhubaneswar, Odisha, India
|Date of Submission||22-Jan-2022|
|Date of Decision||12-Feb-2022|
|Date of Acceptance||19-Feb-2022|
|Date of Web Publication||30-Mar-2022|
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “o” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Background: Headache is a universal clinical presentation in the course of everyone's life. In Rhinogenic contact point headache (RCPH), intranasal mucosal contact points are seen between the opposing mucosal surface of the nasal septum and turbinates of the lateral wall of the nasal cavity. Objective: To study the details of endoscopic treatment of RCPH and its effectiveness to relieve headache. Materials and Methods: There were 68 patients of RCPH who participated in this prospective study. The mucosal contact points inside the nasal cavity were excised by the endoscopic approach under general anesthesia. The olfactory mucosal lining was protected from injury during this surgical process. P < 0.05 were considered statistically significant. Results: Out of 68 patients with RCPH participated in this study with 38 (55.88%) males and 30 (44.11%) females with a male-to-female ratio of 1.26:1. All patients underwent endoscopic excision of the intranasal mucosal contact points. After 3 months of endoscopic excision of the intranasal mucosal contact points, the symptoms disappeared in 52 (76.47%) patients, and significantly improved in 13 (19.1%) patients. Only 3 (4.41%) patients did not show obvious improvement. Satisfactory results were archived by endonasal excision of the mucosal contact points in 65 (95.58%) patients with RCPH. Conclusion: RCPH is an important cause of headache. Endoscopic surgical excision of the intranasal mucosal contact points in patients of RCPH is useful to relieve headache effectively.
Keywords: Deviated nasal septum, endoscopic surgery, rhinogenic contact point, septoplasty, spur
|How to cite this article:|
Swain SK, Agrawala R. Endoscopic treatment of rhinogenic contact point headache-our experiences at a tertiary care teaching hospital of Eastern India. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:35-9
|How to cite this URL:|
Swain SK, Agrawala R. Endoscopic treatment of rhinogenic contact point headache-our experiences at a tertiary care teaching hospital of Eastern India. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 May 16];24:35-9. Available from: https://www.sjohns.org/text.asp?2022/24/1/35/341362
| Introduction|| |
Headache is a common symptom experienced by a person during his or her life period. Patients with headache often attend the otolaryngology clinic to rule out sinusitis or sinonasal cause. The headache is often classified into three groups such as headache due to sinonasal pathology, headache not associated with sinonasal pathology which includes migraine, neuralgias, vascular and seasonal allergies, and third group include headache by sinus origin but cannot be identified. The third group of headache includes rhinogenic contact point headache (RCPH). Intranasal mucosal contact point results in headache, called RCPH is a newly added secondary headache disorder in the International Classification of Headache Disorders-2. RCPH is a new terminology in the medical literature where patients present with intranasal mucosal contact points because of anatomical variations in the nose in the absence of inflammation in the sinonasal tract and patients present with headache. RCPH provides a painful sensation in the face and head due to intranasal mucosal contact points without any inflammatory findings or mass lesions. The pathogenesis of the RCPH is still a subject of controversy. It often needs a multidisciplinary approach for getting the exact cause of the headache and prompt treatment. This study aims to assess the effectiveness of endoscopic treatment of RCPH.
| Materials and Methods|| |
This prospective study was conducted at the department of otorhinolaryngology and head and neck surgery of a tertiary care teaching hospital from December 2018 to January 2022. This study was approved by the Institutional ethical committee (IEC) with a reference number of IEC/IMS/SOA/84/12.08.2018. Informed consent was obtained from all the participants of this study. The inclusion criteria of the participants of this study include: (1) History of long-standing headache at least 6 months; (2) Absence of sinonasal inflammatory findings; (3) No olfactory disorders, no sinonasal tumors; (3) Lack of any causes of headache after a thorough evaluation by ophthalmologist, neurologist, dentists, orthopedic specialist, internist, and other related specialists; (4) Presence of intranasal mucosal contact points between any turbinates with septum which confirmed by diagnostic nasal endoscopy [Figure 1] or computed tomography (CT) scan of the nose and paranasal sinus [Figure 2]; (5) Failure of medical treatment for at least 3 months for headache (topical corticosteroids sprays and flunarizine). A total of 68 patients were enrolled in this study. The intensity of the headache/pain was evaluated with help of the visual analog score (VAS). The severity of the headache was graded on a scale of 0–10 points where 0 indicates trouble-free and 10 indicates worst thinkable troublesome. We documented the VAS, the average number of headache attacks per month, and the mean duration of each attack of headache before and after endoscopic excision of the intranasal mucosal contact points. The results were evaluated postoperatively at 3 months for a follow-up visit.
|Figure 1: Diagnostic nasal endoscopy showing sharp spur touching to the inferior turbinate|
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|Figure 2: Computed tomography scan of the nose and paranasal sinus showing sharp spur touching to the inferior turbinate|
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The endoscopic surgical approach for RCPH was done under general anesthesia. All the endoscopic surgical excision of the intranasal mucosal contact points was performed by the senior author. Patients RCPH with deviated nasal septum or spur underwent endoscopic septoplasty along with excision of the mucosal contact point. Septoplasty was performed first and then the middle turbinate was lateralized to expose the superior turbinate and superior meatus. Then posterior ethmoidectomy was performed and the medial wall of the ethmoid sinuses was excised. Afterward, the bone and mucous membrane under the armpit of the superior turbinate and 1/3rd of the lower portion of the superior turbinate were excised. Then, the superior turbinate was lateralized to remove the mucosal contact between the nasal septum and superior turbinate. The olfactory mucosal lining was not injured during this surgical process. In the case of mucosal contact points on both sides of the nasal cavity, the surgery on both sides was done at the same time after the completion of the surgery on one side. At last, the olfactory area was filled with absorbable hemostatic gauze. The rest of the nasal cavity was packed with merocele which was removed after 48 h. Endoscopic cleansing of the nasal cavity was performed on the 7th day after surgery. Regular saline nasal douching was advised for 1 month. If mucous adhesions were present in the olfactory region, these were cleared. Nasal endoscopy findings and VAS for pain, the average number of headache attacks per month, and the average duration of each attack of headache were noted during follow-ups visits at 1 month and 3 months after endoscopic surgery. Patients of RCPH with complete cessation of symptoms following endoscopic surgery were considered as “cured.” Patients with a significant reduction of pain in intensity and frequency attacks were considered as “improved.” The absence of significant change was considered “unchanged.”
Statistical Package for the Social Science (SPSS) Statistics for Windows, version 20, was used for all statistical analyses (IBM-SPSS Inc., Chicago, IL, USA). The difference between preoperative and postoperative pain scores of patients with RCPH was analyzed using a paired t-test and Wilcoxon signed-rank test. P < 0.05 were considered statistically significant.
| Results|| |
Out of 68 patients with RCPH participated in this study with 38 (55.88%) males and 30 (44.11%) females with a male-to-female ratio of 1.26:1. The age range of the patients was between 12 years to 48 years (mean age: 22.8 years). The most common site for headache in RCPH was the frontal area (57.35%) followed by pain at the medial canthus/periorbital area (n = 32.35) and temporozygomatic areas (13.23%) [Table 1]. There were four patients with RCPH who presented with headaches in both frontal and temporozygomatic areas. Preoperative evaluation with diagnostic endoscopy and CT scan of the paranasal sinuses showed 52 cases presented with intranasal mucosal contacts on one side and 16 showed mucosal contacts in both nostrils. After 3 months of endoscopic excision of the intranasal mucosal contact points, the symptoms disappeared in 52 (76.47%) patients and significantly improved in 13 (19.1%) patients (P < 0.001). Only 3 (4.41%) patients did not show obvious improvement. Pain score before and after endoscopic surgery for rhinogenic contact point headache is given in [Table 2].
|Table 1: Localization of the headache in patients with rhinogenic contact point headache|
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|Table 2: Pain score before and after endoscopic surgery for rhinogenic contact point headache|
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| Discussion|| |
Headache is a commonly encountered clinical entity with a wide range of severities. There are various causes for headache such as migraine, neuralgic pain, cervical causes, vascular, temporomandibular joint dysfunction, dental abscess, head-and-neck neoplasms, ophthalmological conditions, and intracranial pathology. In the absence of inflammation or sinusitis, the referred headache due to intranasal mucosal contact points by anatomical variations in the nose result in RCPH. RCPH is often undiagnosed, even this clinical entity is not suspected during the early evaluation of the patient with headache. The exact mechanisms for headache in RCPH are still not clear. The cause for RCPH is multifactorial. RCPH may occur from nociceptors in the nasal mucosa, which ends up in the sensory nucleus of the trigeminal nerve. Release of substance P and stimulation of unmyelinated fibers at the intranasal mucosal contact points are considered as the cause of headache in RCPH. Substance P is a well-known neurotransmitter and neuromodulator, has been investigated in RCPH in adults, but presently no studies investigating its role in children with RCPH. The anatomical variations of the nasal cavity such as concha bullosa or inferior turbinate hypertrophy touching to the nasal septum cause pain.
The mucosal contact between concha bullosa and nasal septum or other mucosal surface of the nasal cavity can cause referred pain at periorbital or ocular pain via the anterior ethmoidal nerve, a branch of the ophthalmic division of the 5th cranial nerve. In this study, the most common site for headache in RCPH was the frontal area (57.35%) followed by pain at the medial canthus/periorbital area (n = 32.35) and temporozygomatic areas (13.23%). The diagnosis of RCPH requires a multidisciplinary approach. The diagnosis of the RCPH is often misdiagnosed during the evaluation of headache patients. Patients with headache in the absence of inflammation of the sinonasal area should be examined by a neurologist, ophthalmologist, dentist, and internist to rule out other causes. Diagnostic nasal endoscopy and CT scan of the nose and paranasal sinuses are helpful to confirm the intranasal contact points and also to rule our sinusitis. These investigations are useful to find out the anatomical variations of the nasal cavity. The diagnosis of RCPH is properly done with help of diagnostic nasal endoscopy and CT scan of the nose and paranasal sinuses. Nasal endoscopy and CT scan of the nose and paranasal sinuses is also helpful to rule out any sinonasal pathology causing the headache. CT scan is helpful to check pathologies that cannot be detected by physical examination of the nasal cavity and help to find out the exact location of mucosal contact points and the necessity of the surgical intervention. The intensity of headache is usually evaluated by using VAS. The headache severity is graded on a scale of 0–10 points, where 0 indicates trouble-free and 10 indicates worst thinkable troublesome.
There are surgical and medical treatments available for RCPH. The medical treatment includes topical nasal steroids which relieve the RCPH. The topical nasal steroid application improves the nasal patency on a short-term basis. However, long-term improvement requires surgical interventions. Few authors documented the treatment of RCPH by the transaction of the 5th cranial nerve or injection of Gasserian ganglion More Details by novocaine or alcohol. In the case of middle turbinate concha bullosa causing RCPH, endoscopic lateral lamellectomy is the gold standard treatment. However, there is a chance of recurrence of mucosal contact points and formation of synechia postoperatively leading to frontal sinus diseases as a complication of this surgical technique. Before the introduction of endoscopic sinus surgery, complete excision of the middle turbinate was performed to treat the middle turbinate concha bullosa. In the case of the deviated nasal septum with RCPH, septoplasty is useful to relieve headache. Bulla ethmoidalis consists of anterior group of ethmoidal air cells. When the bulla ethmoidalis is pneumatized and hypertrophied, it can cause contact with the middle turbinate and result in RCPH. These anatomical variations can be easily treated by endoscopic anterior ethmoidectomy. The endoscopic anterior ethmoidectomy or conchoplasty helps to remove the contact point between the two opposing mucosal surfaces. Aggar nasi cells are the most anterior ethmoid air cells and are found anterior superior to the attachment of the middle turbinate at the lateral wall of the nasal cavity. Hyperpneuatization of the agger nasi cells may cause contact of the mucosal lining of the nasal septum and result in RCPH. This intranasal mucosal contact can be easily removed by the endoscopic approach. There is usually a resolution of the headache in less than a week following excision of the mucosal contact points in the nasal cavity. One study showed 83% of the patients with RCPH recovered completely after surgery with 8% of the patients improved significantly and the overall success rate was seen to be 92%. In that study, the contact points between the nasal septum and superior lateral nasal wall were present whereas the contact points between the nasal septum and middle turbinate. Another study showed 70% of patients with RCPH were completely recovered after removal of the intranasal mucosal contact between the superior turbinate and septum. In that study, 25% improved the symptoms of RCPH significantly and the overall success rate was 95%. One study on 66 patients with RCPH due to middle turbinate concha bullosa, deviated nasal septum, and orbito-ethmoidal (Haller's) cells where authors found a reduction of intensity and frequency of headache after surgical excision of intranasal mucosal contact points. Chow et al. found a decrease in severity and frequency of headache in 82% of cases with RCPH. Another study on RCPH showed a reduction of severity and frequency of headache of patients with RCPH following surgical excision of the mucosal contact points in the nasal cavity. In our study, after 3 months of endoscopic excision of the intranasal mucosal contact points, the symptoms disappeared in 52 (76.47%) patients, and significantly improved in 13 (19.1%) patients. Only 3 (4.41%) patients did not show obvious improvement. The endoscopic approach for excision of the intranasal mucosal contact points in patients with RCPH is very effective.
| Conclusion|| |
RCPH is an important cause of headache. It is often considered as an exclusion of diagnosis. The correct identification of the intranasal mucosal contact points is helpful for early treatment and avoidance of morbidity. Preoperative evaluation with diagnostic endoscopy and CT scan of the paranasal sinuses are helpful for diagnosis of the RCPH. Endoscopic excision of the intranasal mucosal contact points is a useful technique for significant relief of the headache in the RECPH. This study showed that removal of intranasal mucosal contact points by endoscopic approach causes significant relieves headache.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]