Abstract
Dear Sir We read with interest the article by Lin et al. (1). We have major concerns regarding the conclusion drawn that surgical management can be beneficial in the treatment of sinus headaches. There are a number of issues we would like to highlight.
The paper identified 1500 patients who had nasal surgery with the chief complaint of headache. We were not told which surgery patients had and no details were given about these patients. This is a huge number of patients to receive surgery who had headache. What were the indications in these patients? What proportion had sinus surgery? Did they all have sinus pathology? We infer that in all but the 36 patients who formed the study group, their headache was not improved by sinus surgery. It has been shown that in a significant proportion, the pain may persist (2) or be made worse after surgery (3). Furthermore, McAuliffe's original work implicating contact points as a cause of facial pain (4) has not been replicated in a controlled study (5).
The report focused on 36 patients with sinus pathology who primarily presented with headache and it appears that the only difference between these and the aforementioned 1500 patients was that their headache was better after surgery. None of the 36 patients had rhinological symptoms, yet 42% were diagnosed with sinusitis. Our experience shows that patients with genuine sinusitis almost invariably have coexisting nasal symptoms (6) with endoscopic signs of disease (7).
The role of imaging continues to cause controversy. The benefits and limitations of computed tomography (CT) scanning in the assessment of rhinosinusitis have been well described (8). We would like to point out that approximately 30% of asymptomatic patients demonstrate mucosal thickening in one or more sinuses on CT scanning (9). The presence of this finding is not an indication that pain is sinogenic in origin. Patients with facial pain and no objective evidence of sinus disease, as detected by endoscopy and CT, respond well to neurological treatment and surgical treatment is unnecessary (10). In the experience of the senior author, chronic sinusitis, fungal sinusitis and mucolcoeles are usually painless except during an acute excubation (11).
For these reasons we would exercise caution against recommending sinus surgery for patients with headache or facial pain, particularly as a primary symptom.