Abstract
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.
Introduction
Contact points (CPs) in the nasal cavity present contact spots of 2 intranasal opposing mucosal structures, mostly between the nasal septum and lateral wall. 1 Intranasal CPs are not frequent, they are present in about 4% of the population. 2 Deviations of the nasal septum, nasal turbinate hypertrophy, or pneumatization, as well as posttraumatic nasal deformities are promoting factors for CP occurrence. 3 The phenomenon of CP headache is associated with expressive variability of sinonasal anatomy. Contact point headache is a type of secondary headache of rhinogenic origin (caused by factors in the sinonasal region) in the absence of a nasal inflammatory process. 3 This type of headache is included in the classification of the International Headache Society (third revision, 2013) in the appendix as a headache caused by diseases of the nasal mucosa, nasal turbinate, and nasal septum. 4 Although modern medicine firmly accepts CP as one of the causes of headaches, the role of rhinogenic CP headache is still debated in the literature. 5 West and Jones 6 reported good outcomes after neurological treatment in a retrospective study of 973 patients with rhinogenic headache. The authors of the study found that only 11% of patients with sinonasal disease actually had a headache of rhinogenic origin. On the other hand, Peric et al 7 reported high long-term effectiveness of surgical removal of nasal CP in headache treatment and a low rate of residual symptoms.
The aim of the study is to evaluate the effectiveness of the surgical and nonsurgical treatment of headache caused by CP between the nasal septum and inferior or middle turbinate and to identify diagnostic pitfalls of this disease.
Patients and Methods
Study Population
This prospective clinical case-series study was conducted at the Clinic for Otorhinolaryngology, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Serbia, from January 1, 2016, to December 31, 2020. The study was approved by the Ethical Committee of Clinical Center of Serbia. Study has been carried out in accordance with the Helsinki declaration, and the investigators have obtained written consent from each participant.
Contact point headache is clinically defined by 4 criteria
7
: Intermittent pain in the periorbital region, around the medial canthus, as well as in the temporozygomatic regions. Headache that disappears within 5 minutes after topical anesthetic is applied to the site of contact. Contact point presence confirmed by nasal endoscopy or computerized tomography (CT) scan (absence of rhinosinusitis, nasal polyps, or tumor). The headache disappears within 7 days after mucosal contact resection.
Patients with CP were included in the study if they fulfilled inclusion criteria: (1) >16 years, (2) symptoms ≥3 months, and (3) no signs of acute or chronic inflammatory process.
Exclusion criteria were: (1) patients diagnosed with another type of headache/facial pain confirmed by neurologist or dentist, (2) patients who had multiple CP in the nasal cavity, and (3) those who had previously undergone functional endoscopic sinus surgery or septoplasty.
Study Design
The patients with CP headaches were offered to choose between 2 treatment options, surgery and medical treatment. Those patients who chose medical treatment was assigned to a nonsurgery group and was administered 3 courses of 1.5 months therapy: (1) fluticasone propionate aqueous nasal spray only (50 µg, 2 actuations in each nostril, every morning); (2) fluticasone propionate aqueous nasal spray (50 µg, 2 actuations in each nostril, every morning) with oxymetazoline nasal spray (0.05%, 2 puffs in each nostril, every evening); and (3) fluticasone propionate aqueous nasal spray (50 µg, 2 actuations in each nostril, every morning) with azelastine hydrochloride nasal spray (137 µg, 1 puff in each nostril, every evening). 7 Patients who underwent surgery constituted surgery group and were divided depending on the position of CP. Patients with a nasal septum deviation or spur that makes mucosal contact with inferior turbinate presented the surgery group 1, while patients with a mucosal contact between nasal septum and middle turbinate, whether is concha bullosa or not, presented the surgery group 2. Headache intensity and frequency were assessed in all patients before treatment (baseline), 1 month, and 6 months after the end of the treatment.
All patients underwent CT of paranasal sinuses and flexible endoscopy of the nasal cavity, which determined the existence of a mucosal CP, and excluded the presence of sinonasal inflammation. Only patients with a positive lidocaine test participated in the study, confirming the diagnosis. The test result is considered as positive if pain intensity is reduced ≥50% within 15 minutes after application of a 5% lidocaine-soaked piece of cotton wool directly on the CP.
Study design flowchart is shown in Figure 1.
Flowchart: patient selection process and the allocation in the different study groups.
Surgical Treatment
Surgical treatment was performed under general endotracheal anesthesia. The first group of patients underwent septoplasty (conventional Cottle or endoscopic), lateralization, and submucosal reduction of inferior turbinate, whereas the second group of patients underwent septoplasty, lateralization, and endoscopic turbinoplasty/submucosal reduction of the middle turbinate. Headache intensity was measured using a visual analogue scale (VAS) value from 0 to 10; the frequency of headache was expressed as the number of days during 1 month with headache (before surgery, 1 month, and 6 months after surgery).
Statistical Analysis
Statistical analysis was performed using the SPSS 19.0 software package for Windows (SPSS). Data were expressed as mean ± standard deviation. Clinical characteristics and demographic data of patients with CP headache were compared between groups by Fisher exact test. A paired t test and student t test were used to examine the difference in headache intensity and frequency between nonsurgery and surgery groups, as well as between different groups of operated patients. All differences were considered significant at P < .05.
Results
Clinical Characteristics and Demographic Data of Patients With CP Headache
A total of 45 patients with rhinogenic headache with no signs and symptoms of rhinosinusitis were evaluated. Medical treatment of CP headaches was chosen by 19 patients and the rest of 26 patients were operated on due to the persistent CP headache. Of the total number of patients, 24 patients were male (53.33%) and 21 were female (46.67%). The mean age of the patients was 39.17 ± 5.35 years, with a range of 21 to 59 years. Among the operated patients, 16 had a mucosal contact between the nasal septum and inferior turbinate (surgery group 1), and 10 patients were found to had a mucosal contact between the nasal septum and middle turbinate (surgery group 2). There was no statistical difference between the surgery and nonsurgery groups regarding age, gender, and CP site (P = .428, P = .935, and P = .550, respectively). Clinical characteristics of patients and types of interventions performed depending on the endoscopic finding are shown in Table 1.
Clinical Features of Medically and Surgically Treated Patients and Types of Surgical Interventions.
Headache Intensity and Frequency Data of Surgically Treated Patients With CP Headache
The results of the intensity and frequency of headache before surgery and 6 months after surgery are shown in Table 2.
Comparison of Intensity and Frequency of Headache Between Surgery Groups 1 and 2 Before and 6 Months After Surgery.
Abbreviations: VAS, visual analogue scale; SD, standard deviation.
a According to paired t test, P < .05.
Bold values denote statistical significance at the P < 0.05 level.
Comparing VAS scores of headache intensity, as well as the frequencies of headache before surgery, we found a statistically significant difference between surgery group 1 and surgery group 2 (P = .008 and P = .003, respectively). These results confirmed the greater intensity and frequency of headache in patients who had CP between the nasal septum and the middle turbinate. A statistically significant reduction in headache intensity was observed in patients of both groups, 1 month after surgery compared to the period before surgery; however, this reduction was more pronounced in surgery group 2 (P = .014 and P = .000, respectively). Reduction in headache intensity persisted during 6 months after surgery, especially in surgery group 2 (P = .011 and P = .000, respectively). In surgery group 2, there was no difference in VAS score 6 months after surgery compared to period of 1 month after surgery (P = .081). Thus, rhinological intervention in patients in the surgery group 2 made the reductive effect on the intensity of headache, which was of similar extent at 1 month and 6 months after surgery.
A comparison of headache frequency in both operated groups before surgery and 1 month after surgery revealed a statistically significant reduction (P = .009 and P = .000, respectively). The reduction was also found in the patients 6 months after surgery. Examining the frequency of headache in both surgery groups, no statistically significant difference was found 6 months after surgery compared with the period of 1 month after surgery (P = .362 and P = .662, respectively).
Headache Intensity and Frequency Data of Whole Population of Patients With CP Headache
The results of the intensity and frequency of headache of nonsurgically and surgically treated patients are shown in Table 3.
Comparison of Intensity and Frequency of Headache Between Patients Treated With Medicaments and Surgery.
Abbreviations: VAS, visual analogue scale; SD, standard deviation.
a According to student t test, P < .05.
b According to paired t test, P < .05.
In the moment before treatment was carried out, nonsurgically treated patients had no significant difference in headache intensity and frequency compared with operated patients (P = .158 and P = .218, respectively). Both types of treatment made a significant impact on the reduction of headache intensity at 1-month break point (nonsurgery group, P = .012, and surgery group, P = .000). At the 6-month follow-up, pain intensity in the surgery group was significantly reduced (P = .000), whereas nonsurgery group didn’t reveal a significant reduction of pain intensity compared with the baseline level (P = .114).
Nonsurgical treatment made a significant reduction of headache frequency at the end of the first month of the posttreatment period, as well as surgical treatment (P = .031 and P = .008, respectively). At 6-month follow-up, a significant reduction of headache frequency compared with baseline was found in a group of operated patients (P = .000), but not in nonsurgically treated patients (P = .088).
Discussion
Our prospective clinical case-series study revealed that the: (1) the surgery gave a statistically significant reduction in the intensity and frequency of headache; (2) in nonsurgically treated patients, there was significant reduction of headache intensity and headache frequency at 1-month follow-up, but not at 6-month follow-up; and (3) surgery was found as superior to nonsurgical treatment in the therapy of CP headache.
Papers published by Stammberger and Wolf 8 have shown that this type of headache can result from any intranasal mucosal contact. Therefore, stimulation of various regions of the nasal mucosa may cause pain in different parts of the face. Rhinogenic headaches may be very similar in character to migraines, since they are sometimes preceded by an aura. Neurological treatment is ineffectual and the etiology should be sought in intranasal mucous contact. 9,10 Symptoms of the headache usually alleviate after CPs removal.
Bilal et al 11 reported that the mucosal contact site was most commonly identified between the nasal septum and inferior turbinate, which is also the case in our study. Rhinogenic headache can be caused by obstructive septal deviation or even septal spur. 1 Surprisingly, septal spur causes more frequent and longer-lasting headaches than septal deviation, as it was reported by Tosun et al. 12 In our study, mucosal contact with middle turbinate was associated with higher intensity and frequency of headaches. The exact reason is not completely clear, although the size of the mucosal contact has a key role. Some authors believe that mucosal contacts are not able to induce headache unless the CP is under pressure. 13 Furthermore, mucosal edema may not be sufficient to cause the pain. On the other hand, hyperplasia of inferior or middle turbinate could make such a compression resulting in chronic headache. The middle turbinate pneumatization is frequent cause of wide mucosal contact with nasal septum. A drawback of this study is a lack of comparison between patients with concha bullosa and those with the contact of nasal septum and middle turbinate of other origins. Other possible reasons for the CP headache occurrence are contact between the convex side of nasal septum and middle, upper turbinate or ethmoid cell, medialized middle or superior turbinate, concha bullosa, paradoxical curvature of the middle turbinate, large bulla ethmoidalis, and contact between nasal septum and medial wall of posterior ethmoid cells.
Substance P and stimulation of unmyelinated C fibers play an essential role in pathophysiology of rhinogenic CP headaches. 14 Eyigor and coworkers 15 have demonstrated an association between CP headaches and elevated mucosal levels of substance P. They have demonstrated a direct correlation between VAS headache score and substance P level, but not between substance P and inferior turbinate volume. Scarupa et al 16 demonstrated a higher concentration of substance P in patients with CP headache with nasal polyps or hyperplastic mucosa. Furthermore, the same authors found increased headache intensity in patients with allergic rhinitis due to turbinate hypertrophy. Consequently, there must be a difference in headache intensity among patients with CP between nasal septum and inferior turbinate due to various contact surface areas and pressures.
Nonsurgical treatment with intranasal steroids is optimal in selected patients with a reduction of headache intensity due to decrease in mucosal swelling and contact area. 3 Surgical treatment involves septoplasty, endoscopic turbinoplasty, medialization or lateralization of nasal turbinates, endoscopic ethmoidectomy, and other methods of mucosal contact removal. Depending on the reported study, the success rate of corrective surgery is between 60% and 96%. 1,17 A systematic search of the literature showed that functional nasal surgery may improve symptoms in selected chronic headache patients. 18
The long-term effects of surgical treatment in patients with rhinogenic headache are still debated in the literature. Several authors have hypothesized the temporary subjective reduction of headache intensity within 2 years after surgery may be related to the cognitive dissonance phenomenon or neurological stimulus of surgery, affecting the neuroplasticity within the brainstem sensory nuclear complex. 3,6 The influence of cognitive dissonance is expected to decrease over time, and longer follow-up is recommended to evaluate the benefit from surgery. A recent meta-analysis demonstrated excellent long-term surgical outcomes and clarified the primary role of endoscopic surgery in patients with CP headache. 19 Unfortunately, this study wasn’t able to provide the analysis of treatment response in regard to the type of surgical intervention or anatomical structures responsible for headache. Long-term results are also affected by the capacity for postoperative restoration of nasal physiological function and therefore quite depend on the surgical technique performed in patients. Cocuzza et al 20 recently demonstrated excellent long-term results of radiofrequency turbinate surgery, comparing techniques with coblation technology and Molecular Quantum Resonance. Both methods have been shown to be effective in managing patients with chronic hypertrophic rhinitis, demonstrating even an objective improvement in nasal cytology.
Furthermore, there is a report of long-term effects of endonasal surgery in patients with CP headache that were refractory to conservatory treatment. 21 Our results demonstrated the long-term superiority of surgery in headache intensity and frequency reduction compared with medical treatment. Intranasal steroids showed provisional effect by reducing mucosal swelling, without lasting effect on the underlying chronic disease or anatomic variations. Further evaluation of CP headaches in surgically treated patients who previously did not respond positively after medical treatment may provide additional information.
It is estimated that in about 50% of patients with unilateral facial pain, CP is verified on the opposite side of nasal cavity. 22 Also, substantial number of patients with CPs seen during endoscopy or CT scan did not have a headache or facial pain at all. 23 On the other hand, residual headaches after surgical treatment despite CT evidences of CP absence exist in approximately 13% of patients. 24 Probably there was concurrent causation of headache by CP and some other factor that was not resolved by surgery. A thoughtful selection of patients with CP headaches as candidates for rhinologic procedure and long-term follow-up may improve the success rate of surgical treatment.
In conclusion, surgery gave a statistically significant reduction in the intensity and frequency of headache, which was accessed 6 months after surgery. In nonsurgically treated patients, there was a significant reduction of headache intensity and frequency at 1-month follow-up, but not at 6-month follow-up. Surgery was found as superior to nonsurgical treatment in the therapy of CP headache.
Footnotes
Authors’ Note
Participants signed informed consent regarding publishing their data. All authors read and approved the final version of manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
