Which of the following conditions describes inflammation and or infection of the sinus cavity?

Definition

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The term “sinus headache” has been superseded by the diagnosis “headache attributed to disorder of the nose or paranasal sinuses” in the International Headache Society ICHD-3 because the former has been applied both to primary headache disorders and to headache supposedly attributed to various conditions involving nasal or sinus structures.1 The new definition excludes primary headache disorders. Unfortunately, this distinction has yet to filter through to patients and even many treating physicians.

The new definition excludes primary headache disorders and is defined as headache caused by a disorder of the nose and/or paranasal sinuses and associated with other symptoms and/or clinical signs of the disorder.2

The subclassifications are headache attributed to acute rhinosinusitis and headache attributed to chronic or recurring rhinosinusitis (Table E1 andBox E1).1 The diagnostic criteria of these subcategories are highly evidence based and valuable in defining “sinus headache” to patients and referring physicians.

The International Consensus on Allergy and Rhinology publication2 defines acute rhinosinusitis (ARS) as sinonasal inflammation lasting less than 4 wk associated with the sudden onset of symptoms, which must include nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior) and facial pain/pressure or reduction/loss of smell. A diagnosis of chronic rhinosinusitis is made when the symptoms of nasal obstruction/congestion/blockage, nasal drainage (mucopurulent) that may drain anteriorly or posteriorly, facial pain/pressure/fullness, and decreased or loss of sense of smell persist over 12 wk.

Recurrent ARS has been defined as 4 episodes per year of ARS with distinct symptom-free intervals between episodes. Patients may also experience acute exacerbations of chronic rhinosinusitis when a previous diagnosis of chronic rhinosinusitis exists, and a sudden worsening of symptoms occurs, with a return to baseline symptoms following treatment.2

This consensus document also supports facial pressure/headache as one of the symptoms of all the aforementioned types of sinusitis. This is supported by the American Academy of Otolaryngology Head and Neck Surgery clinical practice guideline, which includes facial pain-pressure-fullness as one of the cardinal symptoms of rhinosinusitis.3

However, there is also evidence demonstrating that rhinosinusitis does not necessarily lead to facial pain or headache, where more than 80% of patients with visible purulence endoscopically had no facial pain,4,5,6 and a significant proportion of patients with facial pain and sinusitis had persistent symptoms postoperatively. Aggregate evidence suggests that headache and facial pain are symptoms experienced by some patients with rhinosinusitis, but not universally, and the contradicting evidence may be a reflection of the complexity of correctly diagnosing and classifying a headache disorder. Furthermore, potential origins of pain from the nose and paranasal sinuses is not limited to rhinosinusitis and certainly goes beyond inflammatory processes.

Table E1. The International Classification of Headache Disorders

From Stovner LJ, Hagen K, Jensen R, et al: The global burden of headache: a documentation of headache prevalence and disability worldwide,Cephalalgia 27(3):193–210, 2016.

BOX E1

Classification of Headache Disorders

11.5. Headache attributed to disorder of the nose or paranasal sinuses. Previously used term: The term “sinus headache” is outmoded because it has been applied both to primary headaches and headache supposedly attributed to various conditions involving nasal or sinus structures.Description: Headache caused by a disorder of the nose and/or paranasal sinuses and associated with other symptoms and/or clinical signs of the disorder.

11.5.2. Headache attributed to chronic or recurring rhinosinusitis

Description: Headache caused by a chronic infectious or inflammatory disorder of the paranasal sinuses and associated with other symptoms and/or clinical signs of the disorder. Diagnostic criteria:

Any headache fulfilling criterion C

Clinical, nasal endoscopic, and/or imaging evidence of current or past infection or other inflammatory process within the paranasal sinuses

Evidence of causation demonstrated by at least 2 of the following:

Headache has developed in temporal relation to the onset of chronic rhinosinusitis

Headache waxes and wanes in parallel with the degree of sinus congestion, drainage, and other symptoms of chronic rhinosinusitis

Headache is exacerbated by pressure applied over the paranasal sinuses

In the case of a unilateral rhinosinusitis, headache is localized ipsilateral to it

Not better accounted for by another International Classification of Headache Disorders-3 (ICHD-3) diagnosis.

Comment: It has been controversial whether or not chronic sinus pathology can produce persistent headache. Recent studies seem to support such causation.

11.5.1. Headache attributed to acute rhinosinusitis

Description: Headache caused by acute rhinosinusitis and associated with other symptoms and/or clinical signs of this disorder.

Diagnostic criteria:

Any headache fulfilling criterion C

Clinical, nasal endoscopic, and/or imaging evidence of acute rhinosinusitis

Evidence of causation demonstrated by at least 2 of the following:

Headache has developed in temporal relation to the onset of the rhinosinusitis

Either or both of the following:

Headache has significantly worsened in parallel with worsening of the rhinosinusitis

Headache has significantly improved or resolved in parallel with improvement in or resolution of the rhinosinusitis

Headache is exacerbated by pressure applied over the paranasal sinuses

In the case of a unilateral rhinosinusitis, headache is localized ipsilateral to it

Not better accounted for by another ICHD-3 diagnosis.

Comments: 1. Migraine and 2. Tension-type headache can be mistaken for 11.5.1 Headache attributed to acute rhinosinusitis because of similarity in location and, in migraines, because of the commonly accompanying nasal autonomic symptoms. The presence or absence of purulent nasal discharge and/or other features diagnostic of acute rhinosinusitis help to differentiate. However, an episode of 1. Migraine may be triggered or exacerbated by nasal or sinus pathology. Pain as a result of pathology in the nasal mucosa or related structures is usually perceived as frontal or facial but may be referred more posteriorly. Finding pathologic changes on imaging of acute rhinosinusitis, correlating with the patient’s pain description, is not enough to secure the diagnosis of 11.5.1 Headache attributed to acute rhinosinusitis. Treatment response to local anesthesia is compelling evidence but may also not be pathognomonic.

III.D Sinus Headache

Sinus headache is an often cited complaint of many patients, although the acute headache due to actual sinusitis occurs less frequently than the rate quoted by the advertising media. Acute sinusitis presents with fever, pain triggered by pressure or direct percussion, and headache. Fever is the cardinal sign of this infective process. The pain associated with sinus diseases is a constant, dull ache. If the patient is suffering from acute sinusitis, the headache will typically increase in intensity as the day progresses. To confirm the diagnosis, sinus X-rays or sinus CT should be performed. Treatment consists of antimicrobial therapy and decongestants.

Headache Attributed to Disorders of the Nose or Paranasal Sinuses (Previously TermedSinus Headache)

The diagnosis of pain that results from acute sinus inflammation is rarely difficult. A prior history of sinus inflammation or respiratory allergies is often elicited. In general, the pain is of low to moderate intensity and is present on a daily basis. The pain usually is localized to the frontal or maxillary area, and there is tenderness to percussion over the affected sinus. The pain is often worsened by bending forward and may be accentuated by blowing the nose or sneezing. Symptoms of nasal “stuffiness” are usually present, and mucopurulent drainage from the nostrils may be seen. If the nasal passages are blocked, use of a nasal decongestant can be useful diagnostically and often results in discharge. In doubtful cases, a simple plain film of the sinuses or an opinion from an otolaryngologist should be obtained.

Sphenoid mucoceles may invade the orbital apex, resulting in ocular motility disturbances or optic neuropathy. Nasopharyngeal carcinoma has a propensity to invade the base of the skull by traveling along neural foramina.39 These tumors may cause ocular motility disturbances, most commonly sixth cranial nerve palsy, facial numbness or pain, or decreased hearing as a result of closure of the eustachian tube. These tumors can be missed easily on plain films and require computed tomography (CT) or MRI for early detection.

Disorders of the Paranasal Sinuses (see Table 31-3)

Sinus pain or “sinus headache” is another common complaint. Rhinosinusitis is inflammation of the nose or paranasal sinuses (or both) and is characterized by blockage or congestion, discharge, facial pain or pressure, loss of smell, or any combination of these symptoms. The inflammation is often due to allergy, infection, drugs, or hormones. Patients may also complain of sore throat, dysphonia, or coughing. The symptoms are frequently bilateral. Unilateral symptoms or associated bloody discharge may result from neoplasm and necessitates further evaluation and identification of the source of the pain. Immediate referral is necessary when any of the following symptoms are present: periorbital edema, a displaced globe, double vision, reduced visual acuity, or frontal swelling.

The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) recommends nasal endoscopy and CT of the paranasal sinuses for definitive diagnosis of rhinosinusitis, although most cases can be diagnosed clinically. The clinical findings must include two or more major factors or one major factor and two minor factors. These include chronic facial pressure of the maxillary region, headache, rhinorrhea, postnasal drip, decreased sense of smell, and dental pain. Classification of adult rhinosinusitis (acute, subacute, chronic, and acute exacerbations of chronic rhinitis) is important in providing appropriate treatment.

Acute sinusitis is assumed to be viral. Analgesics for pain relief, intranasal decongestants, and nasal irrigation with hypertonic saline can improve the symptoms but will not shorten their duration. If the symptoms worsen or do not improve within 7 days, the AAO-HNS guidelines suggest the addition of antibiotics and topical steroids. When the symptoms are severe or do not respond to treatment, appropriate referral must be considered.

Management of chronic rhinosinusitis is dependent on the underlying cause. The goal of treatment is elimination of infection and inflammation, removal of occlusion, and improvement of symptoms. Proper referral for evaluation and management is necessary. Patients who are refractory to conservative therapies may require surgery.

Chronic facial pain and headache are not generally thought to be due to chronic/recurrent sinus pathology and are probably another headache or facial pain syndrome. Recent consensus guidelines offer data to support this along with diagnostic and therapeutic recommendations for facial pain and headaches.5

Sinus Headache

Rhinosinusitis (Chapter 398) is characterized by inflammation or infection of the nasal mucosa and sinuses. The sinuses themselves are relatively insensate, but ducts, turbinates, blood vessels, and ostia are the painful structures.

Headaches attributed to rhinosinusitis are frontal headaches with pain in the face, ears, or teeth. The onset of pain is simultaneous with the rhinosinusitis, and the headache and face pain resolve within 7 days after successful treatment. The diagnosis requires imaging and clinical evidence that support the diagnosis of acute rhinosinusitis. Many acute and most chronic headaches that are initially thought to result from sinus disease are found to be migraine or tension-type headache.

The headache should resolve with treatment of acute sinusitis (Chapter 398). If it does not, an underlying primary headache disorder is likely.

“Sinus” Headache

Patients frequently complain of “sinus headaches.”3–5,19,20 They present after a variety of diagnostic tests have failed to corroborate the diagnosis of chronic sinusitis and after one or more courses of antibiotics, antihistamines, decongestants, nasal steroids, and analgesics have failed to provide significant relief. Those patients almost invariably also self-medicate with a variety of OTC preparations (the hallmark of which is the display of “sinus” and “relief” prominently on the label) that may combine an antihistamine, a decongestant, and an analgesic (with or without caffeine). These are not true sinus headaches, and many of these patients have either some degree of MOH at the time of presentation or an undiagnosed mild to moderate migraine. The diagnostic confusion arises because patients complain of periorbital pain and might also experience some nasal stuffiness; patients thus attribute the origin of the pain to the adjacent sinuses. True sinus pain occurs when the ability of the sinus to drain is impaired by an acute blockage of the osteum (e.g., from an upper respiratory infection or for some anatomic reason), a bacterial infection takes hold, the mucosa becomes inflamed and pressure builds in the sinus; this is accompanied by purulent discharge, fever, and localized tenderness. One caveat is that true sinus or nasal inflammation can be a trigger for migraine. The rest of these “sinus headaches” are likely a multifactorial TTH or CTTH but may represent a mild migraine in which the local parasympathetic activation mediated through the trigeminal nerve causes pain or sinus pressure and nasal discharge.3–5,19,20 The care of these patients needs to be coordinated so that the various potential components of the headache are adequately addressed and treated.

OTHER CHRONIC HEADACHE TYPES

Patients frequently complain of “sinus headaches.”3,4,5,19 They present after a variety of diagnostic tests have failed to corroborate the diagnosis and after one or more courses of antibiotics, antihistamines, decongestants, nasal steroids, and analgesics have failed to provide significant relief. Those patients almost invariably also self-medicate with a variety of OTC preparations the hallmark of which is that they display the words “sinus” and “relief” prominently on the label; they also combine an antihistamine, a decongestant, and an analgesic (with or without caffeine). Needless to say, these are not true sinus headaches and most of those patients have some degree of medication overuse headache at the time of presentation. Most patients complain of periorbital pain and might also experience a sensation of nasal stuffiness. Patients attribute the origin of the pain to the adjacent sinuses. However, these head pains are unaccompanied by purulent discharge, fever, or localized tenderness, and they are not seasonal. True sinus pain occurs when the ability of the sinus to drain is impaired by an acute blockage of the osteum (e.g., following an upper respiratory infection or for some anatomic reason), a bacterial infection takes hold, the mucosa becomes inflamed and pressure builds up in the sinus. One caveat is that true sinus or nasal inflammation can be a trigger for migraine. The rest of these “sinus headaches” are likely multifactorial but may represent a mild migraine in which the local sterile inflammation, perhaps mediated through the trigeminal nerve, gives the impression of sinus pressure, a TTH, or CTTH.3,4,5,19 The care of these patients needs to be coordinated so that the various potential components of the headache are adequately addressed and treated.

Habitual snoring is increasingly being recognized as a cause of chronic daily headache.20 Sleep-disordered breathing from, for example, sleep apnea may precipitate headaches from the resultant hypoxemia and hypercapnia. Snoring, with or without sleep apnea, can disrupt sleep architecture or interrupt sleep, either of which can result in headaches. If a history suggestive of snoring, repeated nocturnal arousals, or paroxysmal leg movements during sleep is obtained, a diagnostic polysomnogram will provide invaluable information. Treatment of the sleep disorder might not provide complete headache relief but it usually provides some. Hypnic headaches represent another syndrome of recurring head pain that awakens patients from REM sleep.21 The headache most commonly has its onset after the age of 50, is about twice as frequent in women as in men, has its onset about 2 to 4 hours after falling asleep, and lasts about 1 hour. This headache responds best to treatment with either indomethacin or lithium.

Another uncommon headache type that may become intractable is the short-lasting, unilateral, neuralgiform headache with conjunctival injection and tearing (SUNCT).22 This headache syndrome is characterized by frequent, short-lasting, unilateral attacks of pain around the periorbital regions and the temples. These pains are accompanied by ipsilateral signs of autonomic activation—among which conjunctival injection and tearing are a sine qua non—and which can include nasal stuffiness or rhinorrhea and eyelid edema with ptosis. SUNCT is intractable to most drugs, but recently good response has been reported after treatment with lamotrigine at doses of 125 to 200 mg/day.

Sinus Headache

Patient and clinician perceptions of “sinus headache” have resulted in incorrect diagnosis. Various studies have shown that when patients self-report their headaches as “sinus” in origin, physicians are more likely to agree with the diagnosis.6,7 The lay term of “sinus headache” continues to be perpetuated in the media. Primary care physicians and patients alike appear to continue to prefer the choice of “sinus headache” as the medical term when patients experience facial pain or pressure – symptoms traditionally associated with sinus disease. A more accurate term could be “rhinogenic headache,” but “sinus headache” continues to be the more imprecise term that actually most commonly represents a misdiagnosis of migraine and leads to inadequate and often improper treatment.

Allergy triggers for migraine and the autonomic nervous system activation occur in approximately 45% of migraineurs. This link may contribute to the misperception of “sinus headache,” and fosters continuation of the migraine as a misdiagnosed sinus headache by patients, physicians, and others – often in primary care settings. Over the past decades, specialists in otolaryngology, allergy, neurology, and headache have conducted multiple studies showing that the majority of patients presenting with “sinus headache” are actually experiencing migraine when appropriate diagnostic criteria are systematically applied. Undaunted by this research and its consensus findings, the label of “sinus headache” persists in primary care, in patient’s minds, in the media, and in the over-the-counter pharmaceutical industry. Meanwhile, the aforementioned specialists often see patients with histories of “sinus headache” transformed into chronic migraine after years of inappropriate and ineffective care. These patients are only referred when the disorder becomes unmanageable with “sinus treatment.”

Why does this mythology persist? Unilateral autonomic symptoms are often mistaken for typical sinus symptoms. Patel and colleagues performed a systematic literature review of >1400 abstracts that included adult patients with the diagnosis of “sinus headache”.6 Following a thorough neurological and otolaryngologic evaluation, they found that <5% of the cases described had organic causes for “sinus headache.” They concluded that the majority of those presenting with “sinus headache” in the absence of significant acute inflammatory findings could be diagnosed with migraine.6 Barbanti and colleagues found that 45.8% of 177 migraineurs evaluated had unilateral autonomic symptoms – nasal congestion, lacrimation, orbital edema, rhinorrhea, conjunctival infection – associated with their “sinus headaches”.23 Likewise, among 100 patients, all with self-diagnosed “sinus headache” evaluated at a tertiary rhinology clinic, none were found to have evidence of sinus disease of mucosal contact points on nasal endoscopy or computed tomography (CT) scan.24

Eross and colleagues, at the Mayo Clinic, applied IHS diagnostic criteria to 100 individuals who had “sinus headache” and found that 63% actually had migraine, 23% had probable migraine, and only 3% had headache secondary to rhinosinusitis.8 Of the subjects, 76% reported pain in the second division of the trigeminal nerve and 62% experienced bilateral maxillary and forehead pain. The most commonly reported triggers for these patients were weather changes (83%) and allergen exposures (62%). Of note, seasonal variation was reported as a “sinus headache” trigger in 73% of patients, and yet only 1% of these patients met criteria for cluster, which is known to have seasonal variation. The most commonly associated symptoms were nasal congestion (56%), eyelid edema (37%), rhinorrhea (25%), and conjunctival injection (22%). Cleverly, the authors suggested that the diagnosis of “sinus headache” was based on “guilt by provocation, location, and association”.8

In a smaller study of self-diagnosed “sinus headache” sufferers by Mehle and Kremer, all patients received sinus CT scans, which revealed that 74% had IHS-defined migraine. Only 5 of these 26 patients also had significant sinus disease.25 This latter study does reiterate the importance of careful history in distinguishing migraine from rhinogenic headache, while serving to remind us that the diagnoses are not mutually exclusive. They may indeed occur in the same patient. Timing and pattern of attacks may be the most helpful approach in these patients.

Treating a “sinus headache” with antibiotics, steroids, and “sinus” medication, instead of treating the actual migraine headache, runs the inherent risk of diminished efficacy and reduced pain relief. Effectiveness may be further complicated by antihistamines, vasoconstrictors, and steroids, which may improve some underlying migraine symptoms. However, treatment response should never be allowed to confirm or support a headache diagnosis, with the notable exception of indomethacin response as required for a hemicrania continua diagnosis.

Schreiber and colleagues showed the likelihood of this reverse approach to treatment in a study of “sinus headache” patients, where, after noting this population met diagnostic criteria for IHS migraine, they utilized the migraine-specific acute treatment sumatriptan and found that 66% of these headaches were reduced to mild or no pain after 2 hours.26 In 2008, Kari and DelGaudio also looked at triptan use in sinus headache patients. Of those patients who had no evidence of sinusitis, 82% had significant response to triptan use.27 Of interest, a telling aspect of patient behavior with respect to study participation was observed when 34% of these “sinus headache” patients withdrew or failed to follow up, being “often reluctant to accept a diagnosis of migraine” despite normal nasal endoscopy and sinus CT. Therein lies a critical issue for clinicians – a diagnosis of migraine in lieu of more patient-acceptable and even primary care physician-acceptable “sinus headache diagnosis” requires time, patience, and a clear explanation regarding misleading triggers, response to acute medications, location of pain, and associated autonomic features (nasal congestion, lacrimation, eyelid edema, rhinorrhea).

For an individual patient, the migraine-specific triptans and FDA-approved valproate, based on multiple studies,27–29 suggest that at least two-thirds of “sinus headaches” respond to treatment. However, in spite of the parallels with sinus medications, neither patients nor their clinicians were moved closer to accurate diagnosis.

Familiarity with the diagnostic criteria, with awareness of overlapping triggers and autonomic features, may help support clinicians striving for accuracy of diagnosis and treatment. Until then, one wonders whether revitalization of the older term “facial migraine” for these patients could help remove them from the diagnostic morass which continues.

Collaborative discussions and sharing of patient profiles between primary care, allergists, neurologists, otolaryngologists, ophthalmologists, and headache specialists may assist in dispelling myths and help patients as they too seek care and understanding of their recurrent patterns of headache. Likewise, inclusion of common autonomic symptoms in diagnostic criteria of the IHS may expand clinician awareness that what is considered “sinus headache” is indeed migraine.

For patients with dual diagnoses of migraine and “sinus” disease, the role of mucosal contact points remains an inadequately studied concern. Contact points are defined as a place within the nasal cavity where two opposing mucosal surfaces border each other. Sinus “abnormalities” may or may not include mucosal contact points. The role that mucosal contact points play in producing headache or facial pain was established by Harold G. Wolff in his text showing that stimulation of the meninges could produce pain in the face and sinus areas.30 Wolff also found that stimulation in sinus areas could produce facial pain and headache, suggesting the referral of pain between the stimulated region and the location of pain.

Treatment of contact point-induced headache remains controversial; no randomized controlled trials have been conducted. Of concern among the prospective studies is the lack of long-term follow-up, which is critical for disorders such as migraine, with the waxing and waning attacks over long periods of time.

In an interesting prospective study of patients with frequent or medication-resistant migraine, Novak and Makek, who had promoted the use of nasal surgery as treatment for migraine for years, examined how these patients responded to nasal surgery.31 The 299 migraine patients underwent various procedures, including sphenoidectomy, middle turbinate resection, ethmoidectomy, and septoplasty. The authors reported an astounding success rate of 90%, with 79% of their patients becoming “permanently asymptomatic.” Yet timelines for follow-up were lacking, making the conclusions uninterpretable as to true long-term measurable outcomes.31

In a careful and systematic review of the literature published in 2013, Patel and colleagues concluded that the patients most likely to benefit from directed nasal surgery to remove contact points included those who have clearly identified contact points, have failed adequate therapy aimed at migraine, have otherwise normal endoscopy and CT scan, and have had a previous positive response to local anesthetic applied to the contact point.6 It should be cautioned that surgery may not render the patient headache- or facial pain free. Furthermore, although the risk of surgical complications for these procedures is low, “it is not zero”.6

For all patients presenting with “sinus headache,” a thorough history should be obtained, and include headache pattern, onset, hormonal milestones, and hormonal medications. Examination of the head and neck and the cranial nerves, and otolaryngologic evaluation, should be performed. If criteria establishing migraine are revealed, acute and preventive therapies (see Chapters 8 and 9Chapter 8Chapter 9) may be initiated.

The Special Challenge of Talking to the Headache Patient … What Patients Tell Us

Since the headache history helps to differentiate benign primary headaches from potentially lethal secondary headaches, an accurate history is critical; however, unfortunately, patients may be imprecise unless we assist them. Medical terminology is often misused, and never assume that the patient has good healthcare literacy. Patients may list diagnoses that might be self-deduced or misdiagnosed by others, so it is important to not accept “legacy” diagnoses without confirming them with specific questions.

Sinus Disorders

Patients frequently describe their facial pain problem as a “sinus headache.” However, sinus disorders do not cause chronic headaches, and the clinician should look for a more specific cause of the pain symptoms in such cases.11 Diseases of the nose and paranasal sinuses typically cause acute pain associated with multiple other symptoms that are generally related to the specific nasal or sinus disease (i.e., allergic, inflammatory, infectious) (Table 31.4). Acute dentoalveolar pathology of the maxillary posterior teeth can often be accompanied by signs and symptoms consistent with sinus disease. In addition, acute dentoalveolar inflammation or infection (dental abscess) can cause secondary maxillary sinus inflammation or infection. These disorders are typically acute in nature but can become chronic. This condition is often confused with other facial pain and headache disorders.