Intranasal contact points as a cause of facial pain or headache: a systematic review

Background

There is a body of opinion in the clinical literature advocating the removal of intranasal contact points to treat facial pain.

Objectives

To review the evidence that intranasal mucosal contact points cause facial pain or headache and their removal is therapeutic.

Type of review

Systematic review.

Search strategy

A systematic search of the available literature was performed using MEDLINE, EMBASE, Cochrane library and NHS Evidence from inception to September 2011. Terms used include facial pain and contact point (3628), rhinologic headache (6) contact point and surgery/endoscopy (38).

Evaluation method

Inclusion criteria applied. Assessment of papers were undertaken by one reviewer and checked by the second. A narrative review of each study was performed and results recorded in tables.

Results

In one study, 973 consecutive patients with a provisional diagnosis of rhinosinusitis were divided into groups with (42%) and without facial pain. There was a 4% prevalence of nasal contact in both groups, which was unrelated to the presence of facial pain. In another study of 100 patient's coronal paranasal sinus CT scans, 29% had headache and 55% had a contact point but their presence was inversely related to the presence of pain.¹ In a further study, ten healthy volunteers had palpation, adrenaline, substance P and placebo applied to different areas throughout the nasal cavity and none of these stimuli caused facial pain. Nineteen studies were identified where nasal mucosal contact points had been removed surgically for the treatment of facial pain. They were small case series, not randomised and subject to selection bias, had no control group, a limited follow‐up and were open to observer bias with level IV evidence. Seven studies had a statistically significant improvement in pain postoperatively compared with preoperative questionnaire results but the majority had residual facial pain.

Conclusion

The majority of people with contact points experience no facial pain. The presence of a contact point is not a good predictor of facial pain. The removal of a contact point rarely results in the total elimination of facial pain making the theory that a contact point is responsible unlikely. The improvement in postoperative symptoms following the removal of contact points in some patients may be explained by cognitive dissonance or neuroplasticity. A randomised, controlled and blinded trial with a followed up period of over 12 months is needed to assess the place of surgery in the removal of a contact point for the treatment of facial pain.     

Prevalence of nasal mucosal contact points in patients with facial pain compared with patients without facial pain

A cohort of 973 consecutive attendants at a rhinology clinic was studied prospectively and divided into patients without facial pain (n = 566, 58 per cent) and patients with facial pain (n = 407, 42 per cent). The prevalence of nasal mucosal contact points was the same in both groups, being four per cent in patients with nasal contact points without facial pain and four per cent in patients with facial pain. A contact point is defined as when contact remains after topical decongestion. Of the 18 patients with facial pain, nine had a spur contacting the lateral nasal wall and nine had a middle turbinate contacting the septum. These 18 patients were followed up for a mean of two years and two months. In the light of their treatment and response the following diagnoses were made: five had tension-type headache, six had midfacial segment pain, one had migraine, two had cluster headache and four had purulent nasal disease. Of the four with unilateral symptoms, two had a contact point on the contralateral side. Eleven of these 18 patients responded to medical treatment for tension-type headache or midfacial segment pain, migraine and cluster headache, three patients were better after surgery for coexisting purulent nasal disease and one patient had a spur removed surgically and remained better at 2 years follow-up, whereas three patients were no better after the same procedure. The results demonstrate that the prevalence of nasal contact points in patients with facial pain is the same as in those within pain. Surgery undertaken to remove mucosal contact points for facial pain is usually unnecessary as the aetiology of this facial pain appears to be a more central processes.     

Nasal septal mucosal contact points: associated symptoms and sinus CT scan scoring

An association between nasal septal mucosal contact points and facial pain has often been quoted, but may be coincidental. CT scans of 100 consecutive rhinology patients were examined for contact points, and the sinuses were scored according to the Lund-Mackay system. The patients' nasal symptoms were recorded using validated questions. Contact of the nasal septum with the lateral nasal structures was identified in 55 patients. The presence of contact was significantly (P < 0.01) associated with nasal blockage and reduction of smell, but there was no association with facial pain. The median Lund-Mackay score for scans with contact was significantly greater than the score for scans without contact. Whereas the results of the study support the hypothesis that nasal contact may impede ventilation and drainage of the paranasal sinuses, the study finds no evidence to support the concept that contact points cause facial pain or headaches.     

Alternative therapies in the management of headache and facial pain

Complementary therapies are now becoming the rule rather than the exception in the management of headache and facial pain. It is incumbent on physicians to be aware of and to have a working knowledge of these increasingly popular modalities.     

Extended endoscopic mucosal resection in the esophagus and hypopharynx: a new rigid device

We present a new device allowing for the diagnosis and treatment of extended superficial lesions of the esophagus and hypopharynx such as early squamous cell carcinoma, intestinal metaplasia with high grade intraepithelial neoplasia or early adenocarcinoma arising in Barrett’s esophagus. A new modified rigid esophagoscope (Karl Storz GmbH, Germany) has been designed. A large mucosal area is sucked against a transparent and perforated hemi-cylindrical window. Mucosal resection is performed by an electrical wire loop at a constant depth of 1 ± 0.1 mm. The resected surface varies from 4 to 12 cm². Circumferential resection consists of two opposite individual hemi-circumferential resections. We performed three series of animal trials: hemicircumferential mucosectomies; circumferential resections of variable (2 to 6 cm) length and long-segment mucosectomies with follow-up. Hemi- and circumferential resections could be done in one or two specimens only which allowed precise histological studies. This facilitated easy orientation and analysis of the surgical margins. The deep resection margin was precisely located at the submucosal level, a prerequisite for a safe resection of superficial cancers of the esophagus and hypopharynx.     

JESREC score and mucosal eosinophilia can predict endotypes of chronic rhinosinusitis with nasal polyps

Objective

Recently, JESREC score and mucosal eosinophil count have been used to diagnose eosinophilic chronic rhinosinusitis (ECRS) in Japan. However, it remains unknown whether the subtypes of CRS diagnosed by these criteria have different endotypes. In the present study, we investigated whether JESREC score and mucosal eosinophil count were appropriate for classification of CRS subgroups into endotypes.

Solitary neurofibroma of the nasal cavity: resection with endoscopic surgery.

We present a case of neurofibroma of the nasal cavity treated by endoscopic surgery. A 71-year-old female had complained of left-sided nasal obstruction for the past four years. Anterior rhinoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a tumour involving the left nasal cavity. Histological and immunohistochemical examination showed the tumour to be a neurofibroma. The tumour was resected with endoscopic surgery. Neurofibroma arising in the area of the nose and paranasal sinuses is rare. We discuss the clinical and pathological characters of neurofibroma arising in the nasal cavity.     

Low-grade fibrosarcoma of the anterior skull base: endoscopic resection and repair

BACKGROUND: Fibrosarcomas of the paranasal sinuses and skull base are uncommon tumors. Traditionally, "open approach" surgery remains the mainstay for treatment of choice for these tumors. METHODS: A 49-year-old man underwent resection of a right anterior skull base fibrosarcoma using the endoscopic approach. RESULTS: Close follow-up using both endoscopic and imaging methods over a period of four years has revealed a well-healed skull base with no evidence of recurrence. CONCLUSION: Significant resistance exists at present for such a technique to deal with malignant diseases of the head and neck but results from advanced centers continue to prove that this may be a technique worth mastering and improving on.     

Mandibular resection in cancer of the tongue and/or mouth floor

The role of the lingual periosteum in the spread of tumours is not yet clear. We examined the histological behaviour of 60 cancers of the tongue and floor of the mouth lying close to the mandible. There were no tumour cells in the periosteal lymphatics. This is in accord with clinical experience that tumour invasion of the periosteum is not associated with an increased rate of metastases to the cervical lymph nodes. From our experience, we conclude that (1) a radical resection of the mandible is mandatory for every lesion lying in the gingivo-lingual gutter that invades bone; (2) for tumours close to, but not directly invading the lingual surface of the mandible, marginal resection of the alveolar ridge is appropriate and provides an adequate margin.     

Nasal endoscopic and CT scan alterations of the paranasal sinuses as predictors of severity in patients with cystic fibrosis

Cystic Fibrosis (CF) results from mutation in the transmembrane conductance regulator gene, responsible for controlling secretory processes. The upper airways (UA) are usually involved in the form of chronic pansinusitis.ObjectiveTo evaluate UA changes in patients with CF and to establish the correlations between sinonasal CT and endoscopic endonasal findings and disease severity.MethodCross-sectional and prospective study with 20 patients older than 5 years with CF, assessing the Shwachman-Kulczycki (S-K) score, paranasal sinus tomography (CT) (Lund-Mackay score) and nasal endoscopy (Meltzer score).ResultsCT scan alterations were observed in 94% of cases. Endoscopic alterations findings in the upper airways were found in 10 patients. Nasal polyps were found in 3 patients (15%). There was a correlation between the intensity of changes on the CT and S-K score (p = 0.0097), and between endoscopic findings and S-K score (p = 0.0318). There was a positive correlation between the presence of chronic colonization and endoscopic findings (p = 0.0325), which was not observed on the CT (p = 0.2941).ConclusionThere is an inverse correlation between the S-K clinical score and nasal endoscopy and CT findings. Therefore, patients who are clinically more severe according to the S-K score have greater UA involvement.     

Functional endoscopic dilatation of the sinuses: patient satisfaction, postoperative pain, and cost

BACKGROUND: The purpose of this study was to determine how functional endoscopic dilatation of the sinuses (FEDS) compares with functional endoscopic sinus surgery (FESS) in a select group of patients with respect to (1) elimination of symptoms, (2) patient satisfaction, (3) postoperative narcotic use, and (4) cost. A retrospective study was performed of 70 patients with chronic rhinosinusitis who underwent FEDS or FESS as primary or revision treatment. METHODS: Symptoms and satisfaction based on the Sino-Nasal Outcome Test (SNOT-20) questionnaires and global patient assessment, postoperative narcotic use, and costs were compared after 3-month follow-up. RESULTS: SNOT-20 change scores indicated that both FEDS and FESS had clinically meaningful treatment responses. Patient satisfaction was higher and postoperative narcotics usage was less with FEDS. The cost for primary procedures was similar, whereas the cost for revision surgery using FEDS was considerably less. Turbinate lateralization and scarring was more common in the FEDS group, particularly early in the study. The incidence of recurrent sinus infections during the follow-up period was similar for both groups. Only one patient in the FEDS group required a repeat intervention within the short-term follow-up period. CONCLUSION: Both FEDS and FESS resulted in significant improvement in SNOT-20 scores for selected patients with mild disease. Patient satisfaction and postoperative narcotic use of FEDS compare favorably with FESS. Cost of FEDS was comparable with FESS for primary procedures but was less than FESS for revision procedures. Long-term efficacy and final cost of FEDS remain to be addressed, taking into account the need for revision procedures after initial FEDS, by means of long-term studies and objective outcome measures.     

Endonasal endoscopic oncologic resection and reconstruction of the anterior skull base in the elderly: A single-center retrospective study

IntroductionIn old and frail patients, oncologic anterior skull-base surgery through an endonasal endoscopic approach avoids the morbidity incurred by transfacial and transcranial approaches, sometimes considered unreasonable, although surgery remains the gold standard treatment for sinonasal cancer.ObjectivesTo assess the functional and oncologic results of this surgery in over-70 year-olds.Material and methodsA single-center retrospective study included all patients aged over 70 years at surgery, who underwent endonasal endoscopic oncologic resection and reconstruction of the anterior skull base, between October 2008 and October 2018.ResultsFifteen procedures in 13 patients met the inclusion criteria. Mean hospital stay was 7 days. All resections were considered R0, apart from one case with positive dura-mater margins (6.7%). All patients had complete radio-surgical treatment, in accordance with the REFCOR recommendations. Two cases of meningitis were reported (13.3%). At a median follow-up of 27 months, 4 patients presented local recurrence, 1 of whom also had lung metastases. Two patients died of disease-related or treatment-related causes.ConclusionThis technique is a feasible treatment in patients aged over 70 years, providing good functional results, and acceptable oncologic outcome.     

Partial temporal bone resection for basal cell carcinoma of the external auditory canal with preservation of facial nerve and hearing

A 44-year-old retired naval airman with recurrent basal cell carcinoma of the external auditory canal underwent a partial temporal bone resection with preservation of the facial nerve and reconstruction of his hearing mechanism. The morbidity associated with radical temporal bone resection was avoided. Useful hearing was obtained by myringostapediopexy with staged split thickness skin grafting. The patient's postoperative appearance is enhanced by wearing of a prosthesis.     

鼻内镜手术治疗老年慢性鼻窦炎鼻息肉的临床分析

目的总结应用鼻内镜手术治疗老年慢性鼻窦炎、鼻息肉的经验.方法回顾分析经鼻内镜手术治疗60～77岁患者52例、82侧的临床资料.结果参照FESS -97海口标准,随访1年以上,52例、82侧患者治愈、好转、无效率分别是64.2%(33/52)、26.6%(14/52)和9.2%(5/52).结论鼻内镜手术治疗老年慢性鼻窦炎、鼻息肉有效且安全.术者应根据老年患者的特点,作好围手术期的处理,控制出血,减少并发症.     

Three-dimensional virtual operations can facilitate complicated surgical planning for the treatment of patients with jaw deformities associated with facial asymmetry:a case report

This article describes a case we experienced in which good postsurgical facial profiles were obtained for a patient with jaw deformities associated with facial asymmetry,by implementing surgical planning with SimPlant OMS.Using this method,we conducted LF1 osteotomy,intraoral vertical ramus osteotomy(IVRO),sagittal split ramus osteotomy(SSRO),mandibular constriction and mandibular border genioplasty.Not only did we obtain a class I occlusal relationship,but the complicated surgery also improved the asymmetry of the frontal view,as well as of the profile view,of the patient.The virtual operation using three-dimensional computed tomography(3D-CT)could be especially useful for the treatment of patients with jaw deformities associated with facial asymmetry.     

面中掀翻结合鼻内镜手术治疗鼻腔鼻窦鼻咽肿瘤16例临床分析

目的观察面中掀翻结合鼻内镜手术治疗鼻腔、鼻窦、鼻咽肿瘤的临床疗效及其技术优势。方法2000～2004年间收治的16例鼻腔、鼻窦、鼻咽肿瘤患者,包括鼻腔内翻性乳头状瘤6例,鼻咽部纤维血管瘤Ⅲ期1例,上颌窦鳞癌2例,鼻腔黑色素瘤2例,蝶窦黑色素瘤1例,蝶窦原位癌2例,筛窦腺样基底细胞癌2例。均采用面中掀翻结合鼻内镜手术进行治疗。结果16例患者手术均成功,术中术野清晰,肿瘤暴露清楚,切除彻底,止血直观,复发率低,面部不遗留瘢痕。结论面中掀翻结合鼻内镜的手术方式增加了手术的精确性和安全性,是手术治疗鼻腔、鼻窦、鼻咽肿瘤的有效术式之一。     

慢性鼻窦炎鼻息肉鼻内镜术后随访的必要性

目的 探讨慢性鼻窦炎鼻息肉鼻内镜术后定期随访的意义。方法 2001年4月-2005年4月间在我科接受鼻内镜手术的慢性鼻窦炎鼻息肉患者308例（530侧），除了42例（68侧）患者的随访观察过程不规则外，其余266例（462侧）均进行了规律的随访与术腔清理。比较分析两组病例不同随访经历对疾病恢复过程的影响。结果经历规律、定期、及时复查处理的患者中，仅15例（27侧）出现息肉复发，其余均治愈；未经定期复查的患者中，37例（57侧）发生鼻腔粘连，26例（32侧）息肉复发，31例（54侧）窦口引流不畅。结论 慢性鼻窦炎鼻息肉患者接受鼻内镜手术后，定期、规律、及时的术后随访和术腔清理与规范、彻底的手术操作具有同等重要的意义。