Three patients with typical (common) migraine unresponsive to conventional therapy were evaluated with complete otolaryngologic examination, diagnostic nasal endoscopy, and coronal sinus computed tomography (CT). Enlargement of the superior turbinate due to pneumatization, with accompanying mucosal contact, was found in each case. Application of topical or injected anesthetic to the superior turbinate lessened or relieved headache, and subsequent endoscopic sinonasal surgery succeeded in providing significant headache relief (follow-up of 6 to 14 months). This is the first report of superior turbinate variations/abnormalities causing migraine, or indeed any type of headache. A discussion of the mechanism of referred pain from mucosal contact is offered after a discussion of each case.

Headache associated with acute sinusitis is a well-recognized entity; the diagnosis is easily made due to the associated nasal and sinus symptoms. However, the phenomenon of referred headache from chronic sinusitis or intranasal abnormalities or both without upper respiratory symptoms is not well understood. Only recently have the nasal and sinus cavities been adequately visualized by both the human eye and radiographic techniques; a fact that may account for the historic neglect in considering this region a factor in headache etiology. Modern techniques employed in the workup of sinusitis, namely the use of rigid nasal endoscopes and coronal-plane CT scanning, have greatly enhanced the clinician's ability to evaluate and diagnose pathology in this area. This report describes a series of patients presenting with various primary headache syndromes without significant nasal or sinus symptoms who failed to respond to conventional antiheadache therapy. On nasal endoscopic and coronal CT examinations, various intranasal and sinus abnormalities were found (either anatomic variations or subclinical inflammation). Medical and/or surgical therapy addressing the sinonasal pathology resulted in improvement in every case, ranging from decreased severity of attacks to total resolution of headaches. A model explaining the possible mechanism of referred vascular-type headache from sinus and nasal origin is proposed.

The fate of the middle turbinate in endoscopic sinus surgery has been a subject of debate for some time. The superior turbinate's role, however, has been largely passed over. Past anatomic descriptions and illustrations have given surgeons the incorrect impression that this structure is well superior and out of the field of dissection. Injury to the superior turbinate may account for postoperative hyposmia. The superior turbinate also serves as a constant landmark for the sphenoethmoidal recess, and a limited resection allows the surgeon to identify and include the natural ostium of the sphenoid sinus in the sphenoidotomy. The embryology and anatomy of the superior turbinate are reviewed. An approach to the natural ostium of the sphenoid sinus from the lateral side of the middle turbinate, using the superior turbinate as a guide, is described.

Osteomas of the internal auditory canal are rare lesions, with only 12 reported cases in the world literature. Symptoms are those of eighth nerve compression, and include unilateral hearing loss and vestibular weakness, thus mimicking symptoms of acoustic neuroma. We report a patient with an osteoma of the internal auditory canal, along with a review of the literature. We note age and sex characteristics from the literature, give evidence of localized trauma as a possible etiologic factor for this lesion, and discuss the pitfalls of relying exclusively on magnetic resonance imaging in the workup of suspected retrocochlear lesions.