Middle Turbinate Headache Syndrome

Abstract

Sinus headaches are attributed to injlammatory disease of the sinus mucosa or ostium. In 1948 H.G. Wolff first recognized that sinus headaches may occur in the absence of injlammatory sinusitis, and may be due to contact between strategic "trigger points" in the sinonasal passages. Since this time there have been sporadic reports of headaches andfacial pain due to an enlarged middle lllrbinate contacting either the seplllm or lateral nasal wall. II is theorized that an enlarged middle lI/rbinate, most commonly due to pneumatization (concha bullosa), can contact the septum or lateral nasal wall and give headaches referred to the ophthalmic division 0/ the trigeminal nerve, the main sensory innervation of the anterior middle turbinate. Middle turbinate headache syndrome is reviewed, with allention to pathophysiology, clinical presentation, and treatment. Eight cases of middle lllrbinate headache will be presented in support of this clinical entity. We hope to alert the clinician to a relatively unknown source of recurrent headaches, that may be readily treated by otolaryngologists. (Am J Rhinology 7: 17-23, 1993) H eadache can be a very frustrating symptom to both patient and clinician. Indeed, many headaches can be difficult to diagnose, and even more difficult to Am J Rhinology treat. Classic etiologies for headache may be obvious, such as tension headache, migraine, or acute frontal sinusitis. There are other less obvious etiologies for headache that are more obscure in nature, and require strong clinical suspicion in order to be appropriately diagnosed. Contact headaches due to an enlarged middle turbinate are an example of this type of headache. It is thought that contact between the middle turbinate and either the septum or lateral nasal waIl leads to stimulation of the sensory portion of the trigeminal nerve. This results in a rhinologic headache that is not due to pressure within the sinus, but rather to abnormal contact between innervated regions of the nasal cavity. This report wiIl attempt to clarify middle turbinate headaches (MTH), describe the pathophysiology, and present supporting cases that demonstrate the clinical presentation and treatment options of middle turbinate headaches. CASE STUDYA 49-year-old woman noted a 12-year history of intermittent daily facial pain and headaches. The headache was located in the left periorbital region and lasted several hours. The patient denied rhinorrhea, postnasal drip, or epistaxis, but noted that the headaches usuaIly occurred foIlowing increasing nasal congestion on the left side. She denied any associated auras, increased salivation or lacrimation, or exacerbation with foods. The patient was treated for migraine by her neurologist, though no medications were effective including ergotamine, calcium channel blockers, and steroids.Physical examination demonstrated normal nasal mucosa, no rhinorrhea, and a septal deviation to the right in the region of the middle meatus. The anterior aspect of the left middle turbinate was asymmetrically enlarged and contact...

Dor craniofacial e anormalidades anatômicas das cavidades nasais

“…These data support the idea that we can define areas of the nasal mucosa that trigger pain such as the anterior portion of the medium concha and the corresponding region of the nasal septum [3][4]6 .…”

“…The importance of the sensorial inervation of the nasal mucosa in triggering the painful symptom was reinforced by the relief of pain after application of topical anesthesia, cocaine, in the nasal cavity, specifically between the medium concha and the septum, whose sensitivity is conducted by the anterior ethmoid nerve 3,8,10,13 . Vasoconstrictors 9 and lidocaine 13 , that cause immediate relief, characterize the positive response to the test, whose clinical meaning will be shown later.…”

“…The pain referred by patients is placed specifically in the areas supplied by the skin branch of the ophthalmic nerve, especially supra and infra-troclear nerves, that is, internal canthi, supra-orbital region and temporal-zygomatic region 3,9 . There are authors that also include the neck and upper limbs 6 .…”

“…It was considered that the stimulus of the reported nasal mucosa region was caused by the contact between the subsequent nasal structures of anatomical variations of constitutional or traumatic origin 4,8,15 , medium concha hypertrophy or pneumatization 3,11,14,16 .…”

“…It is also a difficult to study symptom owing to the great variety of clinical and etiological presentations 2 . In general, people with headache and craniofacial pain of difficult treatment and long evolution come to the ENT, after they had been investigated by the general practitioner, neurologist and ophthalmologist 3 .…”