Chronic daily headache Ppt Powerpoint Presentation slides Steven Houser Medical Slideshow Chronic Daily headache

Chronic daily headache

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Notes

Show Notes

Slide 1 :

Chronic Daily Headache: When to suspect sinus disease Steven M. Houser, MD, FACS Howard L. Levine, MD, FACS Cleveland Nasal-Sinus & Sleep Center

Slide 2 :

“Sinus HA” Differential dx Acute rhinosinusitis (ARS) nasal and facial pain, nasal congestion and purulent nasal drainage. Chronic rhinosinusitis (CRS) nasal drainage, congestion and facial pressure Migraine

Slide 3 :

“Sinus HA” work up Neurologists and internists utilize the International Headache society guidelines Otolarynologists utilize the AAO-HNS rhinosinusitis categories and criteria History Examination, including endoscopic Radiologic examination

Slide 4 :

AAO-HNS Rhinosinusitis Categories Acute rhinosinusitis (the patient has symptoms present for less than 4 weeks) Subacute rhinosinusitis (the patient has symptoms present for more than 4 weeks, but less than 12 weeks) Chronic rhinosinusitis (the patient has symptoms present for greater than 12 weeks) Recurrent acute rhinosinusitis (the patient has more than 4 acute episodes over 1 year) Acute exacerbation of chronic rhinosinusitis (the patient develops an acute infection, with new acute symptoms, superimposed over a chronic infection, with a constant baseline level of symptoms)

Slide 5 :

AAO-HNS Rhinosinusitis Criteria Major Factors Purulence in nasal cavity on examination Facial pain/pressure Nasal obstruction/blockage Fever (acute only) Hyposmia/anosmia Nasal discharge/purulence Discolored postnasal drainage Minor factors Headache Fever (all nonacute) Halitosis Fatigue Dental pain Cough Ear pain/pressure/fullness

Slide 6 :

Nasal/facial pain Nasal mucosa is not uniformly pain sensitive Ostia are more sensitive Rhinosinusitis often affects >1 sinus; multiple pain regions = diffuse pain

Slide 7 :

Nasal/facial pain Nasal sensation poorly represented within the brain Nasal sites refer pain to surface structures

Slide 8 :

Maxillary Sinus Maxillary division of 5th cranial nerve (V2) Posterior superior alveolar Infraorbital Anterior superior alveolar Stimulating the maxillary sinus ostia will produce referred pain at the posterior nasopharynx, posterior teeth, zygoma, and temple. Pressure within the maxillary sinus itself produces a sense of vague fullness in the face

Slide 9 :

Frontal Sinus Ophthalmic branch of 5th cranial nerve (V1) Frontal recess irritation is felt as pain in the inner canthal region, anterior zygoma, and molars. Local irritation within the frontal sinus itself is felt as mild pain at the same approximate frontal location.

Slide 10 :

Anterior Ethmoid Ophthalmic division (V1) Anterior ethmoid nerve off nasociliary Also supplies the anterior septum, turbinates, ostiomeatal complex Pressure in the region of the anterior ethmoid cells results in fairly intense pain in the ipsilateral eye behind the inner canthus and radiates to the maxilla, canine, and bicuspid regions

Slide 11 :

Posterior Ethmoid and Sphenoid Maxillary division (V2) Posterior ethmoid nerve Posterior septum, parts of superior and middle turbinates Ophthalmic division (V1) Greater superficial petrosal nerve Pressure in the region of the posterior ethmoid cells results in intense pain in the ipsilateral eye near the lateral canthus, the lateral nose, canine, and cuspid regions. Sphenoid sinus irritation produces severe deep head pain with some pain over the ipsilateral eye, upper teeth, and coronal suture region

Slide 12 :

Migaine Underdiagnosed condition Physicians will label 50% of subjects meeting IHS criteria as having migraine Patients will label their symptoms as sinus related 90% of the time when they actually meet the IHS criteria for migraine Nasal symptoms often accompany migraine which clouds the diagnosis

Slide 13 :

Migraine theory Sensitization of neural pathways Sterile inflammation of intracranial vessels - trigeminovascular system Serotonin (5-hydroxytryptamine) receptors Epiphenomenon from autonomic discharge Vascular engorgement Other nasal symptoms

Slide 14 :

Migraine Usually unilateral, pulsating nature Pain rated as moderate to severe Lasts 4 to 72 hours 17% of females, 6% of males Nausea, vomiting, photophobia or phonophobia With or without aura (visual scotoma)

Slide 15 :

Migraines - triggers Stress Menses OCP Infection Trauma Vasodilators Wine Aged cheeses

Slide 16 :

Migraine v sinus pain ARS can cause facial pain per IHS and AAO-HNS Straight-forward diagnosis Not a source of constant/daily pain CRS not accepted as a cause of pain per IHS Otolaryngologists feel CRS may be associated with pain, but not the chief complaint

Slide 17 :

CRS and pain Pain described as dull and pressure-like in the bilateral periorbital areas Pain worst in the morning Pain improves during the day Pain tends to last for days Pain not associated with nausea, vomiting, phonophobia, and photophobia

Slide 18 :

CRS and pain Additional nasal symptoms present Subjective: nasal drainage, obstruction, and congestion Objective: nasal inflammation and mucopurulence Improvement with topical anesthetics or decongestants CT sinus displays mucosal thickening Pain/pressure tends to improve after surgery

Slide 19 :

What CT sinus findings are important? Maxillary sinus mucocele without boney erosion is not usually important Mucoceles in other sinuses are important Air-fluid levels usually indicate an acute infection Partial or complete opacification should lead one to consider an otolaryngic exam Location of thickening important: Ostiomeatal complex = confluence of sinus drainage Peripheral thickening with patent sinuses of lesser importance

Slide 20 :

Other nasal and pain Mucosa to mucosa contact points Enlarged turbinates Paradoxically curved middle turbinate Concha bullosa (aerated middle turbinate) Septal spur Barosinusitis Vacuum pain d/t barometric pressure changes

Slide 21 :

Conclusion “Sinus headache” may actually represent migraine Nasal/facial pain or headache is often associated with CRS Careful assessment of Hx, PEX, endoscopy, CT will help to identify Other selected nasal anatomy may produce chronic pain Surgery may alleviate the pain associated with CRS and other anatomic variants

	shouser@metrohealth.org 1 Years ago. Category: Otolaryngology

Tags:	Otolaryngology

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