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11.5:
Nose and sinuses Sinus headache has become a common complaint of patients with facial pain. Although pain is associated with some sinus disease, many experts feel that pain and instances of sinus headache have been exaggerated to the public. Patients, invariably, ascribe their symptoms to sinus disease and are later surprised to discover that they are not infected. In fact, according to Schor (1993) chronic sinusitis is not particularly common, and many headache patients with autonomic features will probably have muscle tension headache or migraines. However, the clinician is obliged to consider the possibility and differential diagnosis and the role of the paranasal sinuses in headache and facial pain is well reviewed by Schor. Headache associated with frontal sinus disease is localized diffusely over the brows and forehead while headache with antral disease is most marked over the maxillary area. Pain associated with ethmoid and sphenoid disease is referred to the back of the eyes and to the vertex. When sinus disease is protracted, pain spreads to the head, the neck, and sometimes to the shoulders. Headache is less intense when the patient is lying down. The reduction in pain in the reclining position is not immediate but usually requires 20---30 minutes (Wolff, 1955). Pain caused by frontal sinus disease commonly begins in the morning, gradually becomes worse, and ends toward evening or upon retiring to bed. Headache from maxillary sinus disease often begins in the early afternoon. In all instances, the pain is deep, dull, aching, and nonpulsatile. It is seldom, if ever, associated with vomiting. The intensity of the headache is usually of a low order. It never equals that caused by migraine, ruptured aneurysm, meningitis, or certain febrile illnesses. Aspirin or codeine usually reduces or abolishes the headache caused by disease of the nasal or paranasal sinuses. The pain is intensified by procedures that increase cephalic venous pressure, such as coughing, straining, or wearing a tight collar. It is also intensified by increased engorgement of the nasal mucosa (from anxiety, menstruation, cold air, or the effects of alcohol). The pathophysiology of headaches from nasal or paranasal sinus disease has not been studied in detail. The mucosa that lines the ostia of the paranasal sinuses is particularly sensitive, but the mucosa that lines the sinuses themselves is relatively insensitive to pain stimuli. Most of the pain evoked by stimulation of the mucosa of the sinuses is of the referred type. Frequently it outlasts the period of stimulation (Wolff, 1955). It is referred chiefly to those regions of the head supplied by the second, and, to a lesser extent, the first, division of the trigeminal nerve. Inflammation and engorgement of the turbinates, ostia, nasofrontal ducts, and superior nasal spaces are responsible for most of the pain emanating from the nasal and paranasal structures. If a zygomatic, frontal, temporal, or vertex headache is not greatly reduced in intensity or eliminated by shrinking or anesthetizing the nasal structures, it is probably not the result of disease of the nasal or paranasal structures. |