ENT

Clinical Study of Headache in Relation to Sinusitis

and its Management
ANUPAMA KAUR*, AMANPREET SINGH†

ABSTRACT
Aim: To study relation of headache with sinusitis and its management. Material and methods: Patients clinically presenting
with headache were selected. Only patients with headache due to rhinogenic causes were subjected to X-ray paranasal sinuses
(PNS) and diagnostic nasal endoscopy (DNE) and were followed up to evaluate management. Results: Majority of the patients
were of age group 21-30 years and it is more predominant in males. Majority of the patients with headache had deviated nasal
septum (DNS) (28.9%), acute sinusitis (28.9%), osteomeatal complex disease (24.63%); few patients had nasal polyp (8.69%),
allergic rhinitis (5.79%) and rarely patients had atrophic rhinitis (2.89%). Headache was localized in forehead (43.4%), more than
one site (34.7%) in majority of cases and few number of patients had headache at glabella (13.04%) and top of head (8.69%).
Majority of the patients who underwent antral washout were not relieved, so they underwent functional endoscopic sinus
surgery (FESS), which gave dramatic results in improving symptoms including headache. Conclusions: Headache is nearly a
universal human experience. The lifetime incidence of headache is estimated to be at least 90%. To know whether the headache
is sinogenic or not, the patient is first assessed clinically and then radiological investigations (X-ray PNS) are done. Role of
FESS is huge and ultimately it is FESS that is the cure for headache due to rhinogenic causes.
Keywords: Headache, sinusitis, FESS

H
eadache is nearly a universal human headache disorders as defined by the International
experience. The lifetime incidence of headache Headache Society are migraine, probable migraine,
is estimated to be at least 90%. Moskowitz has tension type and cluster headache.1
described headache as the symptom produced by the The term ‘sinusitis’ refers to a group of disorders
nervous system when it perceives threat and as such characterized by inflammation of the mucosa of the
is considered part of the protective physiology of the paranasal sinuses (PNS). Because the inflammation
nervous system. When the cause of headache is a nearly always also involves the nose, it is now generally
definable underlying pathologic process, the headache accepted that ‘rhinosinusitis’ is the preferred term to
is diagnosed as a secondary headache. Causes include describe the inflammation of the nose and PNS.2
metabolic, infectious, inflammatory, traumatic,
neoplastic, immunologic, endocrinologic and vascular Patients with chronic headache pain often present
entities. to a variety of specialists, including their primary
care physician, neurologist, dentist, otolaryngologist
When no clear pathologic condition can be identified, and even a psychiatrist. They may present to
headache is considered to be a manifestation of a otolaryngologist because they or their physician
primary headache syndrome. The common primary believe the headache to be related to underlying sinus
pathology. The primary focus of the otolaryngologist is
to exclude this possibility.
*Assistant Professor The diagnosis of headache secondary to acute sinusitis
Dept. of Physiology
†Assistant Professor can be relatively straightforward. Diagnosing headache
Dept. of ENT related to chronic sinus disease can be much more
MM Institute of Medical Sciences and Research difficult depending on patient’s presentation.3
Mullana, Ambala, Haryana
Address for correspondence Endoscopic techniques are now well-established.
Dr Amanpreet Singh
Assistant Professor In combination with modern imaging techniques
Dept. of ENT particularly computed tomography (CT), these
MM Institute of Medical Sciences and Research
Mullana, Ambala, Haryana techniques provide diagnostic possibilities unimagined
E-mail: dr.apsarora@gmail.com a few decades ago.4

Indian Journal of Clinical Practice, Vol. 25, No. 5, October 2014 429
ENT

AIM If the headache was suspected to be of rhinogenic or

sinogenic origin, the patients then underwent detailed
To study the relation of headache in sinusitis and its otorhinolaryngological examination.
management.
ÂÂ Routine blood investigations like hemoglobin (Hb),
MATERIAL AND METHODS total leukocyte count (TLC), differential leukocyte
count (DLC), erythrocyte sedimentation rate (ESR),
The present study was conducted in the Dept. of bleeding time (BT), clotting time (CT), urine for
Otorhinolaryngology in MM Medical College and albumin, sugar and microscopy.
Hospital, Mullana, Ambala, Haryana from October ÂÂ Radiological investigations i.e., X-ray PNS (Water’s
2009 to July 2011. view) was advised in all patients of headache of
rhinogenic or sinogenic etiology.
Source of Data ÂÂ Diagnostic nasal endoscopy (DNE) was advised to
Patients for the study were collected from the Dept. the same group of patients.
of Otorhinolaryngology, MM Medical College and ÂÂ Acute infections were first treated with medicines.
Hospital, Mullana, Ambala, Haryana.
ÂÂ Patients who were found to have haziness of
maxillary sinuses on PNS X-ray were advised
Sample Size
antral wash.
The study included 100 patients and the cases were ÂÂ Patients who had haziness of frontal sinuses and the
diagnosed based upon clinical examination and patients who were not relieved of headache after
investigation. antral washout were advised functional endoscopic
sinus surgery (FESS).
Inclusion Criteria
Patients of all age groups and sexes presenting with RESULTS
clinical features of sinusitis.
A total of 100 patients with headache were
Exclusion Criteria studied for a period of about 2 years i.e., from
October 2009 to July 2011, of which only 69
All patients presenting with clinical features other patients had headache due to rhinogenic causes.
than sinusitis. The highest incidence was in the age group of
21-30 years (59.42%), followed by 11-20 years (36.23%)
Study Procedures (Fig. 1 and Table 1). Patients of age group 21-30
ÂÂ Selected patients were subjected to a complete years were more prone (51.61%), to headache due
examination according to a defined proforma. to other causes (Fig. 2 and Table 2). About 53.62% of
ÂÂ Detailed history with thorough clinical examination patients of headache due to rhinogenic causes were
was done. males and 46.37% were females (Fig. 3 and Table 3).
ÂÂ Patients were asked about history of headache In headache due to other causes about 93.54% of

„„ Mode of onset
16
„„ Duration of complaint
14
„„ Continuous or intermittent 12
No. of cases

„„ Progressive or not 10
8
„„ Site of pain and radiation
6
„„ Type of pain 4
„„ Associated symptoms 2

„„ Aggravating and relieving factors 0

5-10 11-20 21-30 31-40 41-50 51-60
„„ Duration of each attack Age group (years)
DNS Acute sinusitis Osteomeatal complex disease
„„ Frequency of attack
Polyp Allergic rhinitis Atrophic rhinitis
„„ Time of onset of attack
„„ Treatment taken for the same. Figure 1. Age distribution (rhinogenic causes).

430 Indian Journal of Clinical Practice, Vol. 25, No. 5, October 2014
 ENT

Table 1. Age Distribution (Rhinogenic Causes) (n = 69) 14 Male Female

Age group (years) 12
5-10 11-20 21-30 31-40 41-50 51-60

No. of cases
10
DNS - 6 14 - - -
8
Acute
- 8 12 - - - 6
sinusitis
Osteomeatal 4
complex - 7 10 - - - 2
disease
0
Polyp 1 - 5 - - - DNS Acute Osteomeatal Polyp Allergic Atrophic
Allergic sinusitis complex rhinitis rhinitis
- 4 - - - - disease
rhinitis
Rhinogenic causes
Atrophic
- - - 2 - -
rhinitis Figure 3. Sex distribution (rhinogenic causes).

8 Table 3. Sex Distribution (Rhinogenic Causes) (n = 69)

7 Male Female
6
DNS 14 6
No of cases

5
Acute sinusitis 8 12
4
3 Osteomeatal 10 7
2
complex disease
1 Polyp 1 5
0 Allergic rhinitis 4 0
5-10 11-20 21-30 31-40 41-50 51-60
Age group (years) Atrophic rhinitis - 2
Migraine Trigeminal neuralgia Tension headache
Temporomandibular joint arthritis
10
Figure 2. Age distribution (others). Male Female
9
8
7
Table 2. Age Distribution (Others) (n = 31)
No. of cases

6
Age group (years)
5
5-10 11-20 21-30 31-40 41-50 51-60 4
Migraine - - 5 - 7 - 3
Trigeminal 2
- - 7 - - -
neuralgia 1
Temporo- 0
mandibular Migraine Trigeminal Temporo- Tension
- - - - 5 - neuralgia mandibular headache
joint
joint arthritis
arthritis Other causes
Tension
headache
- - 4 - 3 - Figure 4. Sex distribution (other causes).

the patients in headache due to other causes were Table 4. Sex Distribution (Other Causes) (n = 31)
females and 6.45% were males (Fig. 4 and Table 4). Male Female
About 28.9% of patients of headache had deviated Migraine 2 10
nasal septum (DNS) and 28.9% of the patients had Trigeminal neuralgia - 7
acute sinusitis, 24.63% of the patients had osteomeatal Temporomandibular joint arthritis - 5
complex disease and 8.69% of patients had polyp,
Tension headache - 7
5.79% of patients had allergic rhinitis and 2.89% of

Indian Journal of Clinical Practice, Vol. 25, No. 5, October 2014 431
ENT

20
Atrophic rhinitis
(2.90%) 18
Allergic rhinitis 16
(5.80%) DNS
(28.99%) 14
Polyp (8.70%)

No. of cases
Osteomeatal 12
complex disease 10
(24.64%)
8

Acute sinusitis 6
(28.99%) 4
2
Figure 5. Etiology of headache with respect to clinical findings. 0
DNS Acute sinusitis (under OMD
antibiotic cover)
Table 5. Etiology of Headache with Respect to Antral washout
Clinical Findings No. of patients Relieved Not relieved

No. of Rhinogenic Figure 7. Patients who underwent antral washout.

cases causes (%)
DNS 20 28.90
Table 7. Patients Who Underwent Antral Washout
Acute sinusitis 20 28.90 No. of Relieved Not relieved
Osteomeatal complex disease 17 24.63 patients (n = 20) (n = 37)
Polyp 6 8.69 DNS 20 8 12
Acute sinusitis (under 20 5 15
Allergic rhinitis 4 5.79 antibiotic cover)
Atrophic rhinitis 2 2.89 Osteomeatal complex 17 7 10
disease

Forehead
Glabella Top of head (8.70%) No benefit Completely
(43.48%)
(13.04%) from surgery free of
(33%) pain (30%)

More than one site

(34.78%)
Significant symptom
Figure 6. Localization of headache. improvement
(37%)

Figure 8. Patients who underwent FESS due to causes other

Table 6. Localization of Headache than contact points.
Localization No. of cases Rhinogenic causes (%)
Forehead 30 43.4 than one site (34.7%) and then glabella (13.04%)
and top of head (8.69%) (Fig. 6 and Table 6).
More than one site 24 34.7 About 35.08% of patients who underwent antral
Glabella 9 13.04 washout for headache and facial pain were relieved,
Top of head 6 8.69 whereas 64.92% were not relieved (Fig. 7 and Table 7).
About 43.47% of the patients who underwent DNE
for headache had mucosal contact points as the main
patients had atrophic rhinitis (Fig. 5 and Table 5). pathology (Fig. 8 and Table 8). Out of 30 patients
Patients with headache in the forehead were diagnosed as having mucosal contact points, 25
maximum (43.4%) followed by headache at more underwent FESS.

432 Indian Journal of Clinical Practice, Vol. 25, No. 5, October 2014
 ENT

Table 8. Patients Who Underwent DNE (n = 69) had facial discomfort and headache7 and according
to a study conducted by Wolf, 20% of allergy
No. of cases Percentage (%)
patients presented with headache.8 In our study,
Mucosal contact points 30 43.47
out of 69 patients of headache due to rhinogenic
present
causes, 30 (43.4%) patients had headache at forehead,
Mucosal contact points 39 56.52
24 (34.7%) patients had headache at more than one site,
absent
nine (13.04%) patients had headache at glabella and
six (8.69%) patients had headache at top of head. In a
Table 9. Patients Who Underwent FESS due to
study conducted by Kumar et al (2000), localization of
Mucosal Contact Point (n = 25) headache to forehead was 43% while headache at more
than one site was seen in 19%, pain at glabella in 12%
No. of cases Percentage (%)
and at top of head in 9%.5
Total relief from headache 20 80.00
Significant relief 5 20.00 Thus, it can be concluded that headache is localized at
forehead in majority of cases. We also did antral washouts
in our patients of headache but only 35% of the patients
Table 10. Patients Who Underwent FESS due to were relieved. We also did DNE on 69 patients out of
Causes Other than Contact Points (n = 30) which 30 (43%) patients had mucosal contact points.
No. of cases Percentage (%) Patients due to mucosal contact points were advised to
Completely free of pain 9 30.00 undergo FESS. Out of 30 patients, 25 patients underwent
surgery. Postoperatively, 20 patients (80%) had total
Significant symptom 11 36.6
improvement
relief from headache, five patients (20%) had significant
relief. Various other studies in literature show similar
No benefit from surgery 10 33.3
the same results. In a study conducted by Behin et al,
23 patients underwent surgical intervention to relieve
Eighty percent of the patients who underwent FESS for the contact points. Eighty-three percent of patients no
headache due to mucosal contact points had complete longer complained of headache. Eight had significant
relief from headache and 20% had significant relief relief.9
(Table 9). Out of 39 patients of headache due to causes In a study conducted by Parsons et al on 34 patients
other than contact point, 30 underwent FESS. Patients who underwent surgery for contact points, a reduction
who underwent FESS for causes other than mucosal in intensity was reported in 91% of patients and
contact points showed 67% improvement in headache reduction in frequency of headache in 85% of patients
and facial pain (Table 10).
postoperatively 35 (5).10 Thus, from our study and the
above mentioned studies, it is clear that majority of
DISCUSSION
the patients who underwent FESS for mucosal contact
According to our study, the majority of the cases of points were totally relieved of their symptoms. The
headache due to rhinogenic causes were males (54%) remaining 39 patients who had pathologies other than
in the age group of 11-30 years. Similar findings were mucosal contact points i.e., DNS, osteomeatal complex
observed in the study conducted by Kumar et al (2000) disease were also advised FESS to get rid of headache.
wherein majority of patients of headache belonged to Out of the 30 patients who underwent surgery, post-
age group 10-30 years and 53% were males.5 Similarly,
operatively, nine (30%) patients were completely free
in a different study by Wenig et al6 and need Lebovics et
of pain, 11 (36.6%) patients had significant symptom
al demonstrated a male predominance of headache due
improvement and 10 (33.3%) patients had no benefit
to acute frontal sinusitis in both adults and adolescents.
from surgery.
While majority of our patients of headache due to
Thus, it showed 67% improvement and correlates
rhinogenic causes had either DNS, acute sinusitis or
osteomeatal complex disease, we also encountered with studies mentioned below: Welge-Leussen et al
patients having nasal polyps (6 patients) allergic conducted a 10-year follow-up of patients who had
rhinitis (4 patients) presenting with headache. undergone FESS. Out of 20 patients, six (30%) patients
Similarly, in the study by de Freitas et al, the remained completely free of pain, seven (35%) had
patients of polyps along with nasal obstruction also significant improvement and seven (35%) received no
benefit from surgery (65% improvement).11

Indian Journal of Clinical Practice, Vol. 25, No. 5, October 2014 433
ENT
In a study conducted in Dept. of Otolaryngology,
Vajira Hospital, Bangkok, Thailand, 16 patients were
operated on by FESS. Their principal complaint was
facial pain or headache. Ten patients had no headache
postoperatively (62.5%) and six patients (37.5%) had a
reduction in severity.12
Thus, from the present study and the above mentioned
studies, an improvement in headache in 63-67% of
patients operated should be expected after the patients
undergo FESS for headache.
CONCLUSION
Sinusitis refers to a group of disorders characterized
by inflammation of the mucosa of the PNS. Now-a-
days rhinosinusitis is the preferred term to describe
the inflammation of the nose and PNS. Headache is
nearly a universal human experience. The lifetime
incidence of headache is estimated to be at least 90%.
Before treating the headache it should be known if
the headache is primary (when no clear pathologic
condition can be identified) or secondary (metabolic,
infectious, inflammatory, traumatic, neoplastic,
immunologic, endocrine, vascular).
To know whether the headache is sinogenic or not,
firstly the patient is assessed clinically, then radiological
investigations (X-ray PNS) are done. Patients also
undergo DNE. Medical line of treatment with
antibiotics, antihistamines, anti-inflammatories, nasal
decongestants will be beneficial only in acute cases of
sinusitis without any anatomical variation.
Most cases of sinusitis presenting with headache are
acute cases or acute-on-chronic sinusitis. Antral lavage
can be a relief from headache for some patients.
Role of FESS is huge when no obvious clinical
abnormality is made out and ultimately it is FESS that
is the cure for headache due to rhinogenic causes.
Now-a-days suction irrigation endoscopy should be
used for visual control during surgery. Microdebrider
should be used for FESS as it provides atraumatic
dissection with minimum bleeding, which enables
decreased surgical time and faster postoperative
healing.
SUMMARY
ÂÂ A total of 100 patients presenting with headache to
Dept. of ENT were recruited for the study.
ÂÂ Out of 100 patients, 69 patients had headache due
to sinogenic causes.
434 Indian Journal of Clinical Practice, Vol. 25, No. 5, October 2014
ÂÂ Headache can occur at any age. But, the highest
incidence was noted in the age group 21-30 years
followed by 11-20 years.
ÂÂ Sex incidence is slightly more in males (53.62%).
ÂÂ In patients of headache due to sinogenic cause,
20 patients (28.9%) had acute sinusitis, 20 patients
(28.9%) had DNS, 17 patients (24.63%) had
osteomeatal complex disease, six patients (8.69%)
had polyps, four patients (5.79%) had allergic
rhinitis and two (2.89%) had atrophic rhinitis.
ÂÂ Headache was localized to forehead in 30 patients
(43.4%) and more than one site in 24 patients
(34.7%), at the glabella in nine patients (13.04%)
and at the top of head in six patients (8.69%).
ÂÂ Out of 69 patients of headache due to sinogenic
causes, 57 underwent antral washout, 20 patients
were relieved of their headache and facial pain
(35.08%) and 37 patients (64.9%) were not relieved.
ÂÂ All the 69 patients underwent DNE out of which
30 patients (43.47%) were found to have mucosal
contact points.
ÂÂ Out of 30 patients of headache due to mucosal
contact points, 25 underwent FESS; of these, 20
patients (80%) had total relief from headache and
five patients (20%) had significant relief.
ÂÂ Out of the remaining 39 patients of headache,
30 patients underwent FESS, nine patients (30%)
had complete relief from pain, 11 patients (36.6%)
had significant symptom improvement, 10 patients
(33.3%) had no benefit from surgery. This showed
that 67% of patients had improvement of headache
after undergoing FESS.
ÂÂ Endoscopic management of headache due to
sinogenic causes provides a tool to the surgeon
by which he can accurately diagnose meticulously
and with minimal trauma operate and precisely
provide postoperative care and follow-up.
ÂÂ The use of microdebrider provides an excellent
surgical result with fewer complications and faster
healing than traditional techniques in FESS.
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conundrum. Otolaryngol Clin North Am 2004;37(2):267-88.
2. Michaels B. Rhinosinusitis. Scott-Brown’s
Otorhinolaryngology HNS. 7th edition, p.1439-48.
3. Seiden AM, Martin VT. Headache and the frontal sinus.
Otolaryngol Clin North Am 2001;34(1):227-41.
4. Stammberger H. Functional Endoscopic Sinus Surgery:
The Messerklinger Technique. Mosby-Year Book: St. Louis
1991:p.70-6.
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5. Kumar P, Chawla P. A correlative study of sinusitis 9. Behin F, Behin B, Behin D, Baredes S. Surgical management
versus headache. Indian J Otolaryngol Head Neck Surg of contact point headaches. Headache 2005;45(3):204-10.
2000;52(2):125-7. 10. Parsons DS, Batra PS. Functional endoscopic sinus surgical
6. Wenig BL, Goldstein MN, Abramson AL. Frontal outcomes for contact point headaches. Laryngoscope
sinusitis and its intracranial complications. Int J Pediatr 1998;108(5):696-702.
Otorhinolaryngol 1983;5(3):285-302. 11. Welge-Luessen A, Hauser R, Schmid N,
7. Freitas MR, Giesta RP, Pinheiro SD, Silva VC. Antrochoanal Kappos L, Probst R. Endonasal surgery for contact point
polyp: a review of sixteen cases. Rev Brasi Otolaryngol headaches: a 10-year longitudinal study. Laryngoscope
2006;72(6):831-5. 2003;113(12):2151-6.
8. Donald J, Dalessio. Allergy, atopy, nasal diseases and 12. Boonchoo R. Functional endoscopic sinus surgery in
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5th edition. 1997;80(8):521-6.
■■■■

Breastfeeding Tied to Fewer Ear, Sinus Infections in Children

NEW YORK (Reuters Health) - Breastfeeding is known to help ward off infections among infants, but a new US
study suggests that protection may be much longer lasting.
Among thousands of 6 year olds followed from birth, those who were breastfed as babies were far less likely to
have ear, sinus or throat infections later in childhood. And the longer the children were breastfed during their
first year, the lower their odds of those infections at age 6.
“This study provides hard evidence that health benefits of breastfeeding go beyond infancy and breastfeeding
seems to be the best prescription for preventing these infections,” said Dr Ruowei Li, an epidemiologist at the
Centers for Disease Control and Prevention (CDC) in Atlanta, who led the study.

CVS Test Enhances Illness Awareness in Patients with Schizophrenia

Caloric vestibular stimulation (CVS), a test commonly used by ENT specialists and audiologists to test patients’
balance, could transiently enhance illness awareness in patients with schizophrenia, reports a pilot proof-of-
concept study presented at the American Society of Clinical Psychopharmacology (ASCP) 2014 Annual Meeting.

Neck Surgery Unnecessary for Many Throat Cancer Patients

Study shows that among those whose cancer was triggered by a virus, any lingering bumps after chemotherapy
and radiation tend to be benign.
A new study shows that patients with human papillomavirus (HPV) - the same virus associated with both
cervical and head and neck cancer - positive oropharyngeal cancer see significantly higher rates of complete
response on a post-radiation neck dissection than those with HPV-negative oropharyngeal cancer. Fox Chase
Cancer Center researchers presented the findings at the American Society for Radiation Oncology’s 56th Annual
Meeting.
“For patients that achieve a complete response, neck surgery is probably unnecessary,” says Thomas J. Galloway,
MD, Attending Physician and Director of Clinical Research at Fox Chase and lead author on the study.
Interestingly, patients with HPV often respond better to treatment for their oropharyngeal tumors than those
without. The researchers noted the same trend here - people who tested positive for HPV (measured by the
presence of a protein called p16) were less likely to have a recurrence of their cancers, regardless of whether or
not the tumors had completely disappeared following treatment. Indeed, patients’ HPV status was the strongest
predictor of whether or not they were alive at the end of the study.

Indian Journal of Clinical Practice, Vol. 25, No. 5, October 2014 435
 Healthcare

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