INTRODUCTION

Chronic contact headache is a major problem affecting the quality of life. These patients were assessed by many different specialists as ophthalmologists ,neurologists,dentists and psychatrists without satisfactory treatment. That is kept in mind sino genic headache without sino nasal inflammation ¹.

The princible of contact headache is contact of mucosal surfaces between the mucosa of the  septum and mucosa of the lateral wall of the nose including the superior ,middle and inferior turbinate ,that is occurred  in patients with septal deviation and concha bullosa  compressing the ethmoidal nerves causing the facial pain .That is occurred in absence or presence of allergic and vasomotor rhinitis².

Stimulation of sphenopalatine ganglion is responsible for this facial pain ,this occurred through stimulation the medial branches of anterior ethmoidal nerves that supply submucosally the opposing  turbinates and the

septum and their compression stimulate the sphenopalatine ganglion³.

The headache was classified by Stamberger and Wolf into 3 types 1)acute or chronic inflammation of the linning of the nose and PNS  or barotrauma  2)not caused by inflammatory disease of the nose and PNS as neuralgia ,migraine and vascular headache 3)sinonasal  in origin  but its site cannot be confirmed ,that is assumed from pressure between the 2 opposing mucosal surfaces ,that is called contact headache².The development of various neuropeptides in areas of touch mucosal sites is a popular notion. The P substance is the most well-known neurotransmitter, and the septum and middle concha are the most prevalent sites of production⁴.

Headache is a frequent ailment that affects the majority of individuals in varying degrees of severity. Neuralgias, migraines, cervical and vascular diseases, temporomandibular joint disorders, dental abscess, head and neck cancers, and intracranial and ophthalmologic pathologies are different causes of headache⁵.

Rhinogenic headache can be caused by any point of contact between the lateral nasal wall and the nasal septum. Although the pathophysiology is unknown, some propose that substance P (SP) and stimulation of unmyelinated C fibres play a role².When the lateral nasal wall and the septum come into contact, pressure and P substance are released, causing local reflexes such vasodilation, plasma extravasation, hypersecretion, and perivascular inflammation. All of these things can create a headache that looks like a migraine with an aura⁶.

A comprehensive approach is required for the evaluation of rhinogenic headache. In addition to a thorough rhinoscopic and endoscopic examination, a paranasal computerised tomography (CT) should be performed to rule out sinusitis, nasal polyposis, concha bullosa, and other pathologies, as well as to rule out other causes⁷.

Regardless of the type of therapy used, most writers emphasise the importance of carefully selecting cases with a rhinogenic headache and removing possible neurologic or psychiatric causes ².However, multiple investigations show that such patients can be successfully managed⁸.

The study is done to evaluate the efficacy of endoscopic septoturbinal  surgery  in resolving the headache  that caused by contact points between the septum and the lateral wall of the nose.

PATIENTS AND METHODS

This prospective cohort study  done on 30 patients on  presented by chronic headache which is rhinogenic in orgin  due to mucosal  contact between the septum and the lateral wall of the nose due to either abnormalities of the septum or the lateral wall of the nose  or both without other causes of headache . The   mucosal contact is confirmed by rigid sinooscope and CT axial and coronal cuts without contrast and confirmed by xylocaine test (pledget of cotton soacked with 5 % xylocaine  and placed in the nose at the site of mucosal  contact for 15 minutes,if the patients felt relieve of pain more than 50 %, the test is positive and the patient is candidate for the surgery).

Inclusion criteria: patients with contact mucosal headache in which  the contact  points between the septum and the lateral wall of the nose  is  verified by   rigid sinuoscope and CT nose and PNS and confirmed by xylocaine test.No another detectable cause of headache such as sinus disease ,neurological ,dental, ophthalomological or other cause after otolaryngological ,neurological,dental,opthalmological and other related specialist. No drug abuse of narcotic.

Exclusion criteria   : patients with chronic headache caused by another cause as ophthalmological, dental, neurological ,vascular and another internal nasal diseases were excluded .Although patients with another intranasal  anatomical variation  and previous surgical procedures of the nose and  paranasal sinuses were excluded from this study.

Written informed consent was taken from all participants after explanation of the study .Approval of the ethical committee for the  study .

All patients were assessed by complete history  , local examination of the nose ,anterior rhinoscopy, comprehensive endoscopic examination .The key point during endoscopic examination is determination the contact mucosal points that is not detectable by previous examination as result of septal deviation ,spur and mucosal turbinate hypertrophy. The first step is identifying the contact mucosal point by applying pledget  of cotton soaked with 5%  xylocaine for 15 minutes  and sinuscopic examination to determine the impaction or the temporary release of mucosal surfaces. All patients underwent CT coronal and axial cuts to confirm the contact mucosal points and exclude another nasal or sinus diseases.

Surgical technique:

All patients underwent endoscopic correction of underlying pathological mucosal contact points as endoscopic septoplasty ,turbinoplasty for  hyper trophied middle turbinate (resection the lateral lamellae of the middle turbinate with anterior ethmoidectomy that allow access  lateralization the middle turinate away from the septum),turbinoplasty for contact of hypertrophied superior turbinate ( anterior and posterior ethmoidectomy were done with resction the basal lamellae of the middle turbinate  that allow lateralization the superior turbinate away from the septum with application  of sialastic  sheet between the septum and the lateral wall ) and turbinoplasty for hypertrophied inferior turbinate (sub mucous resction of hypertrophied inferior turbinate with micro debrider shaver and laterally fracturing the turbinate along its entire length).

Nasal packing were done for all patients, nasal douching with normal saline and broad spectrum antibiotic was given for 1 week.

The patients were assessed pre and postoperative for headache by visual analogue scale which is psychometric   response scale used for subjective measurement of headache pain level as follow:  0(absence of pain) 1-3(mild pain) 4-6(moderately severe pain  ,7-9 (severe pain),10 (worse pain). We assess also the duration of headache (number of hours of headache over 24 hours) and the frequency of headache (number of attacks of headache over 1 month).All patients were followed up for 6 months postoperative.

RESULTS

The age of the studied   group ranges from 15 to 46 years (mean 32.5years), with a male/female ratio of 0.5.The duration of headache before the septoturbinal surgery ranging from 3-60 months (the mean 24.6) the  mean of  frequency and severity of headache (visual analogue scale) was 7.6 for the patients before the septo turbinal surgery ,then changed into 1.8 after endoscopic removal  of the contact mucosal points as shown in table (1).

Description:

Table 1:The distribution of age ,sex, duration of headache,pre operative frequency and severity of headache before surgery and 6 months postoperative among the studied group.

The prevalence of contact mucosal points among the studied patients were deviation of the nasal septum  with septal spur in 3 patients (10%), septal deviation  with septal spur(SD) and hypertrophied inferior turbinate (HI) in 13 patients (43.3%),contact between the hypertrophied superior turbinate (STH) and the deviated nasal septum (SD) in 4 patients , ,hypertrophied middle turbinate (MTH)with contact of the deviated nasal septum in 1 patient (3.3%), hypertrophied middle turbinate(MTH) was reported in 8 patients (26.7) and hypertrophied both middle turbinate and inferior turbinate in 1 patient (3.3%). The endoscopic surgeries were done either   septoplasty  for deviated nasal septum with septal spur  in 3 patients (10%), both turbinoplasty and septoplasty  in 18 patients(13 patients with SD with HI plus 4 patients SD with STH plus 1 patient SD with MTH)  (60%) and turbinoplasy for hypertrophied inferior  and middle turbinates in 9 patients (9 patients those 8 patients with hypertrophied middle turbinate(MTH) 26.7 plus 1 patient with hypertrophied both middle turbinate and inferior turbinate 3.3%) (30%).According the endoscopic and CT findings, the postoperative   complications reported were synechia in 6 patients (20%) which were corrected in post -operative   office visits by release of adhesion and insertion of sialistic sheet, septal perforation was reported in 1 patient (3.3%) and no more complications were reported table (2) Figure (1,2,3,4).

Table 2:The distribution of the pathological  abnormalities that causing contact mucosal points with the underlying endoscopic surgery  and the postoperative complications.SD(septal deviation),STH (superior turbinate hypertrophy),MTH (middle turbinate hypertrophy),HI (hypertrophied inferior turbinate).

Fig. 1 : CT scan coronal cuts of 37 male patient presented with rhinogenic headache due to deviated nasal septum with contact  hypertrophied superior turbinate.

Fig. 2: Distribution of the studied group of patients with contact mucosal points according to endoscopic and CT finding .

Fig. 3 : endoscopic finding of 44 female patient presented by  rhinogenic headache presented  by deviated nasal septal spur contacting the inferior turbinate.

Fig. 4: Distribution of the endoscopic corrective surgery for the underlying contact mucosal points.

Fig. 5: Distribution of  postoperative complications of the underlying endoscopic corrective surgery.

Evaluation of frequency and severity of headache (VAS) in our studied patients pre operatively was moderately severe pain in 6 patients (20%), severe pain in 21 patients (70%) and worse pain in 3 patients (10%).The (VAS) was assessed 6 months post operatively,9 patients were cured(30%),17 patients were improved (56.7) and 4 patients unchanged their characters of pain.table 3 figure (5,6).

Table 3: Distribution the frequency and severity of headache (VA S) of the studied patients at the time of diagnosis and 6 months postoperative.

Fig. 5 : Distribution the frequency and severity of headache (VA S) of the studied patients at the time of diagnosis.

Fig. 6: Distribution the frequency and severity of headache (VA S) of the studied patients 6 months postoperative.

When compared the values of   (VAS) at the time of diagnosis, to the values at the 3th month after surgical removal of the contact mucosal points, VAS scores were significantly lower at 3 months  (M = 7.6 pre operative was changed into 1.8; p = 0.001)demonstrate a considerable improvement as shown in table 4   and figure (7).

Table 4 : Comparison of (V A S) preoperative at the time of diagnosis and 6 months postoperative.

Pre- operative (VAS) at time of diagnosis                post -operative (VAS) after 6 months

Fig. 7:The ratio of (V A S ) at the time of diagnosis preoperative  and 6 months post operative.