Is 'sinus' pain really sinusitis?

So-called 'sinus pain' is a common complaint in GP and ear, nose and throat clinics, and patients often receive treatment with antibiotics and decongestants. Recent evidence suggests that facial pain may not be related to the sinuses at all and that doctors may have to rethink their prescribing strategy.

Prospective three-year follow up of a cohort study of 240 patients with chronic facial pain.

BACKGROUND: Patients often present with facial pain ascribed to sinusitis, despite normal nasal endoscopy and sinus computed tomography. Facial pain is increasingly recognised to be of neurological origin. METHOD: A cohort of 240 patients with chronic facial pain was followed up for 36 months at an otolaryngological practice in Malta. The types of facial pain were classified according to International Headache Classification criteria. The body mass index, occupation and educational level of patients were compared with the general population. RESULTS: Tension-type mid-facial pain and facial migraine without aura were the most common types of chronic facial pain. The sites of pain, symptoms, treatment and outcomes for these principal pain types are discussed. Patients with mid-facial pain were treated with low-dose amitriptyline for eight weeks. After three years, nearly half of the patients were symptom free, and in a third the pain changed from being chronic to being episodic. The treatment of patients with facial migraine was more varied but the length of time until recurrence of pain was similar. CONCLUSION: The most effective long-term treatments for tension-type mid-facial pain and facial migraine were low-dose amitriptyline and low-dose amitriptyline and triptans, respectively.

Serial blood serotonin levels in a randomized controlled trial comparing the efficacy of low-dose amitriptyline, amitriptyline with pindolol and surrogate placebo in patients with chronic tension-type facial pain.

BACKGROUND: Patients often present with chronic facial pain despite normal nasal endoscopy and sinus computerized tomography. Such pain has increasingly been recognized as being of neurological origin with one of the commonest underlying causes being mid-facial segmental tension-type pain (MFP) which is a version of tension headache in the face. Descending serotonergic neuronal projections are known to modulate pain and intra-platelet serotonin levels are an accepted model reflecting central intra-neuronal serotonin. OBJECTIVES: 1.To determine whether low-dose amitriptyline significantly changes whole blood serotonin compared to a surrogate placebo in patients with chronic MFP 2. To determine whether the addition of pindolol, a beta blocker with serotonin receptor blocking properties further alters blood serotonin. METHODOLOGY: Sixty-two patients were randomized to three treatment groups a) amitriptyline , b) amitriptyline with pindolol, and c) loratadine as surrogate placebo. Whole blood serotonin was taken before and after 8 weeks of treatment. Serotonin was also measured in 40 age-matched healthy controls. RESULTS: There was a significant reduction in blood serotonin levels in the amitriptyline with pindolol group. A non-significant reduction was seen in the amitriptyline group, with no change in serotonin levels in the surrogate placebo group. A comparison of change in serotonin with change in pain frequency and intensity scores is presented. Women in the control group had significantly higher serotonin levels than men. Women with tension-type facial pain who failed to respond to treatment had significantly lower blood serotonin than women in the control group. CONCLUSION: When linked to the clinical response this study provides evidence that the serotonergic system is involved in the modulation of chronic MFP. Serotonin levels are sex-dependent and related to treatment response.

A Randomized Controlled Trial comparing the efficacy of low-dose amitriptyline, amitriptyline with pindolol and surrogate placebo in the treatment of chronic tension-type facial pain.

BACKGROUND: Patients often present to otolaryngologists with chronic facial pain, presumed to be of sinus origin despite normal nasal endoscopy and sinus CT. This pain has increasingly been recognized as being of neurological origin with one of the commonest underlying causes being mid-facial segmental tension-type pain (MFP) which is a version of tension-type headache affecting the midface. PRIMARY OUTCOME MEASURES: 1. To determine whether low-dose amitriptyline reduces pain scores compared to surrogate placebo in patients with chronic MFP. 2. To determine whether the addition of pindolol, a beta blocker with serotonin receptor blocking properties hastens onset of action or improves efficacy of amitriptyline. SECONDARY OUTCOME MEASURE: to determine whether amitriptyline or amitriptyline with pindolol significantly reduces analgesic consumption. METHODOLOGY: Sixty two patients were randomized to three treatment groups (a) amitriptyline 10mg daily (b) amitriptyline 10mg daily with pindolol 5mg twice daily and (c) loratadine 10mg daily. Daily pain scores using a facial pain diary were recorded over eight weeks. RESULTS: At 8 weeks, pain frequency and intensity were significantly reduced in patients treated with amitriptyline and in those receiving amitriptyline with pindolol compared to surrogate placebo. Patients on the combination therapy showed significantly improved clinical outcome and significantly reduced analgesic intake compared to those on amitriptyline alone. CONCLUSION: Low dose amitriptyline is effective in the management of MFP and is enhanced by the addition of pindolol.

Medically unexplained symptoms and somatisation in ENT.

BACKGROUND: Somatisation has been described as the perception of a physiological event influenced by emotion. METHOD: A review of the medical literature was carried out using the following Medical Subject Headings: somatisation (which identified 357 articles), medically unexplained symptoms (749 articles), unexplained or idiopathic dizziness (142 articles), tinnitus (360 articles), catarrh (1068 articles) and globus pharyngeus (3114 articles). RESULTS: Up to 40 per cent of out-patient attendances have medically unexplainable symptoms. In ENT clinics, this includes patients with dizziness, tinnitus, 'pseudo' eustachian tube dysfunction, being 'unable to hear', catarrh and postnasal drip, atypical facial pain, globus pharyngeus, and functional dysphonia. Medical explanations of these symptoms often differ from patients' perceptions. Demonstrating normal test results and providing reassurance have little effect on patients' doubts and anxieties. Consultations that recognise the symptoms and their impact, and offer a tangible and involving explanation are more likely to satisfy and empower patients. CONCLUSION: The treatment of medically unexplained symptoms has changed in recent years; there is now more emphasis on psychological factors due to an association with anxiety and depression.

Intranasal contact points as a cause of facial pain or headache: a systematic review.

BACKGROUND: There is a body of opinion in the clinical literature advocating the removal of intranasal contact points to treat facial pain. OBJECTIVES: To review the evidence that intranasal mucosal contact points cause facial pain or headache and their removal is therapeutic. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: A systematic search of the available literature was performed using MEDLINE, EMBASE, Cochrane library and NHS Evidence from inception to September 2011. Terms used include facial pain and contact point (3628), rhinologic headache (6) contact point and surgery/endoscopy (38). EVALUATION METHOD: Inclusion criteria applied. Assessment of papers were undertaken by one reviewer and checked by the second. A narrative review of each study was performed and results recorded in tables. RESULTS: In one study, 973 consecutive patients with a provisional diagnosis of rhinosinusitis were divided into groups with (42%) and without facial pain. There was a 4% prevalence of nasal contact in both groups, which was unrelated to the presence of facial pain. In another study of 100 patient's coronal paranasal sinus CT scans, 29% had headache and 55% had a contact point but their presence was inversely related to the presence of pain.(1) In a further study, ten healthy volunteers had palpation, adrenaline, substance P and placebo applied to different areas throughout the nasal cavity and none of these stimuli caused facial pain. Nineteen studies were identified where nasal mucosal contact points had been removed surgically for the treatment of facial pain. They were small case series, not randomised and subject to selection bias, had no control group, a limited follow-up and were open to observer bias with level IV evidence. Seven studies had a statistically significant improvement in pain postoperatively compared with preoperative questionnaire results but the majority had residual facial pain. CONCLUSION: The majority of people with contact points experience no facial pain. The presence of a contact point is not a good predictor of facial pain. The removal of a contact point rarely results in the total elimination of facial pain making the theory that a contact point is responsible unlikely. The improvement in postoperative symptoms following the removal of contact points in some patients may be explained by cognitive dissonance or neuroplasticity. A randomised, controlled and blinded trial with a followed up period of over 12 months is needed to assess the place of surgery in the removal of a contact point for the treatment of facial pain.

12 minute consultation: evidence based management of a patient with facial pain.

BACKGROUND: There is a common misconception that facial pain and headache are mainly caused by sinusitis. The findings of nasal endoscopy, computer tomography (CT) and the results of observational studies reveal that this is not the case. Moreover, when sinus surgery is performed in patients where headache/facial pain has been a feature, it has been found that these symptoms persist after sinus surgery, particularly where there had been no nasal symptoms or endoscopic signs of paranasal sinusitis. METHODS: This review was based on a literature search performed on 30 November 2011. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading of facial pain, that is, rhinosinusitis, migraine, cluster headaches, midsegment facial pain, trigeminal neuralgia, paroxysmal hemicrania, hemicrania continua and drug-dependent headache. The search was limited to English language articles. Relevant references from selected articles were reviewed after reading the abstract. RESULTS: A review of the literature shows that headaches are rarely caused by sinusitis. Similarly, only a small proportion of patients with facial pain have sinusitis, and these patients have either acute sinusitis or an acute exacerbation of chronic purulent sinusitis. Importantly, most patients with chronic rhinosinusitis rarely have facial pain unless they develop an acute infection or suffer barotrauma. CT scans should not routinely be performed for facial pain because of the prevalence of incidental changes in asymptomatic patients. Surgery is very rarely indicated in the treatment for chronic facial pain. CONCLUSION: A structured history of the pain and its associated symptoms, nasendoscopy and relevant targeted investigations should lead to a correct diagnosis and the appropriate treatment.

Highly comparative fetal heart rate analysis.

A database of fetal heart rate (FHR) time series measured from 7 221 patients during labor is analyzed with the aim of learning the types of features of these recordings that are informative of low cord pH. Our 'highly comparative' analysis involves extracting over 9 000 time-series analysis features from each FHR time series, including measures of autocorrelation, entropy, distribution, and various model fits. This diverse collection of features was developed in previous work [1]. We describe five features that most accurately classify a balanced training set of 59 'low pH' and 59 'normal pH' FHR recordings. We then describe five of the features with the strongest linear correlation to cord pH across the full dataset of FHR time series. The features identified in this work may be used as part of a system for guiding intervention during labor in future. This work successfully demonstrates the utility of comparing across a large, interdisciplinary literature on time-series analysis to automatically contribute new scientific results for specific biomedical signal processing challenges.

The role of embolisation in ENT: an update.

OBJECTIVE: To provide an update on the ever-increasing role that embolisation plays in the practice of otolaryngology. METHOD: A literature search was performed during November 2008. The Medline, Embase, PubMed and Cochrane databases were searched. This resulted in 285 papers relevant for review. CONCLUSION: The role of embolisation has expanded greatly to include the management of refractory epistaxis, pre-operative preparation of vascular tumours, vascular injuries and as an adjunct in skull base surgery.

Evidence of an increase in the incidence of odontogenic sinusitis over the last decade in the UK.

BACKGROUND: Dental disease is a recognised cause of sinusitis. We perceived an increased incidence of sinusitis secondary to dental disease in recent years. This study reviews the incidence of odontogenic sinusitis, its clinical features and treatment. METHODS: Medical records of patients with odontogenic sinusitis were identified using the senior author's clinical database and Hospital Information Support System data (January 2004 to December 2009). RESULTS: Twenty-six patients were identified, nine females and 17 males (age range, 17-73 years). Rhinorrhoea and cacosmia were the commonest symptoms (81 and 73 per cent, respectively), with presence of pus the commonest examination finding (73 per cent). Causative dental pathology included periapical infection (73 per cent), oroantral fistula (23 per cent) and a retained root (4 per cent). In all 26 cases, treatment resulted in complete resolution of symptoms; 21 (81 per cent) required sinus surgery. The number of patients with odontogenic sinusitis undergoing surgery has steadily increased, from no cases in 2004 to 10 in 2009 (accounting for 8 per cent of all patients requiring sinus surgery). Reduced access to dental care may be responsible. CONCLUSION: The incidence of odontogenic sinusitis appears to be increasing. The importance of assessing the oral cavity and dentition in patients with rhinosinusitis is therefore emphasised.

Paranasal sinus computed tomography anatomy: a surgeon's perspective.

Computed tomography scans serve as a critical 'roadmap' for functional endoscopic sinus surgery. A systematic evaluation of such scans, and an awareness of any anatomical variants that may modify one's surgical approach, allow one to pre-empt complications. This article describes, from a novice's perspective, two methods of evaluating paranasal sinus computed tomography scans: a quick assessment technique; and a step-wise, operative approach covering radiological features relevant to pre- and peri-operative management.

Malignant melanoma of nasal cavity and paranasal sinuses: report of 24 patients and literature review.

OBJECTIVE: To report our experience of the management of patients with primary sinonasal malignant melanoma, and to review the relevant medical literature. METHOD: Retrospective review examining treatment and outcomes. RESULTS: Twenty-four patients were treated between 1982 and 2007. The mean age at presentation was 67.5 years. The overall five-year survival was 30 per cent; mean survival was three years and eight months. CONCLUSION: Sinonasal malignant melanoma is associated with a poor outcome, and survival statistics have not improved over the last 40 years. Treatment should include radical surgery wherever possible. Local recurrence is common; radiotherapy may help control this but does not appear to affect overall survival. The limited evidence available suggests that endoscopic removal of sinonasal malignant melanoma is as effective as other local surgical means, but that craniofacial resection remains the 'gold standard' for tumours that contact or traverse the skull base. Novel biological treatments are emerging and hold promise for the future.

Endoscopic trans-sphenoidal removal of cholesterol granuloma of the petrous apex: case report and literature review.

OBJECTIVE: We report a case of cholesterol granuloma of the petrous apex which was surgically treated via an endoscopic trans-sphenoidal approach. METHODS: Case report and review of the literature concerning cholesterol granulomas of the petrous apex and their management. RESULTS: The lesion was approached endoscopically via a bilateral sphenoidotomy with removal of the vomer. A large cholesterol granuloma was evacuated and marsupialised. The patient made an uneventful recovery. CONCLUSION: Trans-sphenoidal access to the petrous apex represents an alternative route for the drainage and ventilation of cholesterol granulomas. This approach is the technique of choice when the cholesterol granuloma abuts the posterior wall of the sphenoid sinus. The trans-sphenoid approach, unlike other lateral approaches to the petrous apex, spares cochlear and vestibular function and allows post-operative endoscopic follow up.

'Entopy': local allergy paradigm.

Allergy is defined as an immediate hypersensitivity type I immunological disease, which can be IgE or non-IgE driven, and in the latter case may be antibody or cell mediated. Atopy is a term used to describe individuals with a genetic predisposition for developing IgE-mediated allergic disease. But more recently, it has become evident that IgE-mediated disease can occur in non-atopic subjects. While it is now generally accepted that mucosal local IgE has a role in the expression of atopic allergic disease, the concept of 'local allergy' in non-atopic subjects has been proposed, with the term 'entopy' given to this condition. Although there is increasing evidence supporting this paradigm, entopy is only applicable to a proportion of non-atopic patients, suggesting that other disease mechanisms exist to explain non-atopic disease. This review considers the evidence for local mucosal allergy in atopic and non-atopic individuals with an emphasis on diseases affecting the upper airways and eye. Furthermore, the diagnosis, treatment and relationship between local allergy and conventional (systemic) allergy are discussed, and alternative disease mechanisms predominantly involving antibodies or their sub-components (free light chain Igs) are postulated to explain the 'entopy' paradigm. This review is intended to provide an improved understanding of the mechanisms and causes of local mucosal hypersensitivity.

Lessons learnt from an audit of 95 cases of major nasal reconstruction.

BACKGROUND: Several texts detail the possible complications of nasal reconstruction but few critically describe a series. We present an audit of the complications of 95 major nasal reconstructions. METHODS: This is a retrospective analysis of 95 consecutive major nasal reconstructions (49 male, 46 female, aged between 4 and 92 years) over a 16-year period treated in a tertiary refer-ral centre. RESULTS: Fifty-eight patients in our series required nasal reconstruction after Moh's Micrographic surgery for a morpheiform basal cell or a squamous cell carcinoma. Eight patients had further removal using frozen section to determine the margins, as the disease was very extensive. Minor procedures with local random flaps or full thickness skin grafts were excluded. Ninety-five patients underwent major reconstructive procedures and had an average of 2.8 operations. SUMMARY: The main problem was the suboptimal contouring of the alar margin in 6 of 54 patients who had a full thickness defect repaired. Other complications included telangectasia or hair growth requiring laser ablation (13), stenosis of the nasal valve area (2), ectropion after a cheek advancement flap, donor site haematoma of the pinna, and neuropathic pain.

Management of composite defects of the nose, cheek, eyelids and upper lip.

AIM: To assess the results of reconstruction of composite defects involving the nose which extend to involve the cheeks, eyelids or upper lip. STUDY DESIGN: Retrospective observational study. MATERIAL: Sixteen patients with defects of the nose extending to the adjoining cheek, upper lip or eyelid. METHOD: A combination of flaps and grafts were needed to reconstruct these defects so that the aesthetic subunits were replaced and joined at their junctions wherever possible. RESULTS: Where the defect required three or four flaps, there was some unpredictable cicatrisation at their junction that resulted in some asymmetry. This problem primarily occurred at the alar base, and was compounded if there was tissue loss of the premaxilla or maxilla. CONCLUSION: If a defect that involves the nose, cheek and upper lip is repaired with a combination of cheek advancement, nasolabial, paramedian forehead and/or septal flaps, there can be unpredictable cicatrisation at their junction, particularly at the alar base. In these circumstances, we recommend replacing the nasal and other defects with a slightly more generous amount of tissue than would be taken to repair a similar, but solitary, defect. It is important to replace any loss of the facial skeleton, in order to provide support for overlying flaps.

Prescribing antibiotics for sore throat: adherence to guidelines in patients admitted to hospital.

AIM: We prospectively studied patients referred to secondary care with acute tonsillitis, peritonsillar cellulitis and quinsy (peritonsillar abscess) to see if recommended treatment guidelines were being followed and whether antibiotic resistance was contributing to admission. STUDY DESIGN: Prospective observational study in a university teaching hospital of 90 consecutive patients admitted to secondary care over an 18 month period with acute tonsillitis, peritonsillar cellulitis or quinsy were studied. The geographical distribution by postcode, pre-admission history and treatment of each patient was recorded. The patients' general practitioners (GPs) were questioned about the patients' history, their use of antibiotics and prescribing guidelines and a patient questionnaire was completed. The result of hospital admission including throat swabs and blood cultures were recorded together with their treatment and outcome. RESULTS: 58% (n = 28) of patients who were prescribed antibiotics before admission received an inadequate dose or inappropriate antibiotic. Only 56% (n = 45) of GPs said they used guidelines for the treatment of acute sore throat. In 34 cases an organism was isolated, with 33 (97%) being sensitive to penicillin. No resistant organisms were isolated. Hospital doctors prescribed antibiotics contrary to guidelines in 39% (n = 35) of cases. CONCLUSIONS: Antibiotic resistance was not demonstrated in this study. Adherence to guidelines for prescribing antibiotics in patients with features of group A beta-haemolytic streptococcal sore throat is poor. Information support may help to improve prescribing.

Differential protein expression by dendritic cells from atopic and non-atopic individuals after stimulation by the major house dust mite allergen Der p 1.

BACKGROUND: Dendritic cells (DCs) are sentinels of the immune system and are known to play a key role in allergic responses. However, it is not clear how DCs that have been exposed to an allergen support Th2 type immune responses. It is possible that DCs from atopic individuals are inherently programmed to support allergic disease, or it is the exposure of dendritic cells to allergens that is key to the development of allergic sensitisation. METHODS: We used 2D gel electrophoresis and MALDI mass spectrometry to compare the proteome of DCs from atopic and non-atopic individuals in both the resting state and after stimulation with the major house dust mite allergen Der p 1. RESULTS: Our data show that unstimulated DCs from atopic and non-atopic individuals are very similar at the whole cell proteome level, showing few differentially expressed proteins. However, upon stimulation with Der p 1, a number of additional proteins are differentially expressed, and of these several were of potential relevance to Th2 cell differentiation and the allergic response, including GTP-binding regulatory protein Gi alpha-2, frabin and cathepsin D. CONCLUSION: Whilst there are inherent differences between DCs from atopic and non-atopic individuals, it seems that exposure to allergen plays a key role in differential expression of proteins by these key immune cells. Further studies should now focus on establishing the biological relevance of these proteins as biomarkers in house dust mite allergy and their role in allergen induced Th2 cell differentiation.

Profuse epistaxis following sphenoid surgery: a ruptured carotid artery pseudoaneurysm and its management.

OBJECTIVE: We report a rare case of iatrogenic pseudoaneurysm of the internal carotid artery secondary to endoscopic sphenoid surgery. METHOD: The management of this unusual complication and a review of the literature are presented. RESULTS: A 65-year-old woman presented with intractable epistaxis four days following endoscopic sphenoid sinus surgery. Initial, conservative measures were unsuccessful in controlling bleeding. The clinical picture of delayed, severe epistaxis after a sphenoid sinus exploration raised the possibility of injury to the internal carotid artery and subsequent formation of a false aneurysm. The patient's pseudoaneurysm was managed, without visualising it, by packing the sphenoid sinus (achieved by palpating 1 cm above the shoulder of the posterior choana) in order to gain control of the haemorrhage, followed by endovascular occlusion. CONCLUSION: An awareness of this rare complication is essential in order to manage this life-threatening condition efficiently.

Squamous cell carcinoma of the nasal vestibule: a 20-year case series and literature review.

Squamous cell carcinoma of the nasal vestibule is a rare disease with significant morbidity and mortality, and a five-year recurrence-free survival rate of between 42 and 92 per cent. There are several staging systems: the American Joint Committee on Cancer (AJCC) skin and nasoethmoid complex system, the Union International Centre Cancer (UICC) nasal fossa system, and Wang's system. Treatment options include radiotherapy or surgery for early lesions, but more advanced cases require radical surgery with post-operative radiotherapy. We present a case series spanning the last 20 years in one centre, and we compare this series with cases reported in the literature, paying particular attention to staging, treatment and outcome. We found that patients with tumours staged T2 or T3 (Wang system) who received radiotherapy alone did poorly in comparison with those who received surgery or surgery and radiotherapy.