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Nothing metaphorical about it

Headaches, facial pain and sinusitis can acutely test a medical practitioner's clinical acumen. Dr. RAVI K. VISWANATHAN looks at a diagnostic dilemma in ENT practice.

A common symptom every one has experienced, at one time or the other, and to varying degrees of severity and frequency, is a headache and facial pain. Some choose to ignore it, some pop in pain killers, while still others go from general practitioner to specialist and super specialist, with no remedy in sight.

Indeed, headaches, facial pain and sinusitis, can acutely test a medical practitioner's clinical acumen.

Facial pain has significance and ENT surgeons are aware of the importance of the face. Going by the dictum the face is the "window of our soul", and the only part of the body open to unhindered observation, it is not surprising that any pain or blemish here generates maximum adverse emotional response from the sufferer.

The appreciation (or should I say suffering) of pain is through special receptors, called nociceptors, in the skin and the muscles of the head and face, which convey the pain sensation through the sensory nerves to the Vth, Cranial nerve nucleus, and the brainstem. They react specifically to mechanical, thermal and chemical stimuli. The different nerves carrying the pain sensation from the other cranial nerves, also relay in the spinal tracts and, therefore, the pain sensation carried by them is not only poorly localised but also dull in character.

These fibres, irrespective of their origin, are all gathered together in a bundle in the brainstem, and run in the spinal tract of the Vth, Cranial nerve, whence they are carried to the thalamus and connect it to the frontal lobes. It is these fibres which are responsible for the emotional response of the patient, to the pain.

The headache and facial pain confused most with sinusitis is the group included under vascular neuralgias. The underlying mechanism is through irritation of the nerve endings surrounding the blood vessels, causing episodic vasodilatation. The pain therefore is distributed along the territory of blood vessels, rather than along the distribution of nerves.

In some forms of vascular pain, involvement of the nose, produces congestion, a running nose, and watery eyes, thus adding to the confusion with sino-nasal disease. To complicate matters further the vascular pain is also often aggravated by activity which increases pressure in the blood vessels, (e.g.) bending forwards, coughing and exercise.

Sinusitis has been one of the commonest entities to be blamed for persistent, constant chronic headaches. It is therefore of utmost importance to have a thorough diagnostic approach to the problem. This would include a proper and complete history; a complete physical examination and special diagnostic studies.

The diagnosis of acute sinusitis is considered when symptoms of upper respiratory infection persist beyond 10 days and do not improve or when symptoms are more severe than usual.

Symptoms that persist for more than 30 days suggest the diagnosis of chronic sinusitis, and include purulent nasal discharge, nasal obstruction, postnasal drainage, fetid breath, headache, behaviour changes in children, and cough.

Allergic sinusitis may be seasonal, with acute exacerbations during specific times of the year. Pollutants, allergens can trigger off an acute attack in an already predisposed individuals, who may suffer from wheezing, asthma, or atopic dermatitis. Control of these patients with antihistamines, and local nasal steroidal and non steroidal sprays may well help to differentiate this from of sinusitis from infective sinusitis.

Symptoms of chronic sinusitis are multiple and frequently vague and non specific. Physical examination of the sinuses is not possible. As a result radiological studies have become important. However, the radiological diagnosis of sinusitis does not automatically confirm the sinuses as the site of pathology and the source of headaches.

The advent of the sinus endoscope has revolutionised things. Gone are the days of sinus punctures and antral washouts. Today, surgery has become more precise, functional, conservative and curative.

The video diagnostic nasal endoscopy is useful in enabling a precise diagnosis. Video endoscopic photography is helpful in precise documentation, before and after surgery. Virtual endoscopy, is an exciting and visually striking new radiographic technique, that may change the way we perceive, investigate and treat disorders of previously inaccessible areas of the body.

Added to all this, the dimension of laser endoscopic sinus surgery has made surgery of the sinuses, least painful. Yet another technological marvel is the image guidance system, designed to assist the surgeon in performing a safer, more thorough procedure.

State-of-the-art optical localising technology coupled with dynamic referencing system provides continuous accuracy.

Conclusion: Headache, facial pain, and sinusitis, can indeed be a diagnostic dilemma. Medical treatment would involve a wide range of drugs, and would cure if the cause is treated, and the diagnosis is right.

The guiding thought in sinus surgery is the preservation of structure and the reestablishment of function, by preserving the mucous membranes. To remove as little as possible, and of the covering membranes, is stated as the condition sine qua non for rapid and certain recovery. Today, whatever may be the advancements in visualisation, radiography and surgical techniques, the physician or surgeon should not forget the cardinal principle in any treatment ... do no harm ...

Common causes