Correlation of nasal symptoms with objective findings and surgical outcome measurement

Thesis submitted for the degree of Master of Surgery, University of London, 1993.
Published (excluding Chapter 9) 1996.
Recompiled HTML format June 2007
© 1993 – 2014 JW Fairley

Mr James W Fairley BSc MBBS FRCS MS
Consultant ENT Surgeon

Chapter 8
The effect on symptoms of facial pain and headache of medical treatment and operations designed to remove endoscopically documented areas of mucosal contact between the turbinates and nasal septum

Thesis Contents

Summary

There are difficulties, both theoretical and practical, in attributing facial pain and headaches to nasal mucosal contact pressure zones (MCPZ).

Since it is often impossible to state with confidence in a particular patient that a particular abnormality is the cause of the pain, a reasonable approach is to treat the abnormality and see whether the pain is relieved.

In this clinical study, a therapeutic trial is used to provide evidence that mucosal contact pressure zones do cause facial pain and headache, and to look for any factors which might give help in deciding which cases to operate on.

Twenty one patients were selected from a special nasal research clinic.

They were complaining of

  • facial pain or headache of at least moderate severity (Grade 2 or 3 on a scale from 0 – 3)
  • mucosal contact pressure zone(s) between middle or inferior turbinate and nasal septum were visible on rigid endoscopy, and
  • there was no evidence of sinus infection.

All patients underwent initial treatment with topical nasal steroids for at least 6 weeks.

If a good response was obtained to medical treatment, the patient was given the option of titrating the dose down against the symptoms, or opting for surgery to try and effect a permanent cure.

Patients who failed to respond, or who only had partial response to topical nasal steroids, were offered surgery designed to eliminate the mucosal contact pressure zone.

Surgery consisted of either septoplasty, subtotal resection of the turbinate, or both septoplasty and turbinate reduction.

In sixteen patients followed up for between 6 months to one year, mucosal contact pressure zones between the turbinates and septum were successfully eliminated in all cases.

Facial pain and headache were successfully relieved in 12/16 cases.

The patients were carefully selected to ensure that the MCPZ was the only abnormality present. Of the four failures, two were in depressed patients, two had undiagnosed sphenoidal sinus infection (including one of the depressives), and one failed for unknown reasons.

Facial pain and headaches can be relieved in around 75% of cases by a combination of topical nasal steroids and nasal surgery.

Introduction

The difficulties, both theoretical and practical, in attributing facial pain and headaches to nasal mucosal contact pressure zones (MCPZ) have been thoroughly discussed in the preceding chapters.

Since it is often impossible to state with confidence in a particular patient that a particular abnormality is the cause of the pain, a reasonable approach is to treat the abnormality and see whether the pain is relieved.

In this clinical study, a therapeutic trial is used, following in the tradition of Yankauer (1908) Sluder (1918) and Brown Kelly (1943).

The aims are:

  1. To provide evidence by therapeutic trial whether mucosal contact pressure zones do cause facial pain and headache.
  2. To look for any factors which might give help in deciding which cases to operate on.

Method

Patients with the following characteristics were selected from the author’s Nasal Research Clinic:

  1. Complaining of facial pain or headache of at least moderate severity (Grade 2 or 3 on a scale from 0 – 3; 0 = none, 1 = mild, 2 = moderate, 3 = severe)
  2. Mucosal contact pressure zone between middle or inferior turbinate and nasal septum visible on rigid endoscopy
  3. No evidence of sinus infection

133 out of 167 patients listed on the Nasal Research Clinic computer file scored 2 or 3 (moderate to severe) for either headaches or facial/eye pain on their first attendance. Of these, 78 had endoscopically documented mucosal contact pressure zones, 68 of which were involving the nasal septum. 46 of these had evidence of sinus infection (history of purulent discharge, positive antral washouts, radiological evidence or rhinoscopic evidence of pus or inflamed mucosa in the middle meatus). One was an obvious case of trigeminal neuralgia, leaving 21 eligible for the study. Four of these were assessed and given medical treatment, but then lost to follow-up. One has only a few weeks follow-up since operation. This left 16 patients fulfilling all the criteria in whom follow-up data was available. There were 10 men and 6 women, mean age 40 years, range 22 to 64. The median length of history of pain was 9 years, range 1 to 20 years.

Medical treatment

All patients underwent initial treatment with topical nasal steroids. In most cases this consisted of Betamethasone drops in the head down and forward position, for at least 6 weeks. A modification of the “Praying to Mecca” method (Chalton et al 1985) was used, with the patient leaning over the corner of a table. The modified method is considerably easier for the patient (Mackay I.S., personal communication). A leaflet explaining the technique was given to each patient (Figure 8.1). In some cases Beclomethasone aqueous spray was used, again for at least 6 weeks.

Surgical treatment

If a good response was obtained to medical treatment, the patient was given the option of titrating the dose down against the symptoms, or opting for surgery to try and effect a permanent cure. Patients who failed to respond, or who only had partial response to topical nasal steroids, were offered surgery designed to eliminate the mucosal contact pressure zone. Surgery consisted of either

  1. Septoplasty / Submucous resection
  2. Subtotal reduction of turbinate
  3. Septal surgery and subtotal turbinate reduction.

In each case, surgery was done specifically for the indication of pain relief, not to relieve airway obstruction. Three patients had successful reduction of pain from medical treatment alone (Betamethasone drops in the head-down-and-forward position) and decided that this was sufficient and had no operation. Eight patients had septal surgery alone, four had septal surgery combined with middle or inferior turbinate reduction, and one had bilateral middle turbinectomies only.

Outcome measures

The primary outcome measure was the reduction in subjective symptom scores for pain & headache 1 year following treatment.

Outcome was classified as successful if both facial pain and headache scores were reduced to 0 (none) or 1 (mild).

The technical success of treatment in eliminating mucosal contact pressure zones was documented endoscopically.

The need for further surgery was a secondary objective measure of outcome.

Statistical methods

No formal statistical tests were done because of the small numbers and absence of a control group for comparison.

Figure 8.1 Leaflet given to patients showing how to use nose drops

How to use your nose drops - Royal Hallamshire Hospital Ear Nose & Throat Department

Results

In all 16 cases, mucosal contact pressure zones were successfully eliminated, in three cases by medical treatment alone.

Subjective symptoms of pain and headache were successfully relieved in 12 cases.

No patients were made worse and there were no complications.

Of the four failures, two had undiagnosed sphenoidal sinus infection which became apparent during follow-up nasendoscopy. Two patients were depressed, including one of the sphenoidal cases. One patient persisted with pain and headache for unknown reasons.

Discussion

These results show that medical and surgical treatment designed to eliminate mucosal contact pressure zones between the turbinates and septum can be effective in treating facial pain and headache.

The overall success rate in this small series was 75% and no patients were made worse. These patients were carefully selected to ensure that the MCPZ was the only abnormality present. Despite this, two of the failures had undiagnosed sphenoidal sinus infection. Two patients were depressed (including one of the sphenoidal cases) and one remains unexplained (he was a law student and planned to specialise in medico-legal work).

By definition, all the failures were in the surgical group, since the patients who declined surgical treatment were those who had obtained sufficient relief from the topical steroids. Within the surgical subgroup, therefore, the success rate is only 69%.

The technical success rate of treatment in eliminating the mucosal contact pressure zones was 100%, but this does not translate into 100% success rate from the patients’ point of view. In fact, a 69% – 75% success rate sounds worryingly similar to the sort of figures associated with other dubious procedures like saccus decompression for Ménière’s disease….. (McKee et al, 1991).

Sanderson and Rivron (1992) reported successful reduction of facial pain symptoms in a series of 60 patients undergoing septal surgery, although only 26 scored greater than 50 on a visual analogue scale from 0 to 100 pre-operatively. 90% had some degree of reduction in the symptom of facial pain. These patients had no plain X-ray evidence of sinus infection, however the authors do not report detailed rhinoscopic findings, and do not mention the incidence of mucosal contact pressure zones. Some authors quote incredibly high success rates from nasal surgery for facial pain and headache, even in cases of migraine. Hoover (1992) reported that 99.5% of 441 migraine patients were free of headaches following a combination of medical and surgical treatment of the nose. Bonaccorsi (1992) quotes an overall 88% success rate for nasal surgery in a series of 1,000 “primary neurovascular headaches” treated by “neurovascular decompressive septo-ethmoidosphenectomy”. Novak (1992) operated on 299 patients with migraine, cluster and idiopathic headaches, using a standard technique of septal correction, middle turbinectomy and ethmoido-sphenoidectomy. He states that 78.8% were cured completely and 11.3% improved.

Others remain sceptical and advise strongly against surgery unless there is good evidence of sinus infection (Ryan & Ryan, 1979; Couch, 1988; Friedman & Rosenblum, 1989).

ENT surgery can make pain worse. Kuhner (1988) treated 48 patients with atypical facial pain by destruction of the trigeminal nerve. Most of these patients had got worse after ENT or dental operations elsewhere. Following ablation of peripheral trigeminal nerve pathways, 58% of 36 patients deteriorated even further, some attempting suicide.

None of these studies include a control group. The same criticism applies to my own work. It is difficult to think of a surgical control group that would be both scientifically valid and ethical. It would be ethical to have patients on a waiting list for surgery as a control group, but this would not stand up to critical scientific analysis. A better control group would be patients undergoing sham operations – perhaps raising the mucoperichondrial flaps but not resecting anything, leaving the anatomical deformity intact. However, even raising a flap could have an effect on local innervation, vasculature and lymphatic drainage. It is also doubtful whether sham surgery would be ethical in the face of a 69% success rate for the “proper” operation, despite the precedent of the Copenhagen study of Ménière’s disease (Bretlau et al, 1984).

If we accept that surgery is effective in some cases, there are several possible pathophysiological mechanisms by which it may act.

Firstly, the putative peripheral source of noxious stimulation i.e. pressure between apposing mucosal surfaces is removed.

Secondly, sensory neural input could be reduced or interfered with (implying that nasal surgery could be effective even if the abnormality being corrected was not itself the cause of the pain).

A further explanation favoured by Bonaccorsi (1992) Blondiau (1992) and Novak (1992) is that stenoses and mucosal contact zones in the roof of the nose and ethmoids predispose to venous stasis. This could result in local accumulation of vasoactive chemical mediators such as histamine, serotonin and Substance P, which may sensitize nociceptive trigeminal nerve endings. Arborising unmyelinated nerve endings are common in the lamina propria of the nasal mucosa. Some of these are parasympathetic efferents, the remainder are most probably multi-modality C-fibre afferents, since electron microscope studies have shown that there are no specialised receptor organs (Cauna et al, 1969; Cauna, 1970; Jafek, 1983; Widdicombe, 1986). Their normal physiological function is to act as the afferent arm for protective reflexes such as sneezing, increased secretions and mucosal swelling, and also in the regulation of respiration and pulmonary reflexes (Drettner, 1970; Berger et al, 1977; Lunblad, 1984; Widdicombe and Tatar, 1988).

As well as the conventional parasympathetic neurotransmitter, acetylcholine, several vasoactive neuropeptides have been identified in trigeminal afferent C-fibres in the nasal mucosa. These include Substance P (SP), Neurokinin A (NKA) Vasoactive Intestinal Polypeptide (VIP) and Calcitonin Gene Related Peptide (CGRP) (Lunblad et al, 1983; Uddman et al, 1983; Lacroix, 1989; Stjärne, 1991).

Low doses of capsaicin, the pungent agent in red pepper, stimulate sensory nerves to release neuropeptides locally as well as central reflexes (Lunblad et al, 1983; Lunblad 1984). This causes acute pain as well as sneezing, rhinorrhoea and blocking of the nose, due to vasodilatation and increased microvascular permeability with plasma extravasation. Repeated administration of capsaicin is neurotoxic, causing specific degeneration of this sub-population of peptide-secreting neurons, and has been reported as effective in controlling symptoms of hyperreactive rhinopathy (Lacroix et al, 1991; Stjärne, 1991).

CGRP is released into the venous effluent of the nasal mucosa following in-vivo antidromic stimulation of the maxillary division of the trigeminal nerve. Exogenous SP, CGRP and VIP cause concentration dependent vasodilation.

These observations provide the basis for a neurogenic theory of nasal polyp formation in areas of mucosal apposition (Stammberger and Wolf, 1988) as well as a pathophysiological substrate for facial pain and headache. Taken together with the experimental work of Wolff (1943), confirmed by my own physiological experiments (Chapter 3 of this thesis) on pain caused by pressure applied locally to the nasal mucosa, and my statistical study of the relationship between the distribution of pain and endoscopic abnormalities (Chapter 5) there is a reasonable body evidence from independent sources that mucosal contact pressure zones in the nose can cause facial pain and headaches, and that medical and surgical treatment can be effective in such cases.

In deciding which cases to operate on, it is important to bear in mind the fact that mucosal contact pressure zones can exist asymptomatically, so there will be cases where pain and anatomical abnormalities are coincidental. No-one should be offered a guaranteed cure. The psychological state of the patient should be taken into consideration. Two of my failures were in depressed patients, but I would not refuse to operate on the grounds that the patient is depressed. The depression could be exacerbated by a treatable cause of pain. I would proceed with caution, ensure that antidepressant medication had been given a fair trial, and warn the patient that there is a possibility of surgery making matters worse. Fortunately, none of my patients were made worse, but this is a small series with relatively short follow-up and the experience of Kuhner (1988) is worrying.

Conclusions

In a carefully selected series of patients with endoscopically documented mucosal contact pressure zones between the nasal turbinates and septum, headaches and facial pain was successfully relieved in 75% of cases by a combination of topical nasal steroids and nasal surgery. The technical success rate of treatment in eliminating mucosal contact pressure zones was 100%, but this does not automatically translate into a 100% success rate in relieving symptoms.

Implications

Since it is not possible to state with confidence in any given case whether pain is likely to be due to nasal conditions in the absence of obvious signs of inflammation, a reasonable approach clinically would be to offer correction of the abnormalities on the basis that the success rate of treatment is around 69 to 75%. In failed cases, particular care should be taken to detect previously undiagnosed sinus infection e.g. in the sphenoid, and depression.