Chronic
Headache: The role of the Nasal Septum Deformity
..........................................................................................................................
Abed
Rabu Qubilat FRCS*, Nemer Al-Khtoum MD*
*
From department of Otolaryngology,
King Hussein Medical Center, Royal Medical Services
(Amman-Jordan).
Correspondence
to:
Dr. Nemer Al-Khtoum.
P.O. Box 1834 Amman 11910 Jordan.
Email: nemer72@gmail.com
..........................................................................................................................
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ABSTRACT
Objective:
To investigate the nature of these headaches
and the outcome following septal surgery.
Patients
and Methods: Fifty-eight patients of
either sex and above the age of sixteen
years who presented to Otorhinolaryngology
clinic suffering from symptomatic nasal
obstruction due to deviated nasal septum,
were involved in the study.
Patients
with significant rhinitis and sinusitis
diagnosed by history, physical examination,
sinus X-rays, and antral lavage, were excluded
from the study.
ll patients
had submucous resection (SMR) of the deviated
nasal septum and were followed up in the
clinic for 6-24 months postoperatively (mean
13 months).
Results:
Twenty-five patients (43%) had headaches
preoperatively occurring at least once a
month for 1 to 10 years (mean 4.5 years).
The
site where the headache was most intense
was most frequently found over the frontal
region (58.9%). It was described mainly
as pressure-like (47.4%) or dull (35.2%);
occurring frequently in the mornings (37.6%).
After
surgery, eighteen of the 25 patients with
headaches (72%) experienced relief of their
headaches at a mean follow-up period of
13 months.
Conclusion:
Nasal septum deformity is presented as an
easily diagnosed and readily correctable
cause of chronic headache within the confines
of proper diagnostic evaluation and thorough
elimination of other more serious causes
of facial pain and headache.
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Key
words: Headache, Deviated nasal septum, Sub-mucous
resection
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Chronic recurrent frontonasal
headache is a very common complaint which may
lead the patient to seek the services of physicians
in a wide variety of medical and surgical disciplines.
The etiology of these symptoms can run the gamut
from rudimentary tension headache to frontal sinusitis
and finally to a serious intracranial neoplasm.
It is rewarding and refreshing to present a cause
for such facial pain and headache, which is readily
diagnosed and highly amenable to surgical intervention
and is rarely accompanied with postoperative complications.
Headache is reported as a secondary
symptom to nasal obstruction owing to septum deviation
in rates that range from 23%1 to 58%2, and its
surgical correction would lead not only to improvement
of nasal obstruction, but also headache 3. Alternatively,
it is also observed that failure of surgical treatment
to control pain may be related to persistence,
at least partial, of nasal obstruction 4.
Much interest has been focused
on the improvement in nasal patency following
septal surgery. To date, few studies have evaluated
the incidence and nature of headaches associated
with nasal obstruction due to septal deformity
and the effects of septal surgery. Several mechanisms
have been proposed to account for these associated
headaches.
Experimentally-applied stimuli
of touch, pressure, and faradic current to various
parts of the nasal lining in humans resulted in
referred pain which was mainly aching in nature
and unless applied to superior nasal structures,
maxillary in distribution5.
A deviated nasal septum coming
in contact with the lateral nasal wall structures
may be the stimulus, giving rise to referred headaches6,7.
A second mechanism of headache production by a
deviated nasal septum may be through blockage
of the sinus ostia 8. This may be secondary to
mechanical obstruction by the deviated septum
or by local accumulation of mucosal tissue fluid,
secondary to a narrowed nasal passage, based on
the Bernoulli phenomenon9. The compromised sinus
outlets then result in poor aeration of the sinuses
leading to "vacuum" or "hypoxia"
headaches8.
The aims of this study were
to investigate the nature of these headaches and
the outcome following septal surgery.
The sample of this study was
conducted in Otorhinolaryngology department at
King Hussein Medical Center (Jordan).
Fifty-eight patients of either
sex and above the age of sixteen years who presented
to Otorhinolaryngology clinic suffering from symptomatic
nasal obstruction due to deviated nasal septum
were involved in the study.
All patients underwent a detailed
history taking with special emphasis on history
of headache and nasal obstruction and a thorough
general examination; systemic examination and
examination of the nose, throat and ears including
nasopharyngoscopy as well as complete neurological
examinations.
Patients with significant rhinitis and sinusitis
diagnosed by history, physical examination, sinus
X-rays, and antral lavage, were excluded from
the study.
All patients had submucous
resection (SMR) of the deviated nasal septum and
were followed up in the clinic for 6-24 months
postoperatively (mean 13 months).
The number of patients involved
in the study was 58 (8 females and 50 males) with
a mean age of 32 years (range 16 to 43 years).
Twenty-five patients (43%) had headaches preoperatively
occurring at least once a month for 1 to 10 years
(mean 4.5 years).
The site where the headache
was most intense was most frequently found over
the frontal region (58.9%). Other sites include
maxillary, temporoparietal, nasal bridge and orbital
regions.
Regarding the nature of headache,
it was described mainly as pressure-like (47.4%)
or dull (35.2%); occurring frequently in the mornings
(37.6%).
After surgery, patients were
divided into two groups based on the relief of
their headache at a mean follow-up period of 13
months.
Group I consisted of patients
with relief of headaches (18 cases, 72%).
Group II consisted of those
with no relief of headaches (7 cases, 28%).
Regarding the characteristics
of headache, there was significant difference
between the two groups for frontal headaches (11
and 3 cases in group I and II respectively) and
for pressure-like headaches (10 and 2 cases in
group I and II respectively), but not for headaches
in the mornings.
There is significant difference
between the two groups for postoperative relief
of nasal obstruction (16 and 4 cases in group
I and II respectively).
Headache may
be caused by a nasal passage abnormality; there
is almost no limit to the many forms of deviation
of the nasal septum, which can be found in the
nasal passages. The majority of these deviations
are traumatic in origin, but a small percentage
is congenital 10.
Deviations of
the nasal septum may be only minimal or they
may be severe. Some will produce nasal obstructions
and some will not. For example, a mere slight
deviation may produce nasal airway obstruction
if it is in the valve area. This, however, usually
will not produce pressure on the lateral nasal
wall and will, therefore, not result in headache.
On the other hand, there can be marked septal
deviation in another area, which does not result
in airway obstruction. Nasal septum obstruction
actually is a deviation resulting in contact
with the lateral nasal wall 1.
A severe deviation
of the nasal septum is often called septal impaction.
This consists of a marked deviation of the septum
(or a large septal spur) that exerts pressure
upon the lateral nasal wall, which is not relieved
by vasoconstriction. Some septal deviations
will contact the lateral nasal wall, but on
vasoconstriction, the turbinate tissue will
become smaller and the contact with the lateral
nasal wall will be alleviated 11.
Either of these
conditions can be an etiological factor in headache.
This is especially true in the case of septal
impaction. Not all patients who have septal
impactions, however, experience headache 12.
Regardless of the presence of nasal septal deformities,
little is said about the functional aspect,
that is, the correlation between nasal obstruction
per se and headache. We know that many authors
consider headache as an associated symptom of
nasal obstruction, and it is the second most
common cause presented by these patients 1,2,11.
Regardless of the anatomical variation that
causes obstruction, nasal poor ventilation and
consequently complementary oral breathing lead
to other pathophysiological mechanisms, such
as absence of nasopulmonary reflex, with ventilation
repercussion of pulmonary expansion, in addition
to posture affections, reaching areas that go
beyond the care provided by Otorhinolaryngologists.
In the present
study, 43% of patients with blocked nose secondary
to deviated nasal septum had associated recurring
headaches, the frequency comparable to those
from other studies 1,1,13,14.
The headaches in the present study were mainly
pressure like and most intense over the frontal
region, and similar to those observed by Schonsted-Madsen
et al 11 in their study of patients with nasal
obstruction and headaches.
Around the turn
of the century, several reports in the otolaryngology
literature described patients whose headache
resolved with certain nasal operations to correct
an anatomical abnormality (such as a deviated
septum) 15,16. However, there is correlation
between improvement of nasal obstruction and
improvement of headache in patients submitted
to nasal surgical treatment such as septoplasty
1,2,3. What is the importance of each mechanism
of symptom relief? Otorhinolaryngologists tend
to locate the reasons for surgical procedures
in nasal structures rather than in systemic
mechanisms.
In the present study relief of headaches after
surgery occurred in 72% of patients, which is
comparable with other studies 2, 3.
Nasal septum
deformity is presented as an easily diagnosed
and readily correctable cause of chronic headache
within the confines of proper diagnostic evaluation
and thorough elimination of other more serious
causes of facial pain and headache.
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- Low WK, Willatt DJ. Headaches associated
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