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Volume24•Issue1•January-March2022
SAUDIJOURNALof
OTORHINOLARYNGOLOGY
HEADandNECKSURGERY
www.sjohns.org
AnOfficialPublicationofSaudiOtorhinolaryngologySociety
© 2022 Saudi Journal of Otorhinolaryngology Head and Neck Surgery | Published by Wolters Kluwer - Medknow 35
Abstract
Background: Headache is a universal clinical presentation in the course of everyone’s life. In
Rhinogenic contact point headache (RCPH), intranasal mucosal contact points are seen between
the opposing mucosal surface of the nasal septum and turbinates of the lateral wall of the nasal
cavity. Objective:To study the details of endoscopic treatment of RCPH and its eectiveness to
relieve headache. Materials and Methods: There were 68 patients of RCPH who participated
in this prospective study. The mucosal contact points inside the nasal cavity were excised by the
endoscopic approach under general anesthesia. The olfactory mucosal lining was protected from
injuryduringthissurgicalprocess. P <0.05 wereconsideredstatisticallysignicant.Results:Outof
68patientswithRCPHparticipatedinthisstudy with 38 (55.88%) males and 30 (44.11%)females
with a male‑to‑female ratio of 1.26:1. All patients underwent endoscopic excision of the intranasal
mucosal contact points. After 3 months of endoscopic excision of the intranasal mucosal contact
points,the symptomsdisappearedin52 (76.47%)patients,and signicantlyimprovedin13(19.1%)
patients. Only 3 (4.41%) patients did not show obvious improvement. Satisfactory results were
archived by endonasal excision of the mucosal contact points in 65 (95.58%) patients with RCPH.
Conclusion:RCPHisanimportantcauseofheadache.Endoscopicsurgicalexcisionoftheintranasal
mucosalcontact pointsinpatients ofRCPHis usefultorelieve headacheeectively.
Keywords: Deviated nasal septum, endoscopic surgery, rhinogenic contact point, septoplasty, spur
Endoscopic Treatment of Rhinogenic Contact Point Headache‑Our
Experiences at a Tertiary Care Teaching Hospital of Eastern India
Original Article
Santosh Kumar
Swain,
Rohit Agrawala
Departments of
Otorhinolaryngology and
Head and Neck Surgery, IMS
and SUM Hospital, Siksha
“o” Anusandhan University,
Bhubaneswar, Odisha, India
How to cite this article: Swain SK, Agrawala R.
Endoscopic treatment of rhinogenic contact point
headache-our experiences at a tertiary care teaching
hospital of Eastern India. Saudi J Otorhinolaryngol
Head Neck Surg 2022;24:35-9.
Received: 22-01-22 Revised: 12-02-22
Accepted: 19-02-22 Published Online: 30-03-22
Introduction
Headache is a common symptom
experienced by a person during his or her
life period. Patients with headache often
attend the otolaryngology clinic to rule out
sinusitis or sinonasal cause. The headache
is often classied into three groups such
as headache due to sinonasal pathology,
headache not associated with sinonasal
pathology which includes migraine,
neuralgias, vascular and seasonal allergies,
and third group include headache by sinus
origin but cannot be identied.[1] The third
group of headache includes rhinogenic
contact point headache (RCPH). Intranasal
mucosal contact point results in headache,
called RCPH is a newly added secondary
headache disorder in the International
Classication of Headache Disorders‑2.[2]
RCPHisanewterminologyinthemedical
literature where patients present with
intranasal mucosal contact points because
of anatomical variations in the nose in the
absence of inammation in the sinonasal
tract and patients present with headache.[3]
RCPH provides a painful sensation in the
face and head due to intranasal mucosal
contact points without any inammatory
ndingsormasslesions.[4]Thepathogenesis
oftheRCPHisstillasubjectofcontroversy.
It often needs a multidisciplinary approach
forgetting the exact cause of the headache
and prompt treatment. This study aims
to assess the eectiveness of endoscopic
treatmentof RCPH.
Materials and Methods
This prospective study was conducted at
the department of otorhinolaryngology and
head and neck surgery of a tertiary care
teaching hospital from December 2018 to
January 2022. This study was approved by
the Institutional ethical committee (IEC)
with a reference number of IEC/IMS/
SOA/84/12.08.2018. Informed consent
was obtained from all the participants of
this study. The inclusion criteria of the
participantsofthisstudyinclude:(1)History
Access this article online
Website: www.sjohns.org
DOI: 10.4103/sjoh.sjoh_4_22
Quick Response Code:
Address for correspondence:
Prof. Santosh Kumar Swain,
Department of
Otorhinolaryngology and
Head and Neck Surgery,
IMS and SUM Hospital,
Siksha “o” Anusandhan
University, K8, Kalinga Nagar,
Bhubaneswar - 751 003,
Odisha, India.
E-mail: santoshvoltaire@yahoo.
co.in
This is an open access journal, and arcles are
distributed under the terms of the Creave Commons
Aribuon‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Swain and Agrawala: Endoscopic treatment of rhinogenic contact point headache‑our experiences at a tertiary care teaching hospital of eastern India
36 Saudi Journal of Otorhinolaryngology Head and Neck Surgery | Volume 24 | Issue 1 | January-March 2022
of long‑standing headache at least 6 months; (2) Absence
of sinonasal inammatory ndings; (3) No olfactory
disorders, no sinonasal tumors; (3) Lack of any causes of
headache after a thorough evaluation by ophthalmologist,
neurologist, dentists, orthopedic specialist, internist, and
otherrelatedspecialists;(4) Presence ofintranasalmucosal
contact points between any turbinates with septum which
conrmed by diagnostic nasal endoscopy [Figure 1] or
computedtomography(CT) scan ofthenoseandparanasal
sinus [Figure 2]; (5) Failure of medical treatment for at
least3 months forheadache (topical corticosteroidssprays
andunarizine).Atotalof68patientswereenrolled inthis
study. The intensity of the headache/pain was evaluated
withhelpofthevisualanalogscore(VAS).Theseverityof
the headache was graded on a scale of 0–10 points where
0 indicates trouble‑free and 10 indicates worst thinkable
troublesome.WedocumentedtheVAS,theaveragenumber
of headache attacks per month, and the mean duration
of each attack of headache before and after endoscopic
excision of the intranasal mucosal contact points. The
results were evaluated postoperatively at 3 months for a
follow‑upvisit.
Surgical technique
The endoscopic surgical approach for RCPH was done
under general anesthesia. All the endoscopic surgical
excision of the intranasal mucosal contact points was
performed by the senior author. Patients RCPH with
deviated nasal septum or spur underwent endoscopic
septoplasty along with excision of the mucosal contact
point.Septoplastywasperformed rst and then the middle
turbinate was lateralized to expose the superior turbinate
and superior meatus. Then posterior ethmoidectomy was
performedandthemedial wall of the ethmoid sinuseswas
excised.Afterward, the boneandmucousmembrane under
the armpit of the superior turbinate and 1/3rd of the lower
portion of the superior turbinate were excised. Then, the
superior turbinate was lateralized to remove the mucosal
contact between the nasal septum and superior turbinate.
The olfactory mucosal lining was not injured during this
surgical process. In the case of mucosal contact points on
bothsidesofthenasalcavity,thesurgeryonbothsideswas
done at the same time after the completion of the surgery
on one side. At last, the olfactory area was lled with
absorbable hemostatic gauze. The rest of the nasal cavity
waspacked with merocelewhich was removed after 48 h.
Endoscopiccleansing ofthenasalcavity wasperformedon
the7thdayaftersurgery.Regularsalinenasaldouchingwas
advisedfor 1 month. If mucousadhesions were present in
the olfactory region, these were cleared. Nasal endoscopy
ndingsandVASforpain,theaveragenumberofheadache
attackspermonth, and the average durationofeach attack
ofheadachewerenotedduringfollow‑upsvisitsat1month
and 3 months after endoscopic surgery. Patients of RCPH
withcompletecessationofsymptomsfollowingendoscopic
surgery were considered as “cured.” Patients with a
signicant reduction of pain in intensity and frequency
attacks were considered as “improved.” The absence of
signicantchange wasconsidered“unchanged.”
Statistical analysis
Statistical Package for the Social Science (SPSS)
Statistics for Windows, version 20, was used for all
statistical analyses (IBM‑SPSS Inc., Chicago, IL, USA).
The dierence between preoperative and postoperative
pain scores of patients with RCPH was analyzed using a
pairedt‑testandWilcoxonsigned‑rank test. P < 0.05 were
consideredstatistically signicant.
Results
Out of 68 patients with RCPH participated in this study
with 38 (55.88%) males and 30 (44.11%) females with a
male‑to‑femaleratioof1.26:1.Theagerangeofthepatients
wasbetween 12 years to 48 years (mean age:22.8 years).
The most common site for headache in RCPH was the
frontal area (57.35%) followed by pain at the medial
Figure 1: Diagnostic nasal endoscopy showing sharp spur touching to
the inferior turbinate
Figure 2: Computed tomography scan of the nose and paranasal sinus
showing sharp spur touching to the inferior turbinate
Swain and Agrawala: Endoscopic treatment of rhinogenic contact point headache‑our experiences at a tertiary care teaching hospital of eastern India
Saudi Journal of Otorhinolaryngology Head and Neck Surgery | Volume 24 | Issue 1 | January-March 2022 37
canthus/periorbitalarea (n = 32.35) andtemporozygomatic
areas (13.23%) [Table 1]. There were four patients with
RCPH who presented with headaches in both frontal
and temporozygomatic areas. Preoperative evaluation
with diagnostic endoscopy and CT scan of the paranasal
sinusesshowed52casespresentedwithintranasal mucosal
contacts on one side and 16 showed mucosal contacts
in both nostrils. After 3 months of endoscopic excision
of the intranasal mucosal contact points, the symptoms
disappeared in 52 (76.47%) patients and signicantly
improved in 13 (19.1%) patients (P < 0.001). Only
3(4.41%)patientsdidnotshowobviousimprovement.Pain
score before and after endoscopic surgery for rhinogenic
contactpoint headacheisgiveninTable2.
Discussion
Headache is a commonly encountered clinical entity with
a wide range of severities.[5] There are various causes
for headache such as migraine, neuralgic pain, cervical
causes, vascular, temporomandibular joint dysfunction,
dentalabscess,head‑and‑neckneoplasms,ophthalmological
conditions, and intracranial pathology.[6] In the absence
of inammation or sinusitis, the referred headache due to
intranasal mucosal contact points by anatomical variations
inthenose result in RCPH.[7] RCPHisoften undiagnosed,
even this clinical entity is not suspected during the
early evaluation of the patient with headache. The exact
mechanisms for headache in RCPH are still not clear.
The cause for RCPH is multifactorial. RCPH may occur
from nociceptors in the nasal mucosa, which ends up in
the sensory nucleus of the trigeminal nerve.[8] Release of
substance P and stimulation of unmyelinated bers at the
intranasal mucosal contact points are considered as the
causeofheadacheinRCPH.[3]Substance P isawell‑known
neurotransmitterand neuromodulator,has beeninvestigated
inRCPHinadults,butpresentlynostudiesinvestigatingits
roleinchildren withRCPH.[9]Theanatomicalvariations of
thenasalcavitysuchasconchabullosaorinferiorturbinate
hypertrophytouching tothenasalseptum causepain.[10]
The mucosal contact between concha bullosa and nasal
septumorothermucosalsurfaceofthenasalcavitycancause
referred pain at periorbital or ocular pain via the anterior
ethmoidalnerve,abranchoftheophthalmicdivisionofthe
5thcranialnerve.[10] Inthisstudy,themostcommonsitefor
headacheinRCPHwasthefrontalarea(57.35%)followed
by pain at the medial canthus/periorbital area (n = 32.35)
and temporozygomatic areas (13.23%). The diagnosis of
RCPHrequiresamultidisciplinaryapproach.The diagnosis
oftheRCPHisoftenmisdiagnosedduringtheevaluationof
headachepatients. Patientswithheadacheintheabsenceof
inammationof the sinonasalarea should beexamined by
aneurologist,ophthalmologist,dentist, and internist torule
outother causes. Diagnostic nasalendoscopy and CT scan
ofthenoseandparanasalsinusesarehelpfultoconrm the
intranasal contact points and also to rule our sinusitis.[11]
These investigations are useful to nd out the anatomical
variations of the nasal cavity.The diagnosis of RCPH is
properly done with help of diagnostic nasal endoscopy
and CT scan of the nose and paranasal sinuses. Nasal
endoscopy and CT scan of the nose and paranasal sinuses
isalso helpful to ruleout any sinonasal pathology causing
the headache.[12] CT scan is helpful to check pathologies
that cannot be detected by physical examination of the
nasal cavity and help to nd out the exact location of
mucosal contact points and the necessity of the surgical
intervention.[13] The intensity of headache is usually
evaluated by using VAS. The headache severity is graded
on a scale of 0–10 points, where 0 indicates trouble‑free
and10indicatesworstthinkabletroublesome.[14]
There are surgical and medical treatments available for
RCPH. The medical treatment includes topical nasal
steroids which relieve the RCPH.[15] The topical nasal
steroid application improves the nasal patency on a
short‑term basis.[16] However, long‑term improvement
requires surgical interventions. Few authors documented
thetreatmentofRCPHbythetransactionofthe5thcranial
nerve or injection of Gasserian ganglion by novocaine or
alcohol.[17] In the case of middle turbinate concha bullosa
causing RCPH, endoscopic lateral lamellectomy is the
gold standard treatment.[18] However, there is a chance
of recurrence of mucosal contact points and formation of
synechia postoperatively leading to frontal sinus diseases
as a complication of this surgical technique.[19] Before
the introduction of endoscopic sinus surgery, complete
excision of the middle turbinate was performed to treat
the middle turbinate concha bullosa. In the case of the
deviatednasalseptum with RCPH, septoplastyis useful to
relieve headache.[20] Bulla ethmoidalis consists of anterior
groupofethmoidalair cells. Whenthebullaethmoidalisis
pneumatized and hypertrophied, it can cause contact with
themiddleturbinate and resultinRCPH.Theseanatomical
variations can be easily treated by endoscopic anterior
Table 1: Localization of the headache in patients with
rhinogenic contact point headache
Sites Number of patients, n (%)
Frontalarea 39(57.35)
Medialcanthal/periorbitalarea 22(32.35)
Temporozygomaticarea 9(13.23)
Table 2: Pain score before and after endoscopic surgery
for rhinogenic contact point headache
Parameters Before
surgery
Postoperative
follow-up 3 months
P
Averagenumberof
headachespermonth
4 0 <0.001
Averagedurationof
headache
3 0 <0.001
Averagepainscore 5 0 <0.001
Swain and Agrawala: Endoscopic treatment of rhinogenic contact point headache‑our experiences at a tertiary care teaching hospital of eastern India
38 Saudi Journal of Otorhinolaryngology Head and Neck Surgery | Volume 24 | Issue 1 | January-March 2022
ethmoidectomy. The endoscopic anterior ethmoidectomy
orconchoplastyhelpstoremovethecontactpointbetween
the two opposing mucosal surfaces. Aggar nasi cells are
the most anterior ethmoid air cells and are found anterior
superior to the attachment of the middle turbinate at the
lateralwallofthenasalcavity.[21]Hyperpneuatizationofthe
agger nasi cells may cause contact of the mucosal lining
of the nasal septum and result in RCPH. This intranasal
mucosal contact can be easily removed by the endoscopic
approach. There is usually a resolution of the headache in
lessthana week followingexcisionofthemucosalcontact
pointsinthenasal cavity.[17]Onestudyshowed83% of the
patients with RCPH recovered completely after surgery
with 8% of the patients improved signicantly and the
overall success rate was seen to be 92%.[22] In that study,
the contact points between the nasal septum and superior
lateral nasal wall were present whereas the contact points
between the nasal septum and middle turbinate. Another
studyshowed70%ofpatientswithRCPHwerecompletely
recovered after removal of the intranasal mucosal contact
betweenthesuperior turbinate andseptum.[23]Inthatstudy,
25%improvedthesymptomsofRCPHsignicantlyandthe
overall success rate was 95%.[23] One study on 66 patients
with RCPH due to middle turbinate concha bullosa,
deviated nasal septum, and orbito‑ethmoidal (Haller’s)
cells where authors found a reduction of intensity and
frequency of headache after surgical excision of intranasal
mucosalcontactpoints.[24] Chow etal. found adecreasein
severity and frequency of headache in 82% of cases with
RCPH.[25] Another study on RCPH showed a reduction
of severity and frequency of headache of patients with
RCPH following surgical excision of the mucosal contact
points in the nasal cavity.[26] In our study, after 3 months
of endoscopic excision of the intranasal mucosal contact
points,the symptoms disappeared in52 (76.47%) patients,
and signicantly improved in 13 (19.1%) patients. Only
3(4.41%)patientsdidnotshowobviousimprovement.The
endoscopicapproachforexcision of theintranasalmucosal
contactpoints inpatientswithRCPH isveryeective.
Conclusion
RCPH is an important cause of headache. It is often
considered as an exclusion of diagnosis. The correct
identication of the intranasal mucosal contact points is
helpful for early treatment and avoidance of morbidity.
Preoperativeevaluation with diagnostic endoscopy andCT
scan of the paranasal sinuses are helpful for diagnosis of
the RCPH. Endoscopic excision of the intranasal mucosal
contact points is a useful technique for signicant relief
of the headache in the RECPH. This study showed that
removalofintranasalmucosalcontactpointsbyendoscopic
approachcauses signicantrelievesheadache.
Financial support and sponsorship
Nil.
Conictsof interest
Therearenoconictsofinterest.
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