E.N.T.

PERSPECTIVE ON
HEADACHE
Dr Mrudula
2nd year PG
Dept. Of E.N.T.
INTRODUCTION
 There are more than 200 types of headaches.
Some are harmless and some are life threatening.
 Nine areas of head and neck have pain sensitive
structures— periosteum of the skull, muscles,
nerves, arteries, veins, subcutaneous tissues,
eyes, ears, sinuses and mucous membranes.
CLASSIFICATION
 Headache disorders are classified as primary or
secondary*.
 The primary headache disorders do not have an
underlying structural cause. Account to 90% of
all headaches.
 Secondary headache maybe subsequent to ENT
diseases and complications

* Longo D, Fauci A, kasper D, et al. Headache. In: Goadsby

JP, Raskn NH (Eds). Harrison’s Principles of Internal
Medicine, 18th edition. New York: McGraw-Hill
Professional; 2012.pp. 112-28
Causes of headache include:
 Infectious

 Inflammatory

 Neoplastic

 Traumatic

 Immunologic

 Metabolic

 Endocrinologic

 Vascular
 Headaches in ENT may be differentiated as per
system, for the convenience of discussion.
 When subsequent to an ENT problem, headaches
may be varied, ranging from mild to severe forms
basing on the level of complications that may
have been caused by the disease.
NOSE AND SINUSES

20% of all headaches caused are by nose and PNS

diseases
Sinusitis may be classified broadly into:
Inflammatory: acute sinusitis
Allergic
Fungal : invasive or non invasive
ACUTE RHINOSINUSITIS
Headache in Acute rhinosinusitis:
Acute onset of symptoms
Duration of symptoms < 12 weeks
Symptoms resolve completely
Evidence of causation demonstrated by at least two of
the following :
 Headache has developed in temporal relation to the
onset of rhinosinusitis
 Previous headache that has significantly worsened
with worsening of the rhinosinusitis
Headache in Chronic rhinosinusitis:
 Duration of symptoms> 12 weeks

 Persistent inflammatory changes on imaging > 4

weeks after starting appropriate medical therapy with
no intervening acute episodes
 Chronic sinusitis is not validated as a cause of
headache or facial pain unless relapsing into acute
stage.
 Clinical evidence may include facial pain, purulence in
nasal cavity, nasal obstruction, hyposmia/ anosmia
and /or fever.
PATHOPHYSIOLOGY
 Inflammation in nose and sinuses from a variety
of causes can result in sinus ostia obstruction and
predispose to the development of an infection*
These factors include:
 Genetic: cystic fibrosis

 Anatomic abnormalities

 Systemic diseases

 Neoplasms

 Allergic

 Immune disorders
 Environmental factors: bacterial, viral, fungal
infections, secondary colonisation
 Primary or secondary exposure to tobacco smoke,
chronic irritants.

*SCOTT-BROWN’S OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY, 7TH

EDITION, 2008; 1441
PATHO
PHYSIOLOGY Infection

Mucosal swelling with

occlusion or obstruction of
the sinus ostia.

Reduced mucociliary
transport and transudation
of fluid into the sinuses

Mucostasis and bacterial

colonisation
Xray PNS (water’s view) NCCT of PNS
 Other than sinusitis, the following causes that are
often considered to induce headache are not
sufficiently validated as causes of headache(*)
 These include:

1. Deviation of nasal septum

2. Hypertrophy of turbinates
3. Atrophy of sinus membranes
4. Mucosal contact (mucosal contact point headache)

*Headache classification subcommittee of the international

headache society. The international classification of headache
disorders: 2nd edition. Cephalalgia, 2004; 24 suppl 11.5, 118
5. Tumours of nose and PNS
6. Nasal bone fracture
7. Septal abscess
8. Furunculosis of vestibule
 Headache subsequent to nasal causes may be alarming
if there are intracranial and or orbital complications of
chronic sinuses
RED FLAG SYMPTOMS
A red flag symptom means that a headache warrants
further investigations.
 Mental confusion

 Visual loss or visual abnormalities

 Cranial nerve deficits

 Neck stiffness

 Fever

 Headaches in people with HIV

 Headaches in people with cancer or risk factors for

thrombosis.
COMPLICATIONS CAUSING SEVERE
HEADACHES

Orbital (60- Intracranial

Bony (5-10%) Chronic
75%) (15-20%)
• Orbital • Meningitis • Pott’s puffy • Mucocele
cellulitis • Epidural tumour • Pyocele
• Orbital abscess
abscess • Subdural
• Cavernous abscess
sinus • Cavernous
thrombosis sinus
thrombosis
 MANAGEMENT

Periorbital cellulitis Medical

management with IV
Orbital cellulitis antibiotics

Medial subperiosteal
abscess: endoscopic
drainage
Subperiosteal
abscess
Lateral subperiosteal
abscess:
decompression and
drainage of orbit
CONT...

Orbital abscess

IV antibiotics,
Cavernous sinus drain sinuses and
thrombophlebitis abscess

Meningitis ,
epidural abscess,
intra cerebral
abscess
Periorbital cellulitis Orbital cellulitis
Subperiosteal abscess Orbital abscess
CAVERNOUS SINUS THROMBOSIS
ALLERGIC FUNGAL RHINOSINUSITIS

 Immunocompetent patient with an allergy to

fungus.
Pathophysiology :
 Inhalation of ubiquitous fungi which in cases of
atopic patients provokes antigenic stimulus and
an inflammatory response to mucous membrane.
 Clinically : an allergic mucin is produced which is
thick, abundant, green lamellae of dense
inflammatory cells in various stages of degranulation,
eosinophils, fungal hyphae, Charcot layden crystals.
 Diagnosis by CT scan: opacification of sinus cavities,
associated with bone expansion, no invasion of dura or
periorbita
 Treatment : low dose long term steroids, with 20mg
being maintenance dose for a period of 6 months,
antifungals have little role.*

*J CLIN DIAGN RES. 2017 APR; 11(4): MC01-MC03

Fungal mycetoma CECT PNS demonstrating heterogenous
signal intensity characteristic of AFRS
ACUTE FULMINANT FUNGAL
RHINOSINUSITIS
 In immunocompromised patients
 Fungi show marked predilection to vascular
invasion
 Isolated species of fungi: Mucoraceae and
Aspergillus
 Symptoms : cranial nerve deficits, headache
 Diagnosis : DNE- black necrotic turbinates
 Treatment : surgical debridement, antifungals-
Amphotericin is the conventional therapy, new
drugs (azoles, capsofugine)*

*Scott-Brown Otorhinolaryngology and Head and Neck

surgery, 7th edn, 2008, 1455
INVASIVE FUNGAL
RHINOSINUSITIS(CHRONIC INDOLENT)

 Immunocompetent individuals
 Symptoms appearing only when the orbit or skull
base are involved.
 Chronic headache, proptosis and cranial nerve
deficits most common presentation
 Treatment : surgical debridement, antifungal
therapy
EVALUATION
History
 The history is on standard lines, but certain questions,
which are of relevance, are:
 Type of headache: Sinusitis headache
 Whether episodic or continuous
 Time to peak, time and duration
 Triggering or relieving factors like food, fasting or
sleep disturbance
 Whether these symptoms get worse with time
 Aura in the form of nausea, vomiting or photophobia
 Any comorbidity like hypertension, diabetes, seizure
or depression
 Details of previous treatment
EXAMINATION OF NOSE AND PNS

 Anterior rhinoscopy
 Posterior rhinoscopy

 Examination of sinus tenderness:

 Maxillary sinus- by applying pressure lateral to

canine fosse
 Frontal- over floor of frontal sinus

 Ethmoidal- medial to medial canthus

 Endoscopy:
Anatomical Surgical
flexible or
defects correction
rigid

plain Xray
and CT PNS
Radiography
Investigations
CSF leak, soft
MRI
tissue tumours
Nasal swab

Nasociliary
Nasal biopsy mucociliary
clearence
EAR
 Headaches subsequent to ear diseases occurs in
complications of CSOM with Atticoantral disease
(unsafe ear).
 Factors influencing development of such
complications:
 Age- extremes of age

 Poor socio economic status

 Virulence of organism

 Immuno compromised host

 Systemic diseases
SPREAD OF INFECTION
 Bone erosion
 Hematogenous

 Preformed pathways:

1. Congenital dehiscence

2. Patent sutures

3. Temporal bone fractures

4. Surgical defects (iatrogenic)

5. Perilymphatic fistula

6. Normal anatomical openings: oval/ round

windows, IAC, cochlear aqueduct.
PETROSITIS

 Spread of infection
from middle ear and
mastoids occurs
through cell tracts:
 Postero-medial
 Anteroinferior
 Infra labyrinthine
 Subarcuate
 Superior
CLINICAL FEATURES
 Headache , fever, vomitings, neck stiffness
 Gradinego’s syndrome: classic for Petrositis

 6th nerve palsy

 Deep seated retro orbital pain (due to 5th nerve

involvement)
 Persistent otorrhoea

o Diagnosis: HRCT temporal bones

o Treatment : high doses of IV antibiotics that

cross BBB , following which surgery is done
Surgery done:
 Radical mastoidectomy performed along with any
of the following approaches to petrous apex
APPROACHES TO PETROUS APEX
Hearing preserved Hearing not preserved

1. Infracochlear 1. Trans labyrinthine

2. Infra labyrinthine 2. Trans cochlear
3. Middle cranial fossa 3. Sub total
4. Trans sphenoidal petrosectomy
LATERAL SINUS THROMBOPHLEBITIS
Chronic
PATHOGENESIS mastoiditis

Perisinus abscess
following erosion of
bone by
cholesteatoma

Pressure on
wall of sinus

Necrosis
extends to
intima, attracts
fibrin, platelets
Mural thrombus
 Clinical features:
1. Fever : ‘Picket fence’ pattern with diurnal
temperature spikes
2. Headache : due to obstruction of dominant
venous drainage
3. Papilloedema : due to raised ICT
4. Cavernous sinus thrombosis

 Investigations :CECT, MRI

 CT : Delta sign
TREATMENT

Radical mastoidectomy

Sinus and adjacent dura

are addressed by
removing overlying bone

18/20G needle passed

through sinus to
evacuate abscess, clot

Local packing
 Intra venous Antibiotics
 Anticoagulants (recommended when there is
propagation of thrombus after surgery)*
 Ligation of jugular vein in neck

 Corticosteroids

*mediterr J Hematol Infect Dis. 2010; 2(3): e2010027

OTOGENIC BRAIN ABSCESS
Retrograde
thrombophlebitis
of dural vessels

Granulation
tissue, osteitis

Cerebral and
cerebellar
abscess
STAGES OF BRAIN ABSCESS
 Stage of invasion: 1-3 days
 Stage of localization: 4-10 days, pus gets localised
by forming a capsule
 Stage of enlargement: 10-13 days, enlarging
abscess surrounded by a zone of oedema causes
raised ICT
 Stage of termination: 14 days, enlarging abscess
ruptures into ventricle/ subarachnoid space.
 Clinical features:
1. Headache
2. Nausea and vomitings
3. Drowsiness, confusion
4. Papilledema

 Investigations:
 CT scan: ‘Ring sign’- brain abscess appears as a
hypodense area surrounded by oedema
 MRI: detects changes in brain parenchyma,
spread of abscess into subarachnoid space,
ventricles
CT scan MRI
TREATMENT
Medical:
 Antibiotics- IV Chlormycetin, Penicillins,
aminoglycosides
 Dexamethasone 4mg, IV, 6th hourly

 Mannitol 20% on doses of 0.5g/kg body weight

Neurosurgical intervention:
 Aspiration of pus, repeat CT/MRI to check size

 Penicillin installed into abscess

 Burr hole: repeated aspiration of pus

 Excision of abscess
OTITIC HYDROCEPHALUS

PATHOGENESIS

Obstruction to
Raised ICT
venous return
Thrombosis of
sigmoid sinus Extends to Impedes
superior functioning of
sagittal sinus arachnoid villi
 Clinical features:
 Severe headache associated with nausea and
vomitings
 Diplopia due to 6th nerve palsy
 Blurring of vision due topapilledema and optic
atropy
 Investigations:
MRI: to evaluate venous sinuses
 Treatment:
Mannitol
Diuretics
corticosteroids
Otological intervention: ( done only in
neurologically stable patients)
 Radical mastoidectomy to remove disease and
exteriorise infected area
EPIDURAL ABSCESS
 Collection of pus between bone and dura
Clinical features:
 Persistent headache, which disappears with free
flow of pus
 Severe ear pain

 General malaise, low grade fever

 Pulsatile purulent otorrhoea

Diagnosis: CECT or MRI

Treatment: antibiotics
Surgery: MASTOIDECTOMY- overlying bone is
removed until healthy dura appears
Epidural abscess
SUBDURAL ABSCESS OR EMPYEMA
 Collection of pus in subdural space.

Clinical features:
 Sudden , severe headache which is associated
with fever, vomitings
 High grade fever

 Aphasia, contralateral hemiplegia, hemianopia-

due to thrombophlebitis of cortical veins of
cerebrum
 Papilledema due to raised ICT
Diagnosis:
MRI :
To distinguish between epidural and sub dural
abscess
To differentiate between blood, pus
To examine changes in brain parenchyma
CT: loculates subdural abscess seen

Treatment: Neurosurgical emergency

series of burr holes
High dose antibiotics
Radical mastoidectomy done after subdural abscess
is treated
MENINGITIS

PATHOGENESIS

Preformed
pathways

Retrograde
Middle ear or
venous Meningitis
mastoid infection
thrombophlebitis

Direct erosion of
bone
 Microbial organisms: haemophilus influenzae,
streptococcus pneumoniae

Clinical features:
Fever
Headache
Vomitings
Irritability
Photophobia

Diagnosis: HRCT temporal bones, MRI, lumbar

puncture, fundoscopy
 Treatment:
 Antibiotics: crystalline penicillin, chlormycetin,
3rd generation cephalosporins(drug of choice),
give intravenously
 Surgical :

Acute otitis media: myringotomy or cortical

mastoidectomy
Cholesteatoma: Modified radical or radical
mastoidectomy
THANK YOU!!