• Extra trigeminal pain from other oro-

facio-cranial structures travel in 7th,

9th & 10th & upper cranial roots.
• It is not possible to discuss all the
parameter of the subject of
headache & facial pain but a
diagnostic evaluation & otolaryngology
problem as etiological factor has been
stressed.
 Headache
• The term headache means headache
above the eyebrow level
• It is usually a benign symptom but
occasionally it is a manifestation of
serious illness such as brain tumor
subarachnoid-hemorrhage,,
meningitis or giant cell arteritis.
 Classification of Headache
• 1.Migrane - Rec. attack of headache usually
unilateral females are more affected
• Migraine without aura
• Migraine with aura, Retinal migraine
• 2. Tension type headache - usually suboccipital,
pt. complaints of tightness pressure or
contraction.
• 3. Cluster headache & Ch. Paroxysmal
hemicrania
• 4. Headache associated head trauma: -Acute post
traumatic headache & Chronic post traumatic headache
• 5. Headache or facial pain associated with disorders of
facial or cranial structure
-cranial level
-eye,
-ear
-nose&sinuses
-Teeth jaw &related structures
-TM joint diseases
• 6. Headache associated with vascular
disorder:
-Acute ischemic cardiovascular disorder
-Intracranial hematoma
-Subarachnoid hemorrhage
• 7. Headache associated with nonvascular
intracranial disorder -High or Low CSF pressure
-Intracranial Infection
- Intra cranial neoplasm associated with other
intracranial disorder
-
• 8. Headache associated with substance
dependence or their withdrawal
• 9. Headache associated with noncephalic
infection -Viral infection
-Bacterial infection
-Other infection
• 10. Headache associated with metabolic
disorder -Hypoxia
-Hypercapnia
-Mixed hypoxia & hypercapnia
-Hypoglycemia
-Dialysis
-Other metabolic abnormality
• 11.Cranial neuralgias, nerve trunk pain
-Trigeminal (tic doloreux)
-Glossopharyngeal
-Central
• 12. Headache no classifiable
• 13 Psychogenic headache
 Evaluation of Headache
• A complete medical history review is essential
1. Age & Sex
2. Onset, duration, intensity, quality & frequency
of headache
3. Time relation in headache
4. Location of headache
5. H/o any head trauma /hypertension
/allergy/use of drug
6 Aggravating and relieving factors
7 Associated symptoms
• Family history
-emotional disturbances
-sociological factor
• complete ENT examination : PNS, throat
• complete neurological examination
• CVS examination
• Head & neck examination
• ocular & dental exam.
• Assessment of personality profile
radiological assessment
*About 50 % patients presenting to
ENT specialists with symptoms of
sinusitis complain of severe
headache.
*70% patients with chronic sinusitis
requiring surgery have headache
 ENT Causes of Headache
Acute Sinusitis
+ve h/o URI
As an exacerbation of nasal allergy /
vasomotor rhinitis
Local pain and tenderness over
affected sinus
NOSE- turbinate engorgement , mucosal
edema , nasal polyp or generalized
edema
nasal congestion, purulent nasal
discharge
• Frontal sinus - Pain in frontal regions, pain
increased by bending forward
• Maxillary sinus - Pain & tenderness on
related to maxilla.
• Ethmoid Sinus- pain between the eyes

• Diagnosis –Plain sinus radiograph can

diagnose acute maxillary and frontal sinusitis
but often fails to diagnose ethmoid or
sphenoidal sinusitis
• CT PNS Coronal cuts- highly sensitive
• Nasal endoscopy-permits direct visualization
of nasal passage and sinus drainage areas.

• This procedure is complementary to CT or

MRI scan.
 Management of Acute
sinusitis
• Antibiotics (gatifloxacin ,cipro.
Augmentin),
• Antihistaminic & decongestants-
systemic as well as local
• Analgesics
• Mucolytics
 Management of chronic
sinusitis
• Conservative management
• Surgical management- FESS (if pat.
does not respond to 6 weeks of
conservative management)
• Septal deviation/ spur
• Agger nasi cells
(prominent)

• Uncinate process
{.medially/lateraly bent
contacting middle
turbinate
peumatized}
Anatomic variations in the
nose and paranasal sinuses

• Agger nasi cells

prominent
 Anatomical variatons of
middle turbinate

• Paradoxically
curved middle
turbinate
• Anatomical
variatons of middle
turbinate
[concha bullosa
(pneumatized

middleturbinate)
 Headache d/t intracranial
complication of csom or
sinusitis

• Meningitis
• Extra dural abscess
• Sub dural abscess
• Brain abscess
• Lateral sinus thrombsis
 Tempromandibular
disorder
• Pain from TMJ.and associated
musculature and ligaments reffered
to head
• Dental causes-carious
tooth,periapical abscess ,dental
abscess
 Facial Pain
• Glassopharyngeal Neuralgia - unilateral
throat & ear Pain agravated by eating
swellowing and cold stimulation
• Sphenopalatine neuralgia - pain in
orbital area cheek roof of the mouth,
root of the nose and upper jaw &
teeth.
 Trigeminal Neuralgia
• Characterised by
Paroxysmal sharp
excruciating pain
along the
distribution of
Trigeminal nerve on
one half of the
face
 Medical treatment of
Trigeminal neuralgia
• Carbamazepine
• Phenytoin sodium
• Gabapentine
• TCAD
• Micro vascular
decompression
 Surgical Treatment of
TN
• MVD
 Facial Pain
• Dental Cause:
– Periapical abscess,
– periodontitis
– Acute pulpitis
– TMJ disfunctions
– Orthopath
• Eagle syndrome - due to elongated styloid
process, unilateral pharyngeal pain. Digital
palpation of in stonsilar fosa causes pain
• Costent or TM joint syndrome - trismus &
pain in the ear, main wall nose & eyes may
be associated with the crepitation of TM
joint.
• Eagle syndrome - due to elongated styloid
process, unilateral pharyngeal pain. Digital
palpation of in stonsilar fosa causes pain
• Costent or TM joint syndrome - trismus &
pain in the ear, lateral wall of nose & eyes
may be associated with the crepitation of
TM joint.
 Ophthalmic causes of
facial Pain
• Acute Glucoma
• Uvititis, Keratits, Orbital cellulitis
• Inflamatory orbital pseudo tumor
 Headache symptom that
suggest a serious underlying
• Worse headache ever
• First severe headache
• Subacute worsening over days or week
• Abnormal neurological examination
• Fever or unexplained systemic sign
• Vomiting preceds headache
• Distrubs sleep or presents immediately upon
awakening
• Known systemic illness
• Onset after age 55
Thank you
 Anatomic variations in the
nose and paranasal sinuses
• Septal deviation/ spur
• Agger nasi cells (prominent)

• Uncinate process
{.medially/lateraly bent
contacting middle turbinate
peumatized}
• Anatomical variatons of middle turbinate
[concha bullosa (pneumatized
middleturbinate)
Anatomical variatons of middle turbinate
Ethmoid bulla
large filling middle meatus
Anterior growth,overlaping hiatus
semilunaris/or protruding through middle
meatus
• Trotter’s triad
• Ptrygopalatine fossa syndrome
• Foix’s syndrome
• Tolosahunt syndrome
• Vascular Pain;
– (Migrane, cluster headache, temporal
arteritis, Chronic paroxysmal
hemicrania, )
– post herpetic neuralgia
– Central pain (SOL)
– carotidynia
– Causalgia
– Myofacial pain
– Tension Headache
– Atypical facial pain
– Glossdynia