DEFINITION

An Inflammatory condition involving the

paranasal sinuses and linings of the nasal passages that lasts 12 week or longer
This diagnosis requires objective evidence

of mucosal inflammation

Types of Rhinosinusitis per Temporal Course based on Duration of Symptoms

ACUTE

: lasts up to 4 weeks, with total resolution of symptoms

: lasts > 4 weeks but < 12 weeks

SUBACUTE

RECURRENT ACUTE : 4 or more episodes per year, with

resolution of symptoms between attacks

CHRONIC

: 12 weeks or more of signs / symptoms

ACUTE EXACERBATION OF CHRONIC RHINOSINUSITIS

Primary or secondary headache ?

Primary :

- No other causative disorder

Secondary :

- Headache occuring with another disorder

EPIDEMIOLOGY
Headache attributed to rhinosinusitis commonly known

as sinus headache is probably one of the most prevalent secondary headache

Chronic rhinosinusitis is not always associated with

headache

Headache is experienced in three out of four patients

with chronic rhinosinusitis ( Moretz , 2006)

Chronic rhinosinusitis gives a ninefold increased of

chronic headache (Aaseth, et al. 2010)

 Sinusitis is overdiagnosed as a cause of headache

and facial pain

60 % of patients with unrecognized migraine

attrributed to their symptoms to sinusitis

Rhinosinusitis is an uncommon cause of facial pain

> 80% of patient with purulent secretions visible on

nasal endoscopy have no facial pain

CLINICAL FEATURES

The headache associated with rhinosinusitis are usually continuous Pain in maxillary sinusitis usually in the : Cheek Gums Maxillary teeth on affected side Pain in frontal sinusitis: frontal headache over the sinus the medial side of the orbital floor under the supra orbital ridge

 Frontal sinusitis can result in : Brain abscess Meningitis Subdural or epidural abscess Osteomyelitis Orbital edema Orbital cellulitis Ethmoid sinusitis typically produces pain in between the eyes Coughing, straining and lying supine can worse the pain Keeping the head upright lessen it Complication of ethmoid sinusitis: meningitis, orbital cellulitis,

cavernous sinus thrombosis

 Headache is always present in sphenoid sinusitis : Frontal Temporal Complication of sphenoid sinusitis: Meningitis Cavernous sinus thrombosis Subdural abscess Ophthalmoplegia Pituitary insufficiency

DIAGNOSIS
Headache attributed to rhinosinusitis Diagnostic criteria: (ICHD-II / IHS 2004)
A.

Frontal headache accompanied by pain in one or more regions of the face, ears or teeth and fulfilling criteria C and D Clinical, nasal endoscopic, CT and MRI imaging and/or laboratory evidence of acute or acute on chronic rhinosinusitis Headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis Headache and/or facial resolution within 7 days after remission

B.

C.

D.

 Notes: 1.

Clinical evidence may include purulence in the nasal cavity, nasal obstruction, hyposmia/anosmia Chronic sinusitis is not validated as a cause of headache or facial pain unless relapsing into an acute stage.

2.

A major challenge to studying headache attributed to sinus disease Lack of uniform diagnostic criteria
1.

The AAO-HNS Classification: Headache as one

of several criteria for diagnosis

2.

The ICHD-II/IHS Classification: Requires the existence of specific pathophysiological condition that explain the headache

 The ICHD-II does not accept chronic rhinosinusitis as a

cause of headache or facial pain unless relapsing to an acute stage

Several primary headache : migraine, tension-type

headache and cluster headache misclassified as rhinosinusitis or sinus headache

On the other hand, nasal and sinus related pain may

mimic migraine attacks or Tension-type headache attacks

Diagnostic criteria for Rhinosinusitis and headache attributed to rhinosinusitis

(requires 2 Major Factors, or 1 Major & 2 Minor)

Major Factors
Facial Pain / Pressure Nasal Obstruction / Nasal Congestion Nasal or Post-Nasal Discharge/ Purulence/ discoloured post nasal drainage Hyposmia / Anosmia Purulence in nasal cavity on examination

Minor Factors

Headache Fever Halitosis Fatigue Dental Pain Cough Otologic symptoms Ear pain/pressure/fullness

The AAO-HNS Classification

 One of these signs of inflammation must be present and

identified in association with ongoing symptoms consistent with chronic rhinosinusitis:

A. Discoloured nasal drainage from the nasal passages,

nasal polyps or polypoid swelling as identified on physical examination with anterior rhinoscopy after decongestion or nasal endoscopy

B.

Oedema or erythema of middle meatus or ethmoid bulla on nasal endoscopy

 Migraine and tension-type headache are

often confused with Headache attributed to rhinosinusitis because of similarity in location of the headache

TREATMENT
Patients with chronic rhinosinusitis experience

headache relief after sinus surgery

Topic nasal corticosteroids were reported as the

second most frequent reason for headache improvement

( Aaseth, et al. Cephalalgia 2010, 30 (2) : 152-160 )

SUMMARY
Chronic sinusitis is significantly associated with chronic

headache

Both the classification of The AAO-HNS classification

and The ICHD-II/IHS classification provide diagnostic criteria for the diagnosis rhinosinusitis related to headache

Patients with chronic rhinosinusitis experience

headache relief after sinus surgery