ROBERT HUGHES MD · PDF fileThus was born the surgical procedure known as ... his temples in...
Transcript of ROBERT HUGHES MD · PDF fileThus was born the surgical procedure known as ... his temples in...
Trepanning●Primitive man believed that head pain was the work of evil spirits who invaded the body of unfortunate individuals. ●If headache was caused by the invasion of evil spirits, then letting the spirits out of the skull should bring relief. ●Thus was born the surgical procedure known as trepanning which dates back ten thousand years or more.
●Such procedures were found in the South Pacific, Europe, North America and South America.
Imhotep- “the One Who Walked in Peace”
●Vizier of a Pharaoh, lived about 2900 BC;
●He is credited with many accomplishments in many fields and one of his activities seems to have been that of a successful physician.
●He is one of the first medical men whose name is on record and rose from the role of medical hero to become God of Medicine.
●He began using simple surgery instead of just magic.
Sir William Osler tells us that Imhotep was the:
!
● "..first figure of a physician to stand out clearly from the mists of antiquity." Imhotep diagnosed and treated over 200 diseases, 15 diseases of the abdomen, 11 of the bladder, 10 of the rectum, 29 of the eyes, and 18 of the skin, hair, nails and tongue. Imhotep treated tuberculosis, gallstones, appendicitis, gout and arthritis. He also performed surgery and practiced some dentistry. Imhotep extracted medicine from plants. He also knew the position and function of the vital organs and circulation of the blood system. The Encyclopedia Britannica says, "The evidence afforded by Egyptian and Greek texts support the view that Imhotep's reputation was very respected in early times. His prestige increased with the lapse of centuries and his temples in Greek times were the centers of medical teachings."
The Two Great Names in the History of Greek Medicine
●Hippocrates-dominated the beginning of a period of remarkable scientific creativity, which lasted more than 700 years ●Galen—near the end of the period, both furthered scientific knowledge and crystallized it in an amazing volume of written works. His influence lasted for 1500 years/45 generations.
The Role of Otolaryngology
Headache is a common complaint in ENT practices
ENT’s have both the Medical and Surgical expertise
Define if it is Surgical (anatomical)
Specifically Manage if Medical
Perform Allergy Management (if applicable)
My Personal OpinionSinus Headache exists as a distinct entity
!Allergic pathophysiology parallels the vascular models used for migraine HA
!Migraine/Tension/Sinus is a three way
continuum !
Anatomical abnormalities can trigger Migraines
!Confusion in diagnosis a real issue today
WORRISOME HEADACHE RED FLAGS“SNOOP”
! Older: new onset and progressive headache, especially in middle-age >50 (giant cell arteritis)
! Systemic symptoms (fever, weight loss) or ! ! Secondary risk factors (HIV, systemic cancer)
! Neurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness)
! Onset: sudden, abrupt, or split-second
! Previous headache history: first headache or different (change in attack frequency, severity, or clinical features)
How Common is Migraine?
30,000,000 Americans 20% of women
7% of men at any given time Most of us have some migraine
manifestations occasionally
Recognizing Migraine
Pounding unilateral headache Preceded by visual or other aura
Nausea, vomiting Light and sound sensitivity
Migraine DefinitionIHS Diagnostic criteria: migraine w/o aura
HA lasting for 4-72 hrs
HA w/2+ of following:
Unilateral
Pulsating
Mod/severe intensity.
Aggravated by routine physical activity.
During HA at least 1 of following
N/V
Photophobia
Phonophobia
■ IHS criteria: Migraine/aura (3 out of 4) – One or more fully reversible aura
symptoms indicates focal cerebral cortical or brainstem dysfunction.
– At least one aura symptom develops gradually over more than 4 minutes.
– No aura symptom lasts more than one hour.
– HA follows aura w/free interval of less than one hour and may begin before or w/aura.
History, PE, Neuro exam show no other organic disease.
!At least five attacks occur
What is migraine?Migraine without aura (MO)
Migraine with aura (MA)
Headache Classification Committee of IHS (1988)
At least five attacks fulfilling these criteria:
• Headache lasting 4–72 h (2–48 h in children)
At least two attacks fulfilling these criteria:
• At least three of the following: – one or more fully reversible
aura symptoms – gradually developing or
sequential aura symptoms – no one aura symptom lasts
longer than 1 h – headache shortly follows or
accompanies aura• Accompanied by at least one of: – nausea – vomiting – photophobia and/or
phonophobia
• No evidence of organic disease
• With at least two of: – unilateral location – pulsating quality – moderate/severe intensity – aggravated by activity
• No evidence of organic disease
Subtypes?Classic
Atypical
Chronic Daily HA
Cluster HA
Transformed Migraine
Medication overuse HA
Chronic Tension type HA
More subtypes?New Daily Persistent HA
Hemicranial continua
Hypnic Migraine
Paroxysmal Hemicrania
Neuralgiform HA
No Classification For SINUS HEADACHE
World prevalence of migraine:A disorder of First World
● 1-year prevalence rates
● Population-based studies
● IHS criteria (or
USA 12%
Chile 7%
Japan 8%Italy 16%
Denmark 10%France 8%†
Switzerland 13%
Rasmussen and Olesen (1994); Rasmussen (1995);Lipton et al (1994); Lavados and Tenhamm (1997); Sakai
and Igarashi (1997)†Prevalence measured over a few years
Cady (1999); Warshaw et al (1998)
Diagnosis of migraine
• Diagnosis depends on patient history • No specific tests or clinical markers
• Positive diagnosis if attack history fulfils IHS criteria for migraine
• Other pointers include: – family history of migraine – age of onset <45 – presence of aura – menstrual association
• Organic disease must be excluded
VasospasmI. Aura: Arteries Spasm
Visual and focal neurological symtoms Pial and Occipital small artery branches
II. Headache: Compensatory Vasodilation Pounding unilateral sick headache
III. Inflammation and muscle spasm: second pain phase
Phases of MigraineVague Prodrome: psychic change and
cravings e.g. chocolate Aura: Focal symptoms and vision
Headache: Throbbing unilateral pain Inflammation: Prolonged phase and TTH
Postdrome Migraine related stroke
Spreading Wave Brainstem controls Cortical Activity
Epileptic like phenomenon that spreads over Cortex Visual Phenomenon that spreads over surface of
brain like shimmering “C” Cheiro-oral Jacksonian phenomena
Concurrence of migraine and epilepsy Why epilepsy drugs work for migraine
Trigeminal TheorySerotonin again
Trigeminal Afferents: sensory function of face and meninges
Trigeminal efferents to vessels Cause vessel spasm and sensitivity
This theory primarily explains action of Triptans: 5-HT 1b,d agonists
MechanismNeurovascular theory.
Abnormal brainstem responses.
Trigemino-vascular system.
Calcitonin gene related peptide
Neurokinin A
Substance P
!
Extracranial arterial vasodilation.
Temporal
Pulsing pain.
Extracranial neurogenic inflammation.
Decreased inhibition of central pain transmission.
Endogenous opioids.
Allodynia TheoryMigraine is a state of hypersensitivity Light, sounds, smells, touch (head in
headache) Need for dark room
Best preventives decrease sensitivity. Anticonvulsants, tricyclics, beta and calcium
channel blockers
Migraine PhenomenaFocal and paroxysmal onset of symptoms
Specific visual phenomena Spreading numbness and moving visual phenomena and
sensory distortions. Nausea, vomiting “sick” headache Pounding unilateral or bilateral pain
Psychic changes Light and sound sensitivity even between attacks
Effectiveness of triptans Effect of anticonvulants
Role of serotonin
Some Dicta
Any paroxysmal headache is likely to be migraine unless proven otherwise
“Sinus” headaches and “tension” headaches are almost always migraine headaches First ever severe headache or sudden
“thunderclap” headaches may be SAH
Mechanisms for treatment
CGRP NK SP
5-HT1F5-HT1D
5-HT1B
Blood vessel
Trigeminal nerve
Adapted from Goadsby (1997)
CGRP calcitonin gene related peptide
NK neurokinin A
SP substance P
triptan
CONSTRICTION
INHIBITION
Acute Attack Triptans:
sumatriptan, zolmitriptan, almotriptan, naratriptan, frovatriptan, elitriptriptan, riaztriptan
NSAID’s Fioricet
Midrin (isometheptane, chlorphenoxazone, apap OTC: Caffeine, apap, phenacitin, asa Ergots: Caffergot, DHE nasal, injected
Narcotics Depacon
Consider Combinations
Triptan + NSAID Triptan + anti-nausea
Unconventional agents Phenergan, Compazine alone or in combination. Zyprexa or atypicals We don’t have enough alternatives
Triptan worriesNot released under age 18
If you even suspect CAD don’t use or get proper exclusionary tests.
Man or woman of a certain age Smoker or other risk factors
Cerebrovascular disease or complicated migraine - contraindicated
Watch for overuse. These are rescue medicines
ProphylaxisAnticonvulsants: topiramate, valproate, Keppra,
gabapentin Tricyclics
Amitriptylene, nortriptylene, trazodone Beta Blockers
Timolol, propranolol, nadolol Calcium channel blocker – verapamil
ACE inhibitors SSRI’s
Atypicals
Preventive therapyConsider if pt has more than 3-4 episodes/month.
Reduces frequency by 40 – 60%.
Breakthrough headaches easier to abort.
Beta blockers
Amitriptyline
Calcium channel blockers
Lifestyle modification.
Biofeedback.
Botox51% migraineurs treated
had complete prophylaxis for 4.1 months.
38% had prophylaxis for 2.7 months.
Randomized trial showed significant improvement in headache frequency with multiple treatments.
Conclusions
Migraine is common but unrecognized.
Keep migraine and its variants in the differential diagnosis.
“Sinus HA” Differential dx
• Acute rhinosinusitis (ARS) • nasal and facial pain, nasal congestion and purulent
nasal drainage. • Chronic rhinosinusitis (CRS)
• nasal drainage, congestion and facial pressure • Migraine
“Sinus HA” work up
• Neurologists and internists utilize the International Headache society guidelines
• Otolarynologists utilize the AAO-HNS rhinosinusitis categories and criteria • History • Examination, including endoscopic • Radiologic examination
AAO-HNS Rhinosinusitis Categories
• Acute rhinosinusitis (the patient has symptoms present for less than 4 weeks)
• Subacute rhinosinusitis (the patient has symptoms present for more than 4 weeks, but less than 12 weeks)
• Chronic rhinosinusitis (the patient has symptoms present for greater than 12 weeks)
• Recurrent acute rhinosinusitis (the patient has more than 4 acute episodes over 1 year)
• Acute exacerbation of chronic rhinosinusitis (the patient develops an acute infection, with new acute symptoms, superimposed over a chronic infection, with a constant baseline level of symptoms)
AAO-HNS Rhinosinusitis Criteria
• Major Factors • Purulence in nasal cavity on
examination • Facial pain/pressure • Nasal obstruction/blockage • Fever (acute only) • Hyposmia/anosmia • Nasal discharge/purulence • Discolored postnasal
drainage
• Minor factors • Headache • Fever (all nonacute) • Halitosis • Fatigue • Dental pain • Cough • Ear pain/pressure/fullness
Nasal/facial pain
!
• Nasal mucosa is not uniformly pain sensitive • Ostia are more sensitive
• Rhinosinusitis often affects >1 sinus; multiple pain regions = diffuse pain
Nasal/facial pain• Nasal sensation poorly
represented within the brain • Nasal sites refer pain to
surface structures
Maxillary Sinus• Maxillary division of 5th cranial
nerve (V2) • Posterior superior alveolar • Infraorbital • Anterior superior alveolar
• Stimulating the maxillary sinus ostia will produce referred pain at the posterior nasopharynx, posterior teeth, zygoma, and temple.
• Pressure within the maxillary sinus itself produces a sense of vague fullness in the face
Frontal Sinus• Ophthalmic branch of 5th
cranial nerve (V1) • Frontal recess irritation is felt
as pain in the inner canthal region, anterior zygoma, and molars.
• Local irritation within the frontal sinus itself is felt as mild pain at the same approximate frontal location.
Anterior Ethmoid• Ophthalmic division (V1) • Anterior ethmoid nerve off
nasociliary • Also supplies the anterior
septum, turbinates, ostiomeatal complex
• Pressure in the region of the anterior ethmoid cells results in fairly intense pain in the ipsilateral eye behind the inner canthus and radiates to the maxilla, canine, and bicuspid regions
Posterior Ethmoid and Sphenoid• Maxillary division (V2)
• Posterior ethmoid nerve • Posterior septum, parts of superior and
middle turbinates • Ophthalmic division (V1) • Greater superficial petrosal nerve • Pressure in the region of the posterior
ethmoid cells results in intense pain in the ipsilateral eye near the lateral canthus, the lateral nose, canine, and cuspid regions.
• Sphenoid sinus irritation produces severe deep head pain with some pain over the ipsilateral eye, upper teeth, and coronal suture region
Migaine
• Underdiagnosed condition • Physicians will label 50% of subjects meeting IHS
criteria as having migraine • Patients will label their symptoms as sinus related 90%
of the time when they actually meet the IHS criteria for migraine
• Nasal symptoms often accompany migraine which clouds the diagnosis
Migraine theory
• Sensitization of neural pathways • Sterile inflammation of intracranial vessels -
trigeminovascular system • Serotonin (5-hydroxytryptamine) receptors
• Epiphenomenon from autonomic discharge • Vascular engorgement • Other nasal symptoms
Migraine
• Usually unilateral, pulsating nature • Pain rated as moderate to severe • Lasts 4 to 72 hours • 17% of females, 6% of males • Nausea, vomiting, photophobia or phonophobia • With or without aura (visual scotoma)
Migraines - triggers!
• Stress • Menses • OCP • Infection
!
• Trauma • Vasodilators • Wine • Aged cheeses
Migraine v sinus pain
• ARS can cause facial pain per IHS and AAO-HNS • Straight-forward diagnosis • Not a source of constant/daily pain
• CRS not accepted as a cause of pain per IHS • Otolaryngologists feel CRS may be associated with
pain, but not the chief complaint
CRS and pain
• Pain described as dull and pressure-like in the bilateral periorbital areas
• Pain worst in the morning • Pain improves during the day • Pain tends to last for days • Pain not associated with nausea, vomiting,
phonophobia, and photophobia
CRS and pain
• Additional nasal symptoms present • Subjective: nasal drainage, obstruction, and
congestion • Objective: nasal inflammation and
mucopurulence • Improvement with topical anesthetics or
decongestants • CT sinus displays mucosal thickening • Pain/pressure tends to improve after surgery
What CT sinus findings are important?
• Maxillary sinus mucocele without boney erosion is not usually important
• Mucoceles in other sinuses are important • Air-fluid levels usually indicate an acute infection • Partial or complete opacification should lead one to
consider an otolaryngic exam • Location of thickening important:
• Ostiomeatal complex = confluence of sinus drainage • Peripheral thickening with patent sinuses of lesser importance
Other nasal and pain
• Mucosa to mucosa contact points • Enlarged turbinates • Paradoxically curved middle turbinate • Concha bullosa (aerated middle turbinate) • Septal spur
• Barosinusitis • Vacuum pain d/t barometric pressure changes
SURGICAL TREATMENT FOR RHINOSINUSITIS
SEPTAL SURGERY
TURBINATE SURGERY
SINUS SURGERY FOR VENTILATION AND DRAINAGE
SINUS SURGERY FOR POLYPOSIS
Conclusion
• “Sinus headache” may actually represent migraine
• Nasal/facial pain or headache is often associated with CRS • Careful assessment of Hx, PEX, endoscopy, CT
will help to identify • Other selected nasal anatomy may produce
chronic pain • Surgery may alleviate the pain associated with
CRS and other anatomic variants
ALLERGY MANAGEMENT OF THE CHRONIC HEADACHE PATIENT
When is immunotherapy indicated
How does one define the allergy headache patient from the surgical or the TRUE Migraine
Can CT Scans help?
Does Tension Headache require different treatment plans
Hypersensitivity Reactions (Gell & Coombs)
Type I Immediate
(allergic rhinitis, asthma, immediate onset food reactions)
Type II Cytotoxic
(hemolytic anemia, Hashimoto’s)
Type III Immune Complex
(serum sicknesss, delayed onset food reactions, glomerulonephritis)
Type IV Delayed, Cell Mediated
(TB, poison ivy)
Type V Stimulating Antibody Reaction
(Graves’ disease)
Type VI Antibody Dependent Cell Cytoxicity
(transplant rejection)
Sinus & Allergy Health Partnership
RhinosinusitisA Collaborative Initiative of the:
American Academy of Otolaryngic Allergy American Academy of Otolaryngology- Head & Neck
Surgery American Rhinologic Society
• 250 M Americans affected • Average of 3-4 viral URIs/year • 1 Bn cases of viral RS/year • 0.5% - 2% go on to acute bacterial
maxillary disease
National Ambulatory Medical Care Survey, National Center for Health Statistics.
Acute Community-Acquired Bacterial Rhinosinusitis
Rhinosinusitis -vs- Sinusitis
The inflammatory process which causes sinusitis is also associated with inflammation
of the nasal passages
Lanza D, Kennedy D. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117(suppl):S1-S7.
Rhinitis typically precedes sinusitis • Sinusitis without rhinitis is rare • Mucus membranes of the nose and sinuses are
contiguous • Symptoms of nasal discharge and nasal obstruction are
prominent in sinusitis
Implications of Recent Knowledge
• The maxillary sinus was classically considered the major focus of the disorder
• Most maxillary sinusitis is now known to be secondary to disease in the ostiomeatal complex (OMC)
• Even minor swelling in a critical area can result in ostial obstruction and significant symptoms
Ostiomeatal Complex
Obstruction in this small area (from edema, thick secretions, polyps or a
concha bullosa) can block drainage from the anterior
ethmoid, maxillary & frontal sinuses
Paradoxic Middle Turbinate
Courtesy of H Stammberger
Nasal Septum
Middle turbinate
Obstruction of portion of
middle meatus
Factors Predisposing to Bacterial Rhinosinusitis
• Viral Upper Respiratory Infection
• Allergic Rhinitis
• Anatomic Ostiomeatal Obstruction
• Air Pollution
• Nasal Polyposis
• Medication effects
• Pregnancy
• Other Causes
Infection Allergy Nasal Obstruction/Congestion Thin, Watery Discharge Paroxysmal Sneezing Itchy, Runny Nose Seasonal or Perennial (can
increase sinusitis incidence) Other Allergic Symptoms
(conjunctivitis, otitis, laryngitis)
Rhinosinusitis -vs- Allergic Rhinitis
Nasal Obstruction/ Congestion
Thick Nasal Discharge Cough/Irritability
Pressure With Pain Toothache
Fever
Types of Rhinosinusitis: Temporal Courses
• Acute - Up to 4 wks, with total resolution of symptoms
• Subacute - Longer than 4 wks but less than 12 wks
• Recurrent Acute - 4 or more RS episodes/year, with resolution of symptoms between episodes
• Chronic - 12 weeks or more of signs and symptoms
• Acute Exacerbations of Chronic Rhinosinusitis
Lanza D, Kennedy D. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117(suppl):S1-S7.