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Year : 2022  |  Volume : 21  |  Issue : 1  |  Page : 84-86

An unusual Cause of Persistent Frontal Headache in a 9-Year-Old Boy

Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission24-Nov-2021
Date of Decision06-Jan-2022
Date of Acceptance07-Jan-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. 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
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mj.mj_40_21

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Headache is a common clinical experience of the patients and is found in all age groups. Intranasal mucosal contact with the absence of inflammation in the nasal cavity and paranasal sinuses may cause a secondary headache which is called a rhinogenic contact point headache (RCPH). RCPH is currently a topic of interest among clinicians and is accepted as a cause of headaches by the International Headache Society Classification. The diagnostic nasal endoscopy showed an S-shaped deviated nasal septum with intranasal mucosal contact in both nostrils. The headache of the child was disappeared after performing septoplasty and excision of the bilateral mucosal contact points. These anatomical variations in the nasal cavity in the pediatric age with bifrontal headache is a very rare clinical entity. Hence, clinicians and pediatricians should keep in mind RCPH during the evaluation of headaches in a pediatric patient. In this case report, a 9-year-old boy presented with a persistent bifrontal headache due to mucosal contact points in the nasal cavity.

Keywords: Endoscopic excision, frontal headache, pediatric patient, rhinogenic contact point headache

How to cite this article:
Swain SK. An unusual Cause of Persistent Frontal Headache in a 9-Year-Old Boy. Mustansiriya Med J 2022;21:84-6

How to cite this URL:
Swain SK. An unusual Cause of Persistent Frontal Headache in a 9-Year-Old Boy. Mustansiriya Med J [serial online] 2022 [cited 2022 Dec 2];21:84-6. Available from: https://www.mmjonweb.org/text.asp?2022/21/1/84/349317

  Introduction Top

Headache is a common clinical symptom presented by patients in routine clinical practice. Anatomical variation in the nasal cavity may cause headaches due to contact with the opposing mucosal layer.[1] The pressure of the two opposing mucosal linings in the nasal cavity without the presence of inflammation can cause headache and facial pain, which is described as rhinogenic contact point headache (RCPH). RCPH is a new type of headache in the international classification of headache disorders, supported by limited evidence. Intranasal contact points are found in approximately 4% of the noses.[2] RCPH is often misdiagnosed and even not suspected during the primary evaluation of the headache patient. Many times, the RCPH in children is misdiagnosed and even not suspected during primary evaluation. The anatomical variations in the nasal cavity such as deviated nasal septum (DNS), spur, concha bullosa, hypertrophied inferior turbinate, medialized middle turbinate, and septal bullosa may cause headache due to the pressure on the nasal mucosa in the absence of inflammation or mass lesions.[2] Here, we are presenting a case of a pediatric patient with chronic and persistent bifrontal headache where nasal endoscopy revealed bilateral intranasal mucosal contact points. The headache disappeared after the endoscopic excision of the mucosal contact points.

  Case Report Top

A 9-year-old boy attended the outpatient department of otorhinolaryngology with complaints of persistent bifrontal headache for 4 months. He had no history of nasal discharge, nasal bleeding, or postnasal discharge except bilateral mild nasal obstruction. The headache was on the bilateral frontal area, persistent in nature, and not aggravated by sound or light. He had no evidence of nausea, increased salivation, or lacrimation. He was properly examined by a pediatric neurologist to an ophthalmologist to rule out central or ophthalmological causes of headache and found no associated causes. He was initially treated with nonsteroidal anti-inflammatory medications, topical corticosteroids, and decongestants without any successful outcome. At the beginning of the symptoms, he was also treated for migraine without aura by a pediatric neurologist, but no drugs were effective. Anterior rhinoscopy showed septal deformation with a spur to the left side. Diagnostic nasal endoscopy showed healthy nasal mucosa and bilateral nasal septal deviation with spur touching to the mucosal lining of the turbinates and hypertrophy of the right inferior turbinate. Computed tomography (CT) scan of the nose and paranasal sinuses (PNS) revealed S-shaped DNS where a sharp spur in the left side has contact with the inferior turbinate and deviation of the septum in the right side touching to with middle turbinate [Figure 1]. There was no significant evidence of sinusitis or any mass lesion in the CT scan of the PNS. The patient underwent endoscopic-assisted septoplasty and excision of the contact points in both sides of the nasal cavity under general anesthesia. Three days after the surgical treatment, the nasal pack was removed, and the patient denied headaches and facial pain. Both side nasal obstructions were also relieved. He started to use saline nasal drops in each nostril for 1 month. He was come for follow-up visit at 1 month and 3 months postoperatively, reported no further headaches. Nasal breathing significantly improved after septoplasty surgery. The nasal endoscopic examination at 3-month follow-up after surgical treatment revealed no contact between the septum and turbinates with healthy nasal mucosa in the septum and turbinates.
Figure 1: Computed tomography scan of the nose and paranasal sinus showing S-shaped deviated nasal septum with mucosal contact points in both nostrils

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  Discussion Top

Headache is a commonly encountered morbid symptom seen in everybody's life. Chronic headache is a serious problem affecting the quality of life.[3] There are several local or systemic causative factors have been accused of chronic/recurrent headache. The headache may be two types such as primary and secondary headache where the primary headache does not have any specific etiology and include migraine, cluster headache, and tension headache.[4] The secondary headache is due to trauma, infections, vascular lesions, and metabolic diseases.[5] The anatomical variations in the nasal cavity such as septal deviation, septal spur, concha bullosa, and hypertrophied bulla ethmoidalis can cause headache because of contact of mucosal surfaces in the nasal cavity.[5] The exact etiopathogenesis of RCPH is still the subject of controversy. Mechanical effects such as pressure on the mucosal surfaces of the nasal cavity may result in the release of neuropeptides through central orthodromic impulse, peripheral local, and antidromic impulse. The neuropeptides such as substance P (SP) and Calcitonin Gene-Related Peptide (CGRP) cause vasodilatation and edema of the mucosal membrane of the nasal cavity, which again intensifies the pressure effects on the contact area in the nasal cavity.[6] The release of neuropeptides from the central nervous system cause pain sensation, which is similar to migraine without aura. The onset and duration of the pain coincide with the beginning and duration of the nasal cycle.[7] SP, CGRP, and neurokinin are seen in nociceptive fibers in the central nervous system and trigeminovascular system. Hence, the contact point between the mucosal layers in the nasal cavity may cause secondary headaches. Normally, mucosal linings of the nasal cavity have a higher concentration of SP than chronic hyperplastic mucosa or polypoidal tissues. This explains why intranasal contact points that cause headaches are found seen in patients without rhinosinusitis.[8]

The DNS and septal spur cause more severe headaches by intranasal mucosal contact point in the nasal cavity. The most common site for referred headache in RCPH is the frontal area followed by the naso-facial region.[9] RCPH often present with intermittent pain localized in the periorbital and medial canthal or temporozygomatic areas. In this case, the patient was presenting with a persistent bifrontal headache. There is usually cessation of headache within 5 min following topical use of local anesthesia at the contact area.[10] The headache in RCPH often mimics migraine with aura. This is why many individuals with RCPH are treated by neurologists and cannot be cured.[11] Gross DNS or large middle turbinate concha bullosa often present with nasal obstruction. Sometimes, RCPH may give referred ear pain because of the common nerve supply of the nasal cavity and ear such as the trigeminal nerve (D2).[12] Diagnostic nasal endoscopy along with a CT scan of the nose and PNSs is ideal for diagnosis of the anatomical variations of the nasal cavity. Diagnostic endoscopy and CT scan of the nose and PNS is useful to rule out inflammatory pathologies such as sinusitis and mass lesions in the nose and sinuses. CT scan is helpful to find out some pathologies which cannot be detected by physical examination and help to decide the exact site of contact points and the necessity of the surgery.[13] There is a nasal shrinkage test where nasal decongestant and topical anesthetics are applied at the mucosal contact points of the nasal cavity, however, some authors believe that this is an unreliable test.[14]

The treatment of RCPH in pediatric age groups includes multidisciplinary approaches for early diagnosis and treatment of the etiological factors. RCPH is an important etiology for secondary headache which can be managed with surgical or medical treatment. Although topical nasal steroids relieve the RCPH, long-term improvement needs surgical interventions. Surgical resection of the mucosal contact point provides a more effective outcome in patients with RCPH. The topical nasal steroid improves the nasal patency on a short-term basis.[15] In case DNS or septal spur with headache is usually relieved by performing the septoplasty. The intranasal mucosal contact point is easily treated surgically by an endoscopic approach.

  Conclusion Top

In clinical practice, the RCPH is often missed during the evaluation of the headache in the pediatric age group. DNS or septal spur are common anatomical variations in the nasal cavity for causing RCPH. Other anatomical variations in the nasal cavities are the middle turbinate concha bullosa and enlarged bulla ethmoidalis. The clinicians and pediatricians should keep in mind RCPH during the diagnosis and treatment of headaches in pediatric patients. RCPH can be treated with medical or surgical treatment. Although topical nasal steroid relives RCPH, long-term improvement is doubtful. Endoscopic surgical excision of the contact points in the nasal cavity is preferred as a treatment modality for giving long-term outcomes.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Swain SK, Behera IC, Mohanty S, Sahu MC. Rhinogenic contact point headache – Frequently missed clinical entity. Apollo Med 2016;13:169-73.  Back to cited text no. 1
Peric A, Baletic N, Sotirovic J. A case of an uncommon anatomic variation of the middle turbinate associated with headache. Acta Otorhinolaryngol Ital 2010;30:156-9.  Back to cited text no. 2
Swain SK. Middle turbinate concha bullosa and its relationship with chronic sinusitis: A review. Int J Otorhinolaryngol Head Neck Surg 2021;7:1062-7.  Back to cited text no. 3
Swain SK, Mohanty S, Sahu MC. Migraine-related vertigo in an elderly male. Apollo Med 2018;15:112-5.  Back to cited text no. 4
  [Full text]  
Cady RK, Schreiber CP. Sinus headache: A clinical conundrum. Otolaryngol Clin North Am 2004;37:267-88.  Back to cited text no. 5
Altin F, Haci C, Alimoglu Y, Yilmaz S. Is septoplasty effective rhinogenic headache in patients with isolated contact point between inferior turbinate and septal spur? Am J Otolaryngol 2019;40:364-7.  Back to cited text no. 6
Stammberger H, Wolf G. Headaches and sinus disease: The endoscopic approach. Ann Otol Rhinol Laryngol Suppl 1988;134:3-23.  Back to cited text no. 7
Swain SK, Sahu MC, Banerjee A. Non-sinonasal isolated facio-orbital mucormycosis A case report. J Mycol Med 2018;28:538-41.  Back to cited text no. 8
Swain SK, Das A, Sahu MC. Anatomical variations of nose causing rhinogenic contact point headache – A study at a tertiary care hospital of eastern India. Polish Ann Med 2018;25:51-5.  Back to cited text no. 9
Albirmawy OA, Elsherif HS, Shehata EM, Younes A. Middle turbinate evacuation conchoplasty in management of contact-point rhinogenic headache in children. Int J Clin Pediatr 2010;1:115-23.  Back to cited text no. 10
Sadeghi M, Saedi B, Ghaderi Y. Endoscopic management of contact point headache in patients resistant to medical treatment. Indian J Otolaryngol Head Neck Surg 2013;65:415-20.  Back to cited text no. 11
Swain SK, Sahu MC, Samantray K. An unusual cause of otalgia in a child – A case report. Pediatr Pol 2016;91:480-3.  Back to cited text no. 12
Karataş D, Yüksel F, Şentürk M, Doğan M. The contribution of computed tomography to nasal septoplasty. J Craniofac Surg 2013;24:1549-51.  Back to cited text no. 13
La Mantia I, Grillo C, Andaloro C. Rhinogenic contact point headache: Surgical treatment versus medical treatment. J Craniofac Surg 2018;29:e228-30.  Back to cited text no. 14
Peric A, Rasic D, Grgurevic U. Surgical treatment of rhinogenic contact point headache: An experience from a tertiary care hospital. Int Arch Otorhinolaryngol 2016;20:166-71.  Back to cited text no. 15


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