No abstract

Sinus headaches are attributed to injlammatory disease of the sinus mucosa or ostium. In 1948 H.G. Wolff first recognized that sinus headaches may occur in the absence of injlammatory sinusitis, and may be due to contact between strategic "trigger points" in the sinonasal passages. Since this time there have been sporadic reports of headaches andfacial pain due to an enlarged middle lllrbinate contacting either the seplllm or lateral nasal wall. II is theorized that an enlarged middle lI/rbinate, most commonly due to pneumatization (concha bullosa), can contact the septum or lateral nasal wall and give headaches referred to the ophthalmic division 0/ the trigeminal nerve, the main sensory innervation of the anterior middle turbinate. Middle turbinate headache syndrome is reviewed, with allention to pathophysiology, clinical presentation, and treatment. Eight cases of middle lllrbinate headache will be presented in support of this clinical entity. We hope to alert the clinician to a relatively unknown source of recurrent headaches, that may be readily treated by otolaryngologists. (Am J Rhinology 7: 17-23, 1993) H eadache can be a very frustrating symptom to both patient and clinician. Indeed, many headaches can be difficult to diagnose, and even more difficult to Am J Rhinology treat. Classic etiologies for headache may be obvious, such as tension headache, migraine, or acute frontal sinusitis. There are other less obvious etiologies for headache that are more obscure in nature, and require strong clinical suspicion in order to be appropriately diagnosed. Contact headaches due to an enlarged middle turbinate are an example of this type of headache. It is thought that contact between the middle turbinate and either the septum or lateral nasal waIl leads to stimulation of the sensory portion of the trigeminal nerve. This results in a rhinologic headache that is not due to pressure within the sinus, but rather to abnormal contact between innervated regions of the nasal cavity. This report wiIl attempt to clarify middle turbinate headaches (MTH), describe the pathophysiology, and present supporting cases that demonstrate the clinical presentation and treatment options of middle turbinate headaches. CASE STUDYA 49-year-old woman noted a 12-year history of intermittent daily facial pain and headaches. The headache was located in the left periorbital region and lasted several hours. The patient denied rhinorrhea, postnasal drip, or epistaxis, but noted that the headaches usuaIly occurred foIlowing increasing nasal congestion on the left side. She denied any associated auras, increased salivation or lacrimation, or exacerbation with foods. The patient was treated for migraine by her neurologist, though no medications were effective including ergotamine, calcium channel blockers, and steroids.Physical examination demonstrated normal nasal mucosa, no rhinorrhea, and a septal deviation to the right in the region of the middle meatus. The anterior aspect of the left middle turbinate was asymmetrically enlarged and contact...

Although there are statistically significant trends uncovered by the survey, the results reflect a lack of consensus regarding adenotonsillectomy management. Further randomized controlled trials or large-scale outcomes projects are much needed to evaluate critically the current practices of pediatric adenotonsillectomies. Additional efforts may also be required to use the information from these studies in effecting changes in actual practice patterns, moving us toward a more evidence-based paradigm of treating pediatric adenotonsillar disease.