| Abstract|| |
Headache is a common clinical problem, and appropriate diagnosis and management are a challenge for oral physician. Any minor anatomical variation within the nasal cavity may lead to mucosal contact point, which may be an etiological factor for causing headache and often left behind by clinician during preliminary evaluation of patients with headache or facial pain, resulting in misdiagnosis and inappropriate treatment. This article is an attempt to present a case of rhinogenic contact point headache which may be mistaken for a toothache initially leading to incorrect diagnosis and irrelevant treatment. A thorough, accurate and comprehensive history taking and a complete clinical and general physical examination result in appropriate diagnosis of the clinical situation.
Keywords: Headache, mucosal contact point, odontogenesis, pain, rhinogenic headache
|How to cite this article:|
Soni AG. Rhinogenic contact point headache mimicking odontogenic pain: A case report and review of literature. Indian J Dent Res 2020;31:647-51
|How to cite this URL:|
Soni AG. Rhinogenic contact point headache mimicking odontogenic pain: A case report and review of literature. Indian J Dent Res [serial online] 2020 [cited 2020 Oct 30];31:647-51. Available from: https://www.ijdr.in/text.asp?2020/31/4/647/298415
| Introduction|| |
The diagnosis of orofacial pain is a crucial and frequently undervalued component of clinical practice. When the patients seek the care of dentists because of pain localization in the oral cavity and surrounding structures, it is usually assumed to be odontogenic in origin. There are myriads of causes for orofacial pain, and sometimes, it is often common for pain in the orofacial region to be mistaken for a toothache, as they mimic odontogenic pain. Therefore, orofacial pain may sometime pose a diagnostic dilemma for the healthcare professionals. A comprehensive knowledge of both odontogenic and non-odontogenic causes of orofacial pain and the manner in which other orofacial structures may simulate pain in the tooth is very important in deciding the correct diagnosis and appropriate treatment.
A headache or orofacial pain syndrome secondary to mucosal contact points in the nasal/sinus cavities in the absence of any inflammatory sinonasal pathology termed as rhinogenic contact point headache. Intranasal contact points can be described as a contact between two opposing intranasal mucosal surfaces., Intranasal contact points are present in about 4% of noses. In 1980, Morgenstein and Krieger found that any deviation of nasal turbinate anatomy from the normal could cause a headache and were the first investigators to propose the concept of contact point headache.
Often the rhinogenic cause of facial pain is frequently undiagnosed; and many times, this cause is not even suspected on preliminary evaluation. This article is an attempt to present a case of rhinogenic contact point headache that was initially misdiagnosed and treated first surgically, and then endodontically as a pain of odontogenic origin. A surgical removal of mucosal contacts decreases the headache severity and completely alleviated the pain in patient. This case demonstrates the importance of taking a detailed and proper clinical history, highlighting the significance of clinical and general physical examination, and the need for careful diagnosis before undertaking any treatment in managing complex orofacial pain condition.
| Case Report|| |
A 30-year-old male presented with a complaint of pain in the upper right back tooth region and persistent dull headache affecting the forehead and right side of the face, which radiates towards the vertex of the head [Figure 1]. Detailed history revealed that he has been experiencing this pain for the past eight years of his life. Extraoral examination revealed no lymphadenopathy, no palpable tenderness, and no soft tissue enlargements in the head or neck region. Intraoral examination showed buccally erupted right maxillary third molar, with an inflamed tissue around it. Pain could be elicited by percussion of the teeth or palpation of the tissues around it. A panoramic radiograph was made which revealed impacted right maxillary and mandibular third molar with slight haziness of the right maxillary sinus [Figure 2]. As clinical findings were consistent with radiographic findings, the practitioner made the diagnosis of pain due to impacted tooth. The patient had undergone surgical extraction of the same along with the removal of an impacted mandibular third molar on the same side. Following extraction, the socket healed completely.
|Figure 1: Clinical profile of the patient at the time of examination experiencing severe pain affecting the forehead and right side of the face|
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|Figure 2: Panoramic radiograph showing impacted right maxillary and mandibular third molar|
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Approximately 3 months later, the patient returned and reported similar type of pain in the maxillary right posterior area and right side of the face and forehead. At this time, he reported that the intensity of the headache has been increased. Clinical examination revealed no abnormalities. Radiographic examination revealed normal periapical pathology. On further questioning, the patient stated that the pain elicited by digital pressure over the apices of the right maxillary first and second molar teeth, but attempts to reproduce the pain were unsuccessful. The patient insisted that the right maxillary first and second molar teeth were the source of the pain. The clinical findings were explained and the following treatment options discussed: (1) no treatment, (2) root canal treatment of one or both teeth, (3) surgical exposure of the two teeth to explore for vertical root fractures, or (4) extraction of one or both teeth. The patient elected to have root canal treatment, which was completed without complications [Figure 3].
|Figure 3: Intraoral periapical radiograph showing root canal treatment of maxillary right first and second molar|
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Six months later, the patient returned with a complaint of recent recurrence of similar pain, which was extreme and excruciating in nature affecting the frontal part of the face and radiated upwards. Clinical examination revealed that the previously treated teeth were not tender to percussion or palpation. The soft tissues in the area of the previous surgery were normal in appearance. The patient's pain could not be reproduced during this appointment. Upon further questioning recently, he has admitted that his pain was accentuated by pressure build-up whenever he sneezes. There were some persistent right-sided nasal obstruction and persistent rhinorrhoea for many years with post nasal drip. There were no complains of anosmia or hyposmia and nor were there any fever or purulent nasal discharge. On nasoendoscopic examination, inferior turbinates were found to be hypertrophied with a deviated nasal septum towards the right [Figure 4]. CT of paranasal sinus showed a deviated septum to the right and hypertrophied inferior nasal turbinates, with contact between the two without any rhinosinusitis changes [Figure 5]. A simple diagnostic test has been performed clinically, where a local anaesthetic solution has been applied into the nasal passage using cotton pledget and there is significant resolution of headache within 5 min following topical use of local anaesthesia at contact area, which suggests that the pain would be rhinogenic in origin [Figure 6]. On the basis of history and clinical examination, and its correlation with radiographic findings, a final diagnosis of orofacial pain secondary to deep pain input in the nasal mucosa (rhinogenic headache) was made. The patient had undergone septoplasty with conservative partial turbinectomy of inferior turbinate [Figure 7]. The patient responded well after the surgical treatment and reported complete abolition of pain at the 1-month postsurgical follow-up. At 1-year postsurgical follow-up, no complications or recurrence of pain was found [Figure 8].
|Figure 4: Nasoendoscopic examinations showing inferior turbinates hypertrophy with a deviated nasal septum to the right|
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|Figure 5: Coronal computed tomogram through the middle portion of the inferior turbinate. The tomogram showing deviated nasal septum towards the right and hypertrophied inferior nasal turbinates, and contact between the two. No sinusitis changes evident|
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|Figure 7: Coronal computed tomogram through the middle portion of the inferior turbinate after septoplasty with conservative partial turbinectomy of inferior turbinate|
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|Figure 8: One-year postsurgical follow-up of the patient showing no complications or recurrence of pain|
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| Discussion|| |
Rhinogenic contact point headache has been recently added as secondary headache disorder in the second edition of the International Classification of Headache Disorders (ICHD-2), where it is described as being characterized by intermittent pain localized in the periorbital and medial canthal or temporozygomatic regions, associated with evidence of mucosal contact points by nasal endoscopy or computed tomography (CT) imaging. Research has shown that different anatomical variations, especially septal spurs and abnormal turbinates, can be the cause of intranasal mucosal contacts.
To understand the mechanism of a rhinogenic headache, thorough knowledge of the nervous supply to the face and nose is important. The nasociliary nerve is a main branch of the ophthalmic nerve. It divides into the anterior and posterior ethmoidal nerves. The anterior superior part of the septum is supplied by the anterior ethmoidal nerve. The nasopalatine nerve supplies the bulk of the bony septum. The infraorbital nerve which is also a branch of the maxillary nerve supplies sensory innervation to the lateral part of the nose. Thus, it is clear that there are several nerves supplying the nose, which run in close proximity to each other. This suggests that the pain elicited by the contact point may cause non-specific facial pain. Several studies have explained that neuropeptides substancePand CGRP (calcitonin gene-related peptide) are mediators of rhinogenic pain. SubstancePis stored in localized sensory C-fibres in the mucosa. Local substancePmay cause vasodilation and hypersecretion while the release of substancePin the body may cause referred pain., SubstancePalso causes plasma extravasation, histamine release and other inflammatory events. These systemic vascular phenomena may be responsible for migraine-like headache symptoms.
The diagnosis of contact point headache requires a multidisciplinary approach. Patients with headaches without findings of inflammation of mucosal membranes of the sinonasal region should be examined by a neurologist, ophthalmologist, and dentist to exclude other causes. The Headache Classification Committee of the International Headache Society proposed a diagnostic criteria of “Mucosal contact point headache,”  which are shown in [Table 1].
Diagnostic nasal endoscopic examination in conjunction with CT scan of the paranasal sinuses has proven to be an ideal combination for diagnosis of sinonasal pathology. CT is also helpful to decide the location and the type of the surgery. After rhinoscopic and endoscopic examination and CT evaluation of the paranasal sinuses, it is very important to perform the lidocaine test [Figure 9]. It can help not only the diagnosis of this type of a headache but also acts as an indicator of the success of surgical removal of mucosal contact.
|Figure 9: Lidocaine test. (Adapted and Modified from Soni A. Toothache of Non-Dental Origin: A Review of Its Mechanism and Clinical Characteristics. Int J Sci Stud 2018;6 (2):26-35.)|
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After identification of contact points, rhinogenic contact point headache can be managed surgically. After evolution of endoscopic sinus surgery, many authors described different techniques such as partial turbinectomy and turbinoplasty aiming to decrease contact point headache and minimise postoperative synechia. Endoscopic surgical treatment affords superior visualisation of mucosal contacts, which is important for their limited resection and allows for a more controlled and precise surgery, with minimal trauma. The limited endoscopic sinus surgery is a useful surgical technique which helps to remove the contact points [Table 2]. There are several studies that have analysed the success of the surgery of contact point headache. The criteria for inclusion and the results were different from study to study. The biggest series, which was presented by Huang et al., included 66 patients divided into three groups: with the deviation of the nasal septum, with concha bullosa, and with orbitoethmoidal (Haller's) cell. After the surgical treatment, the authors found a reduction of intensity and frequency of a headache in 81.8% of the patients. Parsons and Batra demonstrated an improvement rate of 91% in a retrospective study including 34 subjects with contact between the septum and nasal turbinates. Sadeghi et al. published similar results (improvement in 93.3% of patients) with similar groups for a total of 30 patients. The results of another study by Peric et al. showed an improvement rate of 88.10.
| Conclusion|| |
Rhinogenic contact point headache is often a missed diagnosis, as often other literature has stated that it should remain a diagnosis of exclusion. If no other findings of inflammation for headache are seen, intranasal mucosal contact points should be given due importance. Diagnosing headaches from mucosal contact points require CT, endoscopy and not forgetting a proper medical history. We report this case to highlight the importance of proper diagnosis of rhinogenic headache as our patient had been improperly treated with the wrong diagnosis throughout the years. Therefore, recognizing the rhinogenic headache is essential to avoid unnecessary medications and inappropriate treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Abhishek G Soni
263- Balaji Villa, Shivom Estate, Station Road, Dewas - 455 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figur 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2]