Chronic facial pain is psychogenic

Compiled By; Dr. Hafiz Shahid Amin (MBBS, DCA, DLO) ENT Surgeon, Sargeon Naak Kaan Gala Gujranwala- Pakistan

Spur, tensions, hypertension, migraine, Psychogenic, Concha bullosa middle turbinate, Reflux sinusitis and allergic rhinitis, Post Surgical Nasal Dysfunction (PSND)

Note..you will also see down here the interesting study showing relation of PPIs with sinusitis, headache and treatment reference.

A)..Chronic facial pain is psychogenic. Any response to surgery will be placebo and temporary. The recurrence may be in the same area or elsewhere in the body.

Yes..these are 'pain patients'. There is something wrong with their pain mechanism altogether. They commonly have low back pain, TMJ, and fibromyalgia. They respond to antidepressants, but the depression is secondary to the pain, and the antidepressant is probably acting in some as yet undescribed way to modulate their pain. They are willing subjects for any surgery offerd by a surgeon who 'knows just what to do".

B)..The nasal anatomy may be the cause of the headache.On one case a local SMR. Just enough sedation to carry on a light conversation about favorite restaurants. WhenI moved the bone over she announced - even under Vallium and Demerol - "My Headache. Its Gone!" and indeed it was.

Some rhinologists feel that mucosa to mucosa contact is the cause of pain and polyp specially if cilia beat in different directions on the mucosal layer. I see a large number of noses where mucosa is in contact at some point or the other in nose.In fact in most noses in daytime and at night on bed some point of mucosal contact is there. They get neither pain nor polypii. After surgery with adequate gap we still have polyp formation without mucosal contact. Perhaps more work is need and polyp disease if multifactorial. A posterior vomerine spur pressing in general area of sphenopalatine ganglion i.e. Sluder`s in some cases has given relief specially if local
anesthetic sprayrelieves pain when severe. I would be afraid to say anything outright about "small" concha bullosa. I have cured headaches by reducing large concha bullosa, but I have had huge concha that did not arrive with headache. I don't remember operating a concha bullosa for headache. I tell all my patients, "I don't guarantee to cure headaches and I can't cure allergy." However, it sometimes happens in the course of treatment for another condition such as chronic sinusitis from osteo-meatal obstruction. I have had a few patients over the years with the superior turbinate impinged against a deviated septum along with at least one patient with a large supreme turbinate. I don't remember any that did not have relief of their headache, including one lady who had suffered "migraine headaches" for years. Obviously, one has to examine the patient carefully to see this situation; often it can be seen on the coronal CT scan. A tiny cotton swab moisten with 10 percent cocaine can then make the diagnosis.

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Post Surgical Nasal Dysfunction (PSND

Ref; Fred Herzon University of NM

I just presented the following abstract at the Western Triologic in California on what I am calling Post Surgical Nasal Dysfunction (PSND) describing a syndrome we all know of patients seeing us after having either turbinate or sinus surgery and continuing to complain of the same symptoms for which they had surgery. Additionally Moore and Kerns just published their experience with 242 patients with "Atrophic Rhinitis". They divided their patients into primary, classic Klesbsela ozonea infected patients (45 patients). All patients had nasal mucosal biopsies showing atrophic changes and they called their second group secondary atrophic rhinitis almost all of whom just had turbinate surgery. All of these patients had similar symptoms to the ones in my series and would fit into the PSND syndrome. All of the patients in my series would not fit into secondary atropic rhinitis and I would suggest that PSND is a more inclusive term as there probably other pathophysiologic and behavior factors contributing to this syndrome. Some of the patients in my series had minimal turbinate surgery. It appears that any patient who has had sinus or turbinate surgery can present with symptoms of obstructive rhinosinusitis with little evidence of obstructive pathology. PSND is a multifactoral syndrome which needs further study and definition of its various aspects. So the answer to the original question is that any patient can have turbinate and sinus surgery which is considered post operatively perfect and still complain of continuing symptoms for which they had the original surgery. I hope this is helpful to al of you.

Abstract

Objectives: To describe a syndrome characterized by complaints of facial pain, headache, pressure, recurrent or chronic nasal discharge and congestion in patients who have had one or more nasal sinus surgical procedures and show no significant clinical evidence of obstruction.

Study Design: Case series

Methods: Patients were included in the study if they had prior nasal sinus surgery and reported symptoms of obstructive disease without clinical evidence of obstructive nasal sinus pathology. Data related to the following variables were collected: patient demographics; patient self report of the type and number of nasal sinus surgical procedures; clinical findings related to the nose and paranasal sinuses; and findings from CT scans when these were available.

Results: The study includes 60 patients seen over a 42-month period. Patients reported an average of 2.4 nasal sinus procedures, some done by different surgeons, from 2 to 30 yr. prior to inclusion. Major complaints were facial pain (60 %); headache (47 %); pressure (32 %); recurrent or chronic nasal discharge (82%); and congestion (75%). Forty-nine patients (82%) were female. Evidence of turbinectomy was present in 88% of the patients, one or both antral ostia had been opened in 83%, and one or both ethmoid complexes had been opened in 87%. Prior systemic antibiotic therapy did not relieve symptoms.

Conclusions: The term Post-Surgical Nasal Sinus Dysfunction is suggested for the set of symptoms reported by patients who have had nasal sinus surgery, complain of symptoms that suggest obstructive rhinosinusitis yet have minimal evidence of obstructive disease.

Ref;; Leonardo Mangahas Jr. MD, Philippines

Reflux sinusitis and allergic rhinitis: can the two coexist? How do we distinguish the nasal complaints between these two entities? 8I have been studying these two and I think I have been able to fairly distinguish clinically between the two common diseases.

Allergic rhinitis is present when the nasal congestion is accompanied by itchiness, sneezing and watery rhinorrhea. Family history of asthma or allergy should be of help.

Reflux sinusitis is when there is nasal congestion without the itchiness or
the sneezing. Dryness of the nose is also a prominent feature.There may be
postnasal drip. Accompanying dryness of the throat, throat clearing,
hoarseness and heartburn should also be of help. An allergic rhinitic may also have reflux sinus disease and the clincher in the diagnosis will be the accompanying dryness of the throat, heartburn and hoaseness. The allergic rhinitic who does not respond well to antihistamines or intranasal steroids should be examined further for the possibility of reflux disease. In my clinical work, I have stumbled too on a very interesting phenomenon, more interesting probably than reflux disease itself. This is when I see very dry nasal mucosae in those whom I suspect as having reflux sinusitis. (I must admit that I do not make any distinction between rhinitis and sinusitis. When I say sinusitis I also mean rhinitis).
In five of 62 reflux sinusitis patients this January alone, I have observed actual atrophic rhinitis. Three did not have the Klebsiella infection and two had those gigantic crusts with thick yellowish discharge. All five responded well to therapeutic trial with PPIs alone. The ones without Klebsiella had their mucosae healed in one week of the trial treatment, those with the Klebsiella had a much longer period of healing: 2-3 weeks. So in addition to agreeing that globus is reflux pharyngitis, I now dare say that atrophic rhinitis is a severe form of reflux sinusitis. And that PPIs should be the treatment of choice in this disease. I would want all of you to test this theory.
BTW, Klebsiella bacteria are enterobacters, bacteria that thrive normally in
the gut, and that the Klebsiella when cultured with the triple sugar iron
agar result in an acidic reaction. And that sodium bicarbonate has long been
effective as a long-term nasal wash. Clues that should really point to acid
reflux as the etiology of atrophic rhinitis. The next time you see somebody
with atrophic rhinitis, ask the patient whether there are accompanying symptoms such as dryness of the throat, hoarseness, throat clearing or heartburn. Clues certainly that point to acid reflux as the culprit in atrophic rhinitis.