Etiology of 'Sinus Headache'-Moving the Focus from Rhinology to Neurology. A Systematic Review

Mendelian randomization and single-cell expression analyses identify the causal relationship between depression and chronic rhinosinusitis

Background

The causative relationship between chronic rhinosinusitis (CRS) and depression remains unclear. Herein we employed Mendelian randomization (MR) coupled with single-cell analysis to investigate the causality between CRS and depression.

Methods

Data pertaining to CRS and depression were mined from the genome-wide association study database, and a single-cell dataset was sourced from the literature. To explore causality, we conducted bidirectional MR analysis using MR-Egger, weighted median, inverse variance weighted (IVW), simple mode, and weighted mode, with IVW representing the most important method. Further, sensitivity analysis was performed to evaluate the robustness of MR analysis results. Candidate genes were analyzed via single-cell combined MR analysis.

Results

Forward MR analysis indicated depression as a risk factor for CRS when depression was the exposure factor and CRS was the outcome (OR = 1.425, P < 0.001). Reverse MR analysis revealed the same positive relationship between CRS and depression when CRS was the exposure factor and depression was the outcome (OR = 1.012, P = 0.038). Sensitivity analysis validated the robustness of bidirectional MR analysis results. Ten cell types (endothelial, ciliated, basal, myeloid, mast, apical, plasma, glandular, fibroblast, and T cells) were identified in the single-cell dataset. The network of receptor-ligand pairs showed that in normal samples, cell-cell interactions were present among various cell types, such as epithelial, mast, myeloid, and endothelial cells. In contrast, CRS samples featured only one specific receptor-ligand pair, confined to myeloid cells. TCF4 and MEF2C emerged as potentially crucial for CRS-associated depression development.

Conclusions

Our findings suggest a bidirectional causal relationship between CRS and depression, offering a new perspective on the association between CRS and depression.

Decisions regarding antibiotic prescribing for acute sinusitis in Norwegian general practice. A qualitative focus group study

BACKGROUND

Acute sinusitis is a frequent reason for primary care visits. Most patients recover within two weeks without antibiotic treatment. Despite this, about 50% of patients with acute sinusitis in Norwegian general practice are still prescribed antibiotics. We do not know the reason behind this discrepancy.

AIM

To explore the clinical decision-making process and reasons for treatment with antibiotics for acute sinusitis among Norwegian general practitioners (GPs).

METHODS

Five focus group interviews were conducted (N = 25) in different parts of Norway, including GPs of various age, gender, and experience. The interviews were analysed using Systematic Text Condensation.

RESULTS

The results showed a very diverse management of acute sinusitis among GPs, with decisions regarding antibiotics not always aligning with guideline recommendations. Many of the GPs did not agree with the Norwegian guidelines for antibiotics and chose something other than phenoxymethylpenicillin as their first choice. Clinical predictors emphasized in decision-making were pain complaints and patient exhaustion. Pragmatic factors such as weekday, travel plans, or a full waiting room could also influence the decision.

CONCLUSION

GPs found it difficult to identify when patients would benefit from antibiotic treatment for acute sinusitis, and different strategies were used to make prescribing decisions. For several GPs the degree of pain was one of the decisive reasons for antibiotic prescribing, however the guidelines for antibiotics do not give sufficient advice regarding pain treatment. These results suggest a need for revaluation of guideline contents and the way they are communicated to GPs.

Sinonasal symptoms in migraine without aura: results from the cross-sectional 'Migraine in Poland' study

Background

Migraine without aura (MwoA) is often mistaken for rhinosinusitis. The purpose of this study was to assess the prevalence of sinonasal symptoms, sinusitis-targeting medication use and burden of migraine in a large group of people with MwoA attacks accompanied by rhinologic symptoms.

Methods

Data was collected in a cross-sectional online survey based on an adapted population-based study questionnaire. The analysis included the prevalence of rhinorrhea, mucopurulent nasal discharge, nasal congestion, facial pressure and tenderness to palpation, hyposmia/anosmia and osmophobia.

Results

1,679 (52.73%) MwoA people were identified among 3,225 respondents (women n = 2,809, 87.10%) aged 13-80 years (median age 39; standard deviation 10.4). 1004/1679 (59.8%) migraine patients reported one or more rhinologic symptoms and 341/1679 (20.3%) MwoA respondents had symptoms that met rhinosinusitis clinical diagnostic criteria during their headache attacks. In migraine patients, osmophobia was associated with hyposmia [n = 141 (12.7%) vs. n = 41 (7.2%); p = 0.001] and a sensation of unpleasant smells [n = 216 (19.4%) vs. n = 45 (8.5%); p = 0.001], while facial tenderness to palpation was associated with facial allodynia [n = 532 (50.4%) vs. n = 211 (33.9%); p < 0.001]. People with migraine accompanied by rhinosinusitis-like symptoms experienced more disease burden and used 'sinus medications' more often.

Conclusion

MwoA patients with rhinosinusitis-like symptoms during migraine attacks require cautious assessment, especially that some symptoms seem to have little value in distinguishing between these disorders (i.e., facial tenderness, hyposmia), while many of these patients have a greater disease burden and therefore often choose medications targeting rhinologic instead of neurologic mechanisms.

Problem of headache: A cross-sectional study

Objectives

To assess the medical students, interns, general practitioners, and family physicians' perception of neurological and otolaryngeal causes of headaches.

Materials and Methods

A prospective, qualitative, questionnaire-based cross-sectional study took place. Five hundred and seventy-one senior medical students, interns, general practitioners (GPs), and family physicians from different geographical regions in Saudi Arabia were involved in the study. An online questionnaire is used to estimate the respondents' knowledge regarding neurological and otolaryngeal causes of headaches. The obtained data were statistically analyzed using SPSS version 21.

Results

Five hundred and seventy-one participants were involved in the study. They were 377 females and 194 males with a female-to-male ratio of 1.9:1. Most of them were medical students (69.9%). However, medical interns, general practitioners, and family physicians' respondents were (17.3%), (7.5%), and (5.3%), respectively. They constituted different geographical regions of Saudi Arabia. An average level of knowledge about headaches was recorded in (55%) of the participants, while (42.7%) had a good level of knowledge about its etiologies.

Conclusions

A considerable percentage of the current study population has average knowledge about neurological and otolaryngeal factors of headache. It is advocated that the current national medical curriculum be thoroughly reviewed and clear referral pathways must be established to have better management of these cases.

Care for Patients with Type-2 Chronic Rhinosinusitis

In the last 20 years, growing interest in chronic rhinosinusitis (CRS) has become evident in medical literature; nevertheless, it is still difficult to identify the real prevalence of the disease. Epidemiological studies are few and focused on heterogeneous populations and diagnostic methods. Recent research has contributed to identifying CRS as a disease characterized by heterogeneous clinical scenarios, high impact on quality of life, and elevated social costs. Patient stratification with phenotypes and identification of the pathobiological mechanism at the origin of the disease (endotype) and its comorbidities are pivotal in the diagnostic process, and they should be addressed in order to properly tailor treatment. A multidisciplinary approach, shared diagnostic and therapeutic data, and follow-up processes are therefore necessary. Oncological multidisciplinary boards offer models to imitate in accordance with the principles of precision medicine: tracing a diagnostic pathway with the purpose of identifying the patient’s immunological profile, monitoring therapeutical processes, abstaining from having only a single specialist involved in treatment, and placing the patient at the center of the therapeutic plan. Awareness and participation from the patient’s perspective are fundamental steps to optimize the clinical course, improve quality of life, and reduce the socioeconomic burden.

Role of Computed Tomography and Magnetic Resonance Imaging in the Evaluation of Headache Due to Paranasal Sinus and Teeth Disorder

When brain imaging is performed as a first-line investigation for headaches and no intracranial abnormality is found, attention should always be paid to potential non-CNS causes of headache including paranasal sinus inflammatory, infectious, and occasionally malignant disease, and also to odontogenic sinusitis. Non-enhanced CT (NECT) head offers an initial evaluation of these areas which may be an unexpected source of symptomatology. Further imaging may then be required with either dedicated sinus NECT [particularly if surgical intervention is necessary for paranasal sinus disease], a contrast-enhanced (CECT) head and sinus CT, or an MRI if intracranial complications of sinonasal disease or acute invasive fungal sinusitis is suspected.

COVID-19-related headache and sinonasal inflammation: A longitudinal study analysing the role of acute rhinosinusitis and ICHD-3 classification difficulties in SARS-CoV-2 infection

Background

The genesis of headache in coronavirus disease 2019 (COVID-19) is currently unclear and the multitude of disease symptoms often further hinders locating the source of pain. Interestingly, many subjects with COVID-19 have symptoms of acute rhinosinusitis. The relation between nasal symptoms and headache in SARS-CoV-2 infection remains unknown.

Methods

This bi-center longitudinal study evaluated symptoms in consecutive COVID-19 patients in the participating practices. The first assessment was performed during the initial consultation after infection confirmation. That was followed up by a second consultation after a median 9 days.

Results

130 patients were included in the study (80 women, 50 men; mean age 46.9 years). Headache was highly prevalent at the first visit (72%) and significantly associated with acute rhinosinusitis symptoms. The odds ratio for headache in subjects with rhinosinusitis was 3.5. Headache could be attributed to systemic viral infection in 96% and to acute rhinosinusitis in 51% of cases according to 3rd edition of the International Classification of Headache Disorders. Criterium C.3 (exacerbation of headache by pressure applied over paranasal sinuses) and C.4 (ipsilaterality of headache and sinusitis) had low sensitivity in headache attributed to acute rhinosinusitis.

Conclusions

Nasal inflammation is associated with headache in COVID-19, although the pain mechanism lies probably in a systemic reaction to the virus. 3rd edition of the International Classification of Headache Disorders criteria for headache attributed to acute rhinosinusitis need adjusting to the current understanding of acute sinonasal infection.