Migraine: A look down the nose

BACKGROUND

Studies have suggested that contact between opposing mucosal surfaces in the nasal wall and cavity can be a target of the surgical treatment of migraines. Unfortunately, not enough is known about the role of nasal pathology in the pathogenesis of this condition. The co-existence of further rhinological disorders can be an impediment to defining the cause and effect of anatomical variants. The authors compared the MRI scans of migraine- and non-migraine patients (MPs and NMPs, respectively) to determine the prevalence of such mucosal contact points in order to extrapolate whether there is a significant association with migraines.

METHODS

Coronal and axial MRI brain scans of 522 patients (412 migraineurs and 110 non-migraineurs) were analysed for the prevalence of anatomical variations of the nasal cavity, e.g. concha bullosa, septal deviations, mucosal swelling and contact points.

RESULTS

The results showed no significant difference between MPs and NMPs patients for any of the parameters examined. Moreover, 87% MPs and 79% NMPs had at least one contact point. The most frequent contact point was between the middle turbinate and the septum, observed in 54% of MPs and 45% of NMPs.

CONCLUSIONS

Contact points with the nasal mucosa are highly prevalent in both MPs and NMPs. Although a contact point does not cause a migraine in the absence of the disease, the concomitant presence of migraine and contact points can trigger an attack, and therefore, it is necessary to differentiate or exclude a rhinological disorder in these patients.

Preoperative evaluation of chronic rhinosinusitis patients by conventional radiographies, computed tomography and nasal endoscopy

OBJECTIVES

The aim of this study was to compare the efficacy of conventional radiography (CR), computed tomography (CT) and nasal endoscopy for the preoperative evaluation of chronic rhinosinusitis in patients with persistent complaints despite appropriate medical therapy.

PATIENTS AND METHODS

Forty-three patients (26 males, 17 females; mean age 43 years; range 15 to 73 years) were prospectively evaluated. All patients underwent detailed physical examination, CR and coronal high resolution CT of paranasal sinuses. Thirty of them were evaluated with detailed nasal rigid and/or flexible endoscopy as well. The anatomic variations and mucosal changes in paranasal sinuses were noted. The specificity and sensitivity of CR was calculated using CT findings as a reference point. Surgery was performed on two of the other three patients because of obstructive symptoms of middle turbinate. Paradoxal middle turbinate surgery was performed on one patient due to a headache of rhinogenic origin.

RESULTS

In our study 40 (93%) of all patients showed mucosal abnormalities on CT. Computed tomography scanning of the patients revealed anatomic variations in 74.4% of the cases. Mucosal pathology was most frequently observed in the anterior ethmoid region (middle meatus). While we found mucosal anomalies in 47.4% of all sinuses using CR, 42.2% of these cases were confirmed with CT. Also, 19.5% of all sinuses evaluated as normal with CR presented pathologic findings on CT. An overall correlation of 75.3% was observed between CR and CT, while diagnostic nasal endoscopy and CT findings were correlated at a rate of 87%.

CONCLUSION

(i) While no ipsilateral maxillary or frontal sinus disease was detected when no abnormality in the anterior ethmoid region and infundibulum was observed endoscopically in the presence of mucosal abnormalities similar abnormalities were seen at the same side for maxillary or frontal sinuses. (ii) Anatomic variations of nasal and paranasal sinuses may be considered as etiologic and predisposing factors of chronic rhinosinusitis. (iii) Conventional radiography should not be used as a single diagnostic tool in preoperative evaluation; however, due to its high sensitivity, CR technique may be used alone in the diagnosis and follow-up of maxillary sinus disease. (iv) Nasal endoscopy may reduce unnecessary diagnostic CT scanning procedures.

Ten-year experience using a plastic, disposable curette for the diagnosis of primary ciliary dyskinesia

BACKGROUND

Primary ciliary dyskinesia (PCD) results in impaired mucociliary clearance. Patients with this disorder develop chronic sinopulmonary disease with recurrent sinusitis, otitis media, nasal polyposis, pneumonia, and, ultimately, bronchiectasis. Other associated findings of dysfunctional ciliary activity include situs inversus, dextrocardia, and infertility.

OBJECTIVE

To describe our 10-year experience using a small, plastic, disposable curette to perform a screening procedure for cilia function and to collect samples for electron microscopy.

METHODS

In the past 10 years, we screened infants and children with severe chronic sinusitis and other chronic recurrent upper respiratory tract problems for PCD by using a plastic, disposable curette to collect tissue samples from the nasal mucosa. Samples were placed in sterile saline and examined under light microscopy for the presence of cilia. Failure to note ciliary movement prompted another examination 1 month later. If no functional cilia were noted at the follow-up examination, a specimen was obtained and sent for electron microscopy.

RESULTS

We identified 7 patients with PCD; 2 had situs inversus totalis. Average age at diagnosis was 3 years. The most common symptom at presentation was frequent upper respiratory tract infections with severe otitis media (7 patients) and sinusitis (5 patients). Recurrent pneumonia was present in 6 patients. Dynein arm deficiency was the most common electron microscopic diagnosis.

CONCLUSIONS

Evaluating children for PCD by using a plastic, disposable curette is a relatively simple procedure that could be used by allergists in practice. Primary ciliary dyskinesia occurs frequently enough that physicians should consider it as part of the differential diagnosis in evaluating children with recurrent, severe sinopulmonary infections.

Endoscopic evaluation and management of the lacrimal sump syndrome

Failed dacryocystorhinostomy caused by the presence of residual lacrimal sac has been termed the "lacrimal sump syndrome." Epiphora occurs when tears collect in this residual pouch and lacrimal drainage is delayed. Irrigation into the nose may seem normal. This condition can be easily diagnosed with nasal endoscopy and has a characteristic radiologic appearance. Six patients with failed dacryocystorhinostomy caused by lacrimal sump syndrome were successfully treated with an endoscopic contact Nd:YAG laser technique. Endoscopic dacryocystorhinostomy using the contact Nd:YAG laser is an effective method for treating patients who have persistent epiphora or dacryocystitis after failed dacryocystorhinostomy.

Familial nasal acilia syndrome

Mucociliary dysfunction can be caused by the absence of cilia or by abnormalities in their ultrastructure. A family in which some members were suffering from respiratory morbidity due to lack of cilia is described.

Development of a standardized proforma for reporting computerized tomographic images of the paranasal sinuses

The complex regional anatomy of the paranasal sinuses has only recently been elucidated through the use of modern imaging techniques. The advent of computerized tomography in the delineation of sinonasal pathology and anatomic variation has proven invaluable to the otolaryngologist in preoperative planning for functional endoscopic sinus surgery (FESS). Frequently, the radiologic reporting schemes for these studies are not standardized, and in many respects have been found to be inadequate. This study attempts to develop a simple reporting proforma that the head and neck radiologist can routinely use in order to facilitate the presentation of CT scan findings in evaluating sinus, nasal, or upper airway pathology. Over 100 CT sinus reports that had previously been reported were re-read according to this reporting scheme and were analyzed in order to determine whether any significant discrepancies existed. These differences were then classified according to their incidental, minor, and major surgical significance. It is hoped that through the development of a standardized proforma, the complementary relationship between preoperative imaging and endoscopic intervention can be consolidated and further enhanced.

Open tip rhinoplasty

An open tip rhinoplasty was used to correct moderate to severe secondary cleft lip nasal deformities in 122 patients from January 1986 to January 1988. The results of the surgery on 92 patients who were followed for 1 year or more were evaluated. When the surgery was performed after the age of 3 years, 60% of the patients had a satisfactory result. The pathology of the deformity included 32% with deficiencies of the nasal lining, 35% needed framework support such as a columellar strut, and 45% required correction of columellar deficiencies. Patients using a postoperative nasal stent had a 71% satisfactory result compared with a 37% satisfactory result when the stent was not used. The pathology and techniques to correct the nasal deformity are described.

Short nasal respiratory cilia and impaired mucociliary function

A 48-year-old man was examined because of anosmia. He was otherwise healthy except for mild arterial hypertension. He had stopped smoking 20 years ago. Previously he had been exposed to sulfuric acid gases for 3 years in his work. Clinical examination revealed no findings to explain his anosmia. The patient was fertile, indicating normal sperm/cilia motility. Nasal mucociliary function was examined by radioactive tracer and found to be markedly and constantly impaired. Ciliary ultrastructure in cross-sections was normal. However, in longitudinal sections the length of the cilia varied from 0.6 microns to 3.9 microns. The mean length of the cilia from the cell membrane to the tip was 2.5 +/- 0.9 microns, in contrast to normal ciliary length of 5-7 microns. These findings represent a new structural defect among the various known ciliary abnormalities.

Cilia-lacking respiratory cells in ciliary aplasia

This report describes the ultrastructural alterations observed in the nasal and bronchial mucosa of an 11-yr-old male suffering from immotile cilia syndrome (ICS). The morphological features observed in this patient are consistent with a ciliary aplasia. In fact, ciliated cells appeared to be replaced by columnar cells lacking cilia and basal bodies, and bearing on their surface cilium-like projections without any internal axonemal structure. In spite of the absence of basal bodies, centrioles, and kinocilia, these cells unexpectedly showed mature striated roots and centriolar precursor material scattered throughout the apical cytoplasm. These data suggest that control over basal body assembly is distinct from control over striated root formation. The presence of the above-reported structures in cells otherwise presenting many morphological features of normal ciliated cells is discussed on the basis of current knowledge of respiratory cilia biogenesis.

The nose in anhidrotic ectodermal dysplasia

A case is presented of anhidrotic ectodermal dysplasia, of extreme rarity. This is distinguished by disorders in the structures of ectodermal origin. The clinical characteristics--hypohidrosis, hypodontia, hypotrichosis-, and the genetic features--genealogy, karyotype--are examined first. The patient's face appears to be small, due to the combination of frontal bossing, hypodontia, and a depressed nasal dorsum, somewhat resembling the saddle nose of congenital syphilis. The case is studied from various perspectives: clinical, radiological, anatomicopathological and ultrastructural. The study concentrates principally on the anomalies of the nasal cavities, where there is a notable atrophy of the nasal mucosa. This atrophic rhinitis displays all the features of ozaena: severe crusting, fetid green secretion, nasal obstruction, etc.

[The sick cilia syndrome]

The incidence of bronchiectasis should decrease because of improved immunization, but certain defects would still cause the malady. Fifteen consecutive patients with bronchiectasis were examined for ciliary defects by examining the nasal mucosae with an electron microscope and measuring the clearance of technetium-99m from the lung with a gamma camera. Three patients were found to have defects. Compound cilia, disorganization of the tubular structure, vacuolization and deficient inner dynein arms were observed. In one patient a loss of cell membranes which returned to normal after 4 months, was observed. Ciliary abnormalitites can either be anatomical or physiological and 'sick cilia' should be considered as a cause of bronchiectasis.