Acta Oto-Laryngologica. 2015; Early Online, 1–6
ORIGINAL ARTICLE
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Facial pain/headache before and after surgery in patients with nasal polyposis
DUC TRUNG NGUYEN1,2, MARYLISA FELIX-RAVELO1, FABIEN AROUS2, PHI-LINH NGUYEN-THI3 & ROGER JANKOWSKI1,2 University Hospital of Nancy, Department of ENT – Head and Neck Surgery, Nancy, France, 2Faculty of Medicine, University of Lorraine, France and 3University Hospital of Nancy, Clinical Epidemiology and Evaluation Department, Nancy, France
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Abstract Conclusion: Endoscopic surgery improved facial pain/headache and physical-psychosocial impacts in patients with nasal polyposis. However, one fifth of patients still experienced residual pain after surgery, requiring neurologic counseling to look for the non-sinonasal cause of their symptoms. Objective: Considering the limited amount of literature on facial pain/headache in patients with nasal polyposis, this prospective study assesses facial pain/headache and its impacts on the quality-of-life (QoL) before and after endoscopic surgery. Methods: Facial pain/headache was assessed, using the DyNaChron questionnaire, in 107 patients with nasal polyposis 1 day prior to surgery and 6 weeks after surgery. All patients were operated on endoscopically on the bilateral ethmoidal labyrinths and olfactory clefts. Results: Moderate or severe facial pain/headache was reported by 50% of the patients before surgery and by 20% after surgery. Post-operatively, 79.44% of patients reported no/very mild pain (vs 47.66% pre-operatively) and 20.56% moderate/severe pain (vs 52.33% pre-operatively). The pain was statistically reduced after surgery among patients with previous surgery (p = 0.0006). The scores of all analysed impacts of pain improved after surgery. However, patients with grade 1 polyps seemed to have less benefit from the surgery for facial pain/headache than those with more severe nasal polyposis.
Keywords: Nasal polyposis, facial pain, headache, dynachron questionnaire, quality-of-life
Introduction Nasal polyposis is a chronic inflammatory disease of the nose with a pathogenesis that remains poorly understood. It is defined as chronic rhinosinusitis (CRS) under many guidelines and expert panel documents [1] while evo-devo’s arguments support the hypothesis of it being a specific disease of the ethmoidal labyrinth mucosa [2]. Facial pain/headache is one of the major criteria for the diagnosis of CRS [3,4]. Nasal polyps, for which the main complaints are nasal obstruction and impairment/loss of smell [5], was listed as one of the five main rhinological causes of facial pain by Ryan and Kern [6]. However, mechanisms of facial
pain/headache in nasal polyposis (NP) still remain poorly understood. CRS patients with and without nasal polyposis were often mixed-up in most papers, leading to misguided interpretations of its results. In fact, very few studies have focused on facial pain/ headache in patients with NP, specifically on its impact on the QoL. Patients with NP usually have higher pre-operative endoscopy and CT scores than those with chronic sinusitis [7]. However, facial pain is reported less often than in patients with NP (varying from 16–36%) [8–11]. The aim of the present study was to assess facial pain and its impacts on the QoL before and after endoscopic surgery for NP, using a new instrument – the DyNaChron questionnaire [12].
Correspondence: Dr Duc Trung Nguyen, Service d’Otorhinolaryngologie et Chirurgie Cervico-Faciale, Hôpital de Brabois, Centre Hospitalier Régional Universitaire de Nancy, rue du Morvan, 54511 Vandoeuvre-les-Nancy Cedex, France. Tel: +33383155409. E-mail: [email protected]
(Received 29 March 2015; accepted 14 May 2015) ISSN 0001-6489 print/ISSN 1651-2251 online 2015 Informa Healthcare DOI: 10.3109/00016489.2015.1058531
2
D. T. Nguyen et al. examination and during endoscopic surgery. Polyp grading was performed according to the surgical staging system of Benamara et al. [13].
Materials and methods
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Patient population One hundred and seven patients with NP were prospectively assessed and admitted for surgery in our tertiary referral center. All patients underwent endoscopic surgery on the bilateral ethmoidal labyrinths and olfactory clefts according to the concept of nasalization by removing as completely as possible all the bone and mucosal septation inside the ethmoidal labyrinth as well as mucosa on the lamina, skull base, conchal lamina and lateral side of the middle and superior turbinates. These turbinates were preserved whenever possible. The surgery was indicated when medical treatment failed to control the symptoms associated with NP. Corrective surgery of the septum was associated with nasalization when necessary. No systemic corticosteroid nor antibiotic treatment was systematically given before or after surgery. A day after surgery, all patients started washing their nasal cavities with isotonic saline, using a syringe, at least three times a day, and using a topical steroids spray once a day. Patients with facial trauma, known neuralgias or temporomandibular joint dysfunctions were excluded. This study was approved by the Institutional Review Board of University Hospital of Nancy, France. NP was diagnosed in patients with chronic nasal dysfunction who presented with white edematous polyps in both nasal cavities at nasal endoscopic
Facial pain/headache assessment All patients were asked to rate their levels of facial pain/headache and its impacts on QoL over the last 15 days including the day of the assessment, by using 13 items related to facial pain/headache of the DyNaChron questionnaire. This questionnaire was prospectively completed the day prior to surgery and 6 weeks after surgery, in the waiting room before the medical follow-up visit. This questionnaire assesses 13 complaints (Figure 1) related to facial pain/ headache and four impacts associated with the psychosocial field (affect on mood, ability to concentrate, relationships with others, and affect on a patient’s daily life). Each item is on a 0–10 point scale, with 0 meaning no discomfort at all and 10 meaning unbearable discomfort. Statistics Statistical analyses were performed by means of SAS v9.1 software (SAS Inst., Cary, NC) where a two sided p-value of less than 0.05 was significant. Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as frequencies and percentages. Facial pain/headache
Figure 1. Mean scores of each item before and at 6 weeks after surgery.
Facial pain/headache in patients with nasal polyposis
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was also gathered in categories of none (0), mild (1–3), moderate (4–6), and severe (7–10) to express the pain intensity that required an adapted treatment. The Chi Square Test or Fisher’s exact test was used to assess the difference in incidence of pain before and after surgery as well as between different subgroups of patients. The effect size – the average change divided by the baseline standard deviation – at ‡ 0.5 was defined as the threshold of discrimination for changes in health-related quality-of-life for chronic diseases [14]. Results A total of 107 patients (mean age of 48.8 ± 12.6 years) were enrolled in this study, of which 62 patients (57.94%) were male and 45 female (42.06%). Sixty-three patients (59.43%) had a history of previous sinonasal surgery (polypectomy, ethmoidectomy, or nasalization). Asthma was associated to NP among 64 patients (60.38%). Fifty-five patients underwent septoplasty during the surgery. Grade 1 polyps were found in 14 patients (13.08%), grade 2 in 34 patients (31.78%), and grade 3 in 59 patients (55.14%). Outcomes of headache/facial pain Figure 1 shows mean scores of facial pain/headache and its physical and psychosocial impacts before and after surgery. There was an improvement of all complaints in post-operative scores. The effect sizes were 0.6 for facial pain/headache, 0.58 for ‘moist or runny nose during painful crisis’, 0.61 for ‘affect the mood’, 0.58 for ‘ability to concentrate’, 0.51 for ‘relationship with others’, and 0.53 for ‘affect on everyday life’. The effect size for the ‘stuffy nose during painful crisis’ was 0.76, which by convention is a significant improvement in health-related QoL. The effect sizes of other complaints were lower than 0.5. Polyp staging and prior sinus surgery on outcomes of headache/facial pain Table I shows the distribution of patients according to polyps staging, intensity of pain before and after surgery, and any history of previous surgery. Pain in patients with less severe polyposis (grade 1 polyps) did not change significantly post-operatively. In contrast, patients with grade 3 polyps seemed to have more benefits from the surgery in terms of pain reduction. About one third of patients reported no pain before surgery, which was not correlated to any history of previous surgery. Moderate or severe facial pain/ headache was reported by 50% of patients before
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surgery, but only by ~ 20% of patients after surgery. Pain intensity reported was statistically lower after surgery than before surgery (p = 0.0002): 79.44% of patients with none to very mild pain after surgery vs 47.66% before surgery, 20.56% of patients with moderate-to-severe pain after surgery vs 52.33% before surgery. This difference remained statistically significant among patients with history of previous surgery (p = 0.0006) in contrast to those without any previous surgery (p = 0.15). There was no significant difference in the pre- and post-operative distributions of patients related to pain intensity (none, mild, moderate or severe pain) between gender or abnormal septums requiring a concomitant septoplasty. Discussion ‘Facial pain and pressure’ is considered a major factor and ‘headache’ a minor factor for the diagnosis of CRS in the otolaryngologic literature since 1997 [3]. However, in 2004, the International Headache Society (IHS) stated in the 2nd International Classification of Headache Disorders, that chronic sinusitis is not validated as a cause of headache or facial pain unless considered an acute stage due to the fact that ‘sinus headaches’ are often confused with migraines [15]. Although it remained controversial whether or not chronic sinus pathology could produce persistent headaches, criteria for headaches attributed to chronic or recurring rhinosinusitis were introduced in the recent classification of the International Headache Society [16]. Many papers reported that a large number of patients with headache/facial pain were erroneously self-described or physician-diagnosed ‘sinus’ headaches [17,18]. Schreiber et al. [18] reported that, among 2991 patients screened, 2396 patients (80%) with ‘sinus headaches’ fulfilled IHS criteria for migraine without aura or migraine with aura. Of those, 84% reported sinus pressure, 82% sinus pain, 63% nasal congestion, 40% rhinorrhea, 38% watery eyes, and 27% ‘itchy’ nose [18]. Moderate/severe pain was reported in 97% of patients in this study [18]. However, the co-existence of neurologic facial pain/headache and nasal disease complicates the diagnosis and the adapted treatment. Daudia and Jones [19] reported 29% of patients with migraine (15/51) had co-existing nasal disease. Fahy and Jones [8] reported that, among 190 patients with NP and no nasal purulent secretions, 10 patients with facial pain/headache had a neurologic or medical cause. There are few studies focused on facial pain/ headache in patients with NP. It seems that only a small proportion of patients with NP spontaneously
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D. T. Nguyen et al.
Table I. Distribution of patients according to the severity of pain before and after surgery. We found a similar percentage of patients rating the pain severity in two groups with or without previous sinus surgery. Before surgery Polyp staging
No pain
Mild
Moderate
After surgery Severe
No pain
Mild
Moderate
Severe
p
All patients 1 (n = 14 [13.08%]) 3
1
2 (n = 34 [31.78%]) 17
6
3 (n = 59 [55.14%]) 15
9
Total
4
6
3
4
5
2
5
6
17
12
2
3
16
19
32
17
6
4
35 [32.71%] 16 [14.95%] 25 [23.36%] 31 [28.97%] 52 [48.60%] 33 [30.84%] 13 [12.15%] 9 [8.41%]
0.0002
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With previous surgery 1 (n = 7 [10.94%])
1
1
3
2
2
2
2
1
2 (n = 16 [25.0%])
9
1
1
5
8
5
0
4
3 (n = 41 [64.06%]) 12
6
9
14
20
13
4
Total
22 [34.38%] 8 [12.50%] 13 [20.31%] 21 [32.81%] 30 [46.88%] 20 [31.25%] 6 [9.38%]
4 8 [12.50%] 0.0006
Without previous surgery 1 (n = 7 [16.28%])
2
0
1
4
1
2
3
1
2 (n = 18 [41.86%]) 8
5
4
1
9
7
2
0
3 (n = 18 [41.86%]) 3
3
7
5
12
4
2
0
Total
13 [30.23%] 8 [18.60%] 12 [27.91%] 10 [23.26%] 22 [51.16%] 13 [30.23%] 7 [16.28%] 1 [2.33%]
report facial pain/headache as they complain about other symptoms such as nasal obstruction, hypoanosmia and rhinorrhea. Fahy and Jones [8] showed that only 18% of 220 outpatients with NP reported pain or pressure. Of these, 24/30 (79%) patients with nasal purulent secretions experienced pain and 80% of those responded to treatment for their paranasal sinus disease (with disappearance of pain). Among patients without nasal purulent secretions, only 15/ 190 patients reported pain and only five of those patients reported pain attributable to their paranasal sinus disease [8]. Eweiss et al. [9] found that only 16% of 50 patients with NP had moderate or severe facial pain by using the Sino Nasal Outcome Test 22 (SNOT-22). It is important to highlight that patients with grade 1 nasal polyps were excluded in this study as they were thought to represent a different clinico-pathological group from the one with more advanced grades of NP. No pain was reported in 28 patients (56%). Agius [10] stated that 9/51 patients with NP (17.6%) reported facial pain. However, facial pain/headache was reported in 36.36% of patients with NP before surgery [11]. Our study showed a higher frequency of NP patients with facial pain/ headache before surgery. This difference may be linked to a selection bias as our patients were a surgical group in which the medical treatment failed to control sinonasal symptoms including facial pain/ headache. Moreover, the 0–10-point analog scale is shrewder than the 5-point or 3-point scales or yes/no
0.15
question, and allows one to detect even minimal complaints. Furthermore, this questionnaire allows evaluating symptoms over a longtime period. Finally, some patients may have over-estimated their pain as a psychological and personal justification to have surgery. The mechanisms of ‘sinus pain’, headache and facial pain associated with chronic sinusitis, especially in NP, are poorly understood [4]. There are many explanations related to chronic headache in patients with NP. However, there is no correlation with what we know about the leucotrienes, or other mediators released specifically in NP. In the majority of cases, the pain demonstrates similarities to tension-type headaches. It seems that the grade of polyps was not a predictor for headache/facial pain as all levels of pain were observed among all polyp grades in our study, suggesting that the pain was not due to the blockage of paranasal sinuses in NP. The true sinus pain may be associated with neurologic causes such as migraine, cluster headache, trigeminal neuralgia, hemicrania continua, chronic paroxysmal hemicrania, etc. [17]. Moreover, sinusassociated symptoms such as runny nose, nasal congestion/obstruction, and ocular symptoms (lacrimation, conjunctival injection, eyelid edema) can frequently occur in migraines [19]. In routine practice, the dilemma is whether or not the pain is related to the sinonasal diseases, and which is the optimal treatment for patients having both sinonasal disease
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Facial pain/headache in patients with nasal polyposis and facial pain/headache caused by neurologic diseases. The DyNaChron questionnaire explores in detail the others symptoms associated to facial pain/headache. These elements may help the practitioner establish a more accurate distinction between sinonasal diseases either isolated or associated to a neurological cause. Moreover, these elements reported by patients while in the waiting room are time-saving for the physician and can serve for comparisons in later follow-up visits. Endoscopic sinus surgery has been proven beneficial in terms of symptoms and QoL outcomes among patients with NP. The current study shows pain reduction and symptom improvement after surgery for the majority of patients. However, moderate/ severe pain remains in ~ 20% of patients after surgery (in contrast to 50% of patients before surgery). The number of patients with ‘no pain’ improved from one third before surgery to one half after surgery. Patients with grade 1 polyps seemed to have less benefits from surgery for facial pain/headache than those with more severe NP. However, it is difficult to draw a conclusion due to the small number of patients with grade 1 polyps. There may be another cause of pain that must be looked into for those patients that continue experiencing facial pain/headache after surgery. The pain was significantly reduced among patients with previous history of sinonasal surgery. In contrast, the improvement of pain intensity was not statistically demonstrated among those without previous surgery. This phenomenon could be explained by the limited number of patients in this group. Limitations of this study The main limitation of this study is the assessment of facial pain/headache at a short-term after surgery. The nociceptive pathways involved in pain of neurologic origin may be temporarily disturbed right after surgery and 6 weeks is a short time for follow-up. However, our previous findings showed that scores of pain and its impacts 6 weeks after surgery remained steady even at 7 months after surgery for NP [20]. Other limitations of the present study are the lack of data on post-operative nasal endoscopy and CT scanner. However, it has been shown that there was a poor relationship between symptoms reported by patients and medical findings like those observed with endoscopic examination scores at any specific time after surgery or CT scanner. Moreover, CT scans are not systematically performed after surgery in our routine practice. Certainly, it is an area for further study to investigate the relationship between residual facial pain/headache after surgery and anomalies of the frontal sinus.
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Conclusion In patients with NP requiring surgery, one half of patients reported moderate/severe facial pain/headache before surgery. Sinus surgery improved these symptoms and physical and psychosocial impacts. However, moderate/severe facial pain/headache persisted after surgery in ~ 20% of patients who will need specialized investigations to look into any possible non-sinonasal causes of their pain. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc 2011;86:427–43. [2] Jankowski R. The Evo-Devo origin of the nose, anterior skull base and midface. Paris: Springer Verlag; 2013. [3] Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;11:S1–7; Review. [4] Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl 2012;3:1–298. [5] Alobid I, Benítez P, Bernal-Sprekelsen M, Roca J, Alonso J, Picado C, et al. Nasal polyposis and its impact on quality of life: comparison between the effects of medical and surgical treatments. Allergy 2005;60:452–8. [6] Ryan RE, Kern EB. Rhinologic causes of facial pain and headache. Headache 1978;18:44–50. B, Er B, Akkaynak C, [7] Toros SZ, Bölükbasi S, NaiboGlu Noshari H, et al. Comparative outcomes of endoscopic sinus surgery in patients with chronic sinusitis and nasal polyps. Eur Arch Otorhinolaryngol 2007;264:1003–8. [8] Fahy C, Jones NS. Nasal polyposis and facial pain. Clin Otolaryngol Allied Sci 2001;26:510–13. [9] Eweiss AZ, Lund VJ, Barlow J, Rose G. Do patients with chronic rhinosinusitis with nasal polyps suffer with facial pain? Rhinology 2013;51:231–5. [10] Agius AM. Long-term follow-up of patients with facial pain in chronic rhinosinusitis–correlation with nasal endoscopy and CT. Rhinology 2010;48:65–70. [11] Garrel R, Gardiner Q, Khudjadze M, Demoly P, Vergnes C, Makeieff M, et al. Endoscopic surgical treatment of sinonasal polyposis-medium term outcomes (mean follow-up of 5 years). Rhinology 2003;41:91–6. [12] Kacha S, Guillemin F, Jankowski R. Development and validity of the DyNaChron questionnaire for chronic nasal dysfunction. Eur Arch Otorhinolaryngol 2012;269: 143–53. [13] Benamara A, Nguyen DT, Boulanger N, Arous F, Baumann C, Jankowski R. On the origin of nasal polyposis in the ethmoid sub-compartments. Clin Otolaryngol 2013; 38:402–6. [14] Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care 2003; 41:582–92; Review.
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[15] Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd ed. Cephalalgia 2004;24: 9–160. [16] Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders. 3rd ed. (beta version). Cephalalgia 2013;33:62–808. [17] Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Study (SAMS). Headache 2007;47:213–24.
[18] Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. Arch Intern Med 2004;164:1769–72. [19] Daudia AT, Jones NS. Facial migraine in a rhinological setting. Clin Otolaryngol Allied Sci 2002;27:521–5. [20] Nguyen DT, Guillemin F, Arous F, Jankowski R. Assessment of quality-of-life outcomes after surgery for nasal polyposis with the DyNaChron questionnaire. Eur Arch Otorhinolaryngol 2015;272:367–75.
ORIGINAL ARTICLE
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Facial pain/headache before and after surgery in patients with nasal polyposis
DUC TRUNG NGUYEN1,2, MARYLISA FELIX-RAVELO1, FABIEN AROUS2, PHI-LINH NGUYEN-THI3 & ROGER JANKOWSKI1,2 University Hospital of Nancy, Department of ENT – Head and Neck Surgery, Nancy, France, 2Faculty of Medicine, University of Lorraine, France and 3University Hospital of Nancy, Clinical Epidemiology and Evaluation Department, Nancy, France
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Abstract Conclusion: Endoscopic surgery improved facial pain/headache and physical-psychosocial impacts in patients with nasal polyposis. However, one fifth of patients still experienced residual pain after surgery, requiring neurologic counseling to look for the non-sinonasal cause of their symptoms. Objective: Considering the limited amount of literature on facial pain/headache in patients with nasal polyposis, this prospective study assesses facial pain/headache and its impacts on the quality-of-life (QoL) before and after endoscopic surgery. Methods: Facial pain/headache was assessed, using the DyNaChron questionnaire, in 107 patients with nasal polyposis 1 day prior to surgery and 6 weeks after surgery. All patients were operated on endoscopically on the bilateral ethmoidal labyrinths and olfactory clefts. Results: Moderate or severe facial pain/headache was reported by 50% of the patients before surgery and by 20% after surgery. Post-operatively, 79.44% of patients reported no/very mild pain (vs 47.66% pre-operatively) and 20.56% moderate/severe pain (vs 52.33% pre-operatively). The pain was statistically reduced after surgery among patients with previous surgery (p = 0.0006). The scores of all analysed impacts of pain improved after surgery. However, patients with grade 1 polyps seemed to have less benefit from the surgery for facial pain/headache than those with more severe nasal polyposis.
Keywords: Nasal polyposis, facial pain, headache, dynachron questionnaire, quality-of-life
Introduction Nasal polyposis is a chronic inflammatory disease of the nose with a pathogenesis that remains poorly understood. It is defined as chronic rhinosinusitis (CRS) under many guidelines and expert panel documents [1] while evo-devo’s arguments support the hypothesis of it being a specific disease of the ethmoidal labyrinth mucosa [2]. Facial pain/headache is one of the major criteria for the diagnosis of CRS [3,4]. Nasal polyps, for which the main complaints are nasal obstruction and impairment/loss of smell [5], was listed as one of the five main rhinological causes of facial pain by Ryan and Kern [6]. However, mechanisms of facial
pain/headache in nasal polyposis (NP) still remain poorly understood. CRS patients with and without nasal polyposis were often mixed-up in most papers, leading to misguided interpretations of its results. In fact, very few studies have focused on facial pain/ headache in patients with NP, specifically on its impact on the QoL. Patients with NP usually have higher pre-operative endoscopy and CT scores than those with chronic sinusitis [7]. However, facial pain is reported less often than in patients with NP (varying from 16–36%) [8–11]. The aim of the present study was to assess facial pain and its impacts on the QoL before and after endoscopic surgery for NP, using a new instrument – the DyNaChron questionnaire [12].
Correspondence: Dr Duc Trung Nguyen, Service d’Otorhinolaryngologie et Chirurgie Cervico-Faciale, Hôpital de Brabois, Centre Hospitalier Régional Universitaire de Nancy, rue du Morvan, 54511 Vandoeuvre-les-Nancy Cedex, France. Tel: +33383155409. E-mail: [email protected]
(Received 29 March 2015; accepted 14 May 2015) ISSN 0001-6489 print/ISSN 1651-2251 online 2015 Informa Healthcare DOI: 10.3109/00016489.2015.1058531
2
D. T. Nguyen et al. examination and during endoscopic surgery. Polyp grading was performed according to the surgical staging system of Benamara et al. [13].
Materials and methods
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Patient population One hundred and seven patients with NP were prospectively assessed and admitted for surgery in our tertiary referral center. All patients underwent endoscopic surgery on the bilateral ethmoidal labyrinths and olfactory clefts according to the concept of nasalization by removing as completely as possible all the bone and mucosal septation inside the ethmoidal labyrinth as well as mucosa on the lamina, skull base, conchal lamina and lateral side of the middle and superior turbinates. These turbinates were preserved whenever possible. The surgery was indicated when medical treatment failed to control the symptoms associated with NP. Corrective surgery of the septum was associated with nasalization when necessary. No systemic corticosteroid nor antibiotic treatment was systematically given before or after surgery. A day after surgery, all patients started washing their nasal cavities with isotonic saline, using a syringe, at least three times a day, and using a topical steroids spray once a day. Patients with facial trauma, known neuralgias or temporomandibular joint dysfunctions were excluded. This study was approved by the Institutional Review Board of University Hospital of Nancy, France. NP was diagnosed in patients with chronic nasal dysfunction who presented with white edematous polyps in both nasal cavities at nasal endoscopic
Facial pain/headache assessment All patients were asked to rate their levels of facial pain/headache and its impacts on QoL over the last 15 days including the day of the assessment, by using 13 items related to facial pain/headache of the DyNaChron questionnaire. This questionnaire was prospectively completed the day prior to surgery and 6 weeks after surgery, in the waiting room before the medical follow-up visit. This questionnaire assesses 13 complaints (Figure 1) related to facial pain/ headache and four impacts associated with the psychosocial field (affect on mood, ability to concentrate, relationships with others, and affect on a patient’s daily life). Each item is on a 0–10 point scale, with 0 meaning no discomfort at all and 10 meaning unbearable discomfort. Statistics Statistical analyses were performed by means of SAS v9.1 software (SAS Inst., Cary, NC) where a two sided p-value of less than 0.05 was significant. Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as frequencies and percentages. Facial pain/headache
Figure 1. Mean scores of each item before and at 6 weeks after surgery.
Facial pain/headache in patients with nasal polyposis
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was also gathered in categories of none (0), mild (1–3), moderate (4–6), and severe (7–10) to express the pain intensity that required an adapted treatment. The Chi Square Test or Fisher’s exact test was used to assess the difference in incidence of pain before and after surgery as well as between different subgroups of patients. The effect size – the average change divided by the baseline standard deviation – at ‡ 0.5 was defined as the threshold of discrimination for changes in health-related quality-of-life for chronic diseases [14]. Results A total of 107 patients (mean age of 48.8 ± 12.6 years) were enrolled in this study, of which 62 patients (57.94%) were male and 45 female (42.06%). Sixty-three patients (59.43%) had a history of previous sinonasal surgery (polypectomy, ethmoidectomy, or nasalization). Asthma was associated to NP among 64 patients (60.38%). Fifty-five patients underwent septoplasty during the surgery. Grade 1 polyps were found in 14 patients (13.08%), grade 2 in 34 patients (31.78%), and grade 3 in 59 patients (55.14%). Outcomes of headache/facial pain Figure 1 shows mean scores of facial pain/headache and its physical and psychosocial impacts before and after surgery. There was an improvement of all complaints in post-operative scores. The effect sizes were 0.6 for facial pain/headache, 0.58 for ‘moist or runny nose during painful crisis’, 0.61 for ‘affect the mood’, 0.58 for ‘ability to concentrate’, 0.51 for ‘relationship with others’, and 0.53 for ‘affect on everyday life’. The effect size for the ‘stuffy nose during painful crisis’ was 0.76, which by convention is a significant improvement in health-related QoL. The effect sizes of other complaints were lower than 0.5. Polyp staging and prior sinus surgery on outcomes of headache/facial pain Table I shows the distribution of patients according to polyps staging, intensity of pain before and after surgery, and any history of previous surgery. Pain in patients with less severe polyposis (grade 1 polyps) did not change significantly post-operatively. In contrast, patients with grade 3 polyps seemed to have more benefits from the surgery in terms of pain reduction. About one third of patients reported no pain before surgery, which was not correlated to any history of previous surgery. Moderate or severe facial pain/ headache was reported by 50% of patients before
3
surgery, but only by ~ 20% of patients after surgery. Pain intensity reported was statistically lower after surgery than before surgery (p = 0.0002): 79.44% of patients with none to very mild pain after surgery vs 47.66% before surgery, 20.56% of patients with moderate-to-severe pain after surgery vs 52.33% before surgery. This difference remained statistically significant among patients with history of previous surgery (p = 0.0006) in contrast to those without any previous surgery (p = 0.15). There was no significant difference in the pre- and post-operative distributions of patients related to pain intensity (none, mild, moderate or severe pain) between gender or abnormal septums requiring a concomitant septoplasty. Discussion ‘Facial pain and pressure’ is considered a major factor and ‘headache’ a minor factor for the diagnosis of CRS in the otolaryngologic literature since 1997 [3]. However, in 2004, the International Headache Society (IHS) stated in the 2nd International Classification of Headache Disorders, that chronic sinusitis is not validated as a cause of headache or facial pain unless considered an acute stage due to the fact that ‘sinus headaches’ are often confused with migraines [15]. Although it remained controversial whether or not chronic sinus pathology could produce persistent headaches, criteria for headaches attributed to chronic or recurring rhinosinusitis were introduced in the recent classification of the International Headache Society [16]. Many papers reported that a large number of patients with headache/facial pain were erroneously self-described or physician-diagnosed ‘sinus’ headaches [17,18]. Schreiber et al. [18] reported that, among 2991 patients screened, 2396 patients (80%) with ‘sinus headaches’ fulfilled IHS criteria for migraine without aura or migraine with aura. Of those, 84% reported sinus pressure, 82% sinus pain, 63% nasal congestion, 40% rhinorrhea, 38% watery eyes, and 27% ‘itchy’ nose [18]. Moderate/severe pain was reported in 97% of patients in this study [18]. However, the co-existence of neurologic facial pain/headache and nasal disease complicates the diagnosis and the adapted treatment. Daudia and Jones [19] reported 29% of patients with migraine (15/51) had co-existing nasal disease. Fahy and Jones [8] reported that, among 190 patients with NP and no nasal purulent secretions, 10 patients with facial pain/headache had a neurologic or medical cause. There are few studies focused on facial pain/ headache in patients with NP. It seems that only a small proportion of patients with NP spontaneously
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D. T. Nguyen et al.
Table I. Distribution of patients according to the severity of pain before and after surgery. We found a similar percentage of patients rating the pain severity in two groups with or without previous sinus surgery. Before surgery Polyp staging
No pain
Mild
Moderate
After surgery Severe
No pain
Mild
Moderate
Severe
p
All patients 1 (n = 14 [13.08%]) 3
1
2 (n = 34 [31.78%]) 17
6
3 (n = 59 [55.14%]) 15
9
Total
4
6
3
4
5
2
5
6
17
12
2
3
16
19
32
17
6
4
35 [32.71%] 16 [14.95%] 25 [23.36%] 31 [28.97%] 52 [48.60%] 33 [30.84%] 13 [12.15%] 9 [8.41%]
0.0002
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With previous surgery 1 (n = 7 [10.94%])
1
1
3
2
2
2
2
1
2 (n = 16 [25.0%])
9
1
1
5
8
5
0
4
3 (n = 41 [64.06%]) 12
6
9
14
20
13
4
Total
22 [34.38%] 8 [12.50%] 13 [20.31%] 21 [32.81%] 30 [46.88%] 20 [31.25%] 6 [9.38%]
4 8 [12.50%] 0.0006
Without previous surgery 1 (n = 7 [16.28%])
2
0
1
4
1
2
3
1
2 (n = 18 [41.86%]) 8
5
4
1
9
7
2
0
3 (n = 18 [41.86%]) 3
3
7
5
12
4
2
0
Total
13 [30.23%] 8 [18.60%] 12 [27.91%] 10 [23.26%] 22 [51.16%] 13 [30.23%] 7 [16.28%] 1 [2.33%]
report facial pain/headache as they complain about other symptoms such as nasal obstruction, hypoanosmia and rhinorrhea. Fahy and Jones [8] showed that only 18% of 220 outpatients with NP reported pain or pressure. Of these, 24/30 (79%) patients with nasal purulent secretions experienced pain and 80% of those responded to treatment for their paranasal sinus disease (with disappearance of pain). Among patients without nasal purulent secretions, only 15/ 190 patients reported pain and only five of those patients reported pain attributable to their paranasal sinus disease [8]. Eweiss et al. [9] found that only 16% of 50 patients with NP had moderate or severe facial pain by using the Sino Nasal Outcome Test 22 (SNOT-22). It is important to highlight that patients with grade 1 nasal polyps were excluded in this study as they were thought to represent a different clinico-pathological group from the one with more advanced grades of NP. No pain was reported in 28 patients (56%). Agius [10] stated that 9/51 patients with NP (17.6%) reported facial pain. However, facial pain/headache was reported in 36.36% of patients with NP before surgery [11]. Our study showed a higher frequency of NP patients with facial pain/ headache before surgery. This difference may be linked to a selection bias as our patients were a surgical group in which the medical treatment failed to control sinonasal symptoms including facial pain/ headache. Moreover, the 0–10-point analog scale is shrewder than the 5-point or 3-point scales or yes/no
0.15
question, and allows one to detect even minimal complaints. Furthermore, this questionnaire allows evaluating symptoms over a longtime period. Finally, some patients may have over-estimated their pain as a psychological and personal justification to have surgery. The mechanisms of ‘sinus pain’, headache and facial pain associated with chronic sinusitis, especially in NP, are poorly understood [4]. There are many explanations related to chronic headache in patients with NP. However, there is no correlation with what we know about the leucotrienes, or other mediators released specifically in NP. In the majority of cases, the pain demonstrates similarities to tension-type headaches. It seems that the grade of polyps was not a predictor for headache/facial pain as all levels of pain were observed among all polyp grades in our study, suggesting that the pain was not due to the blockage of paranasal sinuses in NP. The true sinus pain may be associated with neurologic causes such as migraine, cluster headache, trigeminal neuralgia, hemicrania continua, chronic paroxysmal hemicrania, etc. [17]. Moreover, sinusassociated symptoms such as runny nose, nasal congestion/obstruction, and ocular symptoms (lacrimation, conjunctival injection, eyelid edema) can frequently occur in migraines [19]. In routine practice, the dilemma is whether or not the pain is related to the sinonasal diseases, and which is the optimal treatment for patients having both sinonasal disease
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Facial pain/headache in patients with nasal polyposis and facial pain/headache caused by neurologic diseases. The DyNaChron questionnaire explores in detail the others symptoms associated to facial pain/headache. These elements may help the practitioner establish a more accurate distinction between sinonasal diseases either isolated or associated to a neurological cause. Moreover, these elements reported by patients while in the waiting room are time-saving for the physician and can serve for comparisons in later follow-up visits. Endoscopic sinus surgery has been proven beneficial in terms of symptoms and QoL outcomes among patients with NP. The current study shows pain reduction and symptom improvement after surgery for the majority of patients. However, moderate/ severe pain remains in ~ 20% of patients after surgery (in contrast to 50% of patients before surgery). The number of patients with ‘no pain’ improved from one third before surgery to one half after surgery. Patients with grade 1 polyps seemed to have less benefits from surgery for facial pain/headache than those with more severe NP. However, it is difficult to draw a conclusion due to the small number of patients with grade 1 polyps. There may be another cause of pain that must be looked into for those patients that continue experiencing facial pain/headache after surgery. The pain was significantly reduced among patients with previous history of sinonasal surgery. In contrast, the improvement of pain intensity was not statistically demonstrated among those without previous surgery. This phenomenon could be explained by the limited number of patients in this group. Limitations of this study The main limitation of this study is the assessment of facial pain/headache at a short-term after surgery. The nociceptive pathways involved in pain of neurologic origin may be temporarily disturbed right after surgery and 6 weeks is a short time for follow-up. However, our previous findings showed that scores of pain and its impacts 6 weeks after surgery remained steady even at 7 months after surgery for NP [20]. Other limitations of the present study are the lack of data on post-operative nasal endoscopy and CT scanner. However, it has been shown that there was a poor relationship between symptoms reported by patients and medical findings like those observed with endoscopic examination scores at any specific time after surgery or CT scanner. Moreover, CT scans are not systematically performed after surgery in our routine practice. Certainly, it is an area for further study to investigate the relationship between residual facial pain/headache after surgery and anomalies of the frontal sinus.
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Conclusion In patients with NP requiring surgery, one half of patients reported moderate/severe facial pain/headache before surgery. Sinus surgery improved these symptoms and physical and psychosocial impacts. However, moderate/severe facial pain/headache persisted after surgery in ~ 20% of patients who will need specialized investigations to look into any possible non-sinonasal causes of their pain. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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