Headache is a relatively common clinical symptom. In terms of headache caused by otolaryngology, there are two main types of headache: namely, reflex headache, and headache caused by intracranial invasion or intracranial infection.
1.Reflex headache
1.1 Reflex headache of nasal origin
1.1.1 Acute and chronic sinusitis Acute sinusitis causes more severe headache, especially frontal sinusitis and butterfly sinusitis, and the headache occurs mostly on the side of the lesion, caused by purulent secretions, bacterial toxins, swollen mucous membrane, stimulation and compression of nerve endings. Headache can be “vacuum” and “tension”, the former is due to the blockage of the sinus openings caused by mucosal swelling and the gradual absorption of air in the sinuses; the latter is due to the “vacuum” The former is due to swelling of the mucous membrane causing blockage of the sinus openings and gradual absorption of air in the sinuses; the latter is due to “vacuum” for too long, mucosal vasodilation, serum leakage or pus accumulation, resulting in increased pressure in the sinus cavity. In addition to headache, sinusitis also causes nasal congestion and pus, and acute sinusitis can also have symptoms such as local redness and swelling, and pressure pain. It is not difficult to diagnose through local examination and x-ray radiography and CT examination.
1.1.2 Atrophic rhinitis Due to the atrophy of nasal mucosa, the nasal cavity is wide and the cold air with excessive ventilation stimulates the nasal mucosa causing headache; in addition, the formation of pus crust fills the nasal cavity and stimulates the nasal mucosa or blocks the opening of the sinus to form blocking sinusitis also causes headache. Atrophic rhinitis is mainly manifested as wide nasal cavity, and the posterior nostril and posterior pharyngeal wall can be seen directly from the anterior nostril during examination. When secondary infection occurs in late stage, the nasal cavity is filled with filthy secretions or pus crusts, and there is a special odor.
1.1.3 Deviated nasal septum The convex surface of the deviated nasal septum presses the mucosa of the turbinates, which can cause ipsilateral reflex headache.
1.1.4 Benign tumor of nasal cavity and sinus When benign tumor of nasal cavity grows to a large enough size, it not only causes nasal congestion, but also presses the turbinates and causes headache. If the opening of sinus is blocked, it may form obstructive sinusitis or swell the sinus cavity and cause “tension headache”. In addition, it may also protrude into the orbit, causing eye dislocation and headache.
1.2 Otogenic reflex headache
1.2.1 Acute otitis media Acute otitis media leads to increased secretion from the middle ear, which compresses and irritates the tympanic membrane and causes ipsilateral headache, mostly severe and progressive otalgia with otalgia and hearing loss. The tympanic membrane can be seen to be congested and swollen, and if the tympanic membrane is perforated the pain is mostly reduced or disappears.
1.2.2 Acute attack of chronic otitis media Due to increased secretion in the middle ear, it reflexively causes dull pain in the ipsilateral mastoid region, frontal region and top of the head. The patient has three signs of chronic recurrent external ear canal drainage, hearing loss and tympanic membrane perforation. When an acute attack occurs, in addition to pain, there may be a sudden increase or decrease in intra-ear discharge, congestion and swelling of the residual tympanic membrane and tympanic chamber mucosa, and swelling or subsidence of the posterior superior wall of the external auditory canal. Papillary radiographs and CT may show the extent of the lesion.
1.3 Pharyngeal diseases
1.3.1 Acute and chronic nasopharyngitis Nasopharyngitis can cause headache and occipital pain, and nasopharyngeal examination can show mucosal congestion, secretion and dry crust.
1.3.2 Hypertelorism The stimulation of nerve endings by the overgrown stem can cause foreign body sensation in the pharynx, ipsilateral pharyngeal pain and otalgia, etc. If the internal carotid artery is pressed, the pain can be radiated to the top of the head. In patients with overgrown stalk, the tip of the stalk can be palpated in the tonsillar fossa, and the growing stalk can be seen in the frontal and lateral images of the stalk on X-ray.
2.Intracranial invasion or intracranial infection
Intracranial invasion Intracranial invasion is mainly malignant tumor.
2.1.1 Nasopharyngeal carcinoma Reflex headache can appear in the early stage of nasopharyngeal carcinoma, and it may even be the first symptom. In late stage, the tumor may enter the middle fossa of the skull through the rupture hole or the destroyed bone at the base of the skull to compress the trigeminal nerve and cause headache. In addition to headache, nasopharyngeal carcinoma also has symptoms such as metastasis of cervical lymph nodes, nasal congestion, blood in the nose or blood in the morning sputum, hearing loss, invasion of the tympanic membrane and abduction of the abducent nerve causing diplopia and inability to abduct the eye. The nasopharyngeal examination can detect the mass, and CT and magnetic resonance imaging can determine the extent of the tumor and metastatic lymph nodes. The final diagnosis is made by pathology.
2.1.2 Malignant tumor of nasal cavity and sinus This tumor is more hidden, especially the malignant tumor of sinus is not easy to detect in early stage. Headache may be the first symptom, when the tumor invades into the orbit or skull base, it produces severe headache. CT examination can show the extent of the lesion. The final diagnosis depends on pathology.
2.1.3 Middle ear cancer Because the lesion is hidden and not easily detected at an early stage, most of them are noticed only when the tumor damages the bone wall and invades the skull to produce headache. Therefore, when there is suspicion, CT or magnetic resonance examination should be done as early as possible, and biopsy should be done on suspicious tissues. Special attention should be paid to middle ear cancer if one of the following conditions exists: (1) there is a long history of ear pus and red discharge; (7) there are buds or polyps in the ear canal that bleed easily when touched or grow rapidly after removal; (3) there are papillary neoplasms in the external ear canal; (4) middle-aged or older patients with a history of ear pus and ipsilateral facial paralysis; (5) there is persistent and progressive pain in the deep part of the ear and no other lesions are found.
Intracranial infection Most often seen in acute inflammation of the middle ear, sinuses, and external nose or in acute attacks of chronic inflammation.
2.2.1 Acute otitis media or an acute attack of chronic otitis media can produce apical inflammation. If there is an air space in the apical part of the rock, the inflammation of the middle ear spreading to this area is called apical inflammation. It is characterized by severe headache, ear drainage and a low-grade fever in the afternoon. The trigeminal nerve and the abducens nerve are located at the apices of the rocks. The three major symptoms of headache, diplopia, and ear discharge are therefore called apical syndrome, and increased density of the apical air spaces or bone destruction can be seen on CT. Inflammation of the middle ear can enter the skull by the following routes: directly into the middle or posterior cranial fossa through the bone wall destroyed by osteitis, cholesteatoma, or trauma; through the small vessels of the middle ear mucosa communicating with the meninges or the mastoid conduction vessels; and through septic labyrinthitis via the endolymphatic duct, endolymphatic sac, or the internal auditory canal.
The most common intracranial complications of otogenic origin are: ① Epidural abscess: the main features are headache and slight fever, which gradually worsen with the increase of pus, and the symptoms are relieved when there is a large amount of pus in the ear and the pressure is reduced. The diagnosis is confirmed mainly by the intraoperative finding of epidural pus accumulation. ②Sigmoid sinus thrombophlebitis: mainly pain behind the ear and occipital region, sometimes with severe headache. The disease is characterized by septic symptoms in addition to headache: chills, corn, followed by high fever, which subsides after a few hours with sweating, and pressure pain at the mastoid vessels and the superior segment of the internal jugular vein. When the finger compresses the ipsilateral internal jugular vein during the lumbar puncture pressure measurement, the pressure can rise rapidly in normal people and fall rapidly after releasing the hand, while in sigmoid sinus thrombophlebitis, it rises and falls slowly. Intraoperatively, thrombus can be found in the sigmoid sinus. (iii) Meningitis: The main manifestations are high fever and meningeal irritation symptoms, such as severe headache, jet-like vomiting, neck ankylosis, and positive Creutzfeldt-Jakob sign. Lumbar puncture: increased pressure of cerebrospinal fluid, mixed appearance, increased protein and cell count, and decreased sugar content. ④Brain abscess: the main symptoms of increased intracranial pressure: headache, vomiting, optic papillary edema, etc.; cerebral symptoms: hypothermia, slow pulse, apathy, drowsiness and oligophrenia, etc.; localization symptoms: temporal lobe abscess may have contralateral hemiparesis, contralateral central facial palsy, motor aphasia (inability to answer the name of everyday objects correctly while knowing their purpose), etc. CT and MRI may show its location and size.
2.2.2 Sinusitis Sinusitis causes complications mainly by transmission through the destroyed bone wall and blood flow. Inflammation progressing outward can cause septic infection in the orbit, at which point the main focus is on the posterior part of the eye and headache. Inflammation progressing intracranially causes mainly septic meningitis and frontal lobe abscesses.
Rhinogenic septic meningitis presents with the same symptoms as otogenic septic meningitis, but is sometimes more intense. Frontal lobe abscesses of nasal origin also have symptoms of increased cranial pressure and internal symptoms. CT and MRI can show the location and size of the abscess. 2.2.3 Nasal boils Because the facial veins lack a venous valve and are connected to the cavernous sinus, when the nose is inflamed, if it is inadvertently squeezed or mishandled, the pathogenic insects can enter the cavernous sinus along the blood vessels without a venous valve, causing cavernous sinus thrombophlebitis. The main manifestations are malignant cold, high fever, severe headache, edema of the affected eyelid and bulbar conjunctiva, protrusion and fixation of the eyeball, dilatation of the fundus venosus and edema of the optic nerve papilla, etc. In severe cases, the frontal vein can also form a thrombus with a copper wire-like appearance, which is as hard as a cord when touched. This is a very serious and life-threatening complication.
In summary, there are many patients with clinical headaches that may be caused by otorhinolaryngological diseases. Except for a few occult inflammatory diseases and early tumors that do not show local symptoms, most patients have local symptoms appearing. Detailed inquiries about the presence of nasal congestion, excessive runny nose, blood in the runny nose, morning sputum with blood, stuffy ears, pus overflow and other symptoms, followed by targeted specialist examinations, can often reveal the problem. Any headache that is confined to one side, persistent and progressive, regardless of whether there are obvious local symptoms, should be examined in detail to detect the disease early, treat it actively and relieve the patient’s pain.