The sinus headache: “it feels just like eyestrain, doc” james L. Fanelli, O. D., F. A. A. O



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THE SINUS HEADACHE:
“IT FEELS JUST LIKE EYESTRAIN, DOC”

JAMES L. FANELLI, O.D., F.A.A.O.


Visiting Professor of Clinical Medicine, PCO

Case #1

  • 23 year old college student

  • c/o periocular headache, worse on computer, blurred vision, itchy eyes

  • Currently wearing AV II lenses -3.00 OD -3.25OS

  • Meds: Nasonex, Ortho-Tricyclene Lo NKDA

  • Manifest: -2.25-0.50X090 -2.25-1.00X090

  • SLEX: mild GPC INTERNAL: normal

Case #2

  • 27 year old electrical engineer

  • c/o blurred vision eyestrain and headaches after reading or detailed close work

  • Current Rx: (NVO, 6 months old)

  • +1.25-0.50X 090 +0.75 sph

  • Meds: Singulair, Flonase, Ambien PRN NKDA

  • Manifest: +0.75-0.50X080 +0.75-0.25X095

  • UCVA: 20/20 OD,OS BCVA 20/20 OD, OS

  • SLEX: normal INTERNAL: normal

Case #3

  • 46 year old optometrist

  • c/o periocular headaches, varied times of onset, perhaps worse in AM

  • Exascerbated by reading, but only when headache already present

  • d/c CL wear X 15 yrs due to decreased tolerance

  • S/P LASIK X 5 years

  • Meds: ibuprofen 600mg prn

  • Manifest: -0.75 sph - 1.25-0.50X 015

  • SLEX: normal INTERNAL: normal

THE PROBLEM:

  • Patient complaints of periorbital headache pain and discomfort

  • With or without significant ophthalmic or refractive findings, sinusitis must be considered

Contributing Factor

  • We are all eye doctors who are:

  • Busy

  • Tend to get behind schedule

  • See patients all the time who have headaches that are refractive in origin

  • Unless the patient presents with disc edema, we ‘default’ to the eye as the source of the problem

  • We are programmed to think of what we can do for the eye to alleviate symptoms

THE SOLUTION:

  • Proper diagnosis of the condition

  • by the patient, family, friends, employees and co-workers.

  • by the patient's health care provider

  • family practitioner, internist, allergist etc....

  • primary eye care provider

A Closer Look: Patient #1

  • Our slightly overminused college student

  • “Always have strain when reading”

  • Wearing AV II -3.00 and -3.25

  • Manifest: -2.25-0.50X090 -2.25-1.00X090

  • Meds tell us she has allergies (Nasonex)

  • Clinical exam tells us she has allergies (GPC)

A Closer Look: Patient #1

  • Further refractive findings: Convergence Insufficiency

  • Evaluation of Paranasal Air sinuses: Normal

  • ASSESSMENT: GPC, CI, CMA

  • PLAN:

  • d/c CLS (or decrease wt)

  • Proper spherocylindrical Rx

  • VT

  • NO MEDS!

A Closer Look: Patient #2

  • The hyperopic engineer with headaches and eyestrain after reading.

  • Refractive findings generally match up with NVO RX, yet headaches and strain persist.

  • Long standing history of nasal congestion and recurrent URI.

  • Symptoms are better when wearing Rx, but persist.

A Closer Look: Patient #2

  • Evaluation of Paranasal Air Sinuses:

  • Bilateral maxillary and frontal congestion

  • ASSESSMENT:

  • Hyperopia/astigmatism

  • Sinusitis

  • PLAN:

  • Spectacle Rx

  • Oral antibiotics and decongestants

A Closer Look: Patient #3

  • 46 year old optometrist with complaints of headache, pressure and periocular discomfort throughout the day

  • S/P LASIK with residual myopic undercorrection (planned)

  • History of nasal congestion since moving to NC 20 years ago

A Closer Look: Patient #3

  • Evaluation of Paranasal Air Sinuses:

  • In office evidence of sinus disease

  • ASSESSMENT:

  • PLAN:

  • Designer drill mount frame with poly, Crizal, Panamic lenses with transitions

  • PRN oral sinus therapy

The Solution:

  • Proper diagnostic work up of the patient with headache

  • Determination of etiology of headache

  • Clinical exam should include evaluation of the sinus system

Sinusitis

  • Types:

  • allergic sinusitis

  • infectious based sinusitis

  • bacterial sinusitis

  • fungal sinusitis

  • mucosal abnormalities

  • obstructive abnormalities

Anatomy of Paranasal Sinuses

  • Cavities within facial skeleton that communicate with the nose

  • Lined by ciliated respiratory epithelium

  • Maxillary and ethmoid sinuses are present at birth

  • Expansion of ethmoid labrynth above orbital rim gives rise to frontal sinuses

Anatomy of Paranasal Sinuses

  • Unilateral agenesis of one frontal sinus is common

  • 4% of population has complete agenesis of frontal sinus

  • Sphenoid sinus is last to develop and are not mature until early 20’s

  • Mastoid Air Cells/Sinuses also late to develop

  • Unusual for mastoid sinus to be involved alone

Anatomy of Paranasal Sinuses

Anatomy of Paranasal Sinuses

Anatomy of Paranasal Sinuses

Acute Sinusitis

  • Rhinovirus Adenovirus

  • Influenza Parainfluenza

  • 20% of time, bacteria recovered with above virus

Acute Sinusitis-Symptoms

  • Fever

  • Pain

  • Periocular headache

  • Obstruction of the nasal cavity

  • Anosmia

  • Purulent nasal discharge

Acute Sinusitis Microbiology

  • Streptococcus pneumoniae 35%

  • Haemophilus influenzae 25%

  • Both 8%

  • Staphylococcus aureus 5%

  • Streptococcus pyogenes 2%

  • Moraxella catarrhalis 2%

  • Gram-negative 10-15%

Chronic Sinusitis

  • Multiple etiologies

  • Allergic

  • Anatomic (deviated septum, fx, trauma)

  • Persistent signs and symptoms despite continuous treatment

  • Post nasal drainage

  • Facial pain

  • Pressure within face or eyes

Chronic Sinusitis-Clinical Signs

  • Thickening of the sinus mucosa on plain film and CT

  • Anaerobic bacteria more common than in acute sinusitis

  • Chronic presence of thickened nasal or post nasal discharge

  • Waxes and wanes

Chronic Sinusitis Microbiology

  • AEROBIC

  • Streptococcus pyogenes

  • alpha-hemolytic streptococci

  • Staphylococcus

  • S.pneumoniae

  • H.flu

  • Strep. viridans

Location Based Symptoms

  • Frontal Sinusitis

  • Pain above the eyes or in a general mask-like pattern

  • Ethmoid Sinusitis

  • Pain between and behind the eyes

  • Maxillary Sinusitis

  • Pain in the cheeks and temples

  • Sphenoidal Sinusitis

  • Occipital headaches

Clinical Examination

  • Complete Medical History

  • Visualization of the Oropharynx

  • Visualization of the Nares

  • Plain Film X-Rays

  • Computed Axial Tomography

  • MRI ?

Clinical Examination In-Office Pearls

  • Atriculation of facial bones

  • Sinus percussion

  • Sinus transillumination

Articulation of Facial Bones

  • an assessment of the relative pain or discomfort level associated with movement of the mucosal sinus linings.

  • movement created by slight shifting of maxillary, sphenoidal and nasal bone articulations.

  • thumbs are placed on the vertical aspect of the maxillary bones, with the head supported posteriorly, and pressure is exerted to retroplace the maxillary bones.

Sinus Percussion

  • a measure of vibratory sensation in the frontal and right and left maxillary sinuses.

  • the middle or index finger of the non-dominant hand is placed over the sinus to be tested.

  • the index and middle fingers of the dominant hand are used to ‘tap’ the finger laying across the sinus.

  • a positive result is indicated by the presence of a painful, ‘reflected’ sensation radiating posteriorly through the tested sinus.

Sinus Percussion

Sinus Percussion

Sinus Percussion

Sinus Transillumination

  • Easy, inexpensive way to view frontal and maxillary sinuses

  • Must be performed in a completely darkened room

  • Shows us what can be seen in plain film and CT imaging

Conventional Radiography

  • LATERAL VIEW

  • SUBMENTOVERTICAL VIEW

  • WATER’S VIEW

  • CALDWELL’S VIEW

Water’s View

  • AKA: chin-nose position, or occipitomeatal view.

  • patient’s head is upward with the chin and nose against the film surface and the x-ray tube behind the head.

  • gives best view of the maxillary sinuses.

  • also used to evaluate the orbit for orbital floor blowout fractures.

Water’s View

Caldwell’s View

  • AKA: forehead-nose position

  • nose and forehead are placed against the film cassette, and the beam is directed from posteriorly 15 degrees below the horizontal.

  • gives the best view of the ethmoidal sinuses and the nasal cavity.

  • also useful in evaluation of nasal orbital wall fractures.

Caldwell’s View

CT EXAMINATION

  • excellent visualization of all the sinuses.

  • useful in obtaining information about adjacent structures, such as the orbit, cavernous sinus and pituitary fossa.

  • 5mm sections are adequate for sinus evaluation.

  • disadvantage: $$

  • for our evaluation of sinusitis, this is preferred over NMR, primarily due to cost factors.

CT- Frontal Sinus

CT-Maxillary and Ethmoid Sinuses

CT-Sphenoidal Sinus

CT-Mastoid Sinus

Significant Sinus Invasion

Sinus Transillumination

  • Easy to perform in primary eye care office

  • Quick

  • Relative ease in result interpretation

  • Must be performed in a completely darkened examination room.

Sinus Transillumination

  • Frontal Sinus Transillumination

  • the tip of the transilluminator is placed beneath the orbital rim portion of the frontal bone and the light is directed upward toward the frontal sinus.

Frontal Sinus Transillumination

Frontal Sinus Transillumination

Sinus Transillumination

  • Maxillary Sinus Transillumination

  • the patient’s head is tilted back far enough to see the palate, and the light source is placed on the orbital portion of the maxillary bone and aimed downward.

Maxillary Sinus Transillumination

Maxillary Sinus Transillumination

Management of Sinusitis

Medical Therapy

  • ANTIHISTAMINES*

  • DECONGESTANTS*

  • COMBINATIONS*

  • ANTIBIOTICS

  • PAIN/ANTI-INFLAMMATORIES

Antihistamines

  • H1Antagonists:

  • relaxes respiratory smooth muscle (breathe easier)

  • decreases small vessel & capillary permeability (reduces swelling)

  • H1 Antagonists:

  • CNS Depression (somnolence)(50%)

  • Anticholinergic Activity

  • dry mouth
  • dry eyes
  • diplopia
  • hypotension

Antihistamines

BENADRYL (DIPHENHYDRAMINE) 25-50mg PO BID

DRAMAMINE (DIMENHYDRINATE) 50mg PO BID-TID

ANTAZOLINE (VASOCOR A; VASOCON A)

CHLOR-TRIMETON (CHLORPHENIRAMINE) 2-4mg TID-QID

DIMETANE (BROMPHENIRAMINE) 4-8mg TID-QID

PHENERGAN (PROMETHAZINE) 25-50mg BID-QID

NEW ANTIHISTAMINES”

Antihistamines have no direct role in the treatment of sinusitis, and may perpetuate it by thickening mucous. They are useful in treating related allergy symptoms only!!!

Decongestants

  • help promote drainage and decongestion of swollen sinus mucous membranes.

  • conversely, they can excessively dry nasal mucosa, thereby impairing the mucociliary transport system.

  • increase blood pressure

  • agitation

  • mucous membrane drying

  • pseudoephedrine

  • phenylephrine

Antibiotics

  • Antibiotics are the mainstay of treatment of acute and chronic sinusitis.

  • Adjunctive treatment, such as the use of decongestants and antihistamines, serves only to reduce the symptoms of the sinusitis, and not eliminate the causative agent.

  • Generally, sinusitis is managed with both antibiotics and decongestants

Antibiotics of Choice

  • ACUTE:

  • Amoxicillin-clavulanate (Augmentin) 500/125 TID

  • *EES-400 TID*

  • *ECN/Sulfisoxazole (Pediazole)* 5cc BID-TID

  • Trimethoprim-sulfamethoxazole (Septra DS) BID

  • Cephalexin (Keflex) 500 TID

  • *Clarithromycin (Biaxin) *500 BID

  • *Azithromycin (Zithromax)* 250BID day one then QD X 4D

A Word of Caution

  • sedation has been the major complaint with traditional antihistamines, such as Benadryl (diphenhydramine).

  • newer antihistamines have significantly reduced incidences of sedation

  • also require less frequent dosing (QD to BID).

“NEW” ANTIHISTAMINES

  • TAVIST (TAVIST-D)

  • BID dosage

  • OTC

  • CLARITIN (loratadine):

  • 1-10mg cap QD

  • OTC

  • Used alone or with decongestant

  • CLARINEX

  • ZYRTEC (citirizine):

  • 5 or 10mg QD

  • no reported cardiac interactions

  • SINGULAIR

**Precaution**

  • Macrolide antibiotics and certain antifungal agents in conjunction with Seldane (terfenadine) and Hismanal (astemizole) have been reported to increase levels of the antihistamine to toxic levels, causing cardiac arrythmias and death

  • Torsades des Pointes




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