Nick S. Jones

Background: There is a body of opinion in the clinical literature advocating the removal of intranasal contact points to treat facial pain.Objectives: To review the evidence that intranasal mucosal contact points cause facial pain or headache and their removal is therapeutic.Type of review: Systematic review.Search strategy: A systematic search of the available literature was performed using MEDLINE, EMBASE, Cochrane library and NHS Evidence from inception to September 2011. Terms used include facial pain and contact point (3628), rhinologic headache (6) contact point and surgery/endoscopy (38).Evaluation method: Inclusion criteria applied. Assessment of papers were undertaken by one reviewer and checked by the second. A narrative review of each study was performed and results recorded in tables.Results: In one study, 973 consecutive patients with a provisional diagnosis of rhinosinusitis were divided into groups with (42%) and without facial pain. There was a 4% prevalence of nasal contact in both groups, which was unrelated to the presence of facial pain. In another study of 100 patient's coronal paranasal sinus CT scans, 29% had headache and 55% had a contact point but their presence was inversely related to the presence of pain.¹In a further study, ten healthy volunteers had palpation, adrenaline, substance P and placebo applied to different areas throughout the nasal cavity and none of these stimuli caused facial pain. Nineteen studies were identified where nasal mucosal contact points had been removed surgically for the treatment of facial pain. They were small case series, not randomised and subject to selection bias, had no control group, a limited follow‐up and were open to observer bias with level IV evidence. Seven studies had a statistically significant improvement in pain postoperatively compared with preoperative questionnaire results but the majority had residual facial pain.Conclusion: The majority of people with contact points experience no facial pain. The presence of a contact point is not a good predictor of facial pain. The removal of a contact point rarely results in thetotalelimination of facial pain making the theory that a contact point is responsible unlikely. The improvement in postoperative symptoms following the removal of contact points in some patients may be explained by cognitive dissonance or neuroplasticity. A randomised, controlled and blinded trial with a followed up period of over 12 months is needed to assess the place of surgery in the removal of a contact point for the treatment of facial pain.

There is a common misconception that facial pain and headache are mainly caused by sinusitis. The findings of nasal endoscopy, computer tomography (CT) and the results of observational studies reveal that this is not the case. Moreover, when sinus surgery is performed in patients where headache/facial pain has been a feature, it has been found that these symptoms persist after sinus surgery, particularly where there had been no nasal symptoms or endoscopic signs of paranasal sinusitis. This review was based on a literature search performed on 30 November 2011. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading of facial pain, that is, rhinosinusitis, migraine, cluster headaches, midsegment facial pain, trigeminal neuralgia, paroxysmal hemicrania, hemicrania continua and drug-dependent headache. The search was limited to English language articles. Relevant references from selected articles were reviewed after reading the A review of the literature shows that headaches are rarely caused by sinusitis. Similarly, only a small proportion of patients with facial pain have sinusitis, and these patients have either acute sinusitis or an acute exacerbation of chronic purulent sinusitis. Importantly, most patients with chronic rhinosinusitis rarely have facial pain unless they develop an acute infection or suffer barotrauma. CT scans should not routinely be performed for facial pain because of the prevalence of incidental changes in asymptomatic patients. Surgery is very rarely indicated in the treatment for chronic facial pain. A structured history of the pain and its associated symptoms, nasendoscopy and relevant targeted investigations should lead to a correct diagnosis and the appropriate treatment.

Purpose of review Due to the overlap of symptoms and signs in the various types of rhinitis, arriving at a precise diagnosis can be difficult. A diagnosis of idiopathic rhinitis can only be used when all other causes have been excluded and this review tries to clarify whom this term should be applied to, and the reasons why. Recent findings The current literature on idiopathic rhinitis is sparse. Haematological and immunological tests can help to distinguish which individuals have a predisposition to allergic mediated disease, but these results should be interpreted with caution because of the prevalence of false-positives. It has recently been shown that some patients previously labelled as 'idiopathic' suffer from a highly localized form of IgE-mediated allergy known as 'entopy'. Patients with idiopathic rhinitis probably represent a disparate group who may be suffering from a range of immunological or neuroregulatory disease processes in which an inability to down-regulate inflammatory processes may be as important as the process that initiates it. Summary To arrive at a diagnosis of idiopathic rhinitis all other forms of rhinitis must be excluded. With further research and a better understanding of the pathological processes involved in rhinitis, we may need to use the term 'idiopathic' less frequently but be more assured of its correct usage.

Objective: To provide an update on the ever-increasing role that embolisation plays in the practice of otolaryngology.Method: A literature search was performed during November 2008. The Medline, Embase, PubMed and Cochrane databases were searched. This resulted in 285 papers relevant for review.Conclusion: The role of embolisation has expanded greatly to include the management of refractory epistaxis, pre-operative preparation of vascular tumours, vascular injuries and as an adjunct in skull base surgery.

Background: Dental disease is a recognised cause of sinusitis. We perceived an increased incidence of sinusitis secondary to dental disease in recent years. This study reviews the incidence of odontogenic sinusitis, its clinical features and treatment.Methods: Medical records of patients with odontogenic sinusitis were identified using the senior author's clinical database and Hospital Information Support System data (January 2004 to December 2009).Results: Twenty-six patients were identified, nine females and 17 males (age range, 17–73 years). Rhinorrhoea and cacosmia were the commonest symptoms (81 and 73 per cent, respectively), with presence of pus the commonest examination finding (73 per cent). Causative dental pathology included periapical infection (73 per cent), oroantral fistula (23 per cent) and a retained root (4 per cent). In all 26 cases, treatment resulted in complete resolution of symptoms; 21 (81 per cent) required sinus surgery. The number of patients with odontogenic sinusitis undergoing surgery has steadily increased, from no cases in 2004 to 10 in 2009 (accounting for 8 per cent of all patients requiring sinus surgery). Reduced access to dental care may be responsible.Conclusion: The incidence of odontogenic sinusitis appears to be increasing. The importance of assessing the oral cavity and dentition in patients with rhinosinusitis is therefore emphasised.

Aim: To assess the results of reconstruction of composite defects involving the nose which extend to involve the cheeks, eyelids or upper lip.Study design: Retrospective observational study.Material: Sixteen patients with defects of the nose extending to the adjoining cheek, upper lip or eyelid.Method: A combination of flaps and grafts were needed to reconstruct these defects so that the aesthetic subunits were replaced and joined at their junctions wherever possible.Results: Where the defect required three or four flaps, there was some unpredictable cicatrisation at their junction that resulted in some asymmetry. This problem primarily occurred at the alar base, and was compounded if there was tissue loss of the premaxilla or maxilla.Conclusion: If a defect that involves the nose, cheek and upper lip is repaired with a combination of cheek advancement, nasolabial, paramedian forehead and/or septal flaps, there can be unpredictable cicatrisation at their junction, particularly at the alar base. In these circumstances, we recommend replacing the nasal and other defects with a slightly more generous amount of tissue than would be taken to repair a similar, but solitary, defect. It is important to replace any loss of the facial skeleton, in order to provide support for overlying flaps.