The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
Evaluation of the Changes in the Nasal Cavity During the Migraine Attack Hasan Hüseyin Arslan, MD,* Erkan Tokgöz, MD,† Üzeyir Yildizoğlu, MD,‡ Abdullah Durmaz, MD,‡ Semai Bek, MD,† Mustafa Gerek, MD‡ FIGURE 1. A, A sebaceous gland carcinoma in the right upper eyelid of a 49-year-old man. B, The upper eyelid defect after tumor removal. C, A reverse Hughes flap. D, A skin excision design similar to a skin removal in blepharoplasty. E, The excised skin is grafted to the lower portion of the defect. F, The defect is closed. G, Appearance in the postoperative third month. H, The color and texture of the skin graft are well matched to the surroundings, although there is no cilium in the eyelid margin.
well matched to the surroundings, although there was no cilium in the eyelid margin (Fig. 1H).
DISCUSSION An upper eyelid defect after excision of a sebaceous gland carcinoma was successfully reconstructed by making a skin defect similar to a skin removal in blepharoplasty with good cosmetic and functional outcomes. An anterior lamellar defect of the upper eyelid, such as that seen in our patient, is usually reconstructed with an advancement flap with Burrow triangles.1,3 However, because we considered this technique to be cosmetically suboptimal, we sought for a better procedure. We first tried to make an accustomed scenery such as a defect similar to a skin removal in blepharoplasty from an unfamiliar one, such as a defect after a tumor excision. Also, we attempted to use excised skin as a skin graft. As a result, we chose the reconstruction reported in this study. The posterior lamella needs to be reconstructed with a flap in our technique because a skin graft is used for covering an eyelid margin. Therefore, we used a reverse modified Hughes flap.2,3 However, this required 2-step operations and the visual axis was occluded for 2 weeks, which would pose difficulty for patients who are monocular. In this situation, a free tarsal graft with orbicularis oculi muscle sandwich flap could be used.3,4 This is a 1-stage operation with good blood supply to a graft. In conclusion, we successfully reconstructed a defect after a tumor resection by making a defect similar to a skin removal in blepharoplasty. The basic concepts of our procedure were to make an accustomed scenery from an unfamiliar one and to make good use of excised tissue.
REFERENCES 1. Irvine F, McNab AA. A technique for reconstruction of upper lid marginal defects. Br J Ophthalmol 2003;87:279–281 2. Mauriello JA Jr, Antonacci R. Single tarsoconjunctival flap (lower eyelid) for upper eyelid reconstruction (“reverse” modified Hughes procedure). Ophthalmic Surg 1994;25:374–378 3. Sa HS, Woo KI, Kim YD. Reverse modified Hughes procedure for upper eyelid reconstruction. Ophthal Plast Reconstr Surg 2010;26:155–160 4. Paridaens D, van den Bosch WA. Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: a 1-stage sandwich technique for eyelid reconstruction. Ophthalmology 2008;115:189–194
e446
Objectives: There are some subjective symptoms involving the nasal cavity such as nasal congestion during a migraine attack. In this study, we aimed to evaluate the possible changes occurring in the nasal cavity during headache in patients with migraine. Materials and Methods: Patients with migraine were studied. The control group consisted of patients with tension-type headache. The severity of the headache and accompanying complaints were assessed using visual analog scale, and the nasal mucosa was assessed through anterior rhinoscopy and endoscopy. Resistance of the nasal cavity was evaluated through anterior rhinomanometry. Data obtained during the attack periods and attack-free periods were compared. Results: Twenty-five patients with migraine and 15 patients with tension-type headache were enrolled. It was found that 19 patients (76%) of the group with migraine and 5 patients of the group with tension-type headache were experiencing nasal congestion during the attack and that the differences between the groups were statistically significant (P < 0.05). The average of total nasal resistance in the patients with migraine was 0.57 ± 0.60 kPa/L/sn during migraine attacks and 0.28 ± 0.14 kPa/L/sn during attack-free periods. The average of total nasal resistance in the patients with tensiontype headache was 0.32 ± 0.14 kPa/L/sn during attack periods and 0.31 ± 0.20 kPa/L/sn during attack-free periods. In the group with migraine, the change of nasal resistance between during the attack and attack-free periods was found statistically significant, whereas there was no statistically significant difference in the group with tension-type headache. Conclusions: According to the results of this study, complaints regarding nasal obstruction and nasal airway resistance increase during migraine attacks. Cause-and-effect relationship between nasal obstruction and pain is not clear, and clinical trials are needed to determine the effect of nasal obstruction treatment (mucosal decongestion, etc) on the complaint of pain. Key Words: Migraine, tension-type headache, nasal obstruction, rhinomanometry From the *Department of Otorhinolaryngology and Head and Neck Surgery, Etimesgut Military Hospital; †Departments of Neurology, and ‡Otorhinolaryngology, Head and Neck Surgery, Gulhane Military Medical Academy, Ankara, Turkey. Received August 28, 2012. Accepted for publication November 4, 2012. Address correspondence and reprint requests to Hasan Hüseyin Arslan, MD, Etimesgut Military Hospital, Yenimahalle 06790, Ankara, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31827c80b1
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
M
igraine is a common primary episodic headache disorder accompanied by neurologic, gastrointestinal, and autonomic changes in various proportions.1 In our country, it is determined that the incidence of migraine is 21.8% in women and 10.9% in men.2 In recent studies, the trigeminovascular system has been shown to play an important role in the formation of migraine pain.3 According to the trigeminovascular theory, neurogenic inflammation of the meninges during a migraine attack causes pain by the activation of the trigeminal nerve terminals. The release of neuropeptides in the trigeminal nerve ending, which provides the sensory stimulation of the nasal cavity and the sinuses, causes a number of changes that result in frequent symptoms in the nasal mucosa during migraine attacks such as runny nose, nasal congestion, and a feeling of fullness on the face by increasing blood circulation through the effect of vasodilatation in turbinates. In this study, we aimed to evaluate objectively the possible changes that emerge in the nasal cavity during the attack of migraine headache through rhinomanometry and to determine the role of the nasal cavity changes in a migraine attack.
MATERIALS AND METHODS This study was conducted between October 2010 and April 2011 in Gulhane Training Hospital after the approval by The Ethical Committee of Gulhane Military Academy of Clinical and Laboratory Research. Patients with migraine who are subject for follow-up, according to the year 2004 criteria of the International Headache Society,4 and who have no complaints related to the nasal cavity except pain attacks were included in this study. For the control group, patients with a diagnosis of tension-type headache were selected. Acute upper respiratory tract infections, deviated septum that causes mucosal contact, sinonasal inflammatory allergic diseases, diseases that can cause nasal congestion such as adenoid hypertrophy, and disorders that can cause chronic headaches such as cerebrovascular disease, trigeminal neuralgia, and epilepsy were excluded. The severity and frequency of the headache and accompanying complaints of the patients were assessed by applying visual analog scale, and the nasal mucosa was evaluated through anterior rhinoscopy and endoscopy. The nasal cavity resistance was measured through active anterior rhinomanometry (Masterscope Rhino; Jaeger GmbH, Hoechberg, Germany). All measurements were performed according to the recommendations of the International Standardization Committee for Rhinomanometry.5 Active anterior rhinomanometry for the left and right unilateral nasal flow was performed, and the total nasal airflow resistance was calculated using a measurement program (JLAB Lab Manager Software, version 5.3.0; Jaeger GmbH) supplied with rhinomanometry setup. Inspection and measurements were repeated during the attack and attack-free periods. Data were compared by using the Mann-Whitney, Wilcoxon, and Chi-squared tests.
RESULTS Twenty-five patients with migraine and 15 patients with tensiontype headache, with a total of 40 patients, were enrolled in the study. The demographic findings of the groups are summarized in Table 1. When the patients forming the groups with migraine and with tension-type headache were compared for pain character, pain intensity, frequency, and duration, there was no statistically significant difference (P = 0.61; 0.25 and 0.08, respectively; Table 2). When compared for accompanying symptoms, the rate of the symptoms of nausea, vomiting, photophobia, and phonophobia in the patients with migraine during headache was significantly higher than in those with tension-type headache (Table 2).
Brief Clinical Studies
Anterior rhinoscopy findings during headache were compared. Nineteen patients of the group with migraine (76%) and 4 patients of the group with tension-type headache (27%) had the complaint of nasal congestion during the attack, and the difference between the groups was found statistically significant (P = 0.02; Table 2). Hyperemia of the nasal mucosa and inferior turbinate hypertrophy were found significantly higher in the group with migraine (P = 0.01 and P < 0.001, respectively; Table 2). Seven patients of the group with migraine (28%) and 2 patients of the group with tension-type headache (13%) had nasal oversecretion, which was not statistically significant. It was found that the average of the total nasal resistance during migraine attacks and attack-free periods were 0.57 ± 0.60 kPa/L/sn and 0.28 ± 0.14 kPa/L/sn, respectively and that the average of the total nasal resistance during tension-type headache attacks and attack-free periods were 0.32 ± 0.14 kPa/L/sn and 0.31 ± 0.20 kPa/ L/sn, respectively. During periods of headache attack, nasal resistance was significantly higher in the group with migraine than in the group with tension-type headache, whereas there was no statistically significant difference between nasal resistances in both groups during attack-free periods (P = 0.02 and P = 0.52). The difference of nasal resistance in each group during headache attack and attack-free periods was compared. During periods of headache attack, nasal resistance was significantly higher in the group with migraine (P < 0,001; Table 3).
DISCUSSION Migraine is an important health problem affecting a large part of society. Because it is frequently seen in the community and directly affects the quality of life, the importance of effective and accurate treatment options increases. Migraine treatment will be possible through a clear understanding of the pathogenesis. The molecular mechanisms and pathogenesis of migraine are not fully explained yet. Migraine headache is the result of the chain of neuronal-vascular events triggered by the endogenous and exogenous factors in people with genetic susceptibility.6 Activation of the trigeminovascular system constitutes the essence of this chain. The trigeminovascular inflammation firstly proposed by Moskowitz7 in 1984 is the most widely accepted theory of the pathogenesis of migraine today. According to this theory, the peripheral nociceptors at the meninges are activated because of the release of ions and chemical agents close to the sensory fibers that innervate the meninges. Peripheral nociceptors exposed to chemical agents generate a secondary stimulus, causing a feeling of pain.8 The trigeminal nerve is the first way for the conveying of pain. The second-recipient neuron is in the brain stem. The activation and sensitization of the trigeminal system take the pain sense to the trigeminal ganglion and the trigeminal nucleus caudalis.9,10 According to the axon reflex theory, the activation of the peripheral trigeminal axons also causes the release of neuropeptides to the perivascular area contained in the peripheral nerve endings. Calcitonin gene-related peptide (CGRP), substance P, and neurokinin A emerge from these neuropeptides and make vasodilatation in the meningeal vessels.11,12 In addition, when the trigeminal ganglion is stimulated, it is shown that platelet aggregation and degranulation TABLE 1. Demographic Findings of the Groups Migraine (n = 25) Tension-Type Headache (n = 15) Sex Male Female Mean age ± SD (min/max), y
2 23 28 ± 3 (22/53)
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
4 11 27 ± 7 (18/53)
e447
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
TABLE 2. Comparison of the Groups for Symptoms and Findings Migraine (n = 25)
Tension-Type Headache (n = 15)
P
8 4 9.5 20 18 20 21 19 7 13 18
9 4 2 3 0 0 0 4 2 2 2
0.61 0.25 0.08
Brief Clinical Studies
Evaluation of the Changes in the Nasal Cavity During the Migraine Attack Hasan Hüseyin Arslan, MD,* Erkan Tokgöz, MD,† Üzeyir Yildizoğlu, MD,‡ Abdullah Durmaz, MD,‡ Semai Bek, MD,† Mustafa Gerek, MD‡ FIGURE 1. A, A sebaceous gland carcinoma in the right upper eyelid of a 49-year-old man. B, The upper eyelid defect after tumor removal. C, A reverse Hughes flap. D, A skin excision design similar to a skin removal in blepharoplasty. E, The excised skin is grafted to the lower portion of the defect. F, The defect is closed. G, Appearance in the postoperative third month. H, The color and texture of the skin graft are well matched to the surroundings, although there is no cilium in the eyelid margin.
well matched to the surroundings, although there was no cilium in the eyelid margin (Fig. 1H).
DISCUSSION An upper eyelid defect after excision of a sebaceous gland carcinoma was successfully reconstructed by making a skin defect similar to a skin removal in blepharoplasty with good cosmetic and functional outcomes. An anterior lamellar defect of the upper eyelid, such as that seen in our patient, is usually reconstructed with an advancement flap with Burrow triangles.1,3 However, because we considered this technique to be cosmetically suboptimal, we sought for a better procedure. We first tried to make an accustomed scenery such as a defect similar to a skin removal in blepharoplasty from an unfamiliar one, such as a defect after a tumor excision. Also, we attempted to use excised skin as a skin graft. As a result, we chose the reconstruction reported in this study. The posterior lamella needs to be reconstructed with a flap in our technique because a skin graft is used for covering an eyelid margin. Therefore, we used a reverse modified Hughes flap.2,3 However, this required 2-step operations and the visual axis was occluded for 2 weeks, which would pose difficulty for patients who are monocular. In this situation, a free tarsal graft with orbicularis oculi muscle sandwich flap could be used.3,4 This is a 1-stage operation with good blood supply to a graft. In conclusion, we successfully reconstructed a defect after a tumor resection by making a defect similar to a skin removal in blepharoplasty. The basic concepts of our procedure were to make an accustomed scenery from an unfamiliar one and to make good use of excised tissue.
REFERENCES 1. Irvine F, McNab AA. A technique for reconstruction of upper lid marginal defects. Br J Ophthalmol 2003;87:279–281 2. Mauriello JA Jr, Antonacci R. Single tarsoconjunctival flap (lower eyelid) for upper eyelid reconstruction (“reverse” modified Hughes procedure). Ophthalmic Surg 1994;25:374–378 3. Sa HS, Woo KI, Kim YD. Reverse modified Hughes procedure for upper eyelid reconstruction. Ophthal Plast Reconstr Surg 2010;26:155–160 4. Paridaens D, van den Bosch WA. Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: a 1-stage sandwich technique for eyelid reconstruction. Ophthalmology 2008;115:189–194
e446
Objectives: There are some subjective symptoms involving the nasal cavity such as nasal congestion during a migraine attack. In this study, we aimed to evaluate the possible changes occurring in the nasal cavity during headache in patients with migraine. Materials and Methods: Patients with migraine were studied. The control group consisted of patients with tension-type headache. The severity of the headache and accompanying complaints were assessed using visual analog scale, and the nasal mucosa was assessed through anterior rhinoscopy and endoscopy. Resistance of the nasal cavity was evaluated through anterior rhinomanometry. Data obtained during the attack periods and attack-free periods were compared. Results: Twenty-five patients with migraine and 15 patients with tension-type headache were enrolled. It was found that 19 patients (76%) of the group with migraine and 5 patients of the group with tension-type headache were experiencing nasal congestion during the attack and that the differences between the groups were statistically significant (P < 0.05). The average of total nasal resistance in the patients with migraine was 0.57 ± 0.60 kPa/L/sn during migraine attacks and 0.28 ± 0.14 kPa/L/sn during attack-free periods. The average of total nasal resistance in the patients with tensiontype headache was 0.32 ± 0.14 kPa/L/sn during attack periods and 0.31 ± 0.20 kPa/L/sn during attack-free periods. In the group with migraine, the change of nasal resistance between during the attack and attack-free periods was found statistically significant, whereas there was no statistically significant difference in the group with tension-type headache. Conclusions: According to the results of this study, complaints regarding nasal obstruction and nasal airway resistance increase during migraine attacks. Cause-and-effect relationship between nasal obstruction and pain is not clear, and clinical trials are needed to determine the effect of nasal obstruction treatment (mucosal decongestion, etc) on the complaint of pain. Key Words: Migraine, tension-type headache, nasal obstruction, rhinomanometry From the *Department of Otorhinolaryngology and Head and Neck Surgery, Etimesgut Military Hospital; †Departments of Neurology, and ‡Otorhinolaryngology, Head and Neck Surgery, Gulhane Military Medical Academy, Ankara, Turkey. Received August 28, 2012. Accepted for publication November 4, 2012. Address correspondence and reprint requests to Hasan Hüseyin Arslan, MD, Etimesgut Military Hospital, Yenimahalle 06790, Ankara, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31827c80b1
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
M
igraine is a common primary episodic headache disorder accompanied by neurologic, gastrointestinal, and autonomic changes in various proportions.1 In our country, it is determined that the incidence of migraine is 21.8% in women and 10.9% in men.2 In recent studies, the trigeminovascular system has been shown to play an important role in the formation of migraine pain.3 According to the trigeminovascular theory, neurogenic inflammation of the meninges during a migraine attack causes pain by the activation of the trigeminal nerve terminals. The release of neuropeptides in the trigeminal nerve ending, which provides the sensory stimulation of the nasal cavity and the sinuses, causes a number of changes that result in frequent symptoms in the nasal mucosa during migraine attacks such as runny nose, nasal congestion, and a feeling of fullness on the face by increasing blood circulation through the effect of vasodilatation in turbinates. In this study, we aimed to evaluate objectively the possible changes that emerge in the nasal cavity during the attack of migraine headache through rhinomanometry and to determine the role of the nasal cavity changes in a migraine attack.
MATERIALS AND METHODS This study was conducted between October 2010 and April 2011 in Gulhane Training Hospital after the approval by The Ethical Committee of Gulhane Military Academy of Clinical and Laboratory Research. Patients with migraine who are subject for follow-up, according to the year 2004 criteria of the International Headache Society,4 and who have no complaints related to the nasal cavity except pain attacks were included in this study. For the control group, patients with a diagnosis of tension-type headache were selected. Acute upper respiratory tract infections, deviated septum that causes mucosal contact, sinonasal inflammatory allergic diseases, diseases that can cause nasal congestion such as adenoid hypertrophy, and disorders that can cause chronic headaches such as cerebrovascular disease, trigeminal neuralgia, and epilepsy were excluded. The severity and frequency of the headache and accompanying complaints of the patients were assessed by applying visual analog scale, and the nasal mucosa was evaluated through anterior rhinoscopy and endoscopy. The nasal cavity resistance was measured through active anterior rhinomanometry (Masterscope Rhino; Jaeger GmbH, Hoechberg, Germany). All measurements were performed according to the recommendations of the International Standardization Committee for Rhinomanometry.5 Active anterior rhinomanometry for the left and right unilateral nasal flow was performed, and the total nasal airflow resistance was calculated using a measurement program (JLAB Lab Manager Software, version 5.3.0; Jaeger GmbH) supplied with rhinomanometry setup. Inspection and measurements were repeated during the attack and attack-free periods. Data were compared by using the Mann-Whitney, Wilcoxon, and Chi-squared tests.
RESULTS Twenty-five patients with migraine and 15 patients with tensiontype headache, with a total of 40 patients, were enrolled in the study. The demographic findings of the groups are summarized in Table 1. When the patients forming the groups with migraine and with tension-type headache were compared for pain character, pain intensity, frequency, and duration, there was no statistically significant difference (P = 0.61; 0.25 and 0.08, respectively; Table 2). When compared for accompanying symptoms, the rate of the symptoms of nausea, vomiting, photophobia, and phonophobia in the patients with migraine during headache was significantly higher than in those with tension-type headache (Table 2).
Brief Clinical Studies
Anterior rhinoscopy findings during headache were compared. Nineteen patients of the group with migraine (76%) and 4 patients of the group with tension-type headache (27%) had the complaint of nasal congestion during the attack, and the difference between the groups was found statistically significant (P = 0.02; Table 2). Hyperemia of the nasal mucosa and inferior turbinate hypertrophy were found significantly higher in the group with migraine (P = 0.01 and P < 0.001, respectively; Table 2). Seven patients of the group with migraine (28%) and 2 patients of the group with tension-type headache (13%) had nasal oversecretion, which was not statistically significant. It was found that the average of the total nasal resistance during migraine attacks and attack-free periods were 0.57 ± 0.60 kPa/L/sn and 0.28 ± 0.14 kPa/L/sn, respectively and that the average of the total nasal resistance during tension-type headache attacks and attack-free periods were 0.32 ± 0.14 kPa/L/sn and 0.31 ± 0.20 kPa/ L/sn, respectively. During periods of headache attack, nasal resistance was significantly higher in the group with migraine than in the group with tension-type headache, whereas there was no statistically significant difference between nasal resistances in both groups during attack-free periods (P = 0.02 and P = 0.52). The difference of nasal resistance in each group during headache attack and attack-free periods was compared. During periods of headache attack, nasal resistance was significantly higher in the group with migraine (P < 0,001; Table 3).
DISCUSSION Migraine is an important health problem affecting a large part of society. Because it is frequently seen in the community and directly affects the quality of life, the importance of effective and accurate treatment options increases. Migraine treatment will be possible through a clear understanding of the pathogenesis. The molecular mechanisms and pathogenesis of migraine are not fully explained yet. Migraine headache is the result of the chain of neuronal-vascular events triggered by the endogenous and exogenous factors in people with genetic susceptibility.6 Activation of the trigeminovascular system constitutes the essence of this chain. The trigeminovascular inflammation firstly proposed by Moskowitz7 in 1984 is the most widely accepted theory of the pathogenesis of migraine today. According to this theory, the peripheral nociceptors at the meninges are activated because of the release of ions and chemical agents close to the sensory fibers that innervate the meninges. Peripheral nociceptors exposed to chemical agents generate a secondary stimulus, causing a feeling of pain.8 The trigeminal nerve is the first way for the conveying of pain. The second-recipient neuron is in the brain stem. The activation and sensitization of the trigeminal system take the pain sense to the trigeminal ganglion and the trigeminal nucleus caudalis.9,10 According to the axon reflex theory, the activation of the peripheral trigeminal axons also causes the release of neuropeptides to the perivascular area contained in the peripheral nerve endings. Calcitonin gene-related peptide (CGRP), substance P, and neurokinin A emerge from these neuropeptides and make vasodilatation in the meningeal vessels.11,12 In addition, when the trigeminal ganglion is stimulated, it is shown that platelet aggregation and degranulation TABLE 1. Demographic Findings of the Groups Migraine (n = 25) Tension-Type Headache (n = 15) Sex Male Female Mean age ± SD (min/max), y
2 23 28 ± 3 (22/53)
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
4 11 27 ± 7 (18/53)
e447
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
TABLE 2. Comparison of the Groups for Symptoms and Findings Migraine (n = 25)
Tension-Type Headache (n = 15)
P
8 4 9.5 20 18 20 21 19 7 13 18
9 4 2 3 0 0 0 4 2 2 2
0.61 0.25 0.08
