Abstract
Headaches secondary to paranasal sinus disease are a common problem in otolaryngology practice. However, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCTs) are an extremely rare presentation of sinusitis. We report for the first time an unusual case of acute sinusitis presenting with SUNCTs-like symptoms with radiographically-proven isolated ipsilateral sphenoiditis, without any other intracranial pathologies. This case demonstrates an additional spectrum of acute sinusitis, which should be familiar to the otolaryngologist population.
1
Introduction
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCTs) syndrome is a rare disease. The International Headache Society has classified it as a primary headache . The disorder is marked by bursts of moderate to severe burning, piercing, or throbbing pain, usually on one side of the head and around the eye or temple. SUNCTs are most common in men after age 50. The pain usually peaks within seconds of onset and may follow a pattern of increasing and decreasing intensity. Attacks typically occur in daytime hours and last from 5 s to 4 min per episode. Individuals generally have five to six attacks per hour. Autonomic nervous system responses include watery eyes, conjunctival injection, nasal congestion, runny nose, and sweaty forehead, eyelids edema, and increased pressure within the eye on the affected side of the head. SUNCTs have been associated with several intracranial pathologies, such as vascular malformations and posterior fossa lesions . To date, SUNCTs have only been described in association with maxillary and ethmoidal sinusitis . We report the first case of SUNCTs described in a sphenoiditis patient.
2
Case report
A 62-year-old otherwise healthy Asian female with no chronic sinus history presented with a sudden-onset, severe headaches. One week before her presentation, she had common cold symptoms, which included purulent nasal discharge, myalgia, and malaise. The patient lacked any other sinus-related symptoms, including headaches or facial pain. The patient did not respond to standard medical therapy; no antibiotics were prescribed due to clinical impression of self-limiting upper respiratory tract infection. There were no nocturnal attacks. Upon presentation, the pain was severe, stabbing and started in the right occipital region. It then radiated to the ipsilateral frontotemporal region. Her forehead was sweaty. Each attack lasted 1–4 min, and more than 20 attacks occurred after the initial episode. The attacks were accompanied by bilateral epiphora, conjunctival injection and eyelid edema. There were 5–10 min periods between attacks when the symptoms diminished. The total duration of SUNCTs symptomatology was 3–4 h. No nasal discharge was noted. The patient continued to have repeated headache attacks that later included watery rhinorrhea. On physical examination, there were no signs of orbital involvement and no focal neurologic deficits. Ocular examination demonstrated conjunctival injection, and the pupils were normal. Intra-venous fluids and non-steroidal anti-inflammatory drugs significantly relieved the pain. Laboratory workup revealed mild leukocytosis (13,900/cm 3 , normal range: 4500–10,000/cm 3 ), with a mild neutrophilia (77%). The remainder tests were within normal limits. Head computerized tomography (CT) revealed air-fluid levels in the right sphenoid sinus without additional pathology ( Fig. 1 A ). Magnetic resonance imaging (MRI) was not performed. The patient was discharged home with a 2-week course of amoxicillin-clavulanate for an acute sphenoiditis, based on the clinical history and findings, supported by the radiological study. Following completion, the patient reported only minor, intermittent tension-type headaches of decreasing frequency. However, she continued to complain of mild sinus congestion and pressure. At 6-week follow-up, the patient had complete resolution of her symptoms. Repeat CT showed sphenoid sinusitis in resolution ( Fig. 1 B). No further medical therapy was offered. Follow-up for 6 months was unremarkable, with no recurring similar episodes.
