Contact point neuralgia

Headache is a tricky topic.  Sinus infection can, of course, cause facial pain and headache, as well as a runny or congested nose; but migraine can cause nasal congestion, too.

Congestion and pain also accompany one another in a condition known as contact point neuralgia, sometimes also called Sluder neuralgia. Facial pain occurs when structures within the nose press against one another.  Structures that ordinarily do not touch may be brought into contact when the tissues swell from allergies, a cold, or a sinus infection.

Here is how I approach a patient in whom I suspect contact point neuralgia. I ask the patient to come see me when he is in pain. (In some cases, I have to squeeze someone into the schedule, but it’s worth it.) I then examine the patient’s nose with a fiberoptic scope. I do this BEFORE spraying a decongestant or topical anesthetic into the nose. Since I’m examining an unanesthetized nose, needless to say I have to be careful. I’m looking for one or more areas in which two structures touch — most commonly, the septum and one of the turbinates*.

Next, I place a cotton ball moistened with a decongestant spray (like Afrin) and an anesthetic (lidocaine) against the contact area. If the patient notes rapid relief of his pain, AND if reexamination of the nose with the fiberoptic scope reveals that the “contact points” are no longer in contact, this is fairly convincing evidence that the patient’s pain is contact point pain.

Another good maneuver is to place a saline-moistened cotton against the contact area. This should be done before the lidocaine/afrin application, as a control to see if the patient receives benefit from just any intervention. Saline won’t decongest or numb the nose, so it shouldn’t have an effect on the patient’s pain. If saline helps, then the afrin/lidocaine results will be suspect.

Treatment of contact neuralgia can be medical or surgical. Medications which reduce swelling in the nose can bring these areas out of contact. If this doesn’t work, usually there are good surgical options for accomplishing the same thing on a more permanent basis. These operations are known as turbinatoplasty (to change the shape of the turbinates) and septoplasty (to change the shape of the septum) . . . great topics for another day.

D.

*The septum is the cartilaginous/bony partition between the two nasal cavities. The turbinates are shelves of bone, covered with mucosa, which jut out from the lateral walls of the nose. The turbinates warm, humidify and filter the air that we breathe.

Anterior epistaxis treatment: a YouTube video

This isn’t my video, and in fact I’m critical of the technique used. First, some background: this is an example of treatment of an anterior nosebleed with silver nitrate, an oxidizing agent. The doctor is inflicting a chemical burn on the offending vessel in order to make it stop bleeding. You won’t see any bleeding (not for a while, anyway) but you will see a pimple-like projection above the mucosa. I like to think of these as itty bitty models of Mount Vesuvius, ready to blow.

In my opinion, this doc is far too liberal with his application of silver nitrate. Towards the end of the video, you’ll note that the grayness (evidence of silver nitrate burn) is nearly circumferential. Sometimes this is unavoidable, but I try my best NOT to do this, because it can lead to troublesome scarring.

Many bleeding sites are capillaries which do not rise above the surface of the mucosa. In contrast, these little volcanoes are often more troublesome. In my experience, they laugh at silver nitrate. I prefer bipolar electrical cautery for such vessels. This is more painful than silver nitrate, but it also results in a far smaller area of injured tissue. Silver nitrate-treated noses sometimes stay irritated longer than bipolar-treated noses. More to the point, bipolar cautery is more successful for treating these larger vessels.

The first time I treat a patient with epistaxis, the usual question is, “Will this stop me from bleeding again?”  I ask the patient to imagine a pyramid. Most patients will get better after one or two treatments — think of the size of the base of the pyramid. A few patients will have to return for several treatments (we’re a little higher up in the pyramid, and the volume is smaller), while some will need still more aggressive interventions. A very few (the apex of the pyramid) will need surgical or angiographic intervention.

Yes, probably not the clearest metaphor, but folks seem to understand. It helps me to convey that the goal is to begin with low-risk, mild interventions (like silver nitrate or bipolar cautery) and reserve more aggressive methods for folks whose problems are sufficiently severe or stubborn to warrant such.

I will admit an ulterior motive to my pyramid discussion: I know that some of these folks will be back again and again no matter what I do. It’s the nature of the problem. I want them to know from the start that there’s a chance they could be in the apex of the pyramid. Otherwise, come the third or fourth office visit, they might think I’m some yutz who doesn’t know his nostril from a hole in the ground

D.

Posterior nosebleeds

Q: My father-in-law has been experiencing nose bleeds. My concern is that they are not anterior nosebleeds; they begin in the back of the nose, sometimes only flowing down the throat. After the last nose bleed he had, the following day he had dizziness and lightheadedness. The nose bleeds can come on with no warning, i.e., sitting down watching TV, or during physical activity, i.e., playing with a 4 yr old grandchild. I just need to know if these symptoms are something to really worry about? Thank you.

Nasal polyps, steroids, and surgery

Q: I have had nasal polyps for several years which usually don’t bother me except when I have a cold or hay fever. My ENT doctor recommended surgery which I declined because of the chance of recurrence. Recently however, my right eustachian tube feels blocked and I was given a prescription for prednisone plus a steroid nasal spray to treat the polyps. Would prednisone for two weeks plus the nasal spray be better than surgery to relieve the polyps, or is surgery still the best treatment? Also, what is the best treatment for the blocked eustachian tube?

bad breath (halitosis)

Q: I am a XX-year old woman in good health. All my life, I have had “large tonsils.” As a child, most of my colds involved a sore throat (pharyngitis) & often a strep infection, and, often what the doctor classified has “postnasal drip.”

For quite some time now, I have had halitosis. I practice good oral hygiene and have never had a cavity, but I can’t seem to get rid of my bad breath.

I was recently sick for about a month and a half with a bad cold/viral infection. During that time, I noticed that I had a thick, almost fuzzy whitish coating over my tongue and could do little to nothing to get rid of it. Ever since then, the coat has reappeared often in the mornings, but is easily brushed off when I brush my teeth, etc.

The reason I am writing is to see if you have any insight to add into WHY I have chronic halitosis, and even more importantly, HOW I can get rid of it. Is this an ear/nose/throat-related problem?

A friend of mine told me that halitosis can be caused by overly large tonsils, and something known as nasal concretions, which are basically pieces of rotting food trapped within the tonsils or sinus cavities. Is this information accurate?

hereditary nose bleeds

Q: I was told that epistaxis is hereditary. Do you know if this is true? Could a medication such as phentermine affect this? I am really interested in finding out if epistaxis is hereditary and if there are any journals or articles written on this. Any information would be appreciated.