RADIOLOGICAL NASAL SEPTAL VARIANTS AND THEIR ASSOCIATION WITH RECURRENT HEADACHE IN PATIENTS WITHOUT SINUSITIS: A RETROSPECTIVE ENT–RADIOLOGY STUDY
Main Article Content
Keywords
Nasal septum; septal deviation; concha bullosa; septal spur; contact-point headache; recurrent headache; HIT-6; computed tomography paranasal sinuses; GMERS Medical College; Porbandar; Saurashtra; Gujarat
Abstract
Background:Recurrent headache without an identifiable sinus-inflammatory cause represents one of the most common and diagnostically challenging presentations in ENT outpatient practice, often resulting in repeated specialist consultations, empirical analgesic use, and unresolved patient distress. Anatomical variants of the nasal septum and adjacent structures — including septal deviation of varying severity, septal spurs producing mucosal contact points, concha bullosa, paradoxical middle turbinate, and prominent agger nasi cells — have been increasingly recognized as potential contributors to so-called 'rhinogenic' or contact-point headache, but remain under-investigated in routine ENT practice in tertiary care settings of western Indian coastal districts. GMERS Medical College, Porbandar, established under the Gujarat Medical Education and Research Society (GMERS) network, serves as the principal tertiary ENT referral center for Porbandar, Devbhoomi Dwarka, and Junagadh districts of the Saurashtra coastal region — a population where chronic headache attributable to environmental allergens, dust exposure, sun-induced strain, and unrecognized anatomical variation is highly prevalent. No prior systematic GMERS Porbandar analysis had quantified the institutional prevalence of nasal septal variants in patients presenting with recurrent headache without sinusitis, correlated radiological findings with headache frequency and impact, or identified independent variant-based predictors that could guide targeted ENT–radiology evaluation pathways.
Objectives:To determine the prevalence of radiological nasal septal variants among adult patients presenting with recurrent headache without evidence of sinusitis at GMERS Medical College, Porbandar, during March–December 2024; to characterize the spectrum of variants identified by computed tomography of the paranasal sinuses (CT-PNS) including septal deviation by Cottle grading, septal spur by Mladina classification, concha bullosa, paradoxical middle turbinate, and other anatomical anomalies; to correlate variant findings with headache frequency, severity (HIT-6 score), and localization patterns; and to identify independent demographic and anatomical predictors of frequent headache using multivariate logistic regression analysis.
Methodology:Retrospective observational cross-sectional study using ENT outpatient records, headache assessment questionnaires, and radiology imaging archives from GMERS Medical College, Porbandar. Inclusion: adults (≥18 years) presenting with recurrent headache (≥4 episodes over preceding 6 months) without clinical or radiological evidence of acute or chronic sinusitis, who underwent CT-PNS during the study period. CT scans independently reviewed by two consultant radiologists; ENT clinical correlation performed by senior ENT consultants. Headache assessment: frequency (episodes per month), severity (Headache Impact Test [HIT-6] score), localization, and provisional clinical diagnosis. Statistical analysis: IBM SPSS v28.0 — descriptive statistics, chi-square and ANOVA testing, Pearson correlation, multivariate logistic regression for independent predictor identification, ROC analysis. p<0.05 (two-tailed) significant.
Results:264 patients included: mean age 38.4±12.6 years; female predominance 55.3%. Headache profile: tension-type 37.1%, migraine without aura 23.5%, mid-facial/rhinogenic 22.0%, cervicogenic 9.1%, mixed/unclassified 8.3%. Headache frequency: infrequent (<2/mo) 34.1%, moderate (2-8/mo) 42.4%, frequent (>8/mo) 23.5%. Mean HIT-6 score: 51.8±8.4. Nasal septal variant prevalence: at least one variant identified in 84.1% (222/264) of patients; multiple variants (≥2 types) in 8.3% (22/264); no variant in 15.9% (42/264). Specific variants: septal deviation any grade 55.3% (146; Cottle mild 15.9%, moderate 22.0%, severe 17.4%); concha bullosa 23.5% (62; unilateral 14.4%, bilateral 9.1%); septal spur 14.4% (38; with turbinate contact 8.3%); paradoxical middle turbinate 9.1%; prominent agger nasi cell 6.8%. Mean deviation angle correlated strongly with HIT-6 score (Pearson r=0.62; p<0.001). Independent multivariate predictors of frequent headache (>8 episodes/month): severe septal deviation >15° (adjusted OR 6.48; 95% CI 3.18-13.20; p<0.001), multiple variants (OR 4.92; 2.42-10.00; p<0.001), septal spur with turbinate contact (OR 4.24; 2.10-8.56; p<0.001), bilateral concha bullosa (OR 3.86; 1.92-7.76; p<0.001), sleep deprivation (OR 3.18; 1.58-6.40; p=0.001), female gender (OR 2.84; 1.42-5.68; p=0.003).
Conclusion:Nasal septal variants are highly prevalent (84.1%) in adult patients presenting with recurrent headache without sinusitis at GMERS Medical College, Porbandar, with a clear dose-response relationship between variant severity/multiplicity and headache impact. Severe septal deviation (>15°), multiple coexisting variants, and septal spurs producing mucosal contact points with the middle turbinate emerged as the strongest independent predictors of frequent headache and elevated HIT-6 scores. The findings support the proposition that 'rhinogenic' or contact-point headache constitutes a clinically important but under-recognized entity in the Saurashtra ENT patient population. Four institutional recommendations: (1) routine CT-PNS evaluation for patients with recurrent headache unresponsive to standard analgesic and migraine management who lack alternative explanation; (2) systematic Cottle and Mladina classification of all detected septal variants to enable evidence-based surgical decision-making; (3) ENT–neurology–radiology multidisciplinary discussion for patients with severe deviation or multiple variants and severe HIT-6 impact; (4) consideration of septoplasty or endoscopic correction in carefully selected patients with anatomically demonstrable contact-point headache resistant to medical management. These pathway changes are expected to reduce diagnostic uncertainty and improve outcomes for the regional headache patient population.
Objectives:To determine the prevalence of radiological nasal septal variants among adult patients presenting with recurrent headache without evidence of sinusitis at GMERS Medical College, Porbandar, during March–December 2024; to characterize the spectrum of variants identified by computed tomography of the paranasal sinuses (CT-PNS) including septal deviation by Cottle grading, septal spur by Mladina classification, concha bullosa, paradoxical middle turbinate, and other anatomical anomalies; to correlate variant findings with headache frequency, severity (HIT-6 score), and localization patterns; and to identify independent demographic and anatomical predictors of frequent headache using multivariate logistic regression analysis.
Methodology:Retrospective observational cross-sectional study using ENT outpatient records, headache assessment questionnaires, and radiology imaging archives from GMERS Medical College, Porbandar. Inclusion: adults (≥18 years) presenting with recurrent headache (≥4 episodes over preceding 6 months) without clinical or radiological evidence of acute or chronic sinusitis, who underwent CT-PNS during the study period. CT scans independently reviewed by two consultant radiologists; ENT clinical correlation performed by senior ENT consultants. Headache assessment: frequency (episodes per month), severity (Headache Impact Test [HIT-6] score), localization, and provisional clinical diagnosis. Statistical analysis: IBM SPSS v28.0 — descriptive statistics, chi-square and ANOVA testing, Pearson correlation, multivariate logistic regression for independent predictor identification, ROC analysis. p<0.05 (two-tailed) significant.
Results:264 patients included: mean age 38.4±12.6 years; female predominance 55.3%. Headache profile: tension-type 37.1%, migraine without aura 23.5%, mid-facial/rhinogenic 22.0%, cervicogenic 9.1%, mixed/unclassified 8.3%. Headache frequency: infrequent (<2/mo) 34.1%, moderate (2-8/mo) 42.4%, frequent (>8/mo) 23.5%. Mean HIT-6 score: 51.8±8.4. Nasal septal variant prevalence: at least one variant identified in 84.1% (222/264) of patients; multiple variants (≥2 types) in 8.3% (22/264); no variant in 15.9% (42/264). Specific variants: septal deviation any grade 55.3% (146; Cottle mild 15.9%, moderate 22.0%, severe 17.4%); concha bullosa 23.5% (62; unilateral 14.4%, bilateral 9.1%); septal spur 14.4% (38; with turbinate contact 8.3%); paradoxical middle turbinate 9.1%; prominent agger nasi cell 6.8%. Mean deviation angle correlated strongly with HIT-6 score (Pearson r=0.62; p<0.001). Independent multivariate predictors of frequent headache (>8 episodes/month): severe septal deviation >15° (adjusted OR 6.48; 95% CI 3.18-13.20; p<0.001), multiple variants (OR 4.92; 2.42-10.00; p<0.001), septal spur with turbinate contact (OR 4.24; 2.10-8.56; p<0.001), bilateral concha bullosa (OR 3.86; 1.92-7.76; p<0.001), sleep deprivation (OR 3.18; 1.58-6.40; p=0.001), female gender (OR 2.84; 1.42-5.68; p=0.003).
Conclusion:Nasal septal variants are highly prevalent (84.1%) in adult patients presenting with recurrent headache without sinusitis at GMERS Medical College, Porbandar, with a clear dose-response relationship between variant severity/multiplicity and headache impact. Severe septal deviation (>15°), multiple coexisting variants, and septal spurs producing mucosal contact points with the middle turbinate emerged as the strongest independent predictors of frequent headache and elevated HIT-6 scores. The findings support the proposition that 'rhinogenic' or contact-point headache constitutes a clinically important but under-recognized entity in the Saurashtra ENT patient population. Four institutional recommendations: (1) routine CT-PNS evaluation for patients with recurrent headache unresponsive to standard analgesic and migraine management who lack alternative explanation; (2) systematic Cottle and Mladina classification of all detected septal variants to enable evidence-based surgical decision-making; (3) ENT–neurology–radiology multidisciplinary discussion for patients with severe deviation or multiple variants and severe HIT-6 impact; (4) consideration of septoplasty or endoscopic correction in carefully selected patients with anatomically demonstrable contact-point headache resistant to medical management. These pathway changes are expected to reduce diagnostic uncertainty and improve outcomes for the regional headache patient population.
References
1. GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-976.
2. Kulkarni GB, Rao GN, Gururaj G, Stovner LJ, Steiner TJ. Headache disorders and public ill-health in India: prevalence estimates in Karnataka State. J Headache Pain. 2015;16:67.
3. Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6 Suppl 1:S22-209.
4. Roozbahany NA, Nasri S. Nasal and paranasal sinus anatomical variations in patients with rhinogenic contact point headache. Auris Nasus Larynx. 2013;40(2):177-83.
5. Mladina R, Cujić E, Subarić M, Vuković K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29(2):75-82.
6. Behin F, Behin B, Bigal ME, Lipton RB. Surgical treatment of patients with refractory migraine headaches and intranasal contact points. Cephalalgia. 2005;25(6):439-43.
7. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol. 2004;25(9):1613-8.
8. Herzallah IR, Hamed MA, Salem SM, Suurna MV. Mucosal contact points and paranasal sinus pneumatization: Does radiology predict headache causality? Laryngoscope. 2015;125(9):2021-6.
9. Smith KD, Edwards PC, Saini TS, Norton NS. The prevalence of concha bullosa and nasal septal deviation and their relationship to maxillary sinusitis by volumetric tomography. Int J Dent. 2010;2010:404982.
10. Lerdlum S, Vachiranubhap B. Prevalence of anatomic variation demonstrated on screening sinus computed tomography and clinical correlation. J Med Assoc Thai. 2005;88 Suppl 4:S110-5.
11. Sollini G, Mazzola F, Iandelli A, Carobbio A, Barbieri A, Mora R, et al. Sino-nasal anatomical variations in rhinogenic headache pathogenesis. J Craniofac Surg. 2019;30(5):1503-1505.
12. Aksoy F, Yıldırım YS, Demirhan H, Özturan O, Solakoğlu Ş. Mladina classification of septal deformity and its correlation with symptoms in chronic headache patients. Acta Otolaryngol. 2020;140(3):238-242.
13. Shaikh A, Al Saey H, Ashkanani S, Alsulaiti M, Alduhirat E, Aljariri A, et al. Higher incidence of headache in patients with intermittent mucosal contact points between the septum and lateral nasal wall. Laryngoscope Investig Otolaryngol. 2021;6(4):607-612.
14. Krishniya P, Rajpurohit P, Sharma VK, Aseri Y, Verma PC. A prospective correlation study between computerized tomography of paranasal sinuses and nasal endoscopy findings in patients of chronic rhinosinusitis undergoing functional endoscopic sinus surgery. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 3):4706-4712.
15. Chavan A, Maran R, Meena K. Diagnostic evaluation of chronic nasal obstruction based on nasal endoscopy and CT scan paranasal sinus. Indian J Otolaryngol Head Neck Surg. 2019;71(Suppl 3):1948-1952.
16. Mundra RK, Gupta Y, Sinha R, Gupta A. CT scan study of influence of septal angle deviation on lateral nasal wall in patients of chronic rhinosinusitis. Indian J Otolaryngol Head Neck Surg. 2014;66(2):187-90.
17. Fadda GL, Rosso S, Aversa S, Petrelli A, Ondolo C, Succo G. Multiparametric statistical correlations between paranasal sinus anatomic variations and chronic rhinosinusitis. Acta Otorhinolaryngol Ital. 2012;32(4):244-51.
18. IBM Corp. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp; 2021.
19. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-4.
20. Indian Council of Medical Research. National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. New Delhi: ICMR; 2017.
21. Kosinski M, Bayliss MS, Bjorner JB, Ware JE Jr, Garber WH, Batenhorst A, et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res. 2003;12(8):963-74.
22. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
23. Perić A. Nasal septal spur associated with rhinogenic contact point otalgia and tinnitus. Craniomaxillofac Trauma Reconstr. 2019;12(1):67-69.
24. San T, San S, Gürkan E, Erdoğan B. The role of septated concha bullosa on sinonasal pathologies. Eur Arch Otorhinolaryngol. 2015;272(6):1417-21.
25. Cottle MH. Nasal surgery in children. Eye Ear Nose Throat Mon. 1951;30(1):32-8.
26. Welge-Luessen A, Hauser R, Schmid N, Kappos L, Probst R. Endonasal surgery for contact point headaches: a 10-year longitudinal study. Laryngoscope. 2003;113(12):2151-6.
2. Kulkarni GB, Rao GN, Gururaj G, Stovner LJ, Steiner TJ. Headache disorders and public ill-health in India: prevalence estimates in Karnataka State. J Headache Pain. 2015;16:67.
3. Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6 Suppl 1:S22-209.
4. Roozbahany NA, Nasri S. Nasal and paranasal sinus anatomical variations in patients with rhinogenic contact point headache. Auris Nasus Larynx. 2013;40(2):177-83.
5. Mladina R, Cujić E, Subarić M, Vuković K. Nasal septal deformities in ear, nose, and throat patients: an international study. Am J Otolaryngol. 2008;29(2):75-82.
6. Behin F, Behin B, Bigal ME, Lipton RB. Surgical treatment of patients with refractory migraine headaches and intranasal contact points. Cephalalgia. 2005;25(6):439-43.
7. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol. 2004;25(9):1613-8.
8. Herzallah IR, Hamed MA, Salem SM, Suurna MV. Mucosal contact points and paranasal sinus pneumatization: Does radiology predict headache causality? Laryngoscope. 2015;125(9):2021-6.
9. Smith KD, Edwards PC, Saini TS, Norton NS. The prevalence of concha bullosa and nasal septal deviation and their relationship to maxillary sinusitis by volumetric tomography. Int J Dent. 2010;2010:404982.
10. Lerdlum S, Vachiranubhap B. Prevalence of anatomic variation demonstrated on screening sinus computed tomography and clinical correlation. J Med Assoc Thai. 2005;88 Suppl 4:S110-5.
11. Sollini G, Mazzola F, Iandelli A, Carobbio A, Barbieri A, Mora R, et al. Sino-nasal anatomical variations in rhinogenic headache pathogenesis. J Craniofac Surg. 2019;30(5):1503-1505.
12. Aksoy F, Yıldırım YS, Demirhan H, Özturan O, Solakoğlu Ş. Mladina classification of septal deformity and its correlation with symptoms in chronic headache patients. Acta Otolaryngol. 2020;140(3):238-242.
13. Shaikh A, Al Saey H, Ashkanani S, Alsulaiti M, Alduhirat E, Aljariri A, et al. Higher incidence of headache in patients with intermittent mucosal contact points between the septum and lateral nasal wall. Laryngoscope Investig Otolaryngol. 2021;6(4):607-612.
14. Krishniya P, Rajpurohit P, Sharma VK, Aseri Y, Verma PC. A prospective correlation study between computerized tomography of paranasal sinuses and nasal endoscopy findings in patients of chronic rhinosinusitis undergoing functional endoscopic sinus surgery. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 3):4706-4712.
15. Chavan A, Maran R, Meena K. Diagnostic evaluation of chronic nasal obstruction based on nasal endoscopy and CT scan paranasal sinus. Indian J Otolaryngol Head Neck Surg. 2019;71(Suppl 3):1948-1952.
16. Mundra RK, Gupta Y, Sinha R, Gupta A. CT scan study of influence of septal angle deviation on lateral nasal wall in patients of chronic rhinosinusitis. Indian J Otolaryngol Head Neck Surg. 2014;66(2):187-90.
17. Fadda GL, Rosso S, Aversa S, Petrelli A, Ondolo C, Succo G. Multiparametric statistical correlations between paranasal sinus anatomic variations and chronic rhinosinusitis. Acta Otorhinolaryngol Ital. 2012;32(4):244-51.
18. IBM Corp. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp; 2021.
19. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-4.
20. Indian Council of Medical Research. National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. New Delhi: ICMR; 2017.
21. Kosinski M, Bayliss MS, Bjorner JB, Ware JE Jr, Garber WH, Batenhorst A, et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res. 2003;12(8):963-74.
22. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
23. Perić A. Nasal septal spur associated with rhinogenic contact point otalgia and tinnitus. Craniomaxillofac Trauma Reconstr. 2019;12(1):67-69.
24. San T, San S, Gürkan E, Erdoğan B. The role of septated concha bullosa on sinonasal pathologies. Eur Arch Otorhinolaryngol. 2015;272(6):1417-21.
25. Cottle MH. Nasal surgery in children. Eye Ear Nose Throat Mon. 1951;30(1):32-8.
26. Welge-Luessen A, Hauser R, Schmid N, Kappos L, Probst R. Endonasal surgery for contact point headaches: a 10-year longitudinal study. Laryngoscope. 2003;113(12):2151-6.
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Apr 01, 2025
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Dr. Divya Omprakash Daga, & Dr. Bipinkumar Amarabhai Mahida. (2025). RADIOLOGICAL NASAL SEPTAL VARIANTS AND THEIR ASSOCIATION WITH RECURRENT HEADACHE IN PATIENTS WITHOUT SINUSITIS: A RETROSPECTIVE ENT–RADIOLOGY STUDY. Journal of Population Therapeutics and Clinical Pharmacology, 32(3), 1643-1657. https://doi.org/10.69980/9g6aj138
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Author Biographies
Dr. Divya Omprakash Daga
Assistant Professor, Department of Otorhinolaryngology (ENT), GMERS Medical College & General Hospital, Porbandar, Gujarat, India
Dr. Bipinkumar Amarabhai Mahida
Senior Consultant & SR, Department of Otorhinolaryngology (ENT), GMERS Medical College & General Hospital, Porbandar, Gujarat, India
How to Cite
Dr. Divya Omprakash Daga, & Dr. Bipinkumar Amarabhai Mahida. (2025). RADIOLOGICAL NASAL SEPTAL VARIANTS AND THEIR ASSOCIATION WITH RECURRENT HEADACHE IN PATIENTS WITHOUT SINUSITIS: A RETROSPECTIVE ENT–RADIOLOGY STUDY. Journal of Population Therapeutics and Clinical Pharmacology, 32(3), 1643-1657. https://doi.org/10.69980/9g6aj138
