MRI Frontal Sinus - what is the blob?

[hurts_2_much]

Frontal sinus headache has persisted for just over a year now.  Every week the intensity has been getting worse.  No pain medication is working.  

Got a MRI done and there is a white blob just above and between the eyes.  Might be mucus - but seems too much of a coincidence that the pain and white blob are in the same place - for the past year!

Any thoughts?

[tonyad]

   Hi there,
Sorry that you have been troubled by these sinus headaches for so long.
Did you not get the Radiologist report when you picked up your films?

     When you pick up your disk / films of MRI there is usually a report that goes w/ it stating the findings. Do you have that?  If so then could you post what that states?
if not then I would highly suggest that you go back and get the actual Radiologist Report because w/ out that it is so hard to say what is going on.

      I suppose you are seeing an ENT right? Since it is sinus related. Have you been told that you have Sinus polyps?  HAs the doctor mention for you to possibly have an Endoscopic Sinus Surgery to 'Clean out' things?
      Sinus surgery is one of the most commonly performed operations.  Using modern equipment called endoscopes, sinus surgery can almost always be performed through the nose and on an outpatient basis.

    And lastly, is the docotr sure that this is the type of headache that you are having? Sinus Headache?
~Tonya

[Londres70]

I am not sure what it is but it is in your right sinus cavity area and a good size; definitely need an ENT specialist.  

Tonyad has mentioned some very good points/questions.

Keep us posted.

  

[hurts_2_much]

Thanks so much for the comments and questions.  Here are some responses:

The radiologist report stated the following:  "The ventricular system and subarachnoid spaces are normal.  The brain parenchyma is unremarkable without evidence of ischemic injury, mass lesion or hemorrhage.  The midline is appropriate and the basal cisterns are patent.  The bony calvarium and the extracalvarial structures appear normal.  Impression  - normal MRI evaluation of the brain as described.  Specifically, no ischemic injury, mass lesion or hemorrhage is recognized."

We have asked for a second/third opinion as this interpretation seems focused on the brain and not the frontal sinus area.  Our family doctor called two days ago to request an appointment to discuss the "second opinion" so maybe there is some news (we will see him asap).  

As for a ENT - we saw one 2.5 months ago and he/they performed a endoscopy of the nasal cavity.  Everything was deemed normal (but I don't think they went as far into the frontal sinus cavity to reach this "mass").    The ENT had asked for a copy of the MRI results and these were sent a week or so ago but have not heard back yet (but we are hopeful).

As far as the type of headache this is a tough one.   Our daughter wakes up with it, lives with it and goes to bed with it.  On a pain scale they started out as 2/10 a year ago and have since risen to 8-8.5/10).  We have had one day (in August 2009) that she was pain free.  She has had to reduce school activities (ie stop for the most part) due to lack capacity to focus, retain information and to really "do" school work (she is/was an A student by the way).  Recently she has had to stop her music activities and has started having trouble eating due to nausea and lack of appetite.

Needless to say this getting more serious by the month/week.  

Your suggestion of a sinus polyp is interesting.  Last night after posting I came upon some write ups about "osteoma of the frontal sinus causing headaches".  We are still reflecting on this information as well.

Where can we go to find specialists that can properly interpret an MRI (for a fourth opinion etc) or work with us regarding frontal headaches.  

thank you for sharing - hurts2much

[Londres70]

You are welcome.

So sorry for your poor daughter.

Please keep us posted on the outcome.

All the best;bonjour!

[hurts_2_much]

Hi - thanks for the encouragement.

It is still not clear to us who we should pursue for opinions on the MRI.  

The family doctor could not offer much help since he did not have enough experience reading them.  The Neurologist said it was likely mucus - but MRI's are not their area of expertise and ENT specialist may be to help but .....

Is there a specific group of radiologists that have more training in reading head MRI's for example or sinus MRI's etc?  Just wondering if there are areas of specialization within radiology and if so - what are these people called?

We would like to get the MRI results in front of the right people for further comment/evaluation.

Thanks again for your support - hurts2much

[Londres70]

See what this ENT specialist has to say about the MRI; he would be the person to pursue.
The family physician and Neurologist I wouldn't expect them to be to much help; not their expertise.  Hopefully, this ENT physician your daughter is seeing has a extensive rhinology background; dealing with sinus/nose issues.   To recap, the ENT specialist should be able to read, interpret the MRI and present you with an opinion.

Keep us posted.

[tonyad]

    Quick question...how old is your daughter?  Is she a teeneager?
I would ask if the "reading Radiologist" has any expertise in reading MRI films
of otolaryngology.

    I would like to add that reading what you posted on your radiology report, I would "Exclude" any tumors in nature. One more thing.....If you look on your report it should say on the top (first) paragraph, why the MRI was being done and the hx / sx of the patient.  What does that read?

   I'll check back to se when you post that then give you my thought / suggestions / ideas, of how to hit this "Head - On"....(no pun intended)
~Tonya

[hurts_2_much]

We are so appreciative of your comments and suggestions.  We were running out of hope as all the tests have been negative (and that is a good thing too of course) and there just didn't seem like there was much left other than to medicate (we are trying to avoid this if we can).  

By the way we did a spinal tap about a month or so ago and she is just getting over that (the tests were all negative).  Before we did the tap we rationalized "things can't get much worse" - but we were wrong.  She is getting stronger now and she is able to walk about and get up without the "head rushes" she had the first three weeks after the tap.

The neurologist insisted on putting her on topomax (25 mg) (he felt that the mri image was showing mucus) and we finally had to accept it since there was little left to try.  Our daughter still has had no relief from the headache pain.  Maybe with further investigation into the MRI image we will find something to "go after" - thanks to you we can try to think positive again.

Now your questions:

Our daughter turned 16 in February.  Her headaches do not appear to be influenced by weather, diet (she has been keeping a log for about 8 months now) or her periods.  In September 2009 our family doctor tested for allergies and she has a few - grass, dust mites, horses, dogs/cats and few others.  Another point is that we tried T-3's and they would not touch the pain.  We have tried a few other meds - but nothing has given her any relief.

Why the MRI was being done:

"head, MRI"

"Clinical HIstory: Frontal headaches question mass pathology"

"Technique:  Sagittal T1, axial T2 axial FLAIR and axial diffusion weighted imaging of the brain is undertaken."

Not sure if this answers the question about hx/sx of the patient?

Another point:  We were thinking that her sleep deprivation may be contributing  to this situation too - and we recently tried melatonin.  In the last couple of nights she has reported sleeping "better" and not as restless and we are happy about that.

You mention "I would exclude any tumors in nature".  That is certainly reassuring.

Any thoughts on a small "osteoma" in the frontal sinus causing this headache discomfort?

Thanks - hurts2much

[tonyad]

Hi there,
   I would think that Osteoma is NOT a thought either because osteoma presents itself through ocular signs and symptoms (such as proptosis) (meaning bulging eyes) Does she have that?

    The reason I asked about your daughters age is because one of my daughters was going through the same thing  (debilitating headaches etc.)  After several tests it was our Pediatrician of all doctors who prescibed her Sertraline (Zoloft) Yes, I know this drug is known for treating people w/ depression but...

OFF LABEL;
      For people who have migraines more than twice a week, their healthcare provider may recommend medications to help prevent migraines. While Zoloft is not specifically approved to prevent migraines, healthcare providers may prescribe it in certain situations. This is because, based on clinical experience, the drug has been shown to help prevent migrains. Using Zoloft to prevent migraines is known as an off-label use.

     Zoloft is an SSRI and SSRIs increase the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake into the presynaptic cell, increasing the level of serotonin available to bind to the postsynaptic receptor. They have varying degrees of selectivity for the other monoamine transporters, with pure SSRIs having only weak affinity for the noradrenaline and dopamine transporter.

    My daughters headaches dissipated and now lives a normal teenage life. At first she felt a bit funny about taking it because it is classed as an Anti-Depressant and that was not her problem (although it can get depressing having chronic pain). When her pediatrician told her that she was using it OFF Label for her headaches than she did not feel bad. in fact she does not even mind her friends knowing she takes it........It sure beats the alternative!

      I hope that some of this information has helped you and that it can, in turn, help your daughter :)  Please keep me up on how things are going with her. I have her in thought and prayer.

Have a GREAT week.
~Tonya
ps...As a side note, i have MS and use several medications "Off label" for my treatment.
      I use seizure medication to treat my Neuropathy. and some other meds for different things but that's off track, I only mention it because I wanted to make sure that you understood that there are so many meds out there that can be use "Off Label" to help so many other things.

Take Care,
~Tonya

[hurts_2_much]

Thank you for your comments and suggestions!

Sorry to read that your daughter has had to live through a similar experience - yikes.  Our daughter does not have "bulging eyes" just the constant headache (at this point).  We will consider your med suggestion as well.  Since the pain is constant (and increasing steadily over the past 12 months) it just not seem like a migraine.  Thus the reason for asking about the "mass" on the MRI.

Our plan of attack over the next 2 weeks is to get some more opinions on the MRI interpretation.  As we mentioned near the beginning it just be mucus - but if that is the case in another few weeks a second MRI should show the "mass" either getting smaller or gone all together.

Our daughter has reported some interesting sensations in the last week or so as her head now feels like it is "imploding" instead of "exploding" and we are not quite sure how to interpret this one either.  Could be the topomax though as the sensation change happened around the same time she started on that med.

thanks again - we will try to report back to the forum if/and we learn more.

Please know that you have made a difference - hurts2much

[hurts_2_much]

Hi - just wanted to share a short update on Amber's MRI.

We asked for another review of the MRI image on Monday.  Here are the results:

"Addendum: At the request of the referring physician the examination was re-evaluated.  Noted within the anterior right frontal/ethmoid sinus (We thought the "entity" was on the left not the right) is a multilocular area of elevated T2 and FLAIR signal.  The entity likely reflects retained fluid (this means mucus right??) within the sinus complex and its significance is unclear.  Although this is not infrequently (does this means often???) seen and it mostly reflects fluid retention/focal mucosal thickening a small ethmoid mucocele would be difficult to exclude.  Clinical correlation and imaging follow up may be of value."

We were wondering about a couple of the phrases in the interpretation - "retained fluid" and "not infrequently" - can you offer any clarification?  Also - is the entity/mass/mucus on the right or left - we thought it was on her left side.

Our final questions are - what does "Clinical correlation" mean/refer to in this case and do you have any suggestions for what to ask for regarding "imaging follow up" and what would be of "may be of value" with selected follow up tests.

thanks - hurts2much (for sure today!!)

[Londres70]

I am so glad you got an Addendum with answers to what is going on.  I thought and stated in an earlier post that the problem was in the right sinus cavity; you can see it on the right in the MRI you posted.  

All the best.

[hurts_2_much]

We have been reviewing other discussions in this forum and we are learning lots.  Thank you for the comments and the time that you are investing - can't say enough how much it means to the family(s).

I was a bit confused on left and right as we looked at the MRI.  I was thinking that since the "entity" appears to be on Ambers "left side" (as she would standing looking forward) that would be the notation.  By your comments, and those on the image, it must be read meaning that you are "looking" at her and the "entity" is on the right side of the viewer - not the patient.  Right?

update - We received another opinion from a radiologist yesterday (20th).  This was their wording:

"Findings:

There is no focal abnormality within the gray/white matter.  The midline structures are within normal limits.  There is some musosal thickening at the level of the frontal recess on the right, as well as mild mucosal thickening in the adjacent right frontal sinus.  Otherwise, no significant abnormality.

Impression:

No significant etiology for headache seen intracranially, A mild to moderate degree of right frontal sinus mucosal abnormality.  Correlate with possible sinus headache."

So - it now appears that Amber's headache may be sinus related.  Any thoughts/ideas?  Supports my theory since the intensity has been increasing every month since last April.  She has no odors though and does not have fevers thus the sinus infection does not seem to be presenting properly.  Is it possible to have a sinus infection without the fever and odor?

You will be pleased to know that we are tracking down our ENT specialist this week and hope to have another interpretation of the MRI from that specialist in the next few days.  We are keeping our fingers crossed.

Thanks again - hurts2much

[tonyad]

  Hey there, I have not forgotten about you :)
I have been a bit ill but will be back Thursday to comment on what you had posted to me on the 19th.

TTYL,
~Tonya

[Londres70]

When you look at the MRI, go by the patient's right in regards to the positioning of  the "entity."  Positioning is always according to the patient's not the viewers.

Secondly, after reading the posts, etc., I would guess it is a mucous cyst/seal involving the right frontal/ethmoid sinuses causing the headaches.  I don't think infection is involved at this time.

Just a guess.  I will leave the true/appropriate diagnosis to the ENT specialist.

Keep us posted.  You are getting closer to resolving this.  :)

[hurts_2_much]

This is great news!!  Another idea to pursue - thank you!

We have been very suspicious that her frontal sinus area was part of this problem but did not know to ask about "mucous cysts/seal".  This idea makes sense if you think of the gradual pain increase over the past 12 months.  It may also explain why she had one pain free day last August too - if there was a temporary "release" of mucous from the frontal sinus area.

We will do more research on the idea/suggestion.

I/We agree that there is likely no infection due to her "lack" of infection symptoms (fever and odors).

We have not heard from the ENT yet - but it won't be long.  

Thanks for clarifying left and right on the MRI.

This week Amber has spent a lot of time on the couch trying to survive the pain.  She is having a lot of trouble standing now and cannot read/watch TV for long periods of time due to lack of concentration/focus.  Needless to say her situation is very serious.

We have a family doctor appointment next week and with some luck the ENT will have called/reported by then and we can formulate the next plan.

Thanks again for the feedback and support.

hurts2much

[Londres70]

Oh, so sorry she is going through this, so young and all she can do is lay on a couch because of the pain.  

Sinuses can affect alot more than what most people think.  

Keep us posted.  

[hurts_2_much]

Our daughter still has a lot of pain.  We are hoping to get a bit more direction this week.  

The suggestions of a cyst have been good as other pics in the MRI show a small focused white spot about the size of two pencil leads right in the middle of her eye brows about a 1/2 inch in.  It may be nothing but it is something small to hope for as to the cause of her frontal headaches.

Yesterday she described the pain as upside down triangle between her eyes with frequent "shooting/lightning" type of pain on her right side above her eye up to her hair line.  Yikes!

At some point our ENT specialist may choose to investigate the frontal sinus a little more closely.  Do  you know what the latest technique is to do this?

hurts2much

[hurts_2_much]

We got our call from the ENT specialist today.  He told us that after consulting with a colleague it is the general opinion that the frontal sinus area is not a concern (despite the "blob").   It would appear that the entity is simply mucus and that some drainage is still occurring.

Our ENT will consult with another radiologist specialist for one last review/confirmation to be sure.

So it would appear that we are back to ground zero now for our daughters headaches.  We had a bit of hope that the frontal sinus was the problem zone with all the ideas and suggestions posted here.  This was important - so thank you for all the support!  At this point the pain/discomfort is still focused between her eyes as an upside down triangle.

Next steps are to likely redo an eye exam, up the topomax, investigate more drug intervention and then see what happens next.  At some point we will do another MRI to determine if the entity is getting bigger/smaller and likely ask for more opinions/interpretations if the size of the image has increased in any way.

We don't have much hope now for any relief as no meds have worked up to this point.  Not to be discouraging, or to start a pity party, but the reality now is that she will likely soon be hospitalized for short periods of time to administer some type of regulated care for the pain.  Maybe a miracle will happen and this nightmare(s) will be over.

Thanks to everyone who has commented, contributed, prayed and cried.

hurts2much

[Londres70]

I am so sorry you have not gotten any definite answers.  I really thought for sure this "thing" was situated in the frontal/ethnoid sinus area and that is was a mucous cyst; the cyst or "thing" looks a good size.  

Well, she just might have to be hospitalized for pain control unfortunately.  Hopefully increasing the topomax will do the trick; poor child.

As a mom, to see your child in a situation that you can't find any solutions to help her is VERY difficult.  

Keep us posted honey and try to hang in there.  If there is anything I can think of to help you I will let you know ASAP.  

The best always.

Bonjour!  :)  

[horselip]

Hi-
I feel for you and your daughter. I have a few thoughts.

While this is all getting sorted...I wonder if you might have your daughter evaluated by a pain management center?

You mentioned above that no pain medication is working but then later you say that she may be hospitalized for pain control and that you are looking to more drug intervention. I've been working with a Pain Management Center for my constant 4 plus year old headache while hovers around a 6-8. I do get some relief (2-4) from a combination of Oxycontin and Hydomorphone. While I am not thrilled with having to use these meds I don't think that I would be sane without them as headaches are very debilitating.There are tons of combos and other meds too,

Do your daughter's headaches improve at all when she is laying down?
Has a CSF leak has been ruled out?

ok- just thought I'd ad my two cents :)
Horselip

[hurts_2_much]

Thanks for your comments/suggestions and questions.

To date we have not been to a pain management center.  It was suggested a couple of months ago and the request has been made.  It just takes a long time before she will be seen.  We will check on this to make sure that the request has been made and try to determine where we are in the "que".

It probably makes sense now that we may have to go a different route (hospital) for pain relief since, at the rate the pain is increasing, the pain management center appointment will not come soon enough.  

Your question about pain relief by laying down and a CSF leak is interesting.  Back in Dec/Jan we were suspicious that this may be happening but she did not have the classic signs (relief when she did lay down for example).  We wondered about either too much CSF or not enough and if so - why?

At about the end of Feb the neurologist did a spinal tap to measure pressure and to check for "normality" of characteristics of the fluid.  All the tests were negative/normal and her pressures were normal.  The really upsetting thing is that it took her nearly a month to recover and we thought before doing the procedure "how could things get worse - ie worse headaches".  Boy were we wrong!

Since the ST her headaches are worse, she was on bed rest for a week somewhere in there, she is still nauseated from time to time (likely due to pain), and occasionally still gets a head rush when she gets up too fast.

A new one for today was she had persistent tingles in her hands, arms and face for a couple of hours and once she sat/laid for a while the sensations trailed off quite a bit.  As we stated the tingles were a new experience - at least this wide spread - so we will be monitoring that.

We are a bit suspicious of the topomax but ...... we have to keep trying something.

We will investigate your suggestion of oxycontin and hydomorphone.

Thanks for the posting.

hurts2much

[horselip]

Hi again-
Topamax decreases the qty of CSF as it has a diuretic effect. IF you are noticing any changes it is certainly worth asking about!

I had more clear CSF symptoms..headache improves when I lie down, Topamax made things worse not better, headache improved when I had a headcold (sinus swelling=leak plugged up more), had a bout of meningitis and then I had transphenoidal pituitary surgery which carries a risk of me having a leak from that surgery.

Med-wise there are options. A good pain center will do a full history & evaluation to try and get your daughter some relief. The meds are tricky and very individual. What works for me may not be what is best for someone else. It is the pain center where I go that is driving my treatment to try and figure out why I am having the headaches so that we can hopefully find a way to fix the problem (or part of it) while trying to keep me somewhat comfortable.

Horse

[hurts_2_much]

This is great information - thanks so much for sharing.  We will follow up on the CSF-Topamax connection - thank you.  

The ENT called this afternoon and confirmed that he, his team and the radiologist feel that the MRI is normal - ie - frontal sinus and the "blob/entity" are mucus and drainage is fine.  Frustrating that we don't have a cause but thankful for the personal call/service and the follow up that the doctor has given us to rule out the frontal sinus concern.

We will see our family physician tomorrow.  Likely nothing new - but more conversation and possibly a game plan for "what to do" when our daughter has really bad days.

No word on the pain center yet.

thanks so much for sharing - hurts2much