Frontal sinusitis

Frontal sinusitis starts with localized pain above a patient's eye. If he presents late, he may have gross orbital swelling, proptosis, and diplopia. If large doses of penicillin, chloramphenicol, and metronidazole do not control his symptoms rapidly, you may have to drain his frontal sinus. Frontal sinusitis is always secondary to maxillary sinusitis and obstruction of his frontonasal duct, so be sure to wash out his antrum.

FRONTAL SINUSITIS See also Sections 5.5 (infections in the orbit), 7.14 (osteomyelitis of the cranium), and 24.11 (proptosis).

EXAMINATION. Examine the patient's nasal cavity for pus, a deflected nasal septum, and signs of past surgery. Look for associated abnormalities in his maxillary antrum by transillumination (25.9). Antral puncture may reveal pus in it.

X-RAYS. Take an erect film, and look for increased density of the shadow of his frontal sinus on the abnormal side, and a fluid level. A bilateral opacity suggests mucosal thickening, a unilateral one is more likely to be pus.

NON-OPERATIVE TREATMENT. Give him large doses of penicillin and 0.5% ephedrine nose drops instilled in the Moffat position (25-8). Inhalations of tincture of benzoin, or menthol and eucalyptus, will give him useful symptomatic relief.

TO DRAIN HIS FRONTAL SINUS, if you cannot refer him, give him a general anaesthetic, incise under his eyebrow from a point above his pupil to beside his medial canthus. Tie his angular vein. Use a small gouge, or dental drill, to cut a hole in the floor of his frontal sinus, to expose its lumen. Insert a small drain. Also, wash out his maxillary antrum through a cannula inserted through his inferior meatus (25.9). If necessary, refer him for definitive surgery.

TO REMOVE FRONTAL SEQUESTRA see Section 7.14.

CAUTION ! Wash out the maxillary antra of all patients with frontal sinus infections, because this is often the primary source of infection.