AAO-HNSF Primary Care Otolaryngology Handbook

RHINOLOGY, NASAL OBSTRUCTION, AND SINUSITIS

frontal, ethmoid and sphenoid sinusitis that is not appropriately treated or does not respond to therapy can lead to serious intraorbital or intracra-

nial complications. Frontal Sinusitis

Acute bacterial frontal sinusitis typically presents with low-grade fever, malaise, and marked tenderness over the frontal sinus. The frontal sinus lining has veins that penetrate the posterior sinus wall and go directly to the dura on the opposite side. These veins can transmit organisms or become pathways for propagation of an infected clot . This can quickly lead to meningitis and even brain abscess (Figure 8.3). In fact, the most common cause of frontal lobe abscess is frontal sinusitis. Therefore, the diagnosis of

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acute frontal sinusitis requires aggressive antibiotic therapy. The key to frontal sinusitis is to cover S. pneumoniae and H. influenzae , as well as get good cerebrospinal fluid penetration. Pain is severe, and patients may require hospital admission for treatment and close observa- tion. CT scan can aid diagnosis by showing an air fluid level in the frontal sinus and is indi- cated if the patient has no improvement or deterioration in 24 hours, or any central

Figure 8.3. This axial magnetic resonance image depicts a patient with fluid in his right frontal sinus. The infection has spread retrograde and he has developed a frontal abscess.

nervous system or eye symptoms. Topical vasoconstriction to shrink the swollen mucosa around the nasofrontal duct to restore natural drainage into the nose should begin early. Systemic steroids may also be consid- ered to decrease swelling. If frontal sinusitis does not greatly improve within 24 hours of medical management, the frontal sinus should be surgically drained to prevent serious intracranial infections. Ethmoid Sinusitis Severe ethmoid sinusitis can result in orbital cellulitis or abscess. These patients present with eyelid swelling, proptosis, and double vision . While one might assume the double vision is caused by the involvement of the nerves of the cavernous sinus, it can also be caused by an abscess located in the orbit. Children are more prone to orbital complications of

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