In more severe cases there is a vascular-type face-ache which throbs and becomes

more severe when the head is dependent or when venous pressure is raised by

straining. The pain may be excruciating, and associated with lacrimation and

epiphora, and the muscles on that side of the face may go into spasm, indicating

the degree of discomfort.

The site of the pain can indicate which sinus is involved. Maxillary sinusitis

causes pain in the infraorbital region, or in the teeth and gums. Ethmoidal

sinusitis gives pain over the bridge of the nose and between the eyes, and

frontal sinusitis gives pain in the supra-orbital area. This pain of frontal

sinusitis often has a characteristic periodicity, starting in the forenoon,

Increasing around midday and decreasing in the afternoon. Sphenoidal sinusitis,

which is rare, can cause occipital, vertical or retro-orbital pain.

The nose is obstructed on one or both sides, and the watery rhinorrhoea

associated with the prodromal coryza or influenza changes to a thicker

mucopurulent secretion, which in severe cases can be almost entirely purulent in

character. The sense of smell is reduced, or there may be an unpleasant smell,

cacosmia. In children there can be excoriation of the vestibule of the nose and

the upper lip. Much of the purulent secretion runs into the nasopharynx and

pharynx, due partly to the action of the cilia, but also because the ostium of

the maxillary sinus, which is most commonly affected, lies posteriorly in the

middle meatus of the nose. There is an associated systemic upset, with malaise,

headache and fever, and the circulating white-cell count is raised.

CLINICAL FEATURES. Anterior rhinoscopy shows signs of an acute inflammatory

response. The inferior and middle turbinates are red and swollen, and the colour

of the mucosa overlying the septum is similar. The degree of swelling of the

turbinates may preclude an adequate view of the middle meatus, but this swelling

can be reduced by the local application of 0,1% adrenaline solution on a pledget

of cotton wool. If the ostia are patent, pus will be seen in the middle meatus,

high up and anteriorly in frontal sinusitis, and lower and more posteriorly if

the anterior ethmoidal cells or the maxillary sinus is affected. If mucopus is

seen running medial to the middle turbinate, this indicates infection in the

posterior ethmoidal or sphenoid sinuses.

Posterior rhinoscopy will show mucopus on the superior surface of the soft

palate, or dried yellow crusts on the roof of the nasopharynx. There is often an

associated granular pharyngitis. There may be flushing and some swelling of the

affected cheek in maxillary sinusitis, while oedema of the eyelids or forehead

suggests infection of the frontal or ethmoidal sinuses. Tenderness over the

inflamed sinus is elicited on pressure.

Radiography of the sinuses is indicated in acute sinusitis. Should there be a

diagnostic problem the standard occipitomental and occipitofrontal views are

usually sufficient, although oblique views of the ethmoids or submentovertical

views for the sphenoid sinus may be required. The acutely inflamed sinus will

appear homogeneously opaque or a fluid level may be present. Bacteriological

analysis of the discharge should be done. CT-scan of the sinuses is indicated.

Chronic sinusitis

Chronic sinusitis usually follows an episode of acute sinusitis. The latter may,

however, be far in the past and forgotten by the patient. The essential

abnormality is intermittent or constant blockage of a sinus ostium resulting in

poor aeration and stasis of secretions leading to infection. One or more of the

paranasal sinuses may be involved. The condition may be unilateral or bilateral.

The maxillary sinuses are the most commonly affected.

PREDISPOSING CAUSES. These can be divided into nasal and dental. Any

pathological process resulting in a decreased airway over a long period of time

will predispose to chronic sinusitis. In children the commonest cause is adenoid

enlargement. In adults a unilateral pansinusitis may be associated with a

deviate nasal septum. This is not necessarily on the convex side of the

deviation, but may be on the contralateral side as compensatory hypertrophy of

the middle turbinate causes poor aeration of the middle meatus, into which most

sinuses drain through their ostia.

Allergic rhinitis, particularly of the perennial type, causes oedema with

narrowing of the ostia. When allergy and chronic sinusitis, particularly of the

ethmoidal labyrinth, coexist, nasal polypi are found. Chronic rhinitis, which

often has a social or occupational aetiology such as excessive smoking or the