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4. Trismus, due to depression of zygoma on the underly-
5. Oblique palpebral fissure, due to the displacement of
6. Restricted ocular movements, due to entrapment of in-
7. Periorbital emphysema, due to escape of air from the
SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 34.4. Fractured left zygoma.
ing coronoid process.
lateral palpebral ligament.
ferior rectus muscle. It may cause diplopia.
maxillary sinus on nose blowing.
Diagnosis
Waters’ or exaggerated Waters’ view shows the fracture
and displacement the best. Maxillary sinus may show
clouding due to the presence of blood. Comminution
with depression of orbital floor and herniation of orbital
contents cannot be seen on plain X-rays. CT scan of the
orbital will be more useful.
Treatment
Only displaced fractures require treatment. Open reduction and internal wire fixation gives best results. Fracture
is exposed at the frontozygomatic suture through lateral
brow incision and reduced by passing an elevator behind
the zygoma. Wire fixation is done at frontozygomatic suture and infraorbital margin. The latter is exposed by a
separate incision in the lower lid. Fracture of orbital floor
can also be repaired through this incision.
Transantral approach is less favourable. Antrum is exposed as in Caldwell–Luc operation, blood is aspirated,
fracture reduced and then stabilized by a pack in the antrum. Fractures of orbital floor can also be reduced. Antral pack is removed in about 10 days through the buccal
incision, which is left open at the end of operation, or
through the intranasal antrostomy route.
Clinical Features
Characteristic features are depression in the area of zygomatic arch, local pain aggravated by talking and chewing,
trismus or limitation of the movements of mandible due
to impingement of fragments on the condyle or coronoid
process.
Diagnosis
Arch fractures are best seen on submentovertical view of
the skull. Waters’ view is also taken.
Treatment
A vertical incision is made in the hair-bearing area above
or in front of the ear, cutting through temporal fascia.
An elevator is passed deep to temporal fascia and carried
under the depressed bony fragments which are then reduced. Fixation is usually not required as the fragments
remain stable.
E. FRACTURES OF ORBITAL FLOOR
Zygomatic and Le Fort II maxillary fractures are always
accompanied by fractures of orbital floor. Isolated fractures of orbital floor, when a large blunt object strikes the
globes, are called “blow out fractures.” Orbital contents
may herniate into the antrum (Figure 34.5).
Clinical Features
1. Ecchymosis of lid, conjunctiva and sclera.
2. Enophthalmos with inferior displacement of the eyeball. This becomes apparent when oedema subsides.
3. Diplopia, which may be due to displacement of the
eyeball or entrapment of inferior rectus and inferior
oblique muscles.
4. Hypoaesthesia or anaesthesia of cheek and upper lip, if
infraorbital nerve is involved.
Diagnosis
Waters’ view shows a convex opacity bulging into the antrum from above (tear-drop opacity). CT scans may confirm the diagnosis (Figure 34.6). Entrapment of inferior
rectus and inferior oblique muscles is diagnosed by asking
the patient to look up and down, or by the traction test.
The latter is performed by grasping the globe and passively rotating it to check for restriction of its movements.
Treatment
Indications for surgery include enophthalmos and persistent diplopia due to entrapment of muscle. Orbital floor
D. FRACTURES OF ZYGOMATIC ARCH
Zygomatic arch generally breaks into two fragments
which get depressed. There are three fracture lines, one at
each end and third in the centre of the arch.
Figure 34.5. Blow out fracture with herniation of orbital contents
into the maxillary sinus.
Figure 34.6. A CT scan showing blow out fracture of the right orbital
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floor.
fractures can be satisfactorily reduced by a finger passed
into the antrum through a transantral approach. A pack
can be kept in the antrum to support the fragments. Infraorbital approach, through a skin crease of the lower
lid, can also be used either alone or in combination with
transantral approach. Badly comminuted fractures of orbital floor can be repaired by a bone graft from the iliac
crest, nasal septum or the anterior wall of the antrum.
Silicon or teflon sheets have also been used to reconstruct
the orbital floor but autogenous grafts are preferable.
F. FRACTURES OF MAXILLA (FIGURE 34.7)
They are classified into three types:
1. Le Fort I (transverse) fracture runs above and parallel to the palate. It crosses lower part of nasal septum,
maxillary antra and the pterygoid plates.
2. Le Fort II (pyramidal) fracture passes through the
root of nose, lacrimal bone, floor of orbit, upper part of
maxillary sinus and pterygoid plates. This fracture has
some features common with the zygomatic fractures.
3. Le Fort III (craniofacial dysjunction). There is complete separation of facial bones from the cranial bones.
Chapter 34 — Trauma to the Face
The fracture line passes through root of nose, ethmofrontal junction, superior orbital fissure, lateral wall of
orbit, frontozygomatic and temporozygomatic sutures
and the upper part of pterygoid plates.
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Clinical Features
1. Malocclusion of teeth with anterior open bite.
2. Elongation of midface.
4. CSF rhinorrhoea. Cribriform plate is injured in Le Fort
II and Le Fort III fractures.
Diagnosis
X-rays, helpful in diagnosis of maxillary fractures are
Waters’ view, posteroanterior view, lateral view and
the CT scans. They help to delineate fracture lines and
the displacement of fragments.
Treatment
Treatment of maxillary fractures is complex. Immediate
attention is paid to restore the airway and stop severe
haemorrhage from maxillary artery or its branches. For
good cosmetic and functional results, fractures should be
treated as early as the patient’s condition permits. Associated intracranial and cervical spine injuries may delay
specific treatment.
Fixation of maxillary fractures can be achieved by:
1. Interdental wiring.
2. Intermaxillary wiring using arch bars.
3. Open reduction and interosseous wiring as in zygomatic fractures.
4. Wire slings from frontal bone, zygoma or infraorbital
rim to the teeth or arch bars.
III. FRACTURES OF LOWER THIRD
FRACTURES OF MANDIBLE
Fractures of mandible have been classified according
to their location (Figure 34.8). Condylar fractures are
the most common. They are followed, in frequency, by
fractures of the angle, body and symphysis (mnemonic
CABS). Fractures of the ramus, coronoid and alveolar processes are uncommon.
Multiple fractures are seen as frequently as single ones.
Most of the mandibular fractures are the result of direct
trauma; however, condylar fractures are caused by indirect trauma to the chin or opposite side of the body of
mandible. Displacement of mandibular fractures is determined by (i) the pull of muscles attached to the fragments, (ii) direction of fracture line and (iii) bevel of the
fracture.
Figure 34.7. Fractures of maxilla. (A) Le Fort I, (B) Le Fort II and
(C) Le Fort III.
Clinical Features
In fractures of condyle, if fragments are not displaced, pain
and trismus are the main features and tenderness is elicited at the site of fracture. If fragments are displaced, there
is in addition, malocclusion of teeth and deviation of jaw
to the opposite side on opening the mouth.
Most of the fractures of angle, body and symphysis can
be diagnosed by intraoral and extraoral palpation. Step
deformity, malocclusion of teeth, ecchymosis of oral
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Figure 34.8. Fractures of mandible (Dingman classification). Condylar fractures are the most common, followed by those of the angle, body and
symphysis of the mandible. Remember CABS.
SECTION II — Diseases of Nose and Paranasal Sinuses
mucosa, tenderness at the site of fracture and crepitus
may be seen.
Diagnosis
X-rays useful in mandibular fractures are PA view of the
skull (for condyle), right and left oblique views of mandible and the panorex view.
Treatment
Both closed and open methods are used for reduction and
fixation of the mandibular fractures.
In closed methods, interdental wiring and intermaxillary fixation are useful. External pin fixation can also be
used.
In open methods, fracture site is exposed and fragments fixed by direct interosseous wiring. This is further
strengthened by a wire tied in a figure of eight manner.
These days, compression plates are available to fix the
fragments. With their use, prolonged immobilization and
intermaxillary fixation can be avoided.
Condylar fractures are also treated by intermaxillary
fixation with arch bars and rubber bands. Sometimes,
open reduction and interosseous wiring may be required
in adult edentulous patients with bilateral condylar fractures or in fractures of children.
Immobilization of mandible beyond 3 weeks, in condylar fractures, can cause ankylosis of temporomandibular joints. Therefore, intermaxillary wires are removed
and jaw exercises started. If occlusion is still disturbed,
intermaxillary wires are reapplied for another week and
the process repeated till the bite and jaw movements are
normal.
2. Failure of sublabial incision to heal after Caldwell–Luc
operation.
3. Erosion of antrum by carcinoma.
4. Fractures or penetrating injuries of maxilla.
5. Osteitis of maxilla, syphilis or malignant granuloma.
Clinical Features
1. Regurgitation of food. Food or fluids pass from oral
cavity into the antrum and thence into the nose.
2. Discharge. Antrum is always infected. Foul-smelling
discharge is seen, filling the nose or exuding from the
fistulous opening into the mouth.
3. Inability to build positive or negative pressure in
the mouth. Patient will have difficulty to blow the
wind instruments or drink through a straw. To drink
through a straw, negative pressure has to be created in
the oral cavity. This cannot be done in the presence of
an oroantral fistula as air gets drawn from nose to antrum to oral cavity. Reverse is true when blowing wind
instruments; instead of building a positive pressure in
the oral cavity, air is blown out from the oral cavity to
antrum and out through the nose.
Diagnosis
A probe can be passed from the fistulous opening in the
oral cavity into the antrum.
Treatment
recent Fistula. When fistula is discovered immediately
after tooth extraction and there is no infection or a retained tooth in the antrum, conservative treatment with
suturing of gum margins and a course of antibiotics is
effective.
OROANTRAL FISTULA
It is a communication between the antrum and oral cavity. The fistulous opening may be situated on the alveolus
or gingivolabial sulcus.
Aetiology
1. Dental extraction is the most important cause. Roots
of second premolar and upper molars (first and sometimes second and third) are closely related to the antral
cavity and their extraction may lead to fistula formation. Presence of apical tooth abscess predisposes to it.
chronic Fistula or a large Fistula. It requires surgical repair by a palatal or a buccal flap. Maxillary sinusitis is first treated by repeated irrigations and antibiotics.
Squamous-lined fistulous track is excised, bony edges of
the fistula are smoothened and prepared for the flaps
to sit properly. Caldwell–Luc operation may be required
to remove a retained tooth root or a foreign body, clear
the antrum of diseased mucosa and to provide a nasoantral window for free drainage. Some fistulas are better closed by a dental obturator. The latter also permits
observation of antral cavity particularly in those treated
for cancer.
Chapter 35
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Anatomy and Physiology
of Paranasal Sinuses
ANATOMY OF PARANASAL SINUSES
Paranasal sinuses are air-containing cavities in certain
bones of skull. They are four on each side. Clinically, paranasal sinuses have been divided into two groups:
1. Anterior group. This includes maxillary, frontal and
anterior ethmoidal. They all open in the middle meatus and their ostia lie anterior to basal lamella of middle turbinate.
2. Posterior group. This includes posterior ethmoidal
sinuses which open in the superior meatus and the
sphenoid sinus which opens in sphenoethmoidal recess.
Maxillary Sinus (Antrum of Highmore)
It is the largest of paranasal sinuses and occupies the body
of maxilla. It is pyramidal in shape with base towards lateral wall of nose and apex directed laterally into the zygomatic process of maxilla and sometimes in the zygomatic
bone itself (Figure 35.1). On an average, maxillary sinus
has a capacity of 15 mL in an adult. It is 33 mm high,
35 mm deep and 25 mm wide.
relations
• Anterior wall is formed by facial surface of maxilla and
is related to the soft tissues of cheek.
• Posterior wall is related to infratemporal and pterygo-
palatine fossae.
• Medial wall is related to the middle and inferior mea-
tuses. At places, this wall is thin and membranous. It
is related to uncinate process, anterior and posterior
fontanelle, and inferior turbinate and meatus.
• Floor is formed by alveolar and palatine processes of
the maxilla and is situated about 1 cm below the level
of floor of nose (Figure 35.1). Usually it is related to
the roots of second premolar and first molar teeth.
Depending on the age of the person and pneumatization of the sinus, the roots of all the molars, sometimes the premolars and canine, are in close relation
to the floor of maxillary sinus separated from it by a
thin lamina of bone or even no bone at all. Oroantral fistulae can result from extraction of any of these
teeth. Dental infection is also an important cause of
maxillary sinusitis.
• Roof of the maxillary sinus is formed by the floor of
the orbit. It is traversed by infraorbital nerve and
vessels.
Frontal Sinus
Each frontal sinus is situated between the inner and outer
tables of frontal bone, above and deep to the supraorbital
margin. It varies in shape and size and is often loculated
by incomplete septa. The two frontal sinuses are often
asymmetric and the intervening bony septum is thin and
often obliquely placed or may even be deficient. Frontal
sinus may be absent on one or both sides or it may be
very large extending into orbital plate in the roof of the
orbit. Its average dimensions are: height 32 mm, breadth
24 mm and depth 16 mm (remember code 8, i.e. 8 × 4,
8 × 3 and 8 × 2).
Anterior wall of the sinus is related to the skin over
the forehead; inferior wall, to the orbit and its contents;
and posterior wall to the meninges and frontal lobe of the
brain.
Drainage of the frontal sinus is through its ostium into
the frontal recess. In fact frontal sinus, its ostium and the
frontal recess form an hour glass structure. Frontal recess is
situated in the anterior part of middle meatus and is bounded by the middle turbinate (medially), lamina papyracea
(laterally), agger nasi cells (anteriorly) and bulla ethmoidalis (posteriorly). It may be encroached by several anterior
ethmoidal cells, which may obstruct its ventilation and
drainage and lead to sinusitis. Frontal recess drains into the
infundibulum or medial to it, depending on the superior
attachment of the uncinate process (refer to Figure 23.6).
Due to encroachment of small air cells in the frontal
recess, the drainage pathway may be reduced to a straight
or more often tortuous pathway which was earlier called
nasofrontal duct. It is an erroneous term as no true duct
exists.
Ethmoidal Sinuses (Ethmoid Air Cells)
Ethmoidal sinuses are thin-walled air cavities in the lateral masses of ethmoid bone. Their number varies from
3 to 18. They occupy the space between upper third of
lateral nasal wall and the medial wall of orbit. Clinically,
ethmoidal cells are divided by the basal lamina into an
anterior ethmoid group which opens into the middle meatus and posterior ethmoid group which opens into the superior meatus and into supreme meatus, if that be present.
Roof of the ethmoid is formed by medial extension of
the orbital plate of the frontal bone, which shows depressions on its undersurface, called fovea ethmoidalis. The
lateral wall is formed by a thin plate of bone called lamina
papyracea.
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Figure 35.1. Coronal section showing relationship of maxillary and
ethmoidal sinuses to orbit and the nasal cavity. Floor of maxillary sinus
is about 1 cm below the floor of nose.
SECTION II — Diseases of Nose and Paranasal Sinuses
anterior group. Important ethmoid cells in the anterior group include:
1. Agger nasi cells – present in the agger nasi ridge.
2. Ethmoid bulla – forms the posterior boundary of the
hiatus semilunaris.
3. Supraorbital cells.
4. Frontoethmoid cells – situated in the area of the frontal recess and may encroach the frontal sinus.
5. Haller cells – situated in the floor of the orbit.
posterior group. The posterior group of ethmoid sinuses lies posterior to the basal lamina of middle concha.
They are 1–7 in number and open into superior meatus
or in the supreme meatus, when present. One important
cell of this group is sphenoethmoid cell, also called the
Onodi cell. It is the most posterior cell of this group and
extends along the lamina papyracea, lateral or superior to
the sphenoid and may extend 1.5 cm behind the anterior
face of sphenoid. Optic nerve and sometimes the carotid
artery are related to it laterally and are in danger during
endoscopic surgery.
At birth anterior ethmoids are 5 × 2 × 2 mm and pos-
terior ethmoids are 5 × 4 × 2 mm. They attain their adult
size by the 12th year.
Figure 35.2. Coronal section of sphenoid sinuses. Note the reliefs
made by various structures in the cavity of sphenoid sinus. Optic nerve
forms the superolateral ridge.
Figure 35.3. Relations of sphenoid sinus.
Sphenoid Sinus
It occupies the body of sphenoid. The two, right and left
sinuses, are rarely symmetrical and are separated by a thin
bony septum which is often obliquely placed and may
even be deficient (compare frontal sinus) (Figures 35.2
and 35.3). Ostium of the sphenoid sinus is situated high
up in the anterior wall and opens into the sphenoethmoidal recess, medial to the superior or supreme turbinate. It
may be slit like, oval or round and can be seen endoscopically. In adults, it is situated about 1.5 cm from the upper
border of choana. The average distance from the anterior
nasal spine to the ostium is about 7 cm.
An adult sphenoid sinus is about 2 cm high, 2 cm deep
and 2 cm wide, but its pneumatization varies. In some
cases pneumatization may extend into greater or lesser
wing of sphenoid, pterygoid or clivus, i.e. basilar part of
occipital bone.
relations oF the sphenoid sinus. Lateral wall of the
sphenoid is related to the optic nerve and carotid artery.
The opticocarotid recess can be seen in between the two.
It may extend laterally when the anterior clinoid processes are also pneumatized. Maxillary nerve may be related
to lower part of the lateral wall of sphenoid. The optic
nerve and internal carotid artery are usually covered by
a thin bone, but sometimes this bony covering may be
dehiscent, and then these structures lie exposed, covered
only by mucosa.
Floor of the sinus is related to the Vidian nerve. Rela-
tion of the roof can be divided into two parts. Anterior
part of the roof is related to the olfactory tract, optic chiasma and frontal lobe, while posterior part is related to
the pituitary gland in the sella turcica and laterally to the
cavernous sinus. Posterior wall of the sphenoid forms the
clivus.
Relations of the sphenoid sinus are important in endo-
scopic skull base surgery.
Chapter 35 — Anatomy and Physiology of Paranasal Sinuses
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MUCOUS MEMBRANE OF PARANASAL
SINUSES
Paranasal sinuses are lined by mucous membrane which
is continuous with that of the nasal cavity through the
ostia of sinuses. It is thinner and less vascular compared
to that of the nasal cavity. Histologically, it is ciliated columnar epithelium with goblet cells which secrete mucus.
Cilia are more marked near the ostia of sinuses and help
in drainage of mucus into the nasal cavity.
DEVELOPMENT OF PARANASAL SINUSES
Paranasal sinuses develop as outpouchings from the mucous membrane of lateral wall of nose. At birth, only the
maxillary and ethmoidal sinuses are present and are large
enough to be clinically significant.
Growth of sinuses continues during childhood and
early adult life. Radiologically, maxillary sinuses can be
identified at 4–5 months, ethmoids at 1 year, frontals at
6 years and sphenoids at 4 years (Table 35.1).
LYMPHATIC DRAINAGE
The lymphatics of maxillary, ethmoid, frontal and sphenoid sinuses form a capillary network in their lining mucosa and collect with lymphatics of nasal cavity. Then
they drain into lateral retropharyngeal and/or jugulodigastric nodes.
PHYSIOLOGY OF PARANASAL SINUSES
VENTILATION OF SINUSES
Ventilation of paranasal sinuses takes place through their
ostia. During inspiration, air current causes negative pressure in the nose. This varies from −6 mm to −200 mm
H2O, depending on the force of inspiration. During expiration, positive pressure is created in the nose and this
sets up eddies which ventilate the sinuses. Thus, ventilation of sinuses is paradoxical; they are emptied of air during inspiration and filled with air during expiration. This
is just the reverse of what takes place in lungs which fill
during inspiration and empty during expiration.
MUCOCILIARY CLEARANCE OF SINUSES
maxillary sinus. Mucus from all the walls of the maxillary sinus—anterior, medial, posterior, lateral and roof—
is transported by the cilia to the natural ostium and then
through it into the middle meatus (Figure 35.4A). Mucus
always drains from the natural ostium, even though accessory ostia be present in the fontanelle. It is also observed that inferior meatal antrostomy made in Caldwell–
Luc operation provides ventilation to the sinuses, but it
does not help in mucociliary clearance which still takes
place through the natural ostium.
Frontal sinus. Mucociliary clearance of the frontal sinus is unique (see Figure 35.4B). Mucus travels up along
the interfrontal septum, along the roof of the lateral wall,
along the floor and then exits through the natural ostium.
At two points, one just above the ostium and other in the
frontal recess, part of the mucus recycles through the sinus and this may carry infection of the frontal recess and
sinuses draining into it, towards the frontal sinus. Circulation is anticlockwise in the right and clockwise in the
left frontal sinus.
sphenoid sinus. Mucociliary clearance is towards its ostium into the sphenoethmoidal recess.
ethmoid sinus. Mucus from anterior group of ethmoid
sinuses joins that from the frontal and maxillary sinuses
and travels towards eustachian tube, passing in front of
torus tubarius into the nasopharynx. Mucus from posterior ethmoids drains into superior or supreme meatus
and then joins the mucus from the sphenoid sinus in the
sphenoethmoidal recess, passes above and behind the torus tubarius into the nasopharynx (Figure 35.4C).
It is noted that infected discharge from the anterior
group of sinuses, passes behind the posterior pillars and
causes hypertrophy of lateral pharyngeal bands. Discharge from posterior group of sinuses spreads over the
posterior pharyngeal wall.
FUNCTIONS OF PARANASAL SINUSES
It is not clear why nature provided paranasal sinuses.
Probable functions are:
1. Air-conditioning of the inspired air by providing large
surface area over which the air is humidified and
warmed.
2. To provide resonance to voice.
3. To act as thermal insulators to protect the delicate
structures in the orbit and the cranium from variations
of intranasal temperature.
4. To lighten the skull bones.
TABLE 35.1 DEVELOPMENT AND GROWTH OF PARANASAL SINUSES
Maxillary Present at birth
Ethmoid • Presentatbirth
Frontal Not present Invades frontal bone at the age of 4 years. Size increases
Sphenoid Not present Reaches sella turcica by the age of 7 years, dorsum sellae
Status at birth Growth First radiologic evidence
Volume 6–8 mL
• Anteriorgroup:5× 2 × 2 mm
• Posteriorgroup:5× 4 × 2 mm
Rapid growth from birth to 3 years and from 7–12 years
Adult size – 15 years
Reach adult size by 12 years 1 year
until teens and complete development by 20 years
by late teens and basisphenoid by adult age Reaches
full size between 15 years to adult age
4–5 months after birth
6 years
4 years
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SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 35.4. Mucociliary clearance of paranasal sinuses. (A) Maxillary sinus. (B) Frontal sinus. (C) Anterior and posterior group of sinuses. See
text for details.
5. To provide extended surface for olfaction; olfactory
mucosa is situated in the upper part of nasal cavity and
extends over ethmoid as well.
6. To provide local immunologic defence against
microbes.
7. To act as buffers against trauma and thus protect brain
against injury, e.g. frontal, ethmoid and sphenoid
sinuses.
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SECTION II — Diseases of Nose and Paranasal Sinuses
Figure 36.1. Pathophysiology of acute viral rhinosinusitis.
ACUTE MAXILLARY SINUSITIS
AETIOLOGY
1. Most commonly, it is viral rhinitis which spreads to
involve the sinus mucosa. This is followed by bacterial
invasion.
2. Diving and swimming in contaminated water.
3. Dental infections are important source of maxillary
sinusitis. Roots of premolar and molar teeth are related to the floor of sinus and may be separated only
by a thin layer of mucosal covering. Periapical dental abscess may burst into the sinus; or the root of
a tooth, during extraction, may be pushed into the
sinus. In case of oroantral fistula, following tooth extraction, bacteria from oral cavity enter the maxillary
sinus.
4. Trauma to the sinus such as compound fractures, penetrating injuries or gunshot wounds may be followed
by sinusitis.
Predisposing factors
One or more of the predisposing factors enumerated for
sinusitis in general may be responsible for acute or recurrent infection.
Figure 36.2. Sequence of acute viral to acute bacterial rhinosinusitis.
4. Antihistamines should be used if there is concurrent
allergy. Antihistamines make the mucus thick.
5. Decongestants give relief from nasal obstruction.
Topical use of xylmetazoline should be limited only
for a few days, as prolonged used can cause rhinitis
medicamentosa.
Oral nasal decongestants can be used if there are
no contraindications such as hypertension or peptic
ulcer.
6. Intranasal steroids. They are anti-inflammatory in nature and are used to relive oedema and associated allergy and cut down the course of the disease.
CLINICAL FEATURES
Clinical features depend on (i) severity of inflammatory
process and (ii) efficiency of ostium to drain the exudates.
Closed ostium sinusitis is of greater severity and leads
more often to complications.
1. Constitutional symptoms. It consist of fever, general
malaise and body ache. They are the result of toxaemia.
2. Headache. Usually, this is confined to forehead and
may thus be confused with frontal sinusitis.
3. Pain. Typically, it is situated over the upper jaw, but
may be referred to the gums or teeth. For this reason
patient may primarily consult a dentist. Pain is aggravated by stooping, coughing or chewing. Occasionally,
pain is referred to the ipsilateral supraorbital region
and thus may simulate frontal sinus infection.
4. Tenderness. Pressure or tapping over the anterior wall
of antrum produces pain.
5. Redness and oedema of cheek. Commonly seen in
children. The lower eyelid may become puffy.
6. Nasal discharge. Anterior rhinoscopy/nasal endoscopy shows pus or mucopus in the middle meatus.
Mucosa of the middle meatus and turbinate may
appear red and swollen.
7. Postnasal discharge. Pus may be seen on the upper
soft palate on posterior rhinoscopy or nasal endoscopy.
DIAGNOSIS
• Transillumination test. Affected sinus will be found
opaque.
• X-rays. Waters’ view will show either an opacity or a
fluid level in the involved sinus. Computed tomography (CT) scan is the preferred imaging modality to investigate the sinuses.
Chapter 36 — Acute Rhinosinusitis
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TREATMENT
Medical
1. Antimicrobial drugs. Ampicillin and amoxicillin are
quite effective and cover a wide range of organisms.
Erythromycin or doxycycline or cotrimoxazole are
equally effective and can be given to those who are
sensitive to penicillin. β-lactamase-producing strains
of H. influenzae and M. catarrhalis may necessitate the
use of amoxicillin/clavulanic acid or cefuroxime axetil.
Sparfloxacin is also effective, and has the advantage of
single daily dose.
2. Nasal decongestant drops. One per cent ephedrine or
0.1% xylo- or oxymetazoline are used as nasal drops
or sprays to decongest sinus ostium and encourage
drainage.
3. Steam inhalation. Steam alone or medicated with
menthol or Tr. Benzoin Co. provides symptomatic relief and encourages sinus drainage. Inhalation should
be given 15–20 min after nasal decongestion for better
penetration.
4. Analgesics. Paracetamol or any other suitable analgesic should be given for relief of pain and headache.
5. Hot fomentation. Local heat to the affected sinus is
often soothing and helps in the resolution of inflammation.
Surgical
Antral lavage. Most cases of acute maxillary sinusitis respond to medical treatment. Lavage is rarely necessary. It
is done only when medical treatment has failed and that
too only under cover of antibiotics.
COMPLICATIONS
1. Acute maxillary sinusitis may change to subacute or
chronic sinusitis.
2. Frontal sinusitis. Due to obstruction of frontal sinus
drainage pathway because of oedema.
3. Osteitis or osteomyelitis of the maxilla.
4. Orbital cellulitis or abscess. Infection spreads to the
orbit because of oedema either directly from the roof
of maxillary sinus or indirectly, after involvement of
ethmoid sinuses.
i.e. comes up on waking, gradually increases and
reaches its peak by about mid day and then starts subsiding. It is also called “office headache” because of its
presence only during the office hours.
2. Tenderness. Pressure upwards on the floor of frontal
sinus, just above the medial canthus, causes exquisite
pain. It can also be elicited by tapping over the anterior wall of frontal sinus in the medial part of supraorbital region.
3. Oedema of upper eyelid with suffused conjunctiva
and photophobia.
4. Nasal discharge. A vertical streak of mucopus is seen
high up in the anterior part of the middle meatus. This
may be absent if the ostium is closed with no drainage.
Nasal mucosa is inflamed in the middle meatus.
X-rays. Opacity of the affected sinus or fluid level can
be seen. Both Waters’ and lateral views should be taken.
CT scan is the preferred modality.
TREATMENT
Medical
This is same as for acute maxillary sinusitis, i.e. antimicrobials, decongestion of the sinus ostium for drainage
and analgesics. A combination of antihistaminic with an
oral nasal decongestant (phenylephrine hydrochloride)
is useful. Placing a pledget of cotton soaked in a vasoconstrictor in the middle meatus, once or twice daily,
helps to relieve ostial oedema and promotes sinus drainage and ventilation. If patient shows response to medical
treatment and pain is relieved, treatment is continued for
full 10 days to 2 weeks.
Surgical
Trephination of frontal sinus. If there is persistence
or exacerbation of pain or pyrexia in spite of medical
treatment for 48 h, or if the lid swelling is increasing
and threatening orbital cellulitis, frontal sinus is drained
externally. A 2 cm long horizontal incision is made in
the superomedial aspect of the orbit below the eyebrow
(Figure 36.3). Floor of frontal sinus is exposed and a hole
drilled with a burr. Pus is taken for culture and sensitivity, and a plastic tube inserted and fixed. Sinus can now
ACUTE FRONTAL SINUSITIS
AETIOLOGY
1. Usually follows viral infections of upper respiratory
tract followed later by bacterial invasion.
2. Entry of water into the sinus during diving or swimming.
3. External trauma to the sinus, e.g. fractures or penetrating injuries.
4. Oedema of middle meatus, secondary to associated ipsilateral maxillary or ethmoid sinus infection.
Predisposing factors, pathology and bacteriology are
the same as in acute sinusitis in general.
CLINICAL FEATURES
1. Frontal headache. Usually severe and localized over
the affected sinus. It shows characteristic periodicity,
Figure 36.3. Trephination of right frontal sinus.
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