Management of Frontal ,Sinus Affections

S.R. REGE K.L. SHAH, S.A. KANTAWALA

Bombay

Despite chemotherapy and multi- r u d e of antibiotics nasal and s inus infections have been able to progress a n d extend to serious intracranial complicat ions. This may be due to the three important reasons:

i) Adequate antibiotic therapy was not given early enough and maintained for a sufficiently long period of time.

ii) Organisms are of a virulent nature.

iii) Ignorance and poor socio- eco- nomic status.

It is also important to note that ch ron ic infections of paranasal sinuses have not responded as well to sulpho- namides and antibiotics as have acute infections in these regions.

Similarly chronic frontal sinusitis or even acute is not so common as compared to maxillary sinu.~itis.

This paper deals with pathogenesis and management of affections of fron- tal sinuses.

* Dr.S.R. Rege, M.S. F.C.P.S, D .LO, F,A.C.S. Honorary E. N. T. Surgeon x Dr. K.L Shah, M.S. Honorary Associate E.N.T. Surgeon Dr. S.A. Kantawala, M. S , ID.O.R.L. Senior Registrar E.N.T. Depart- ameat, K.E.M. Hospital, Bombay-12

T ab le I

A. Inf lammatory condi t ions"

B.

C.

D.

a. Osteomyelitis b. Chronic fistula c. lntracranial abscess

i. Subdural

ii. Frontal lobe

Mucocoele

Pneumosinusitis

Tumours

a. Papilloma undergoing malignancy 1

b. Carcinoma 2

c. Multiple o~teoma 1

Total

I0

3 5

1

1

1

1

4

96

Two tissues are primarily involved in uncomplicated frontal s inusi t is - - mucosa and underlying bone--g iv ing rise to mucocoele and osteomyelitis respectively. Osteomyelitis is commonly associated with acute infections of the sinus. Our findings are tabulated here.

Total 16

Table I I : Acute osteomyelitis

St. No. Sex Age Clinical findings X-rays

1 F. 13 Abscess under scalp Destruction of frontal bone with sequestrum

2 F. 14 .do - - d o - -

3 M. 20 - - d o - - - - d o - -

Unusual features :

i. Epilepsy (incidental) ii. Extensive area involvement

iii. Areas of pachymeningitis

Comments : In the first two cases there was extensive area of frontal bone involvement; in addition Case No. 2 suffered from idiopathic epilep- sy. These cases have undergone ex- ternal frontal operation (Howarth sype). Removal of bone and sequestra was done until normal healthy dura was exposed on all sides, clear off the areas of pachymeningitis. Due to extensive removal of frontal bone the first two cases did develop a deformity o f the scalp and have been referred to Plastic Surgery Unit to cover the defect with bone grafts.

Mucoeoele--Changes in mucosa pre- sent as simple thickening or formation o f small polypi within the sinus. If the oedematous mucosa undergoes cystic degeneration, it would present as a mucocoele. Mucococle is usually unilateral and contains thick, gela- tinous fluid, is lined by pseudostrati- fled ciliated columnar epithelium. It is a benign lesion and does not cause any major problem except that of a diplopia and facial disfigurement.

Comment : A small soft fluctuating swelling of mucocoele caused destruc- tion of posterior wall of frontal sinus yet there was no infection of dura. External frontal operation eradicated the disease.

Subdural abscess : Commonly the infection travels by continuity through posterior wall of the frontal sinus with external pachymeningitis developing first. However, in some cases infec- tion may travel by way of anastomos- ing veins from the frontal sinus mucosa to internal layer of dura without pro- ducing inflammation of the outer layer.

B.V., 25 year old male was admitted in Neurosurgical ward for hemiparesis, fever and headache. Temporal lobe brain abscess was suspected but temporal burr hole was negative and frontopa- rietal burr hole evacuated 30 ml: pus from subdural space. Patient did not impro,,e after this treatment and was referred to E.N.T. surgeon. On exter- nal frontal operation an extradural abscess was discovered and drained. Frontal sinus demonstrated a thicken- ed mucosa and there were polypi in the ethmoids. Patient made an un- eventful recovery on eradicating pri- mary disease in frontal sinus and ex- tradural space.

Table I I I : Mucocoele

Case No. 4 F/50 Left-sided mucocoele X-ray confirmation Radiolucent area

Table IV : Subdural abscess

Case No. 5 M/25 Hemiparesis Mental changes Speech incoherent

Treated with temporal and frontoparietal Burr holes

97 Ind. J. Otol. Vol. X X I I I , No. 3, September, 1972

Fig. 1. Postoperative X ray showing a large bone defect (Case 3)

Fig. la. Photograph showing fistulae (Case 3)

Frontal lobe abscess

This complication is usually due to infection extending both by continuity

polypoidal. The maxillary sinus w a s filled with pus. Ethmoid cells con- tained polypi. All disease w a s exenterated.

Table V : Frontal lobe abscess

<3ase No. 6 M/38 --Headache --VI nerve

paralysis --Weakness Rul

Treated in Neurosurgical unit with temporal and frontoparie- tal Burr holes

and contiguity. In the latter cases gross changes in the bone and dura may be observed at surgery.

38 year old male was admitted and treated in Neurosurgical department for frontal lobe abscess (L). He was referred to E.N.T. surgeon as the primary site required eradication. On performing external frontal operation the frontal sinus mucosa appeared

Chronic fistula of the frontal sinus

The fistula is a result of deep seat- ed suppuration in the frontal s inus coming to the surface in the form of an abscess which bursts by itself leav- ing be hinda fistula. Any fistula oc- curring above the level of medical palpebral ligament is due to a frontal sinus lesion.

_Management of Frontal Sinus/Patel et al 98

Table VI : Chronic fistula

Case No. Sex Age Clinical picture Operative finding Recovery

7 F 60 Super-orbital Thicksinus mucosa Uneventful fistula

8 F 48 Fistula in upper - -do-- - -do- - eyelid with orbital swelling

9 F 64 Orbital swelling Pyocoele with - -do- - with sinus pachymeningitis

10 M 58 Fistula (L) eyebrow Pyocoele - -do- -

II M 36 Multiple fistula in Pachymeningitis - -do- - frontal bone

Comments : All these patients report- ed with swelling over frontal region or supra-orbital region with a fistula in the upper eyelid of varying duratien between 6 weeks and 6 months. All of them had thickened mucosa in frontal sinus and disease in the eth-

moid cells. Two of these had a des- truction of posterior wall of the sinus and pachymeningitis on dural surface. All showed good uneventful recovery on routine external frontal operation.

Mt, ltiple osteomas of skull with" frontal sinusitis : (Case 12)

N.K., male aged 15 years had multiple painless swellings on head since the birth gradually increasing in size. There were in all six swelling-- over the vertex, occiput, left tragus, bridge of the nose, and two swellings near the left inner canthus--all hard and non-tender. There was polypoidal mass in left nostril. X-Rays of skull showed multiple soft tissue shadows in relation to these masses. In addition left frontal maxillary and ethmoids showed changes of chronic sinusitis. External frontoethmoidectomy and left Cold Wel Luc's operation was per- formed. At operation entire frontal sinus was seen filled with polypoidal thickened mucosa and so were the ethmoids. One of the swellings near the inner canthus was removed for biopsy purposes. The biopsy report was chronic hyperplastic sinusitis and swelling was a osteofibroma.

Fig. 2 Left sided mueeeoele (Case 4)

Malignancy in frontal sinus

Malignancy in frontal sinus is un- common. Primary carcinoma is very

99 Ind. J. Otol. Vol. XXIV, No. 3, September, 1972

Fig. 3x4 Carolid angio graphy; AP veiw showing the shift of vessels across mid-line (Case 6)

Fig. 5-6 Case no. 12. multiple fibroma.

rare--only about 1120 cases are report- ed in lhe world literature. We had 2 cases of primary carcinoma and one case of a papilloma undergoing malig- nancy. Malignancy in this region

simulates chronic inflammation of the sinus. Case 14 is the youngest amongst the cases of primary carci- noma of frontal sinus reported in literature.

Management of Frontal Sinus/Patel et al I00

Table VII

<2ase No. Sex Age Clinical picture Biopsy Treatment

13 M 30 Irregular frontal Epidermoid swelling with hard submandibular gland

Deep X-rays

14 M 25 Midline granuloma Sq. cell with scar on surface carcinoma

Surgery+ Deep X-rays

15 M 40 Soft polypoidal mass (L) nostril

Papilloma Surgery + undergoing Deep X-rays malignancy

Comment : All these cases of malign- ancy were iridiated with a dose of 5500 r. Only one of 'them turned up for follow up for 6 months and was doing fine at the time of reporting. Prognosis as a rule is bad in these patients. Death occurs within one year. They die from infiltration of meninges and widespread secondaries ~an the face.

Asymptomatic Pneumosinus Frontalis (Case 16)

A male 15 years old came up for ,welling on forehead increasing in size gradually without any symptoms ex- cep~ deformity. On X-ray pneumosi- nus fron:alis was detected. No treat- ment was advised.

Operation details : 1. Howarth's operation is performed. 2. In suspected intracranial spread

posterior wall of sinus is removed to visualise dura.

3. Inter sinus septum is removed to inspect opposite frontal sinus.

4. Complete exenteration of ethmoids done.

5. Maxillary sinus is drained through middle meatus through same inci- sion.

-6. Large P.V.C. tube used to drain frontal region.

Conclusions : During last 10 years in E.N.T.

Department, K . E . M . Hospital, Bombay, we encountered 16 cases of various affections of frontal sinuses.

This speaks of rarity of entity. In pre-antibiotic era various extracranial and intracranial complications were not uncommon and mortality rate was high. In the present days complica- tions are rare, morbidity is persistent but mortality is almost unknown. We had no death in the series, inspite of serious nature of complications.

Management is primarily surgical once complications occur. Aim is the eradication of the primary disease and provision of drainage. It is best achieved with external procedure with removal of floor of the sinus. There is hardly any facial disfigurement ex- cept in cases of extensive osteomyelitis of skull requiring plastic surgery to close the bony defects. Spreading osteomyelitis of skull can be controlled with appropriate antibiotics. It was noted that the maxillary sinus was invariably involved and is a part of pansinusitis on same side. By extending the incision around the orbit downwards access to maxillary sinus is possible and drainage of latter through middle meatus can be achieved. Since maxillary sinus disease is secondary to frontal sinusitis such a drainage ap- pears to be satisfactory. We believe that ethmoidal exenteration is a part of external frontal operation since the frontonasal duct has intimate relation- ship to ethmoidal labyrinth. The pos- terior wall of the frontal sinus must be removed whenever there is suspi- cion of an intracranial spread. As mentioned before when infection tra- vels by way of veins of the mucosa to

101 Ind. J. Otol. Vol. XXIV, No. 3, September, 1972

Fig. 7. Fronlal sinus Carcinoma (Case No. 13)

internal layer of dura and the relative normal appearance of dura when ex- posed at surgery must not be permitted to prevent adequate search for the source of symptoms. Less commonly subdural abscess developing by conti- nuity may occur with thrombophlebit is o f dural sinuzes. Veins of the inner layer of dura drain to the dural sinu- ses. With thrombophlebit is of super- ior longitudinal sinus infection may travel to frontal lobe area and result in a subdural abscess without develop- ment of external pachymeningitis. As with subdural abscess brain abscess may be present beneath bone and dura which appear normal. Brunner states tha t in his experience bone was grossly normal in 70% of cerebral abscess. He also noted that there was no external pachmeningit is in 44% of cerebral abscess. Moral is, therefore, whenever symptoms point to an intracranial spread the extradural and subdural spaces must be explored in surgery of

Fig. 8. Frontal sinus Carcinoma (Case No. 13)

the frontal sinus. We have two patients in the series

who had frontal lobe abscess drained in Neuro-surgical unit and then trans- ferred to our care for primary focus.

Finally we conclude by observing that though malignancy is rare in this region, it may simulate chronic infec- tion.

Summary During the last !0 years, 16 cases

of complications of frontal sinus dise ase were recorded in our unit. Patho- genesis and management of these cases is discussed. External frontal operation aims a t e r a d i c a t i o n of disease and gives good access to intrac- ranial structures.

Acknowledgement We thank Dr. T.H. Rindani, Dean,

K.E.M. Hospital , Bombay for use of hospital records.

Ind, J. Otol, Vol, XXIV, No. 3, September, 1972 102