39 The nose and sinuses ROBERT W RUCKLEY Surgical anatomy of the nose The supporting structures of the nose are shown in Fig. 39.1. The paired nasal bones join in the midline with a suture and are supported by the septum, which consists of the anterior quadrilateral cartilage, the perpendicular plate of the ethmoid and the vomer (Fig. 39.2). In children the length of the nasal bone equals its width, whereas in the adult the length is three times the width. The lateral wall of the nasal cavity contains the superior, middle and inferior turbinates (Fig. 39.3). Opening on to the lateral nasal wall are the ostia of all the nasal sinuses except for the sphenoid sinus (Fig. 39.4). The nasolacrimal duct opens into the inferior meatus beneath the inferior turbinate approximately 3 cm posterior to the external nasal opening. Below the middle turbinate is the middle meatus into which the nasofrontal duct, the anterior ethmoid cells and the maxillary antrum open (Fig. 39.5).The superior meatus between the middle and superior turbinates contains the opening for the posterior ethmoid cells. The sphenoid ostium lies at this level on the anterior wall of the sphenoid sinus. The nasal cavities and sinuses are lined by respiratory epithelium. The olfactory mucosa, innervated by fibres from the olfactory nerve, lines the area of the olfactory cleft and the cribriform plate. The nasal fossae and sinuses receive their blood supply via the external and internal carotid arteries. The external carotid artery supplies the interior of the nose via the maxillary and sphenopalatine arteries. The greater palatine artery supplies the anteroinferior septum via the incisive canal. The contribution from the internal carotid artery is via the anterior and posterior ethmoidal arteries which are branches of the ophthalmic artery (Fig. 39.6). Allof these arteries anastomose to form a plexus of vessels (Kiesselbach’s plexus) on the anterior part of the nasal septum. Venous drainage is via the ophthalmic and facial veins and the pterygoid and pharyngeal plexus. Intracranial drainage into the cavernous sinus via the ophthalmic vein is of particular clinical importance because of the potential for intracranial spread of nasal sepsis. The nasal cavity and sinuses have a sensory nerve supply provided by the first and second branches of the trigeminal nerve. The olfactory epithelium is supplied by the olfactory nerve. Autonomic innervation comprises sympathetic fibres to the blood vessels via the cervical and pterygopalatine ganglia. Parasympathetic fibres also synapse in the pterygopalatine ganglion before passing to the mucous glands. Investigation Plain X-rays are of limited value in the assessment of sinus disease. A minimum of four views namely occipitomental, occipitofrontal, submentovertical and lateral views —are required to demonstrate the paranasal sinuses adequately. Computerised tomography (CT) scanning is far superior in demonstrating sinus pathology. Coronal and axial scans are necessary for detailed assessment. Nasal airway resistance can be assessed by means of rhinomanometry which can be performed by either active or passive techniques. It may be used to quantify pre- and post-medical and surgical treatment for nasal obstruction and for the assessment of response to treatments for rhinitis. Both rigid and flexible naso endoscopes can be used for direct visualisation of the nasal fossa and the paranasal sinuses. Endoscopic techiques can be used for diagnosis and treatment. Trauma to the nose Injuries to the nose are commonly sustained in fights, sport-ing injuries and road traffic accidents. A blunt injury of moderate force may lead to springing of the nasal septal cartilage with separation of the overlying mucoperichondrium. Bleeding into this potential space will cause a septal haematoma which may be unilateral or bilateral. The haema-toma will give rise to nasal obstruction and can be easily overlooked in the presence of extensive facial injuries. It is, however, an important diagnosis not to miss because untreated, a septal haematoma will progress to abscess forma-tion and ultimately result in necrosis of the septal cartilage. Robbed of this support the tip of the nose will collapse. A septal haematoma should be treated by incision and evacuation of the blood clot. The insertion of a small silicone drain and packing of the nasal fossa will prevent reaccu-mulation and encourage the mucoperichondrium to readhere to the septal cartilage. A broad spectrum prophylactic antibiotic should be prescribed. A more violent blunt injury to the nose can fracture the nasal bones. This may be a simple crack of the nasal bones without displacement, but greater force may result in deviation of the bony nasal complex laterally (Fig. 39.7) or depression of the bony pyramid if the blow is directly from the front. Greater impacts from this direction may cause a comminuted fracture and widening of the nasal bones or involve the lacrimal bones causing a nasoethmoidal fracture. Lateral injuries with displacement of the nasal bones may also be associated with a C-shaped fracture of the septal cartilage and the anterior portion of the perpendicular plate of the ethmoid (Jarjavay fracture). Nasal bone fractures can extend into the lacrimal bone tearing the anterior ethmoidal artery to produce catastrophic haemorrhage. This may be delayed, occurring only as the soft-tissue swelling subsides and the torn artery opens up. Violent trauma to the frontal area of the nose can result in a fracture of the frontal and ethmoid sinuses extending into the anterior cranial fossa. Dural tears and brain injuries are then at risk from ascending infection through the fracture line from the nose or sinuses which may progress to meningitis or a brain abscess. Cerebrospinal fluid (CSF) rhinorrhoea is a certain sign of a dural tear. There may be associated surgical emphysema, proptosis with or without loss of vision or frontal pneumoencephalocele. Anosmia occurs in 75 per cent of patients with these injuries, and cranial nerves II—VI may be injured. A clear discharge from the nose may be confirmed to be CSF by a simple stix test demonstrating the presence of glucose, which is not present in nasal mucus. Such injuries are man-aged by neurosurgical exploration to remove bone fragments, repair the skull base and close the dura. Late complications of this injury include CSF fistula, recurrent late meningitis, brain abscess, osteomyelitis and the formation of mucopyoceles. Management of fractured nasal bones Fractured nasal bones are often accompanied by extensive overlying soft-tissue swelling and bruising which may hinder the assessment of the underlying bony deformity. Reviewing the patient 4—5days later will give time for the soft-tissue swelling to subside and make subsequent assessment of any deformity much easier. If a fracture to the nasal bones has caused a significant degree of nasal deformity then this should be corrected by manipulation of the nasal bones under general anaesthesia. This must he carried out within 10 days of the injury while the bony fragments are still mobile. The deviated nasal bones are repositioned to restore the correct alignment of the nose or, in the case of a depressed fracture, the fragments are elevated and supported if necessary with anterior nasal packing. Often a satisfactory result can be obtained by simple manipulation, but should this fail then a rhinoplasty procedure (see later) may be necessary at a later date to obtain further improvement in the appearance of the nose. Any blow to the nose may cause displacement or fracture of the cartilaginous septum giving rise to post-traumatic nasal obstruction. Unlike the nasal bones, the nasal septum cannot be manipulated back into position and requires a formal septoplasty to restore the anatomy and the patency of the nasal airways (see later). Nasal trauma — summary •Do not overlook a septal haematoma •Displaced nasal bone fractures should be reduced within 10 days of injury •Severe epistaxis suggests lacrimal bone fracture and anterior ethmoid artery injury •CSF rhinorrhoea indicates fracture involving frontal or ethmoid sinuses with a dural tear Epistaxis Although in the majority of patients this is a relatively easy clinical problem to deal with, this may not always be the case and in certain situations the haemorrhage may be life threatening. The most common site of bleeding is from Kiesselbach’s plexus in Little’s area of the anterior portion of the septum (Fig. 39.6). The usual cause is microtrauma to these blood vessels sandwiched between the mucosa and the underlying cartilage. In young children, heavy bleeding sometimes occurs from an engorged retro-columellar vein. Less often bleeding arises from the lateral nasal wall. Anterior bleeding is common in children and young adults as a result of nose blowing or picking. In the elderly, arteriosclerosis and hypertension are the underlying causes of arterial bleeding from the posterior part of the nose. The degeneration of the muscle layer of small arteries with age and the gradual replacement with collagen and calcification hinder post-traumatic vasoconstriction and prolong bleeding. Less common causes are trauma, foreign bodies within the nose, blood diseases, disorders of coagulation and malignant tumours of the nose or sinuses. Nasopharyngeal angiofibroma is a rare condition that affects boys and may lead to massive life- threatening attacks of bleeding. Hereditary haemorrhagic telangiectasia (Osler’s disease) gives rise to recurrent multifocal bleeding from thin-walled vessels deficient in muscle and elastic tissue (Fig. 39.8). Management of epistaxis Bleeding from Kiesselbach’s plexus may be controlled by silver nitrate cautery under local anaesthesia. Bleeding from further back in the nose, as seen in the elderly, may require anterior nasal packing with Vaseline-impregnated ribbon gauze. The packing is inserted in layers starting on the floor of the nasal cavity. Sometimes hypoxia can be induced by nasal packing and may be exacerbated in patients with chronic obstructive airways disease. The packing is usually kept in place for 48 hours and the patient commenced on a broad-spectrum antibiotic. An alternative to anterior packing is the use of an epistaxis balloon catheter (Fig. 39.9). The catheter is inserted in the nose and the distal balloon is inflated first within the choana to secure the catheter and then the proximal balloon, which is sausage shaped, is inflated within the nasal cavity proper. These catheters are usually effective but can be quite uncomfortable. Sometimes anterior nasal packing alone is not sufficient to control haemorrhage and posterior nasal packing may be required. This is usually carried out under general anaes-thesia inserting a gauze pack into the naso pharynx, which is then secured by tapes passed through each side of the nose and tied together across a protected columella. A third tape is brought out through the mouth and taped to the patient’s cheek. The nasal fossae are then packed with anterior nasal packs. All packs are left in for 48 hours and prophylactic antibiotics are given. The tape attached to the cheek is to facilitate removal of the pack usually without a general anaesthetic. In uncontrolled life-threatening epistaxis where the above methods have proved ineffective, haemostasis is achieved by vascular ligation. Depending on the origin of bleeding itmay be necessary to ligate the internal maxillary artery in the pterygopalatine fossa and the anterior and posterior eth-moidal arteries within the orbit. An alternative measure is external carotid artery ligation above the origin of the lingual artery. In Osler’s disease anterior nasal packing is best avoided if at all possible because it is most likely to lead to further mucosal trauma and bleeding. High-dose oestrogen induces squamous metaplasia of the nasal mucosa and has been used effectively in treating this condition. In some cases however, it may be necessary to resort to excision of the diseased nasal mucosa via a lateral rhinotomy and replace it with a split skin graft — a procedure known as septodermoplasty. It is not unknown, however, for the grafted skin to undergo similar abnormal vascular change over time. Epistaxis — summary •Young people bleed from the anterior septum —Kiesselbach’s plexus •Older people bleed from the posterior part of the nose •Silver nitrate cautery is good for controlling anterior septal bleeding •Moderate bleeding may require anterior nasal packing •Severe bleeding may require anterior and posterior nasal packing •Persistent bleeding will probably require arterial ligation Nasal polyps Nasal polyps are benign swellings of the ethmoid sinus mucosa. Histologically polyps consist of a water-logged stroma infiltrated with eosinophils. The cause of polyp. for-mation is unknown but itis thought that itmay be related to a disorder of arachidonic acid metabolism. Nasal polyps are erroneously linked to allergic rhinitis, but many patients with allergic rhinitis never have polyps and many patients who suffer from nasal polyposis have no evidence of nasal allergy. Approximately a third of patients with nasal polyps also have asthma, while the triad of nasal polyps, aspirin allergy and asthma is not uncommon. The vast majority of nasal polyps arises from the ethmoid sinuses, each individual ethmoid air cell giving rise to a single polyp as its swollen mucosal lining prolapses out of the air cell to hang down inside the nasal cavity. Polyps can arise from the other nasal sinuses, and a single large polyp arising from the maxillary antrum is referred to as an antrochoanal polyp. This usually fills the nose and eventually prolapses down into the nasopharynx. The diagnosis can often be made by looking into the patient’s mouth and observing the fundus of the polyp hanging down beyond the free margin of the soft palate. Ethmoid polyps are usually bilateral but when unilateral in an adult or associated with bleeding then malignancy must be excluded. Nasal polyps are unusual in children and if multiple often occur in conjunction with cystic fibrosis in 10 per cent of cases. A unilateral nasal polyp in a child must be distinguished from a meningocele or encephalocele by high-resolution CT scanning of the anterior cranial fossa. Clinical features Polyps cause nasal obstruction associated with watery rhinor-rhoea and often anosmia. They are easily identifiable within the nose as pale, semitransparent grey masses which are mobile and insensitive when palpated with a fine probe, allowing them to be distinguished from turbinate hypertrophy. Extensive nasal polyposis often gives rise to secondary pan sinusitis, by occluding the ostia and interfering with sinus ventilation. If left untreated they will eventually result in expansion of the nose and prolapse through the nasal vestibule (Fig. 39.10). Management of nasal polyps Polyps are best treated by surgical removal either by avulsion with a nasal snare or with a powered nasal microresector (Fig. 39.11). Antral lavage should be performed at the same time. Benign transitional cell papilloma (inverted papilloma) can be mistaken for simple nasal polyps (see later) and therefore the polyps should always be submitted for histological examination. Polyps often recur in a seemingly random and unpre-dictable way. There is evidence to suggest that long-term treatment with low-dose topical nasal steroids (beta-methasone) postoperatively lessens the tendency for polyps to recur. After multiple recurrence external ethmoidectomy should be considered. Although polyp formation may still occur after the procedure, the interval between recurrences will be longer. Polyps usually shrink while a patient is taking oral steroids but recur when treatment is stopped. Nasal polyps — summary •Polyps are insensitive to touch • Transitional papilloma may be mistaken for simple polyps •Polyps can be removed by nasal snare or powered nasal microresector •Recurrent polyps, may require external ethmoidectomy • Meningocele and encephalocele should be excluded in children with polyps •Bleeding polyps may indicate malignancy Nasal septum The nasal septum consists of the quadrilateral cartilage ante-riorly and the bony perpendicular plate of the ethmoid and vomer posteriorly. Few, if any, people are born with an entirely straight septum and symmetrical nasal airways. In some individuals a naturally occurring deviated nasal septum gives rise to significant nasal obstruction. In others minor nasal trauma is responsible for displacement of the septum and restriction of the nasal airway (Fig. 39.12). Further encroachment of the anterior nasal airway can occur if the ventral edge of the septal cartilage is dislocated from the columella and projects into the nasal vestibule. Inferior turbinate hypertrophy is frequently seen on the concave side of a deviated nasal septum. This is particularly likely to occur after nasal injury. The physical obstruction of the nasal airway by a deviated septum is readily apparent on anterior rhinoscopy. Septal deformity can be corrected by means of a septo-plasty procedure or by a submucus resection of the septum (SMR). In the former procedure the septal cartilage is preserved but the anatomical abnormalities giving rise to its deformity such as a twisted maxillary crest or inclination of the bony septum are corrected, permitting the septal cartilage to be repositioned in the midline with the restoration of nasal airway patency. In the SMR procedure the deformed septal cartilage is excised, while preserving a dorsal strut along with the anterior 5 mm of septal cartilage in order to support and maintain the normal shape of the nasal tip. Both operations are performed through a vertical incision of the septal mucosa with elevation of mucoperichondrial flaps. Postoperatively, the nose is packed for 24—48 hours to prevent haematoma formation. Complications of septal surgery include septal perforation giving rise to excessive crusting within the nose, nasal obstruction and epistaxis. If too much cartilage is excised in the SMR procedure the loss of support to the dorsum of the nose may result in a saddle deformity or drooping of the tip of the nose. Septal perforation The causes of septal perforation are listed in Table 39.1. The commonest cause is a complication of septal surgery. Septal perforations seldom heal spontaneously. They give rise to extensive crusting at the margins of the perforation, often with mucosal bleeding. If situated towards the front of the septum embarrassing whistling can occur. Patients also often complain of a sensation of nasal obstruction. Crusting can be controlled to a degree with nasal douches or the use of topical antiseptic creams to minimise mucosal drying. A great variety of operations has been described to close septal perforations but none of them has met with universal success. A more certain option is to occlude the perforation by inserting a sialastic biflanged prosthesis (Fig. 39.13). Rhinitis Rhinitis is inflammation of the nasal mucous membranes and can be of various types (Table 39.2). A clinical diagnosis of rhinitis can be made if a patient has two or more of the following symptoms: anterior rhinorrhoea, postnasal catarrh, nasal obstruction, nasal itch or irritation, and sneezing. The management of these conditions is determined largely by the type of rhinitis and the predominant symptom and lies within the province of the otolaryngologist, seldom requiring surgery and therefore not referred to further in this chapter. External nasal deformity Anomalies of the shape of the nose may be congenital or acquired. The latter may be the result of trauma, previous nasal surgery or destructive processes such as Wegener’s granulomatosis. Correction of a deformity of the bony nasal complex is referred to as a rhinoplasty procedure and if combined with a procedure to correct a deviation of the nasal septum the procedure is known as a septo rhinoplasty. In a standard rhinoplasty procedure the nasal bones are approached through an intercartilagenous incision between the upper and lower lateral cartilages within the nasal fossa and the soft tissues covering the nasal skeleton are elevated. Superior and lateral osteotomies are used to mobilise the nasal bones, which are then repositioned to produce a pleasing shape to the nose. This procedure can also be carried out through an external approach where the skin of the col-umella is divided allowing elevation of the soft tissues of the tip of the nose to provide access to the nasal bones and septum. With adequate exposure by either method a dorsal hump can be removed with hammer and chisel and a saddle nose deformity can be corrected by dorsal augmentation us-ing either bone from the iliac crest, harvested septal cartilage or a suitably shaped sialastic implant. Cosmetic deformities of the soft tissues of the tip of the nose require the specialised surgical techniques of a facial plastic surgeon. Tumours of the nose Benign tumours Osteomas of the nasal skeleton are not uncommon and are usually detected on X-ray as an incidental finding. They are usually seen in the frontal and ethmoid sinuses (Fig. 39.14). Some may produce symptoms such as headache or recurrent sinusitis if the location interferes with the drainage of one of the paranasal sinuses. Plain X-rays demonstrate a calcified, well-demarcated tumour of variable size. In symptomatic individuals the osteoma can be removed via the frontal sinus or an external ethmoidectomy. Transitional cell papilloma (inverted papilloma) can occur in both the nasal cavity and the nasal sinuses. They can be quite extensive (Fig. 39.15) and give rise to nasal obstruction and sometimes epistaxis. Although usually unilateral, red, firm and vascular they can sometimes look like simple nasal polyps, and in 25 per cent of cases the diagnosis is made by the pathologist after a routine nasal polypectomy. When large they can erode the lateral nasal wall and infiltrate the antrum and ethmoid. Calcification within the tumour may be seen on CT scanning along with sclerosis of bone at the margins of the growth. Transitional cell papilloma can undergo malignant change; synchronous lesions occur in 5—10 per cent, while metachronous lesions develop in 1 per cent of cases. For this reason more radical surgery is employed than for simple polyps to ensure complete removal of all papillomata and will usually involve a partial maxillectomy. Benign nasal tumours —summary •Osteomas are frequently asymptomatlc • Transitional papilloma may undergo malignant change Malignant tumours Skin tumours involving the nose are not uncommon. Basal cell carcinomas (rodent ulcer) are confined to the head in 86 per cent of cases and of these 26 per cent occur on the nose. Adequate surgical excision may require some form of reconstructive flap procedure to eliminate the resulting defect. Keratinising squamous cell carcinoma is the second most common tumour of the external nose, which should be adequately excised with a generous margin of healthy skin and the defect reconstructed with a local flap. About 10 per cent of all melanomas occur in the head and neck. Wide surgical excision is mandatory, frequently requiring the skills of a plastic surgeon for reconstruction (see Chapter 13 on ‘Plastic surgery’). The most common tumours to occur within the nasal cavity and paranasal sinuses are squamous cell carcinoma (Fig. 39.16), adenoid cystic carcinoma and adenocarcinoma. (Table 39.3). Presenting symptoms include unilateral nasal obstruction, chronic nasal discharge, which is often haemor-rhagic and offensive, and loss of skin sensation on the face (trigeminal nerve). There may be swelling of the cheek, buccal sulcus or the medial canthus of the eye and a feeling of fullness or pressure within the nose or face. Suspicious signs of invasion of neighbouring tissues include diplopia, proptosis, loosening of the teeth (Fig. 39.17), trismus, cranial nerve palsies and regional lymphadenopathy.Biopsy via nasal endoscopy will permit a tissue diagnosis, while assessment of bone errosion and the extent of the disease can be determined by CT scanning (Fig. 39.18). If invasion of the skull base is suspected then angiography will be required, and distant metastases to lung, bone, brain and liver should be excluded. Patients with sinus or intranasal malignancy are best managed in a combined clinic where the expertise of ear, nose and throat (ENT) surgeons, maxillofacial surgeons and radiotherapists can be employed. Detailed surgical management is outside the scope of this book, but the adequacy of any surgical resection will need to be confirmed by frozen section control of soft-tissue margins. Inevitably reconstruction will require the use of myocutaneous flaps or free grafts with microvascular anastomosis. Surgery is followed by radiotherapy. At present chemotherapy is reserved for palliation of inoperable tumours. Malignant nasal tumours —summary •Skin cancer of the nose requires wide excision and expert reconstruction •May present late with signs of invasion •Should be managed by ENT and maxillofacial surgeons with a radiotherapist Paranasal sinus infection Patients with paranasal sinusitis will usually only be referred to an ENT surgeon if they have failed to respond to conservative treatment with antibiotics or if complications are developing. Maxillary sinusitis Patients with persistent maxillary sinusitis have postnasal discharge, headache which is variable in severity and location, nasal obstruction and usually general malaise. The nasal mucosa is swollen and bathed in mucopurulent secretions. Plain sinus X-rays may show a fluid level in the antrum or complete opacity (Fig. 39.19). The most likely causative organisms are Streptococcus pneumoniae and H. influenzae. As the infection becomes chronic the likelihood of anaerobic infection increases. The consideration of a Branhamella catarrhalis as a primary pathogen and the possibility of 3-lactam-producing strains of H. influenzae will also influence the choice of antibiotic. Adequate penetration of antibiotics into chronically inflamed sinus mucosa is doubtful, and therefore treatment may need to be given for several weeks. Topical nasal decongestants such as ephedrine nasal drops will often encourage the sinus to drain. About 10 per cent of infections of the maxillary antrum are due to dental sepsis from anaerobic organisms. The resultant mucopurulent nasal secretion has a foul smell and taste. Maxillary sinusitis from any cause may, through irritation of the superior alveolar nerve, give rise to referred upper toothache. Antral lavage under local or general anaesthesia allows confirmation of the diagnosis and provides the opportunity to obtain samples for bacteriology. The antrum is entered through the inferior meatus below the inferior turbinate where the bone separating the antrum from the nasal fossa is extremely thin and can be penetrated by a trocar and cannula (Fig 39.20). If infection has caused a significant degree of inflammation and fibrosis of the lining of the antrum then the natural ostium may be completely obstructed. In this situation an intranasal inferior meatal antrostomy may be fashioned to facilitate drainage from the antrum. Alternatively, intranasal endoscopic techniques may be employed to create a middle meatal antrostomy. The middle turbinate is lifted and the infundibulum is located and enlarged anteriorly, sometimes requiring the excision of the anterior end of the uncinate process under direct endoscopic control. The antrum itself can be inspected through the antrostomy using a combination of 30degree and 70degreerigid endoscopes (Fig. 39.21). For persisting disease a Caldwell—Luc radical antrostomy may be performed, whereby the entire diseased maxillary sinus mucosa is removed through an opening in the anterior wall of the antrum via an incision in the upper gum. Once the diseased antral mucosa is removed a large window is created in the lateral nasal wall allowing drainage into the inferior meatus. Endoscopic nasal surgery allows a more functional approach to disease’s of the paranasal sinuses and the indi-cations for radical antrostomy are on the decline. Areas of chronically diseased mucosa and infected granulation tissue hinder mucociliary transport and lymphatic drainage leading to retained secretions and the perpetuation of infection. Intranasal endoscopic operations permit the precise removal of diseased mucosa with minimal trauma to adjacent tissues. By removing scar tissue from the narrow recesses within the nose, ventilation and internal drainage can he restored allowing permanent resolution of the chronically inflamed mucosa. In this way precise endoscopic surgery directed towards the middle meatus and the ethmoid system restores the normal physiological function of the paranasal sinuses with minimal mucosal resection (Fig. 39.22). Complications of maxillary sinusitis Untreated chronic maxillary sinusitis can lead to acute cellulitis or Osteitis and rarely, if there is a breach in the roof of the antrum, infection may spread into the orbit. Maxillary sinusitis — summary • Commonest organisms S. pneumoniae and H. influenzae •May result from dental sepsis •Antral lavage is diagnostic and therapeutic •lntranasal antrostomy or endoscopic middle meatal antrostomy may be needed Frontoethmoidal sinusitis If treated promptly with antibiotics and topical nasal decongestants this type of sinus infection is unlikely to be a long-term problem. If allowed to persist chronic frontoethmoiditis gives rise to mucopurulent catarrh, frontal headaches, pressure feeling between the eyes, nasal obstruction and hyposmia. Nasal endoscopy will confirm pus issuing from the middle meatus. The ethmoid sinuses can only be properly assessed radiologically by CT scanning, including coronal as well as axial sections. If frontoethmoiditis fails to settle with conservative treatment then frontal drainage may be required. The frontal sinus is entered through its anterior wall via a small incision below the medial end of the eyebrow. After pus is drained a small sialastic tube is left in the wound to allow regular irrigation of the sinus. Where the disease is more extensive intranasal endoscopic ethmoidectomy may be required. Removal of the uncinate process provides access to the osteomeatal complex, so that if necessary the entire ethmoid complex can be cleared and the frontonasal recess opened. If endoscopic nasal equipment is not available then the tried and tested radical external ethmoidectomy through a Lynch—Howarth incision provides excellent access to the frontal, ethmoid and sphenoid sinuses. Chronic frontal sinus disease can be cleared by means of an osteoplastic flap pro-cedure. Using an X-ray template, the boundaries of the frontal sinus are marked out and a fissure burr is used to cut through the frontal bone along the outline of the sinus. The front wall of the sinus is then prised downwards and for-wards to produce an inferiorly based osteoplastic flap. The diseased lining can then be removed and the sinus obliterated with fat taken from the anterior abdominal wall. Complications of frontoethmoiditis These are potentially extremely serious. Quite often infection can spread to involve the other sinuses because of the close proximity of their ostia. Orbital cellulitis is not an uncommon complication (Fig. 39.23) and may progress to an extra periosteal abscess, which typically displaces the eyeball down forwards and laterally. If unrecognised and untreated this can lead to blindness. Treatment consists of intravenous broad-spectrum antibiotic and an orbital decompression by an exter-nal approach. Orbital cellulitis may progress to cavernous sinus thrombosis and septicaemia. Spread of infection by direct bone penetration or via the diploic veins can give rise to either extradural, subdural or frontal lobe abscess formation. Frontoethmoidal sinusitis — summary •May require open surgical drainage •Chronic frontal sinusitis may require obliterative osteoplastic flap procedure •Orbital complications may threaten sight • Intracranial complications include cerebral abscess and cavernous sinus thrombosis Further reading Mackay, 1.5. and Bull, T.R. (1988) Scott Brown’s Otolaryngology, Butterworths, London. Maran, A.G.D. and Lund, VJ. (1990) Clinical Rhinology, Thieme, New York. Wigand, M.E. (1990) Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base, Thieme, New York.
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