|Year : 2013 | Volume
| Issue : 2 | Page : 163-165
Chronic frontal sinusitis presenting with complications
Zainab Sunu Ali, Deviprasad
Department of ENT, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||13-Dec-2013|
Zainab Sunu Ali
Department of ENT, Yenepoya Medical College, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
A frontocutaneous fistula secondary to chronic frontal sinusitis can present with a fistulous opening in the forehead or in the eyelid. It may or may not be associated with Pott's puffy tumor. In this article, we present 2 cases. A case of frontocutaenous fistula with opening in the upper eyelid at the lateral portion of floor of frontal sinus and another case of chronic frontal sinusitis with sub-periosteal abscess in the forehead on the right side near the eyebrow. Relevant literature has also been reviewed.
Keywords: Frontal sinusitis, frontal sinus fistula, frontal bone osteomyelitis, sinocutaneous fistula
|How to cite this article:|
Ali ZS, Deviprasad. Chronic frontal sinusitis presenting with complications. Arch Med Health Sci 2013;1:163-5
| Introduction|| |
Complications of chronic frontal sinusitis are uncommon in the modern era. Possible causes include direct spread of infection from the sinus to the frontal bone. A sinocutaneous fistula maybe the result of a mucocele, chronic osteomyelitis, or a Pott's puffy tumor with violation of the overlying skin.  We report a case of frontocutaneous fistula secondary to chronic frontal sinusitis presenting with fistula opening in lateral portion of floor of frontal sinus and a case of chronic frontal sinusitis with sub-periosteal abscess.
| Case Reports|| |
A 42-year-old male patient presented to the otorhinolaryngology outpatient department with complaints of right eye swelling since 3 months, history of purulent discharge from the swelling since 1 day, history of nasal obstruction during upper respiratory tract infections (URTI) over the past 3 years, and right-sided frontal headache since childhood during the episodes of URTI. There was history of repeated episodes of URTI every 3 months since many years and was more frequent since the last 3 years. The eye swelling was gradually progressive in size and associated with visual complaints [Figure 1].
|Figure 1: Clinical photograph of case 1 showing the right upper eyelid cutaneous fistula|
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Examination revealed an external periorbital inflammatory swelling on right side measuring 2 × 1 cm extending onto the right frontal region. Skin over the surface appeared puckered. Over this, there was a small, smooth-surfaced, localized swelling measuring 0.5 × 0.5 cm on lateral portion of the floor of the frontal sinus. On palpation of this swelling, there was no local rise of temperature. Tenderness was present, and the skin was indurated. It was hard in consistency, and margins were ill-defined. Around it, there was a bony margin surrounding an associated bony deficiency. There was pus draining at this point with a fistula. Right eye palpebral fissure was narrowed. Examination of nose revealed a deviated nasal septum to the right. Ear and throat examination were normal. Ophthalmology consultation was normal. Complete blood count and biochemical parameters were within normal range. Computed tomography scan of nose and paranasal sinuses revealed soft tissue opacification involving both maxillary sinus and right frontal sinus with right periorbital soft tissue swelling. Frontal sinus on right side showed bony dehiscence in the lateral portion of the floor of sinus [Figure 2]. The size of frontal sinus cavity was reduced in size due to thickening of the walls of the sinus, which appeared hypodense on bone window, suggestive of fibrous dysplasia. Right frontal sinus surgical exploration and obliteration of sinus with abdominal fat was done under general anesthesia. During surgery, periosteum was elevated from roof of orbit. Fistula tract was identified. Periosteum was elevated till the bony defect in the roof of orbit. Frontal sinus was exposed by drilling out anterior part of floor of the sinus, and bony defect was identified from above [Figure 3]. Sinus mucosa was appearing unhealthy. It was curetted and sent for histopathological examination. Bony sinus walls were polished with burr after removing the infected mucosa, and the frontal sinus was obliterated with abdominal fat. Fistulous opening was closed in layers after excising the tract and freshening the margins of the opening. Histopathology of the sinus mucosa showed abundant granulation tissue with chronic inflammatory cells while the bone was normal. In the post-operative period, patient was put on antibiotics. Follow-up of the patient was done upto 1 year, and he was symptom-free.
|Figure 2: CT scan showing the fistula in the lateral portion of floor of right frontal sinus|
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|Figure 3: Intra-operative photograph showing the fistulous tract in the lateral part of the floor of the right frontal sinus|
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A 66-year-old female patient presented with history of frontal headache since 2 months with foul smelling mucopurulent nasal discharge. There was also history of swelling over the forehead and the right upper eyelid since 5 days and fever since 2 days.
Clinical examination revealed a diffuse swelling over the forehead extending over the root of the nose with edema of right upper eyelid and right infraorbital region along with tenderness over the above mentioned areas. Eye examination was normal. Examination of the nose revealed edema over the root and bridge of the nose. Nasal mucosa was congested, and mucopurulent nasal discharge was present in the right nasal cavity. Ophthalmology consultation was normal. Complete blood count and biochemical parameters were within normal range. The patient was started on intravenous antibiotics. The patient did not respond to antibiotics, and pus was aspirated from the forehead swelling which on culture revealed no growth. The swelling continued to progressively increase in size with medical management, and further surgical line of management was considered. External frontal sinusotomy and right frontonasal drainage was done under general anesthesia. During the procedure, no bony deficiency was found in the anterior wall of the frontal bone. The right frontal sinus was entered by drilling in the medial part of the floor of the sinus. Mucopus was found in the sinus, which was cleared. Necrosed mucosa from all the bony walls of the sinus was cleared. Necrosed mucosa over the opening of the frontonasal duct was also cleared. Left frontal sinus was similarly opened. It was found to be normal. Lower part of the inter-sinus septum was drilled out to create communication between the sinuses. Right frontonasal duct patency was established by inserting rubber catheter for 3 weeks. External incision was sutured in layers. In the post-operative period, patient was put on antibiotics. Follow-up of the patient was done upto 1 year, and she was symptom-free.
| Discussion|| |
A frontal sinocutaneous fistula develops as a communication from the wall of the frontal sinus to the overlying skin. Such a lesion can be the result of osteomyelitis and necrosis of bone, erosion of the bone via a mucocele or tumor, or traumatic injury to the bone. 
In the study by Wu et al., out of the 3 patients, one presented with a left forehead fistula, another had a midline forehead fistula, while the last case had a left upper eyelid fistula. In all cases, the anterior wall of the frontal sinus was found breached. All patients had a history of frontal sinusitis. 
Marshall and Jones describe a review where out of 7 cases of osteomyelitis, 4 had frontal swelling with forehead fistula.  Marfatia et al. reported a case of a persistently discharging fistula on the left side of forehead, which had a defect in both anterior and posterior walls of frontal sinus with history of frontal sinusitis.  Goldfarb et al. reported a case of Pott's puffy tumor, which was mistaken as a large mid-forehead swelling and was drained, and a large hole in anterior plate of frontal sinus was seen. However, there was no history suggestive of frontal sinusitis. 
Frontal sinusitis occurs secondary to blockage of fronto-nasal duct leading to accumulation of secretions in the sinus. This leads to pressure necrosis of the walls of the sinus, most often involving the posterior and inferior walls. The management of these depends on the clinical presentation and results of investigation. The standard workup includes a computed tomography of the nose and paranasal sinus. The treatment includes antibiotics and surgery. Surgery in the past involved an external approach to the frontal sinus and frontal end of frontonasal duct. With the recent advances, they have been approached endoscopically with computerized stereotactic localization system. However, the approach depends on the extent and site of the disease. In our first case, we used an external approach to identify the laterally placed fistulous tract along with eradication of disease from the right frontal sinus and excision of the fistulous tract. In the second case, we used an external approach to clear the disease from the frontal sinus as well as the sub-periosteal collection.
| References|| |
|1.||Wu VF, Smith TL, Poetker DM. Sinocutaneous fistula secondary to chronic frontal rhinosinusitis: Case series and literature review. Ann Otol 2008;117:759-63. |
|2.||Marshall AH, Jones NS. Osteomyelitis of the frontal bone secondary to frontal sinusitis. J Laryngol Otol 2000;114:944-6. |
|3.||Marfatia HK, Muranjan SN, Navalakhe MM, Kirtane MV. Persistent frontal fistula. J Postgrad Med 1997;43:102-3. |
|4.||Goldfarb A, Hocwald E, Gross M, Eliashar R. Frontal sinus cutaneous fistula: A complication of Pott's puffy tumour. Otolaryngol Head Neck Surg 2004;130:490-1. |
[Figure 1], [Figure 2], [Figure 3]