NSC 510: ENT Nursing

7.2 Diseases of the Nose and Paranasal Sinuses

7.2.1 Congenital Disease of the Nose

Choanal Atresia
Choanal atresia is a rare congenital closure of posterior nasal opening due to failure of
canalization of the primitive bucconasal membrane. This results in the persistence of a bony
plate (most commonly), membrane or both, obstructing the posterior nares. The condition may
be unilateral (75%) or bilateral (25%).

Clinical picture:
• Bilateral presents as an emergency at birth because neonates are obligate nasal breathers.
The neonate suffers severe respiratory difficulties and cyanosis until he cries and the
mouth is opened. After a few quick breathes, the lips close again and this sequence of
events continues. If not properly managed, the child may die from respiratory
obstruction.
• Unilateral cases are usually asymptomatic at birth. It usually presents later in life with
unilateral nasal obstruction and persistent thick mucoid discharge.
Investigations:
• Inability to pass a catheter or coloured drops from the nose to the nasopharynx.
• X-ray after instillation of a radio-opaque dye will show arrest of the dye in the nose. i.e.
not posses to nasopharynx.
• CT is the method of choice for detection of the atresia.
• Diagnostic endoscopy in older children and adults shows atresia.

Treatment:
First aid: In bilateral cases the first priority is to insert and maintain an oral airway. An emergent
perforation of the occluding plate by a probe or a wide bore trocar may be tried.

Defintive treatment:
 NSC 510: ENT Nursing
• Transnasal: The transnasal route entitles the use of burrs or laser to perforate and widen
the occluding plate under microscopic or endoscopic visualization. A stent may be
inserted for 6 weeks.
• Transpalatal: After elevation of a mucoperiosteal flap, the atretic plate and the posterior
part of the nasal septum are resected followed by insertion of a stent.

7.2.2 Inflammations of the Nose

7.2.2.1 Furunculosis of the vestibule

It is an infection of a hair follicle in the nasal vestibule caused mainly by staphylococcus aureus.

Clinical picture:
§ The nose shows a red, hot, very painful swelling. The extreme tenderness is due to the tight
attachment of the skin to the underlying cartilage.

Management:
1. Systemic and topical antibiotics.
2. The patient is advised not to squeeze the furuncle as there is a potential risk of spreading
infection to the cavernous sinus via the facial and ophthalmic veins (dangerous area of the face).
3. In recurrent cases,
a. A swab should be taken.
b. Blood glucose level should be tested to exclude diabetes mellitus.
c. Exclude the possibility of a nasal carrier.
4. Incision is delayed unless the furuncle is pointing if needed.

7.2.2.2 Rhinitis
The term rhinitis implies an inflammation of the lining membrane of the nose. Actually the nasal
mucous membrane is continuous anatomically with the paranasal sinuses mucous membrane. So
every case of rhinitis is accompanied by a degree of sinusitis, also every case of sinusitis is
 NSC 510: ENT Nursing
associated with a variable degree of rhinitis. So the term (rhinosinusitis) is commonly used for
description of inflammations of the nose and paranasal sinuses. However for simplification of the
subject we use the term (rhinitis) when the main lesion is in the nose while the term (sinusitis) is
used when the main lesion is in the sinuses.

7.2.2.3 Acute rhinitis:

a. Acute non-specific rhinitis e.g. acute coryza (common cold) and influenza rhinitis.
b. Acute specific rhinitis e.g. Nasal diphtheria.
Common cold (coryza)
In the common cold, nasal mucosa is infected by a virus. Those particularly implicated are,
adenovirus, rhinovirus, respiratory syncytial virus and para influenzae virus. A secondary
bacterial infection usually supervenes.

Predisposing factors:
General factors:
· Bad ventilation.
· Fatigue.
· Malnutrition and vitamin deficiency.
· Low general resistance e.g. renal, hepatic, diabetic and immunodeficient patients.
Local factors:
· Nasal obstruction.
· Foci of chronic infection in the sinuses and nasopharynx.

Clinical picture:
The course of a common cold passes in four stages:
1. Prodromal stage: nasal dryness, irritation and sneezing.
2. Hyperaemic stage: nasal obstruction, watery discharge and general symptoms of mild
toxaemia and fever. The mucous membrane appears red and swollen.
3. Stage of secondary infection: the discharge thickens, diminishes and becomes mucopurulent.
Nasal obstruction and toxaemia are at their maximum.
 NSC 510: ENT Nursing
4. Resolution stage: the symptoms and signs gradually diminish and recovery takes place after 5
10 days.

Complications:
• Sinusitis.
• Otitis media.
• Tonsillitis and pharyngitis.
• Laryngitis, tracheitis, bronchitis, pneumonia and asthma exacerbation.

Treatment:
· Treatment is symptomatic as the disease is self-limiting.
· The constitutional symptoms of pyrexia and muscular pain are controlled by an analgesic
antipyretic such as aspirin or paracetamol.
· Steam inhalation and topical nasal decongestants may provide some relief from nasal
obstruction.
· Antibiotics may be required for control of secondary infection.

7.2.2.4 Nasal Diphtheria

Diphtheria now is extremely rare. Nasal diphtheria is an inflammation of the nasal mucous
membrane caused by Corynebacterium diphtheriae. It is usually secondary to faucial diphtheria,
but very rare may be primary.
The nasal symptoms are obstruction and fetid discharge which is watery at first and later
becomes blood stained and mucopurulent. The inferior turbinate, the floor of the nose and
sometimes the septum are covered with a greyish adherent membrane. Removing this membrane
leaves a raw bleeding surface.

Nasal swabs are essential for diagnosis.

Treatment:-
• Systemic antibiotics, usually parentral penicillin and nasal toilet.
• Systemic antitoxins are also indicated.
 NSC 510: ENT Nursing
• Patients should be isolated until negative 3 successive nasal swabs.

7.2.2.5 Chronic Rhinitis:

1. Chronic Non-specific Rhinitis
a. Chronic Hypertrophic Rhinitiis

Aetiology:
1. Recurrent acute rhinitis or sinusitis.
2. Allergic rhinitis.
3. Vasomotor rhinitis.

Pathology: Hypertrophy of the nasal mucosa and submucosa.

Symptoms:
1. Bilateral Nasal obstruction.
2. Bilateral Mucoid nasal and postnasal discharge.

Signs:
1. Congested hypertrophied nasal mucosa.
2. Congested hypertrophied inferior turbinate. It does not shrink with decongestive drops
indicating irreversible changes.

Treatment:
1. Treatment of the cause.
2. Topical steroids.
3. Reduction of the inferior turbinate by:
a. Surgical partial inferior turbinectomy.
b. Submucous diathermy.
c. Laser turbinate reduction.
 NSC 510: ENT Nursing
b. Atrophic rhinitis (Ozaena):-
Atrophic rhinitis is a chronic non-specific rhinitis characterized by progressive atrophy of the
nasal mucosa and underlying bony turbinates. It usually commences at puberty.

Aetiology:
Primary atrophic rhinitis more common in females
The aetiology of atrophic rhinitis is still unknown but may be due to:-
· Infection: cocobacillus ozaenae, klebsiella ozaenae and other gram negative organisms have
been isolated from cultures.
· Endocrine imbalance: oestrogen deficiency has been suspected.
· Malnutrition: iron and vitamin A deficiency have been claimed.
· Autoimmune disease.
· Autonomic imbalance.
· Hereditary factors.

Secondary atrophic rhinitis

· Long standing purulent rhinitis or sinusitis during childhood.
· Excessive surgical destruction of the nasal mucous membranes e.g. radical turbinectomy and
repeated cautery.
· Chronic specific rhinitis e.g. scleroma and syphilis.
· Severely deviated nasal septum (in the wider side).
· Post-irradiation.

Pathology:
• Atrophy of the mucosa, submucosa and bony turbinates.
• Atrophy of the sero-mucinous glands.
• Endarteritis of the arterioles.

Clinical picture:
• Crusty nasal discharge, foul odour. (Usually not smelled by the patient, as he has anosmia
due to atrophy of the olfactory mucosa). Sense of nasal obstruction; in spite of roomy
 NSC 510: ENT Nursing
nose due to dullness of sensation of air on the atrophic mucosa, epistaxis on removing the
crusts and sore throat, due to associated atrophic pharyngitis.
• Clinical examination confirms the presence of fetor and green or black crusts in roomy
nasal cavities. Nasal mucosa is thin, pale, dry (atrophic) with atrophic inferior turbinates.

Treatment:
Conservative:
• Regular nasal douching with an alkaline solution should be considered twice daily. Other
measures include 25% glucose in glycerine pack, topical oestrogen, oral potassium
iodide and human placental extracts.
• Antibiotics after culture and sensitivity tests can be used as well.
• Treatment of the cause in secondary atrophic rhinitis.

Surgical:
• Different surgical procedures have been tried aiming at narrowing the nasal cavities or
temporary closing the nostrils for 6-12 months.

7.2.2.6 Chronic Specific Rhinitis

Rhinoscleroma (Nasal Granuloma)
An endemic chronic specific infection of the nose in Egypt. More common in young adult
females.

Aetiology: Klebsiella rhinoscleromatis: Gram -ve Frisch diplobacillus.

Pathology:
Submucosal chronic inflammatory cellular infiltration characterized by: Mikulicz cells: (large
foamy cells containing the Frisch bacilli within its vacuoles)
Russel bodies: (red-stained degenerated plasma cells), Plasma cells, lymphocytes and fibroblasts.

Clinical picture:
1. Catarrhal stage: resemble acute rhinitis.
 NSC 510: ENT Nursing
2. Atrophic stage: Clinically similar to atrophic rhinitis.
3. Hypertrophic (granulation) stage: Bilateral hard, non-ulcerating submucous granulomatous
nodules appear at the muco-cutaneous junction, then spread and coalesce to fill the nasal cavities
and broaden the nose. Nodules may spread to the subcutaneous tissues of the nasal tip, upper lip
and dorsum of the nose.
4. Fibrotic (Cicatrizing) stage: Dense fibrosis leading to nasal stenosis and external nasal
deformity.

Investigations:
1. Biopsy and pathological examination.
2. Culture and antibiotic sensitivity test.
Sequelae: It may spread to: The pharynx (pharyngoscleroma), larynx (laryngoscleroma), rarely
middle ear (tympanoscleroma) or lacrimal sac (dacryoscleroma).

Treatment:
1. Medical: long course of antibiotics for a minimum 4-6 weeks as the Frisch bacilli are
intracellular and the antibiotics do not reach it easily.
a. Streptomycin: 1gm I.M. daily, for 40 days (ototoxic and nephrotoxic drug).
b. Rifampicin: 300 mg orally twice daily, for 40 days (hepatotoxic).
c. According to the culture and sensitivity test.

2. Surgical:
a. Re-establishment of the nasal or laryngeal air way by removal of the granulomatous masses or
fibrous tissue by surgery or CO2 laser.
b. Tracheostomy in case of severe laryngoscleroma with upper respiratory obstruction.

7.2.2.7 Nasal Lupus Vulgaris

Aetiology: Attenuated form of T.B. bacilli.
Clinical picture: Nasal obstruction and nasal discharge with apple-jelly nodules at the muco-
cutaneous junction of the vestibule and nasal septum. They appear on blanching them by
 NSC 510: ENT Nursing
pressing it with glass slide or decongestive drops. Later on it gives, nodular ulceration with
perforation of the cartilaginous septum and atrophic rhinitis.

Investigations:
1. Bacteriological smear for T.B. bacilli.
2. Biopsy reveals T.B granuloma.

Treatment:
· Anti-tuberculous drugs and calciferol (vitamin D2).

7.2.3 Sinusitis

Inflammation of the mucoperiosteum lining the nasal sinuses.

Classification:

Sinusitis is classified according to the duration of symptoms into acute (less than 4 weeks), subacute
(between 4 -12 weeks) and chronic (more than 12 weeks).

7.2.3.1 Acute Sinusitis

Acute inflammation of the mucoperiosteum lining the nasal sinuses.

Aetiology:

Causative organisms:

· Strept. Pneumonia, Staph. Haemophilus influenza and Moraxella catarrhalis.

· Anaerobes in maxillary sinusitis of dental origin.

Source of infection:

I. Nasal:

1. Acute rhinitis is the commonest.

 NSC 510: ENT Nursing
2. Diving and swimming during acute rhinitis.

3. Nasal packing for long time.

4. Nasal foreign body.

II. Dental:

· Unilateral maxillary sinusitis mostly is an anerobic infection through:-

1. Dental infection: of upper second premolar or first molar tooth.

2. Oro-antral fistula after extraction of the upper second premolar or first molar teeth.

III.Traumatic:

1. Sinus foreign body.

2. Fracture of the sinus.

3. Sinus barotrauma

Pathology: Acute catarrhal followed by suppurative sinusitis: There is congestion and oedema of the
sinus mucosa with inflammatory exudates.

Oedema leads to occlusion of the ostium and retention of exudates inside the sinuses

Clinical picture:

· Fever, malaise and anorexia associated with nasal obstruction, anterior nasal discharge: mucopurulent or
purulent and may be fetid in dental maxillary sinusitis and postnasal mucopurulent discharge with
irritative cough.

· Facial pain and headache, pain is usually over the affected sinus as following: Maxillary sinusitis: over
the cheek and referred to teeth, frontal sinusitis: over the forehead above the eye and periodic vacuum
headache it starts in the morning and subsides at noon when the sinus is drained by gravity, ethmoiditis:
in-between eyes, retro-orbital and occipital.

Signs: Facial examination reveals:-

· Oedema and redness of the skin over the affected sinus, tenderness over the cheek in maxillary sinusitis,
floor of the frontal sinus in frontal sinusitis or inner canthus in ethmoiditis.
 NSC 510: ENT Nursing
Nasal cavity examination:-

1. Congested oedematous nasal mucosa over the turbinates.

2. Mucopurulent or purulent discharge in middle meatus: in maxillary, frontal and anterior ethmoidal
sinusitis, superior meatus in posterior ethmoiditis, sphenoethmoidal recess in sphenoiditis.

3. Postnasal mucopurulent discharge.

Differential diagnosis;

· Other causes of facial pain: dental pain, trigeminal neuralgia, migraine, or tumours of the sinuses.

Complications:

1. Chronic sinusitis.

2. Complications of sinusitis: more common in children. (see later)

Investigations:

1. Culture and sensitivity test of the sinus discharge.

2. Plain X-ray and CT scan: Opacity, fluid level or thickened mucosa of the affected sinus, obstruction of
the osteomeatal complex, complications if present.

Treatment:

Medical:

· Rest, antibiotics (for 10-14 days), analgesics, antipyretics, decongestants, mucolytics and antihistamines.
Decongestive nasal drops and steam inhalation to decrease oedema around the ostium and help sinus
drainage and ventilation.

Surgical:

· Indications: to drain infected sinus in case of:-

1. Subacute sinusitis with failed adequate medical treatment.

2. Threatened complications of sinusitis.

7.2.3.2 Chronic Sinusitis

 NSC 510: ENT Nursing
Chronic inflammation of the mucoperiosteum lining the paranasal sinuses.

Aetiology:

Cause:

· Prolonged obstruction of the natural ostium of one or more of the paranasal sinuses leads to:-

• Inadequate ventilation & drainage of the sinus

• Overgrowth of organisms & infection of the mucous membrane.
• Oedema and damage of the cilia causes more defective ventilation & damage leading to a cycle of
chronic sinusitis.

Predisposing factors to chronic sinusitis

1. Inadequate treatment of acute sinusitis:

a. Virulent or atypical organisms.

b. Inappropriate selection or short course of antibiotics.

2. Local predisposing factors:

a. Anatomic variations that narrow the ostium area e.g. deviated septum or large middle turbinate.

b. Mucosal disease e.g. allergy, polyposis or mucosal transport disease.

c. Adenoiditis or dental infection leads to chronic maxillary sinusitis.

d. Disturbed mucociliary clearance: Cystic fibrosis, immotile cilia (Kartagnar's) syndrome: sinusitis,
bronchiectasis, sterility.

3. Systemic:

a. Poor immunity e.g. DM or prolonged corticosteroid therapy.

b. Environmental factors e.g. smoking or pollution.

Causative organisms: Mixed aerobic and anaerobic organisms.

Clinical picture:

Symptoms:
 NSC 510: ENT Nursing
1. Nasal obstruction, anterior nasal discharge: mucopurulent or purulent and may be fetid in dental
maxillary sinusitis, postnasal mucopurulent discharge with irritative cough.

2. Facial pain is a localized dull aching pain over the affected sinus. Site of pain: below the eye in
maxillary sinusitis in-between eyes in ethmoiditis, above the eye in frontal sinusitis or behind the eye in
sphenoiditis.

N.B. Vacuum headache: is characteristic for frontal sinusitis. This pain is maximal in the morning and
decreases gradually over the day. The cause may be due to closure of the sinus ostium helped by
congestion of the head due to lying position with absorption of the air from within the sinus cavity. Erect
postion during the daytime gradually relieves the ostial obstruction leading to headache release.

3. Symptoms of descending infection: otitis media, pharyngitis, laryngitis and bronchitis.

4. Symptoms of septic focus: low grade fever, headache, rapid fatigue and arthritis.

Signs:

Diagnostic transnasal endoscopy: This should be performed routinely for xamination of all patients with
symptoms suspecting chronic rhinosinusitis. The aim is to detect signs of sinusitis e.g. purulent discharge
from the sinus ostium, oedematous mucosa and polyps and also to identify anatomical or pathological
abnormalities in the middle meatus that may contribute in sinusitis, so you can see:-

1. Congested oedematous nasal mucosa over the turbinates.

2. Mucopurulent or purulent discharge: In middle meatus in anterior group sinusitis, superior meatus in
posterior ethmoiditis or sphenoethmoidal recess in sphenoiditis.

3. Nasal polyps may be present in middle meatus: in chronic ethmoiditis.

Differential diagnosis:

1. Fungal sinusitis.

2. Tumours of the sinuses.

Investigations:

1. Radiological examination:
 NSC 510: ENT Nursing
a. Plain x-ray is no longer performed for diagnosis of chronic sinusitis as it poorly demonstrates the
ethmoid, upper two thirds of the nasal cavity and frontal recess.

b. Computed tomography (CT) scanning is the gold standard for diagnosis of chronic sinusitis. The aim is
to determine the extent of pathology and to delineate the anatomy in patients undergoing surgery.

2. Culture and sensitivity test of the discharge.

Treatment:

Medical:

· Antibiotics should be given for at least 2 weeks, analgesics, decongestants, mucolytics.

· Decongestive nasal drops, steam inhalation and alkaline nasal wash.

Treatment of the predisposing factors: Septoplasty or adenoidectomy.

Surgical:

· Indication: Failed proper medical treatment or if complications occurred as indicated by endoscopic

examination and CT scan.

· Functional Endoscopic Sinus Surgery (FESS): The aim of this type of surgery is to restore function
and patency of the natural ostium of the sinus to provide normal ventilation and drainage. This will allow
diseased intra-sinus mucosa to return to its normal functioning state. This is achieved by endoscopic
removal of the predisposing cause of ostium obstruction e.g. septoplasty, polyp removal and widening of
the natural ostium of the involved sinus..

N.B. Indications of Endonasal Endoscopic Surgery of the sinuses:

1. Chronic rhinosinusitis.

2. Sinonasal polyposis.

3. Acute or chronic sinusitis with certain complications.

4. Mucoceles of the paranasal sinuses

5. Choanal atresia.
 NSC 510: ENT Nursing
6. Endoscopic resection of benign nasal tumours when feasible (e.g. inverted papilloma and
angiofibroma).

7. It can be used in epistaxis for identification and cautery of the bleeding vessel or ligation of the
sphenopalatine artery transnasally when indicated.

8. Endoscopic closure of CSF rhinorrhea.

9. Endoscopic DCR (dacryocystorhinostomy)

10.Endoscopic removal of antrochoanal polyp.

11.Endoscopic orbital & optic decompression.

Conventional sinus surgery: which are rarely needed now after FESS.

· Repeated antral puncture and lavage, intranasal inferior meatal antrostomy or radical antrum (Caldwell-
Luc) operation for Maxillary sinusitis.

· External ethmoidectomy for Ethmoiditis.

· External frontal operation frontal sinusitis if ESS fails.

· External spheno-ethmoidectomy for Sphenoiditis.

Disadvantages:

1. The external facial scar and disturbed bony skeleton of nose and sinuses after external sinus operations.

2. The removed sinus mucosa is replaced by fibrosis lacking mucociliary activity and leading to recurrent
symptoms.

3. The mucociliary clearance of the maxillary sinus is always towards the natural ostium and bypass the
inferior meatal antrostomy.

7.2.3.3 Fungal Sinusitis

Types:

1. Allergic fungal sinusitis

2. Non-invasive fungal sinusitis

 NSC 510: ENT Nursing
3. Invasive fungal sinusitis

1. Allergic Fungal Sinusitis

This is not true infection but represents an allergic response to fungal growth within the sinuses leading to
accumulation of fungal hyphae and allergic mucin within the sinus.

Aetiology: Aspergillus Fungi.

Clinical picture: Usually unilateral sinusitis.

· Similar to chronic sinusitis with brownish tenacious mucoid nasal discharge, allergic mucin with
multiple allergic nasal polyps arising from the middle meatus.

Investigations:

· CT scan: heterogeneous sinus opacity with focal hyperdense spots.

· Biopsy and culture of discharge with special stains for fungus.

Treatment:

· Endoscopic sinus surgery to drain and ventilate the sinuses.

· Steroids and immunotherapy.

2. Non-Invasive Fungal Sinusitis (Mycetoma or Fungal ball) Accumulation of fungal hyphae (fungal ball)
within the sinus.

Aetiology: Aspergillus, in immuno-competent patients.

Clinical picture: Similar to chronic sinusitis, or asymptomatic and may be discovered accidentally.

Treatment: Endoscopic sinus surgery to remove the fungal ball to ventilate the sinuses.

3. Invasive Fungal Sinusitis

A. Acute Invasive (Fulminate) Fungal Sinusitis

Aetiology:

· In immuno-compromised patients as leukaemia, AIDS, organ

 NSC 510: ENT Nursing
transplant, chemotherapy and uncontrolled DM.

· Mucormycosis cause intravascular thrombosis and gangrene of the sinuses.

Progress: Acute onset, rapid progressive course and lethal in short time.

Clinical picture: Unilateral sinusitis.

1. Similar to acute sinusitis with rapid deterioration of the general condition.

2. Necrosis of the nasal mucosa with gangrenous blackish turbinates.

Complications:

· Extension to orbit leads to proptosis, blindness and intracranial invasion or to the palate cause necrosis
of palate, leads to coma and death.

Investigations:

1. CT scan: unilateral sinus opacity extending to the orbit or cranial cavity.

2. Culture of discharge with special stains for fungus: biopsy showed invasion of tissue with fungus.

Treatment:

1. Urgent endoscopic drainage of the sinus and debridement of gangrenous tissues at the same time with
systemic antifungal:

Amphotericin B.

2. Control of predisposing factor.

B. Chronic (Indolent) invasive fungal sinusitis

Aetiology:

· Aspergillus, in immuno-competent patients.

Progress:

· Insidious onset and slowly progressive course for months or years.

 NSC 510: ENT Nursing
Clinical picture:

· Similar to chronic sinusitis but the infection is invasive to orbit or intracranial.

Investigations:

· Similar to acute invasive fungal sinusitis.

Treatment:

1. Endoscopic endonasal complete surgical debridement of gangrenous

tissues.

2. Systemic antifungal, Amphotericin B.

Complications of Sinusitis

Spread of infection into or beyond the bony walls of the sinuses.

Aetiology:

1. Acute sinusitis.

2. Acute on top of chronic sinusitis.

3. Invasive fungal sinusitis.

I. Extracranial Complications

Orbital Complications: -

The commonest complications of sinusitis and usually occur in children. They are common in ethmoid
sinusitis. The extension of infection can occur either by direct extension from the ethmoid through the
medial orbital wall (lamina papyracea) or by retrograde thrombophlebitis via valveless veins.

1. Eyelid oedema (preseptal cellulitis)

2. Orbital cellulitis (postseptal cellulitis) is inflammation of the orbital contents. It is manifested by axial
proptosis, chemosis and ophthalmoplegia. It may progress to orbital abscess and blindness

3. Subperiosteal abscess: collection of pus between periorbita (periostium of orbit) and the bony orbital
well. The clinical picture shows pain, lateral proptosis and limitation of eye movements.
 NSC 510: ENT Nursing
4. Orbital abscess: collection of pus in the orbit. It has the same clinical presentation of orbital cellulitis.
CT scan with contrast on paranasal sinuses and orbit can distinguish between orbital cellulitis,
subperiosteal and orbital absess.

5. Cavernous sinus thrombosis: proptosis, ophthalmoplegia, chemosis, lid oedema and visual loss with
development of contralateral ocular signs if the case is neglected.

Orbital complications of sinusitis: (A) Preseptal cellulitis

(B) Orbital cellulitis

(C) Subperiosteal abscess

(D) Orbital abscess

(E) Cavernous sinus thrombosis.

Treatment:

Medical: Extensive broad spectrum antibiotics should be given.

Surgical: surgery in the form of FESS or external frontoethmoidectomy.

II. Cranial Complications

Osteomyelitis of the Frontal Bone

Symptoms:

1. Fever, headache, malaise, anorexia and toxaemia.

2. Severe pain and swelling over the forehead.

Signs:

1. Oedema and tenderness of the forehead.

2. Fluctuant swelling over the forehead ( Pott’s puffy tumour) due to subperiosteal abscess . It may
rupture leading to fistula.

Investigations:

· Plain X-ray and CT scan: Moth-eaten appearance and sequestration of frontal bone.
 NSC 510: ENT Nursing
· Culture and sensitivity test for discharge.

Treatment:

1. I.V. Broad-spectrum antibiotics.

2. Endoscopic sinus surgery to drain and ventilate the sinus.

3. External frontal drainage operation and sequestrectomy.