Sharp fronts

Acute frontitis is characterized by acute inflammation of the mucous membrane of the frontal sinus, which passes through the same stages (catarrhal, exudative, purulent) that are characteristic of other sinusitis.

[1], [2], [3]

Causes of acute frontitis

Etiology and pathogenesis of acute frontitis are typical for common sinusitis, symptoms, clinical course and possible complications are determined by the anatomical position and structure of the frontal sinus, as well as the length and size of the lumen of the frontal-nasal canal.

The frequency of acute onsetitis and its complications, the severity of the clinical course are directly dependent on the size (airiness) of the frontal sinus, the length of the frontal-nasal canal and its lumen.

Acute frontitis can occur for a number of the following reasons and occur in various clinical forms.

• On etiology and pathogenesis: banal rhinopathy, mechanical or barometric trauma (baro or aerosynexitis), metabolic disorders, immunodeficiency states, etc.
• On pathomorphological changes: catarrhal inflammation, transudation and exudation, vasomotor, allergic, purulent, ulcerative-necrotic, osteitis.
• On microbial composition: banal microbiota, specific microbiota, viruses.
• According to the symptomatology (according to the prevailing sign): neuralgic, secretory, febrile, etc.
• According to the clinical course: the torpid form, subacute, acute, supra-acute with a general severe condition and involvement in the inflammatory process of neighboring organs and tissues.
• Complicated forms: orbital, retro-orbital, intracranial, etc.
• Age forms: distinguish, like all other sinusitis, the frontins in children, mature persons and the elderly, who have their own clinical features.

[4], [5], [6], [7], [8],

Symptoms and clinical course of acute frontitis

Patients complain of a constant or throbbing pain in the forehead region radiating into the eyeball, into the deep sections of the nose, accompanied by a sense of fullness and expansion in the region of the superciliary arches and the nasal cavity. The upper eyelid, the internal commissure of the eye, the periocular region are edematic, hyperemic. On the side of the lesion, lacrimation increases, there is photophobia, sclera hyperemia, and sometimes anisocoria due to miosis on the diseased side. At the height of the inflammatory process, when the catarrhal phase passes into the exudative, the pains in this area are intensified, generalized, their intensity increases at night, sometimes becomes intolerable, bursting, tearing. At the beginning of the disease, the discharge from the nose is meager and is caused mainly by inflammation of the nasal mucosa, the endoscopic pattern of which is characteristic of an acute catarrhal rhinitis. Headaches intensify with the cessation of discharge from the nose, which indicates their accumulation in the inflamed sinus. Application of applicative decongestants improves nasal breathing, widens the lumen of the middle nasal passage and restores the drainage function of the frontal-nasal canal. This leads to abundant secretion from the corresponding frontal sinus, which appear in the anterior parts of the middle nasal passage. At the same time, headaches are reduced or stopped. There is only pain in the palpation of the frontal notch, through which the medial branch of the supraorbital nerve emerges, a dull headache when shaking the head and biting over the brow. With the accumulation of secretions, the pain syndrome gradually builds up, the body temperature rises, the general condition of the patient deteriorates again.

The above symptoms are aggravated at night due to an increase in the edema of the nasal mucosa: a common headache, pulsating irradiating pain in the orbit and in the retroxmaxillary region, into the area of the pterygoal node, which plays a major role in the pathogenesis of inflammation of all anterior paranasal sinuses. The pyloric node, related to the parasympathetic nervous system, provides excitation of cholinoreactive structures of the inner nose and mucous membrane of the paranasal sinuses, manifested by the widening of the blood vessels, increased functional activity of the mucous glands, and an increase in the permeability of cell membranes. These phenomena are important in the pathogenesis of the disease in question and play a nosolic role in the elimination of toxic products from the affected paranasal sinuses.

Objective signs of acute frontitis

When examining the facial area draws attention to the diffuse swelling in the region of the brow, the root of the nose, the inner commissure of the eye and the upper eyelid, puffiness of the outer covers of the eyeball and lacrimal passages, edema in the area of the lacrimal flesh, hyperplasia of the sclera and lacrimation.

These changes cause marked photophobia. The skin in these places is hyperemic, sensitive when touching, its temperature is increased. When pressure is applied to the outer-lower angle of the orbit, the pain point described by Ewing, as well as the pain during palpation of the supraorbital incision, is the place of the exit of the supraorbital nerve. There is also a sharp soreness of the nasal mucosa in the area of the middle nasal passage with indirect palpation with a button probe.

With anterior rhinoscopy, nasal passages reveal mucous or mucopurulent discharge, which after their removal again appear in the anterior parts of the middle nasal passage. Particularly abundant discharges are observed after anemia of the middle nasal passage with an adrenaline solution. The mucous membrane of the nose is sharply hyperemic and edematic, the middle and lower nasal conchaes are enlarged, which narrows the common nasal passage and obstructs nasal breathing on the side of the pathological process. There is also a one-sided hyposmia, mainly mechanical, caused by swelling of the nasal mucosa and the attachment of ethmoidite. Sometimes there is an objective cacosmia caused by the presence of ulcerative-necrotic process in the area of the maxillary sinus. Sometimes the average nasal concha and the ager nasi area are thinned, as if corroded.

The evolution of the acute frontal ganglion passes through the same stages as the acute sinusitis described above: spontaneous recovery, recovery due to rational treatment, transition to the chronic stage, the emergence of complications.

The prognosis is characterized by the same criteria that apply to acute maxillary sinusitis and acute rhinoemoideitis.

Diagnosis of acute frontitis

The diagnosis is made on the basis of the symptoms described above and the clinical picture. It should be borne in mind that often acute inflammation, starting in any one sinus, spreads through natural strokes or hematogenously into adjacent sinuses, which can be involved in the inflammatory process with a more pronounced clinical picture and mask the primary focus of inflammation. Therefore, purposefully diagnosing, for example, acute frontalitis, it is necessary to exclude diseases of other paranasal sinuses. As preliminary diagnostic methods, diaphanoscopy, thermography or ultrasound (sinuscan) can be used, however the main method is the x-ray of the paranasal sinuses, produced in various projections with the obligatory evaluation of the x-ray picture of the sphenoid sinus. In some cases, with insufficient efficiency of non-operative treatment and increasing clinical symptoms, trpanopuncture of the frontal sinus is resorted to.

Differential diagnosis is carried out primarily with exacerbation of the chronic sluggish current frontitis. Differentiation of acute frontitis should also be from acute sinusitis and acute rhinoemoideitis. If after purging and puncturing the maxillary sinus in the middle nasal passage, in front of it, purulent discharge still appears, this indicates the presence of an inflammatory process in the frontal sinus.

Pain syndrome with acute frontitis should be differentiated from various neuralgic facial syndromes caused by defeat of the trigeminal nerve branches, for example, from Charlene syndrome caused by neuralgia of the ciliary nasal (anterior branches of nn ethmoidales), usually arising from inflammation of the trellis labyrinth: severe pains in the medial corner eyes with irradiation on the back of the nose; one-sided swelling, hyperesthesia and hypersecretion of the nasal mucosa; injection of sclera, iridocyclitis (inflammation of the iris and ciliary body), hypopion (accumulation of pus in the anterior chamber of the eye, which descends down into the corner of the chamber and forms here a characteristic yellowish strip of a semilunar form with a horizontal level), keratitis. After anesthesia of the nasal mucosa, all symptoms disappear. In addition, the acute frontitis should be differentiated from the secondary purulent complications arising from frontal sinus tumors.

[9], [10], [11], [12], [13], [14]

Treatment of acute frontitis

Treatment of acute frontitis does not differ in principle from that which is carried out with other inflammatory processes in the paranasal sinuses. The main principle is to reduce the edema of the mucous membrane of the frontal sinus, restore the drainage function of the frontal-nasal passage and fight infection. To do this, use all the above means for the treatment of the maxillary sinus and the latticed labyrinth: the systematic intranasal use of decongestants, the introduction through the catheter in the frontal sinus of a mixture of adrenaline, hydrocortisone and the corresponding antibiotic, with the presence in the middle nasal passage of formations (the type of polypoid tissues) the functioning of the frontal-nasal canal, they are spared gently in the normal tissues or aspirated by applying the method of endoscopic rypochis urgii. In more severe cases resort to trepanonomy of the frontal sinus. Trepanopuncture of the frontal sinus is performed by iodine local infiltration anesthesia.

Preliminary X-ray examination of the paranasal sinuses with the use of special radiopaque metokorientirov in the forehead and nasal and lateral projections to determine the optimal point of puncture. There are various modifications to these labels. The simplest of them is a cross-shaped (10x10 mm) for a direct shot and in the form of a circle with a diameter of 5 mm for a lateral shot, cut from sheet lead. The tags are fixed with the help of adhesive plaster on the area of the projection of the frontal sinus in the place of its supposed maximum volume. The cross mark is the reference point for the front extension of the frontal sinus, the circular mark for the largest sagittal size of the sinus. When removing marks on the skin of the forehead, a pattern corresponding to the position of the markers along which the point of trephination of the frontal sinus is determined is applied. There are various modifications required for trepanation devices, manufactured primarily by handicraft. Any instrument consists of two parts: a conductor in the form of a short thick needle, to which a special fixator for the second and third fingers of the left hand is welded, with which the needle is pressed against the forehead and rigidly fixed to the bone at the selected point, and the puncture drill included in form of "mandrana" in the conductor. The length of the drill exceeds the length of the conductor by no more than 10 mm, but not so much as to rest against the puncture of the sinus in its posterior wall. The drill bit is equipped with a round knurled handle, with which the operator makes drilling operations with a drill inserted into the conductor, while constantly sensitively controlling the drilling process. Achieving the endosteus causes a feeling of "softness", and penetration in the frontal sinus - a sense of "failure" in it. It is important that, when penetrating into the bosom of the drill, the minimum pressure is applied, which prevents rough and deep insertion of the drill into the deep sections with the risk of injury to the brain wall. Further, tightly fixing the conductor to the bone, not allowing even the smallest displacements of its relative to the hole made in the frontal bone, the drill is extracted and a rigid plastic conductor is introduced instead. Then, keeping the conductor in the bosom, remove the metal conductor, and a plastic metal conductor is inserted into the bosom of a special metal or plastic cannula, which is fixed with a plaster adhesive to the skin of the forehead. This cannula serves to rinse the sinus and inject medicinal solutions into it. Some authors recommend performing microtracking of the frontal sinus after a small incision made 2 mm above the frontal nasal suture, using a microfrequency. Before operation trepanopunktsii frontal sinuses carry out a thorough anemization of the mucosa of the middle nasal passage.

Surgical treatment with a wide opening of the frontal sinus and the formation of an artificial frontal-nasal canal is indicated only when purulent complications arise from neighboring organs and with intracranial complications (osteomyelitis of the skull bones, leptomeningitis, abscess of the frontal lobe, thrombophlebitis of the venous plexus of the orbit, thrombosis of the cavernous sinus, phlegmon of the orbit , RBN ZN, etc.). In these cases, surgical intervention is performed only by external access using a milling cutter or chisels, excluding the use of bits and hammers, since the hammer-type method of bone removal leads to shocks and vibrations to the skull organs, which in turn helps mobilize microthrombi and their migration through the blood vessels and the introduction of infection in remote areas of the brain. In practice, the curettage of the mucous membrane, which contributes to the destruction of barriers and the opening of venous emissaries, is also to be excluded, but to which a diffuse spread of the infection is possible. Only superficial-lying pathological formations, especially those that encircle the funnel (granulation tissue, pus of clots, areas of necrotic bone, polypoid and cystic formations, etc.) are to be removed.