Acute frontitis

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

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Causes of acute frontal sinusitis

The etiology and pathogenesis of acute frontal sinusitis are typical for common sinusitis; the 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 incidence of acute frontal sinusitis and its complications, the severity of the clinical course are directly dependent on the size (airiness) of the frontal sinus, the length of the frontonasal canal and its lumen.

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

• By etiology and pathogenesis: banal rhinopathy, mechanical or barometric trauma (baro- or aerosinusitis), metabolic disorders, immunodeficiency states, etc.
• According to pathomorphological changes: catarrhal inflammation, transudation and exudation, vasomotor, allergic, purulent, ulcerative-necrotic, osteitis.
• By microbial composition: common microbiota, specific microbiota, viruses.
• By symptoms (by the predominant feature): neuralgic, secretory, febrile, etc.
• According to the clinical course: torpid form, subacute, acute, hyperacute with a general severe condition and involvement of neighboring organs and tissues in the inflammatory process.
• Complicated forms: orbital, retro-orbital, intracranial, etc.
• Age-related forms: like all other sinusitis, frontal sinusitis in children, mature individuals and the elderly is distinguished, each with its own clinical characteristics.

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Symptoms and clinical course of acute frontal sinusitis

Patients complain of constant or pulsating pain in the forehead, radiating to the eyeball, to the deep parts of the nose, accompanied by a feeling of fullness and distension in the area of the superciliary arches and nasal cavity. The upper eyelid, the inner commissure of the eye, the periocular area appear edematous, hyperemic. On the affected side, lacrimation increases, photophobia, hyperemia of the sclera appear, sometimes anisocoria due to miosis on the affected side. At the height of the inflammatory process, when the catarrhal phase passes into the exudative, pain in the specified area intensifies, generalizes, its intensity increases at night, sometimes becoming unbearable, bursting, tearing. At the onset of the disease, nasal discharge is scanty and is caused mainly by inflammation of the nasal mucosa, the endoscopic picture of which is characteristic of acute catarrhal rhinitis. Headaches intensify with the cessation of nasal discharge, which indicates their accumulation in the inflamed sinus. The use of topical 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 discharge from the corresponding frontal sinus, which appears in the anterior sections of the middle nasal passage. At the same time, headaches decrease or stop. Only pain remains when palpating the frontal notch through which the medial branch of the supraorbital nerve exits, a dull headache when shaking the head and when tapping on the superciliary arch. As discharge accumulates, the pain syndrome gradually increases, body temperature rises, the general condition of the patient worsens again.

The above symptoms intensify at night due to increased swelling of the nasal mucosa: general headache, pulsating radiating pain to the orbit and retromaxillary region, to the area of the pterygopalatine ganglion, which plays a major role in the pathogenesis of inflammation of all anterior paranasal sinuses. The pterygopalatine ganglion, which belongs to the parasympathetic nervous system, provides excitation of the cholinergic structures of the internal nose and the mucous membrane of the paranasal sinuses, which is manifested by the expansion of blood vessels, increased functional activity of the mucous glands, and increased permeability of cell membranes. These phenomena are of great importance in the pathogenesis of the disease in question and play a positive role in the elimination of toxic products from the affected paranasal sinuses.

Objective signs of acute frontal sinusitis

When examining the facial area, attention is drawn to diffuse swelling in the area of the superciliary arch, root of the nose, internal commissure of the eye and upper eyelid, swelling of the outer coverings of the eyeball and lacrimal ducts, swelling in the area of the lacrimal caruncle, hyperemia of the sclera and lacrimation.

The above changes cause severe photophobia. The skin in the above areas is hyperemic, sensitive to touch, and its temperature is elevated. When pressing on the outer-lower angle of the orbit, a painful point described by Ewing is revealed, as well as pain when palpating the supraorbital notch - the exit point of the supraorbital nerve. Sharp soreness of the nasal mucosa in the area of the middle nasal passage is also revealed when indirectly palpating with a button probe.

During anterior rhinoscopy, mucous or mucopurulent discharges are detected in the nasal passages, which, after their removal, reappear in the anterior sections of the middle nasal passage. Particularly abundant discharges are observed after anemization of the middle nasal passage with an adrenaline solution. The nasal mucosa is sharply hyperemic and edematous, the middle and lower nasal turbinates are enlarged, which narrows the common nasal passage and complicates nasal breathing on the side of the pathological process. Unilateral hyposmia is also observed, mainly mechanical, caused by edema of the nasal mucosa and the addition of ethmoiditis. Sometimes objective cacosmia is observed, caused by the presence of an ulcerative-necrotic process in the area of the maxillary sinus. Sometimes the middle nasal turbinate and the ager nasi area are thinned, as if eaten away.

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

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

Diagnosis of acute frontal sinusitis

The diagnosis is established based on the symptoms and clinical picture described above. It should be borne in mind that acute inflammation, having started in one sinus, often spreads along natural passages or hematogenously to neighboring sinuses, which may be involved in the inflammatory process with a more pronounced clinical picture and mask the primary focus of inflammation. Therefore, when purposefully diagnosing, for example, acute frontal sinusitis, it is necessary to exclude diseases of other paranasal sinuses. Diaphanoscopy, thermography or ultrasound (sinuscan) can be used as preliminary diagnostic methods, but the main method is radiography of the paranasal sinuses, performed in various projections with a mandatory assessment of the radiographic picture of the sphenoid sinus. In some cases, if non-surgical treatment is insufficiently effective and clinical symptoms increase, trepanopuncture of the frontal sinus is used.

Differential diagnostics are carried out primarily with an exacerbation of chronic sluggish frontal sinusitis. Acute frontal sinusitis should also be differentiated from acute sinusitis and acute rhinoethmoiditis. If, after puncture and rinsing of the maxillary sinus, purulent discharge continues to appear in the middle nasal passage, its anterior part, this indicates the presence of an inflammatory process in the frontal sinus.

The pain syndrome in acute frontal sinusitis should be differentiated from various neuralgic facial syndromes caused by damage to the branches of the trigeminal nerve, for example, from Charlin's syndrome caused by neuralgia of the cilionasal nerve (anterior branches of the nn. ethmoidales), usually occurring with inflammation of the ethmoid labyrinth: severe pain in the medial corner of the eye radiating to the bridge of the nose; unilateral swelling, hyperesthesia and hypersecretion of the nasal mucosa; scleral injection, iridocyclitis (inflammation of the iris and ciliary body), hypopyon (accumulation of pus in the anterior chamber of the eye, which descends downwards into the corner of the chamber and forms a characteristic yellowish strip of a crescent shape with a horizontal level), keratitis. After anesthesia of the nasal mucosa, all symptoms disappear. In addition, acute frontal sinusitis should be differentiated from secondary purulent complications that arise with tumors of the frontal sinus.

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Treatment of acute frontal sinusitis

Treatment of acute frontal sinusitis is not fundamentally different from that carried out for other inflammatory processes in the paranasal sinuses. The main principle is to reduce swelling of the mucous membrane of the frontal sinus, restore the drainage function of the frontonasal passage and fight infection. For this purpose, all the above-mentioned means are used in the treatment of the maxillary sinus and ethmoid labyrinth: systematic intranasal use of decongestants, introduction of a mixture of adrenaline, hydrocortisone and an appropriate antibiotic through a catheter in the frontal sinus, in the presence of formations in the middle nasal passage (type of polypoid tissues) that serve as an obstacle to the functioning of the frontonasal canal, they are gently bitten off or aspirated within the normal tissues using the method of endoscopic riposurgery. In more severe cases, trepanopuncture of the frontal sinus is used. Trepanopuncture of the frontal sinus is performed under local infiltration anesthesia.

A preliminary X-ray examination of the paranasal sinuses is performed using special X-ray contrast landmarks in the frontal-nasal and lateral projections to determine the optimal puncture point. There are various modifications of these marks. The simplest of them are a cross-shaped one (10x10 mm) for a direct image and a circle with a diameter of 5 mm for a lateral image, cut from sheet lead. The marks are attached with adhesive tape to the projection area of the frontal sinus at the site of its expected maximum volume. The cross-shaped mark is a reference point in relation to the frontal extent of the frontal sinus, the circular one is in relation to the largest sagittal size of the sinus. When removing the marks, a pattern is applied to the skin of the forehead corresponding to the position of the marks, which is used to determine the point of trepanation of the frontal sinus. There are various modifications of the devices required for trepanation, made mainly by handicraft methods. Any instrument consists of two parts: a conductor in the form of a shortened thick needle, to which a special retainer for the II and III fingers of the left hand is welded, with the help of which the needle is pressed to the forehead and rigidly fixed on the bone at the selected point, and a puncture drill, which enters the conductor in the form of a "mandrin". 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 its back wall when puncturing the sinus. The drill is equipped with a round ribbed handle, with the help of which the operator makes drilling movements with the drill inserted into the conductor, all the time sensitively controlling the drilling process by sensation. Reaching the endosteum causes a feeling of "softness", and penetration into the frontal sinus - a feeling of "failure" into it. It is important that minimal pressure is exerted on the drill when penetrating the sinus, which prevents rough and deep penetration of the drill into deep sections with the risk of injury to the brain wall. Next, firmly fixing the guidewire to the bone, not allowing even the slightest displacement of it relative to the hole made in the frontal bone, remove the drill and insert a rigid plastic guidewire instead. Then, keeping the guidewire in the sinus, remove the metal guidewire and insert a special metal or plastic cannula into the sinus along the plastic guidewire, which is fixed to the skin of the forehead with adhesive tape. This cannula is used to wash the sinus and introduce medicinal solutions into it. Some authors recommend performing microtrepanation of the frontal sinus after a small incision made 2 mm above the frontonasal suture, using a micromill. Before the operation of trepanopuncture of the frontal sinus, careful anemization of the mucous membrane of the middle nasal passage is performed.

Surgical treatment with wide opening of the frontal sinus and formation of an artificial frontonasal canal is indicated only in the case of purulent complications from adjacent organs and intracranial complications (osteomyelitis of the skull bones, leptomeningitis, abscess of the frontal lobe, thrombophlebitis of the venous plexuses 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 chisels and hammers, since the hammer method of removing bone tissue leads to concussions and vibration effects on the cranial organs, which in turn contributes to the mobilization of microthrombi and their migration through the blood vessels and the introduction of infection to distant areas of the brain. Curettage of the mucous membrane should be practically excluded, as it promotes the destruction of barriers and the opening of venous emissaries, which may allow diffuse spread of infection. Only superficial pathological formations are subject to removal, especially those that obstruct the funnel (granulation tissue, purulent clots, areas of necrotic bone, polypoid and cystic formations, etc.).