Acute frontal sinusitis
- Frontal sinusitis should be suspected in patients with facial pain particularly in the frontal sinus area. The suspicion should be confirmed by x-ray.
- Any concurrent maxillary sinusitis should be treated effectively.
- Frontal sinusitis becomes complicated more easily than other types of sinusitis. Patients with severe symptoms should be treated by an ENT specialist.
- Acute frontal sinusitis usually follows a viral respiratory infection.
- A large share of patients also have maxillary sinusitis at the same time 1.
- The infection spreads to the frontal sinus from the anterior ethmoidal sinuses through the nasofrontal duct. The narrow duct is easily obstructed by infection, allergy or other mucosal irritation.
- The nasofrontal duct is more sensitive than other sinuses to changes in atmospheric pressure. Frontal sinusitis may therefore occur in association with diving or flying.
- Causative agents and their frequencies are the same as for maxillary sinusitis.
- This is a disease of adolescents and adults; separate frontal sinuses are only formed after the age of 8 to 10 years. It is also possible that frontal sinuses are not formed at all (picture 1).
Symptoms and diagnosis
- Acute frontal sinusitis should be suspected if a patient has headache in the frontal sinus area.
- Frontal headache may be preceded by rhinitis and other upper respiratory tract symptoms.
- There may also be a history of diving or air travel.
- A diagnosis suspected on the basis of symptoms and findings should be confirmed by x-ray (picture 2).
- Facial pain particularly in the frontal sinus region
- Purulent nasal discharge manifesting either as purulent rhinitis or constant postnasal drip
- Impaired sense of smell
- Prolonged cough, rhinitis or nasal congestion
- Concurrent maxillary sinusitis may also manifest as toothache in upper canine or molar teeth.
- Clinical examination
- Tenderness to percussion over the frontal sinus
- Tenderness to palpation in the area of the base of the frontal sinus
- Discharge consistent with rhinitis, mucosal oedema and erythema visible in the nose
- Purulent discharge visible in the middle nasal meatus
- Possibly purulent postnasal drip
- X-ray examinations
- A fluid level on the AP sinus x-ray is a clear sign of frontal sinusitis (picture 3).
- An entirely opaque frontal sinus may be interpreted as undeveloped, which may delay the diagnosis. In this case, comparison with previous x-rays will help.
- Symptoms and signs suggestive of complications
- Compromised general condition
- Intensive pain
- Palpable mass on the forehead
- Eyelid oedema
- Double vision or pain on eye movement
- Neurological symptoms (such as confusion, lowered level of consciousness, meningism)
- The first-line antibacterial agents for the treatment of acute frontal sinusitis are
- amoxicillin 500–750 mg twice daily
- doxycycline; initially 150–200 mg, then 100–150 mg once daily
- first or second generation cephalosporins, such as cephalexin 750 mg twice daily or cefuroxime axetil 250 mg twice daily.
- Concurrent maxillary sinusitis should be effectively treated, preferably by lavage 2.
- Supportive treatment
- Glucocorticoid spray
- Decongestant nasal drops (for no more than 10 days)
Indications for referral
- Emergency referral
- Suspected complication
- Severe symptoms (frontal pain)
- Referral for appointment
- Symptoms of frontal sinusitis persisting despite appropriate medication
- Recurrent episodes of frontal sinusitis
- Nasal polyposis in patients with frontal sinusitis
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