Frontal Sinusitis

The exact percentage of persons developing frontal sinusitis is not known although roughly 3-6% of children with pansinusitis will have frontal disease.

Frontal sinus is a pyramidal shaped structure with vertical and horizontal segments in the frontal bone. It borders the anterior cranial fossa and the roof of the orbit.

The frontal sinus, not present at birth, develops from either the frontal recess or from anterior ethmoidal cells. It is radiographically visible by seven years of age and reaches full size by adulthood.

Frontal sinusitis stems from blockage of the nasofrontal duct ostium. Mechanical obstruction and local mucosal edema lead to symptoms of frontal headache, fever, rhinorrhea and cough. Frontal sinusitis is a very serious condition requiring aggressive medical management.

Acute sinusitis in adults has been tied to non-typable H. influenza, S. pneumonia, S. pyogenes, alpha hemolytic streptococcus, and neisseria. S. pneumonia, B. catarrhalis, and H. influenza account for acute disease in children.

Medical treatment consists of analgesics, topical decongestants, and antibiotics. Persistent frontal pain, periorbital edema, and forehead edema indicate disease progression mandating surgical intervention.

Though endoscopic enlargement of the frontal sinus ostium is beginning to gain attention, endoscopic frontal sinus approaches have not gained wide popularity in the pediatric population. The removal of agar nasi cells and entrance through the floor of the frontal sinus with silastic stenting provides drainage without disfiguring skin incisions.

Complications of frontal sinusitis include recurrent sinusitis, mucocele, pyocele, orbital sequelae, and intracranial spread of infection. Intracranial spread of infection leads to meningitis, subdural empyema, brain abscess, and cavernous sinus thrombosis. The consortium of frontal osteomyelitis and subperiosteal abscess has been termed Pott's Puffy Tumor. Signs and symptoms include a soft and fluctuant forehead mass, headache, photophobia and fever.

Complications often require evaluation by the neurosurgical service with a combined surgical approach to remove infected tissues. The length of antibiotic therapy is dictated by the seriousness of disease.