Intracranial empyema complicating sinusitis in childhood: Epidemiology, imaging findings and outcome.

BACKGROUND: To describe clinical presentations of intracranial sinusitis complications in childhood, their pitfalls and imaging findings. MATERIEL AND METHODS: This retrospective IRB-approved single-center study included infants diagnosed with sinusitis and empyema and/or other intracranial complications who underwent imaging between September 2008 and September 2019. Three radiologists individually reviewed clinical charts and imaging findings, including sinusitis complications and at-risk anatomical variations. RESULTS: 21 children (76% males and 24% females, mean age 13±3.1 years) with imaging pansinusitis were included. Headache (95%) and fever (90%) were the main clinical nonspecific signs. Ten (48%) children presented an extradural empyema, nine (43%) children had a subdural empyema and two (10%) children had both. Frontal location sinusitis was the most common (76%). In MRI, all empyema presented as a hypo intensity on pre-contrast T1-WI, a hyperintensity on T2-WI, a reduced apparent diffusion coefficient (ADC) on diffusion weighted imaging (DWI) and a peripheral contrast enhancement on post-contrast T1-WI. CT or MRI revealed intracranial complications such as a collection size increase (52%), a midline shift (62%), intraparenchymal abscesses (24%), a cerebral venous thrombosis (29%), an intracranial pressure increase (29%), cerebral ischemia (43%) and Pott's Puffy Tumor (10%). Imaging highlighted sinus anatomical abnormalities in 52% of cases. All children were treated with sinus drainage and/or neurosurgery. Long-term follow-up was favorable in 14 cases (67%). CONCLUSION: Complications of sinusitis are life threatening in the studied population. Empyema and cerebral complications may be misleading. Brain contrast-enhanced CT covering sinuses and orbits, is mainly the first examination done but MRI is mandatory.

The prevalence of frontal cell variants according to the International Frontal Sinus Anatomy Classification and their associations with frontal sinusitis.

BACKGROUND: The International Frontal Sinus Anatomy Classification (IFAC) is introduced to simplify the classification of different frontal cell variants based on their topographical structures. The objectives of our study were to determine the prevalence of the frontal cell variants according to IFAC and their association with the development of frontal sinusitis. METHODOLOGY: A retrospective chart review on computed tomography paranasal sinus (CTPNS) was conducted. A total of 200 patients who had clinical and endoscopic findings of chronic rhinosinusitis (CRS) and undergone CTPNS were reviewed. The CTPNS was evaluated for the presence of frontal cell variants according to IFAC and mucosal changes consistent with frontal sinus involvement. RESULT: A total of 400 sides of the CTPNS were analyzed. The agger nasi cells (ANCs) were the most common (95.5%) followed by supra bulla cells (SBCs) (60.8%), supra bulla frontal cells (SBFCs) (53.0%), supra agger cells (SACs) (50.0%), supra agger frontal cells (SAFCs) (36.0%), frontal septal cells (FSCs) (8.3%), and supraorbital ethmoidal cells SOECs (5.5%). There was significant association between SOEC (p = 0.001) and FSC (p = 0.044) with the development of frontal sinusitis. CONCLUSIONS: Apart from ANCs, the posterior-based cells (SBCs and SBFCs) have higher prevalence than the anterior-based cells (SACs and SAFCs). Despite being the least, both SOECs and FSCs are significantly associated with frontal sinusitis.

Frontal sinus "mega-trephination" in a tertiary rhinology practice.

BACKGROUND: Frontal sinus trephination is traditionally performed through a small cutaneous incision and osteotomy, allowing irrigation of the frontal sinus. Utilizing the trephination osteotomy for endoscopic visualization and surgical manipulation requires a larger opening. This "mega-trephination" is thought to carry an increased risk of cosmetic deformity given the increased bony removal at the anterior table. The purpose of our study was to clarify the risks of frontal sinus mega-trephination and examine how this technique is incorporated into a modern, tertiary care rhinology practice. METHODS: Patients were identified through billing records and confirmed by retrospective chart review. All patients underwent frontal sinus mega-trephination, which is defined as an osteotomy large enough for insertion of a 4-mm endoscope and an operative instrument simultaneously. All patients had at least 2 years of follow-up. The primary outcome was complication rate, including cosmetic deformity. RESULTS: Sixty-four patients underwent frontal sinus mega-trephination from 2006 to 2016. The most common surgical indications were chronic sinusitis (34%), mucocele (19%), osteoma (17%), acute sinusitis (11%), and inverting papilloma (9%). Ten patients (16%) underwent mega-trephination alone, whereas the others had mega-trephination with endoscopic sinus surgery. Twenty-one patients (33%) had minor complications. The most common complications were self-limited paresthesia (11%), infection (8%), and epistaxis (3%). No patient complained of permanent cosmetic deformity or required revision surgery for cosmesis. CONCLUSION: Frontal sinus mega-trephination is a useful tool to augment the rhinologist's armamentarium in complex frontal sinus anatomy and pathology. This procedure is well tolerated, safe, and not associated with long-term cosmetic deformity.

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis.

OBJECTIVE: To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management. METHODS: Longitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed. RESULTS: The frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement. CONCLUSIONS: Our long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions.

A comparison of radiographic evidence of frontal sinusitis in middle-turbinate sacrificing versus middle-turbinate sparing approaches to the sella.

BACKGROUND: Initial descriptions of endoscopic approaches to the sella and pituitary involved resecting the middle turbinate (MT) to help improve access and visualization. Modifications of these procedures to preserve the MT have since been described, one rationale being to reduce the incidence of frontal sinusitis. The objective of this study was to establish the incidence of postoperative frontal sinusitis in MT sparing (MTsp) and MT sacrificing (MTsc) approaches to the sella. OBJECTIVE: A retrospective cohort study that compared radiographic evidence of frontal rhinosinusitis or frontal recess obstruction after skull base surgery in patients who underwent MTsc and MTsp endonasal approaches to the sella. METHODS: Consecutive retrospective review of pre- and postoperative magnetic resonance imaging from two institutions in geographic proximity but with different approaches to the sella. Mucosal thickening in the frontal sinus was measured and graded by a radiologist blinded to patient cohorts. RESULTS: Seventy-five patients, based on sample size calculations, were included at each site. Baseline demographics and indications for surgery were not significantly different between the groups. No difference was seen between the groups in the overall grade of radiographic frontal sinusitis seen on postoperative imaging. A total of 8 patients (10%) in the MTsc group had measured mucosal thickening, which was increased from their preoperative scan versus 15 in the MTsp group (20%) (p = 0.10). New mucosal thickening of >1 mm was found in three patients in the MTsc group and eight patients in the MTsp group (p = 0.21); the only patient with postoperative complete frontal sinus opacification was in the MTsp group. CONCLUSIONS: The choice of MTsc versus MTsp in endonasal endoscopic approach to the sella does not seem to make a difference in the incidence of postoperative radiographic frontal sinusitis.

Geographic and temporal trends in frontal sinus surgery.

BACKGROUND: The purpose of this study was to evaluate geographic and temporal trends in frontal sinus surgery procedures. METHODS: Medicare Part B data files from 2000 to 2011 were examined for temporal trends in various frontal sinus procedures, and the most recent year containing geographic information (2010) was evaluated for Current Procedural Terminology (CPT) code use. Additionally, nationwide charges per procedure were recorded. Regional populations of individuals ≥ 65 years old were obtained from the 2010 U.S. Census, and surgical society websites were used to determine the number of practicing rhinologists and otolaryngologists in each region. RESULTS: The use of open approaches declined by one third, while endoscopic procedures went from 6463 to 19262 annually, with the most marked increases occurring from 2006 through 2011. Geographic variation was noted, with practitioners in the South Atlantic states performing the greatest number of endoscopic procedures in 2010, whereas the East South Central states had the greatest number when controlling for population. There was an inverse relationship between endoscopic procedures performed and number of fellowship-trained rhinologists (controlling for regional populations) (R(2) = 0.66). The first year frontal sinus ballooning had a unique CPT code illustrated decreased reimbursements for non-balloon endoscopic surgery ($609) relative to balloon approaches ($2635). CONCLUSION: Declines in open frontal sinus surgery and marked increases in endoscopic approaches have potential implications for residency training. Potential reasons for marked increases in endoscopic approaches include the rising popularity of balloon technologies, although this is speculative. Geographic variation exists in frontal sinus surgery patterns, including an inverse relationship between endoscopic approaches and the number of fellowship-trained rhinologists.

Les sinusites chroniques de la face dans le service d'ORL du CHU Yalgado Ouedraogo de Ouagadougou; a propos de 365 cas

But: Analyser les aspects epidemiologiques; diagnostiques et therapeutiques des sinusites chroniques de la face. Methode: Il s'est agit d'une etude retrospective de 05 ans; portant sur 365 cas de sinusites chroniques. Resultats: L'incidence annuelle etait de 73 cas/an et l'age moyen de 33 ans. Les principaux motifs de consultation etaient les cephalees (80;80); l'obstruction nasale (34;79) et la rhinorrhee (19;72). Les sinus maxillaires (96;44) et ethmoidaux (60;39) etaient les plus touches et les facteurs etiologiques etaient domines par les allergies naso-sinusiennes (73;15); les infections aero-digestives (19;18) et les blocages ostiaux mecaniques (7;67). Le traitement; medical (79;45) et medico-chirurgical (20;55) a permis d'obtenir une evolution favorable (90;96). Les complications ont ete observees dans 5;75 avec un taux de letalite de 1;92

Celulitis orbitaria, celulitis frontal y empiema como complicaciones de sinusitis / Orbital cellulitis, frontal cellulitis and empyema as sinusitis complications

La celulitis orbitaria usualmente ocurre como complicación de infecciones de los senos para nasales, y la etiología es principalmente bacteriana. Para realizar un diagnóstico e implantar terapéutica temprana tiene gran importancia reconocer las manifestaciones clínicas de la sinusitis y las edades más afectadas, pues dada su ubicación anatómica, pueden complicarse también con infecciones del sistema nervioso central, que en la edad pediátrica tienen una connotación especial. Se presentan aquí dos pacientes de 10 y 14 años de edad respectivamente, que desarrollaron celulitis orbitaria en un caso, y celulitis frontal y empiema en el otro; así mismo, se muestran los medios diagnósticos utilizados para identificar signos tempranos de posibles complicaciones, con el objetivo que el pediatra pueda identificarlos, así como la terapéutica implantada para dar solución o evitar estas complicaciones(AU)

Orbital cellulite generally occurs as a complication of paranasal sinus infections and the etiology is mainly bacterial. It is very important to recognize the clinical manifestations of sinusitis and the most affected ages to make a correct diagnosis and to apply early treatment, since its anatomical location may bring complications with central nervous system infections which, at pediatric ages, can acquire special significance. Here are two patients aged 10 and 14 years, who developed orbital cellulitis in one case and frontal cellulitis and empyema in the other. Likewise, the diagnostic means used to identify the early signs of possible complications were presented, in order that a pediatrician can detect them, as well as the treatment to solve or to prevent these complications(AU)

Celulitis orbitaria, celulitis frontal y empiema como complicaciones de sinusitis / Orbital cellulitis, frontal cellulitis and empyema as sinusitis complications

La celulitis orbitaria usualmente ocurre como complicación de infecciones de los senos para nasales, y la etiología es principalmente bacteriana. Para realizar un diagnóstico e implantar terapéutica temprana tiene gran importancia reconocer las manifestaciones clínicas de la sinusitis y las edades más afectadas, pues dada su ubicación anatómica, pueden complicarse también con infecciones del sistema nervioso central, que en la edad pediátrica tienen una connotación especial. Se presentan aquí dos pacientes de 10 y 14 años de edad respectivamente, que desarrollaron celulitis orbitaria en un caso, y celulitis frontal y empiema en el otro; así mismo, se muestran los medios diagnósticos utilizados para identificar signos tempranos de posibles complicaciones, con el objetivo que el pediatra pueda identificarlos, así como la terapéutica implantada para dar solución o evitar estas complicaciones

Orbital cellulite generally occurs as a complication of paranasal sinus infections and the etiology is mainly bacterial. It is very important to recognize the clinical manifestations of sinusitis and the most affected ages to make a correct diagnosis and to apply early treatment, since its anatomical location may bring complications with central nervous system infections which, at pediatric ages, can acquire special significance. Here are two patients aged 10 and 14 years, who developed orbital cellulitis in one case and frontal cellulitis and empyema in the other. Likewise, the diagnostic means used to identify the early signs of possible complications were presented, in order that a pediatrician can detect them, as well as the treatment to solve or to prevent these complications

Orbital subperiosteal hematoma associated with sinus infection.

OBJECTIVES: There are few reports of orbital subperiosteal hematomas as a result of sinusitis complications. The present study reports on 2 such cases and presents a literature review regarding this condition. METHODS: We report 2 cases of orbital subperiosteal hematoma, and reviewed previous literature reports. RESULTS: Including the 2 current patients, 11 cases of orbital subperiosteal hematoma involving sinusitis appear in the literature. The current cases involved 2 older females presenting with proptosis. One had frontal sinusitis and the other a postoperative frontoethmoid mucocele. Both patients underwent a superior orbitotomy and sinus surgery, which resolved the orbital symptoms. CONCLUSION: Orbital subperiosteal hematomas can develop associated with sinus infection. Such a condition should be treated as a sinusitis complication and the associated sinus infection must be treated concomitantly.

Sinus balloon dilators: one surgeon's experience and proposed indications for their use.

From October 2006 through September 2007, balloon sinusotomies were attempted on 89 sinuses in 45 patients with chronic sinus disease. Ninety-eight percent of sinuses were successfully dilated, 3.4% required revision surgery, and one complication (unlikely related to use of the balloon) occurred. Forty-four percent had previous conventional endoscopic sinus surgery (ESS), 87% were hybrid cases (combination of balloon and conventional ESS instruments used), 33% had nasal polyposis, and 1.98 sinuses per patient were dilated. Preoperative Lund-Mackay radiographic sinus-staging scores averaged 12.62. Sinus balloon dilators (SBDs) were used on the frontal sinuses 81% of the time, sphenoids 13%, and maxillary sinuses 6%. SBDs were found to be efficacious and safe. The devices were useful in identifying and dilating the frontal recess, especially in cases with altered anatomy or limited visibility. When compared to conventional ESS instrumentation, however, SBDs were found to offer little advantage in opening the maxillary or sphenoid sinuses. In frontal sinus hybrid cases, using the author's proposed surgical algorithm reduces operative time, costs and, in some cases, the need for balloon dilatation. SBDs have limited indications in a select group of patients.

Frontal sinus mini-trephination for acute sinusitis complicated by intracranial infection.

INTRODUCTION: Acute bacterial sinusitis is common in the pediatric population. Intracranial spread of infection is a rare but life-threatening complication of acute sinusitis. Due to the infrequent presentation of this complication, there are no well-defined management protocols for the acute sinusitis. CASE SERIES: We present three pediatric cases where children presented with intracranial sepsis, and the underlying source of infection was from the paranasal sinuses. In all cases, endoscopic sinus surgery was performed in the acute setting, with the use of frontal sinus mini-trephines playing a significant role. DISCUSSION: We describe our experience and review the available literature.

Concha bullosa types: their relationship with sinusitis, ostiomeatal and frontal recess disease.

PURPOSE: To assess the relationship among the concha bullosa types and sinusitis, ostiomeatal and frontal recess disease. MATERIALS AND METHODS: Computed tomography (CT) studies of 76 patients diagnosed with concha bullosa were reviewed retrospectively. All examinations were performed for evaluation of a symptom referable to sinonasal region. Concha bullosa cases were grouped according to the location of pneumatization of middle concha as lamellar, bulbous, and extensive. Each group was compared according to sinus, ostiomeatal and frontal recess disease. We have assessed the location of ostium (frontal recess, air cells along the basal lamella, hiatus semilunaris) with respect to the types of concha bullosa. RESULTS: There was not a significant relationship between concha bullosa types and sinus disease, ostiomeatal disease, and frontal recess disease (p > 0.05). The location of ostium of the bulbous type was the hiatus semilunaris (p < 0.05) and that of the extensive type was the frontal recess (p < 0.05) preferentially. CONCLUSION: There is no statistically significant difference between lamellar, bulbous and extensive type concha bullosas in terms of sinus disease, ostiomeatal disease and frontal recess disease incidence. Bulbous type preferentially drains into the hiatus semilunaris, and extensive into the frontal recess.

Monitorización con ultrasonografía portátil de la respuesta al tratamiento antibiótico de la sinusitis maxilar y frontal en una consulta pediátrica de atención primaria / Use of portable ultrasonography for monitoring of response of maxillary and frontal sinusitis to antibiotic therapy in primary pediatric care

Objetivo. Determinar si la utilización de ultrasonografíaportátil en la monitorización de la desaparición delexudado sinusal maxilar y/o frontal permite reducir significativamentela duración del tratamiento antibiótico de lasinusitis paranasal pediátrica, sin aumentar la incidenciade recidivas ni complicaciones, en una consulta pediátricade atención primaria.Método. Estudio prospectivo de un año de duración,controlado, abierto y aleatorizado, en el que se han incluidotodos los niños diagnosticados ecográficamente desinusitis maxilar y/o frontal. En el grupo de estudio se hahecho tratamiento antibiótico de 4 días de duración, concontrol clínico y ecográfico al 5º día, y en caso de no resoluciónde la clínica y/o ecografía, se ha mantenido el tratamientocon controles seriados a los 9, 11, y 15 días hasta laresolución. El grupo de control ha recibido tratamiento 14días, y en caso de no-resolución se ha mantenido hasta el21. Se ha evaluado la respuesta al tratamiento, y se hanhecho controles clínicos y ecográficos a los 30, 60 y 90 días,valorando la presencia de recidivas y complicaciones enambos grupos.Resultados. Se han estudiado 83 niños, 37 en el grupode estudio y 46 en el de control. El 75% de los niños delgrupo 1 han presentado clínica y ecografía negativas al 5ºdía. En el 16% se ha observado discrepancia entre una clínicanegativa y ecografía alterada. En el 8% no ha habidomejora clínica ni ecográfica. En estos dos últimos grupos seha mantenido el tratamiento hasta los 8 días, con una resolucióntotal en el 78%. El resto se han tratado hasta los15 días con resolución de todos los casos. El 95% del grupo2 han presentado resolución total a los 15 días. El 5% hapresentado clínica negativa con ecografía positiva. En estegrupo se ha prolongado el tratamiento hasta los 21 días,con resolución total. No han habido diferencias significativasentre ambos grupos ni en el número de recidivas ni enla aparición de complicaciones. La media de duración deltratamiento ha sido significativamente inferior en el grupode intervención (6 días) que en el de control (15 días). Conclusiones. La monitorización ecográfica permite reducirde manera significativa la duración del tratamientoantibiótico de la sinusitis maxilar y frontal pediátrica, sinaumentar las recidivas ni las complicaciones

Objective. To determine whether the use of portableultrasonography for the evaluation of the resolution ofthe maxillary and/or frontal sinus exudates in primary careallows to shorten the duration of antibiotic therapy inparanasal sinusitis in children, without increasing the rateof recurrences or complications.Methods. One year prospective, open, controlled andrandomized study, including all cases of paranasal sinusitisdiagnosed by ultrasonography. In the study group, antibiotictherapy was given for 4 days, and clinical andultrasonographic evaluation was performed on day 5. Forpatients with clinical and/or ultrasonographic signs ofpersistent disease, antibiotic therapy was continued untilday 8, with follow-up evaluations on days 9, 11, and 15,until a complete resolution of infection was obtained. Inthe control group, antibiotic treatment was given for 14days, and was extended for 21 days in patients with persistentsymtoms. Clinical and ultrasonographic evaluationof response to therapy was performed on days 30, 60, and90, and recurrences and complications were documented.Results. The study included 83 children, 37 in the studygroup and 46 in the control group. Seventy-five percent ofpatients in the study group had clinical improvement andnormal ultrasonography on day 5 evaluation. Sixteen percentof the study group patients had clinical improvementwith abnormal ultrasonographic findings, and 8% hadpersistent clinical and ultrasonographic disease. In thosetwo later groups, treatment was continued until day 8,and complete resolution was documented in 78% of thepatients. The remainder of the patients were treated untilday 15, with complete resolution of sinusitis in all patients.For the patients in the control group, 95% of them hadcomplete resolution of sinusitis at day 15. Five percent ofpatients had clinical improvement with persistent ultrasonographicfindings. In this group of patients, treatmentwas continued until day 21, with complete response in allof them. There were no significant differences in recurrencerate or incidence of complications between groups.The median length of treatment was significantly lower inthe study group (6 days vs. 15 days in control group).Conclusions. The use of ultrasonography for evaluationof response of paranasal sinusitis to antibiotic therapyallows for a significant reduction in the duration of treatment,without an increased incidence of recurrences orcomplications

Acute and chronic frontal sinusitis.

This review summarizes the recent literature published on the microbiology, diagnosis, and medical and surgical management of acute and chronic frontal sinus disease. Two retrospective studies investigated the microbiology of frontal sinusitis in patients that underwent sinus surgery. Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus predominated in acute infection in patients with acute frontal sinusitis, and S. aureus and anaerobic bacteria were commonly isolated in chronic sinusitis. Surgery is indicated to treat patients with acute and chronic sinusitis and their complications. Several surgical procedures were recently evaluated, and these are briefly reviewed.

Bacteriology of acute and chronic frontal sinusitis.

Aspirates of 15 acutely and 13 chronically infected frontal sinuses were processed for aerobic and anaerobic bacteria. A total of 20 isolates (1.3 per specimen) were recovered from the 15 cases of acute frontal sinusitis, 16 aerobic and facultative isolates (1.1 per specimen) and 4 anaerobic isolates (0.3 per specimen). Aerobic and facultative organisms alone were recovered in 13 specimens (87%), and mixed aerobic and anaerobic bacteria were recovered in 2 (13%). The predominant aerobic and facultative organisms were Haemophilus influenzae (6), Streptococcus pneumoniae (5), and Moraxella catarrhalis (3). A total of 32 isolates were recovered from the 13 cases (2.5 per patient) of chronic frontal sinusitis, 12 aerobic and facultative isolates (0.9 per specimen) and 20 anaerobic isolates (1.5 per specimen). Aerobic and facultative organisms only were recovered in 3 instances (23%), anaerobes only in 7 instances (54%), and mixed aerobic and anaerobic bacteria in 3 instances (23%). The predominant aerobic bacteria were gram-negative bacilli (H influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa). The predominant anaerobes included Prevotella species (8), Peptostreptococcus species (6), and Fusobacterium species (4). These findings illustrate the microbiologic features of acute and chronic frontal sinusitis.

[Incidence of purulent frontal sinusitis in Samara]. / Zabolevaemost' gnoinym frontitom v Samare.

The author analyses incidence of purulent frontal sinusitis in Samara, structure of this disease and its social implications by the data from the ENT clinic of the Samara State Medical University for 1990-2000.

Complications of frontal sinusitis and their management.

Because of the anatomic location and venous drainage pattern of the frontal sinus, complications commonly involve intracranial structures but can involve the orbit and adjacent bony and soft tissue structures also. Evaluation of patients by a thorough history and physical examination, culture of purulent discharge or infected bone, and axial and coronal CT scanning with contrast is important for diagnosis and treatment planning. Treatment of complications uniformly involves the use of intravenous antibiotics and appropriate drainage procedures to arrest the infection and allow for resolution of the inflammatory complication. Significant morbidity and mortality from complications can occur despite aggressive medical and surgical treatment.

A survey of contemporary management of frontal sinus disease in the United Kingdom.

Surgery for frontal sinus disease historically has required an external approach. With the advent of endoscopic sinus surgery, endoscopic treatment for various frontal sinus pathologies has been described. This survey examined how widespread the use of endoscopy in frontal surgery has become. We were interested both in the acute emergency situation and in the more chronic situations such as mucocoeles. The replies of 266 practising United Kingdom surgeons to a postal questionnaire were evaluated. While 45% of surgeons regularly practise functional endoscopic sinus surgery (FESS), approximately 25% would attempt endoscopic drainage of acute frontal sinusitis and most perform an external trephine. Most surgeons also rely on external approaches to manage mucocoeles or pyocoeles (54%), although some (39%) attempt endoscopic drainage if the cyst lies sufficiently medially. Even with recurrent or intractable disease one-third attempt endoscopic surgery. When external surgery is used in the United Kingdom, only a small number of surgeons favour obliteration.