Case Stories

A 21-year-old fell  off his motorcycle and struck the side of his face on the murram road. When seen at the Emergency clinic, he was found to have a bruised and swollen left cheek. There was a subconjuctival hemorrhage in the left eye, and the lower orbital margin and maxilla were tender. Sensation, over the left cheek was normal. The initial radiograph taken at the clinic did not show a fracture of the maxilla, but there was a fluid level of blood in the left maxillary air sinus. He was therefore presumed to have a fracture involving the maxilla. It is important to examine the sinuses of radiographs of injured patients, because sometimes an opaque sinus will be the only clue to bony injury. His facial swelling subsided during the subsequent weeks, and further radiographs failed to show the fracture. The floor of the orbit was stable and he did not develop double vision. Sensation remained normal over the cheek, indicating that the Infraorbital nerve had not been damaged. The student should test for double vision and cheek sensation whenever he is presented with an injury to the front of the face. A repeat radiograph 6 weeks after the injury showed that the blood had cleared from the maxillary sinus.

A 40-year-old nurse, caught a cold from her ward. She remained in bed for a week and then decided to start work again. She developed a severe left-sided frontal headache, and pain below the left eye. When seen at the local health center, she had pyrexia and was tender over both the left maxillary and left frontal sinuses. A radiograph showed that the left maxillary sinus was opaque and that there was a fluid level in the left frontal air sinus. She was given a course of antibiotics, and made some improvement. Over the course of the next few weeks, the frontal sinusitis cleared, but the maxillary sinus remained full. She was referred for proof puncture and antral lavage. (Maxillary air sinus is often called antrum by the ENT surgeon). Proof puncture was done under local anaesthetic. A trocar and cannula were driven through the thin bone beneath the inferior turbinate into the maxillary sinus. The trocar was removed, and a syringe attached to the cannula.

Pus was aspirated and a specimen sent for culture and antibiotic sensitivity. A syringe was then attached to the cannula and the sinus was washed out with sterile saline at body temperature. This procedure blew open the opening of the maxillary sinus and washed out the sinus. At the end of the operation, a polythene tube was inserted through the cannnula into the sinus and left in place. The nursing staff washed out the maxillary antrum3 times daily for the following 2 days, by which time it was clear.

A 46-year-old chronic alcoholic vagrant, presented himself at the emergency unit with a swollen and inflamed forehead. On examination, there was bony tenderness of the forehead and both maxillae. He was pyrexial. A radiograph showed that both maxillae were opaque; there was also opacity of the left ethmoidal and frontal sinuses. The frontal bone had a fluffy appearance, indicating spread of infection from the sinus to bone. He therefore had frontal osteomyelitis (inflammation of bone).He was admitted for an intensive course of antibiotics and for rehabilitation. He was discharged after 3 weeks of treatment in a reasonably fair state of health, but was seen a few weeks later in the emergency with hepatitis.

The Nasal Cavity and Paranasal Sinuses