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The treatment of orbital complications of nasosinusal processes has seen numerous modifications. Traditionally, cases with purulent collections were treated by external drainage. Currently, the introduction of new optical systems allows such complications to be approached from within the nasal cavity. We report a case of a 3-year-old girl with a subperiosteal orbital abscess secondary to ethmoiditis, which was cured by minimally aggressive endoscopic management and medical treatment.

Ethmoid mucocele, a condition that usually affects adults, can be found in both children and infants with cystic fibrosis. We have cared for two patients with cystic fibrosis and ethmoid mucoceles. Because we could find no references to the prognosis or any long-term follow-up data for this disorder, we contacted the physicians and families of six of the seven patients with this condition previously reported in the English literature to determine how they were managed surgically and the incidence of recurrence. Regardless of the mode of therapy, none of the mucoceles recurred.

Although sinus surgery may reduce the incidence of recurrent infection in patients with chronic sinusitis, little is known about the effect of such surgery on a patient's quality of life. One hundred eight patients undergoing ethmoid sinus surgery were prospectively evaluated with statistically validated measures of sinusitis-specific and general health-related quality of life. Twelve months after surgery significant improvements were found in sinus-specific health status, including a reduction in symptoms (p < 0.001) and medication usage (p < 0.001). An overall improvement was found in 82% of patients, whereas 11% were worse, and 7% remained unchanged. Measures of general health status demonstrated preoperative decrements in five of eight subscales as compared with the normal population. Six months after surgery significant improvements were noted in six categories (p < 0.05), and most attained near-normative levels. Individuals with asthma demonstrated greater overall improvement in general health status than did other cohorts (p < 0.05). We conclude that patients with chronic sinusitis achieve large improvements in sinusitis-specific quality-of-life measures 12 months after sinus surgery, as well as improvements in general health status.

Intracranial suppurative complications of sinusitis remain a challenging and contemporary topic. To determine the prevalence of sinogenic sources in intracranial infectious complications, we reviewed the records at a large public hospital between 1985 and 1995. There were 203 patients with 212 suppurative intracranial infections. Sinogenic sources were identified in 12 patients with 19 infections. Most patients had ethmoid or frontal sinusitis. We discuss the presentation, microbiology, diagnosis, treatment, and clinical course of these 12 cases. The diagnosis of intracranial complications of sinusitis requires a high index of suspicion and radiographic imaging of the head and paranasal sinuses. The mean hospital stay was 31.4 days and all 12 patients survived, although three patients had significant neurologic sequelae.

The relationship of paranasal sinusitis to optic neuritis remains controversial. One of the major sources of this controversy is that there are some reports of rhinogenic optic neuritis (RON) in patients with mild paranasal sinusitis or with almost normal paranasal sinuses. The Onodi cell is a posterior ethmoid cell which pneumatized far laterally and to some degree superiorly to the sphenoid sinus and is intimately associated with the optic nerve. Coronal CT scanning is requisite to detect the Onodi cell; when it is present, an image of the sphenoid sinus just as if it were divided into top and bottom is characteristic. In our material from 200 patients (direct coronal CT scans 10 mm in width), the Onodi cell was observed in 7%. A case of RON whose pathogenesis was considered to be a direct spread of inflammation from the localized infection of the Onodi cell is reported. Ethmoiditis localized to the Onodi cell seems to play an important role in the pathogenesis of RON. Continued careful documentation of the localized posterior paranasal sinus lesion around the optic canal by detailed diagnostic imaging and endoscopic sinus surgery is necessary to resolve the disease entity of RON.

The ethmoid and maxillary sinuses are the sinuses most frequently involved with orbital infections. Routes of spread are by direct extension through bone and indirectly through the valveless venous plexuses of the orbit, nose, and sinus. Classification of orbital infections can be thought of as either preseptal or postseptal and then further subdivided from there. The diagnosis has been greatly improved by the use of CT scans; however this should never be the only entity used for diagnosis. The determination of visual acuity (VA) is the single most important finding and will ultimately determine treatment modality. Orbital infections show different and more virulent bacteria than does non-complicated sinusitis and this should be reflected in the choice of medical and surgical therapy. Medical management is well accepted for infections without abscesses, and surgery is generally needed for infections with an abscess.

Objective: To limit endoscopic abscess drainage to the opening of the ethmoid cells involved, adjacent to the subperiosteal orbital abscess., Design: Prospective study., Patients: Twenty children with subperiosteal orbital abscess complicating acute sinusitis., Intervention: Endoscopic opening of the medial wall of the bulla ethmoidalis and of the lamina papyracea., Results: The limited endoscopic approach allowed subperiosteal orbital abscess drainage in all patients with positive clinical outcomes. Extensive ethmoidectomy was not necessary to achieve drainage., Conclusions: Endoscopic subperiosteal orbital abscess drainage does not require complete ethmoidectomy as was previously performed and can be limited to the opening of the bulla ethmoidalis and the lamina papyracea through the bulla ethmoidalis.

Background: Although vision-threatening sinusitis complications are not uncommon, an unusual case of asymptomatic posterior orbital cellulitis resulting from maxillary and ethmoidal sinus infection is presented., Methods, Results: An 11-year-old girl was brought to us for a routine optometric examination, reporting only blurred distance vision. A mild afferent pupillary defect was the key to detection and diagnosis of a vision-threatening posterior orbital cellulitis., Conclusions: A literature review of relevant anatomic and pathologic mechanisms, as well as radiologic recommendations, follows. This case appears to be a new clinical entity, an asymptomatic variant of posterior orbital cellulitis.

Analysis of a clinical case of secondary purulent meningitis due to the spread of inflammation from back cells of the ethmoid bone is the focus of this review. Attention is concentrated on difficulties of diagnosing this variant of ethmoiditis and high risk of development of cerebral complications. It is advisable that clinical methods of examination be combined with instrumental ones in order that to avoid gross blunders in diagnosis might be avoided.

Chronic sinus disease associated with progressive mucosal disease is often a cause for anosmia. Despite aggressive allergic, medical, and surgical intervention, long-term relief of anosmia has been difficult to document. Fifty patients sought treatment for subjective anosmia and symptoms of progressive sinusitis and underwent endoscopic sinus surgery. After surgery 52% maintained significant improvement in smell by subjective measures that correlated with objective olfactory University of Pennsylvania Small Identification test ("UPSIT") results. Of the remaining patients, some had intermittent improvement, but most remained hyposmic or anosmic despite clinically well-healed ethmoid surgical beds. Of the preoperative and postoperative historical, clinical, and radiological data analyzed, severity of the presenting sinus disease (defined as stage II In the Kennedy staging criteria or disease extending beyond the ethmoids on preoperative computed tomography scan) and persistent mucosal disease in the surgical bed are associated with persistent anosmia (p = 0.005).

Objective: The purpose of this study was to assess the usefulness of computerized tomography (CT) scan in the diagnosis and management of the complications of acute ethmoiditis in children., Materials and Methods: A retrospective revision of the records of pediatric patients admitted to Sant Joan de Déu Hospital from January 1985 to June 1994 was performed., Results: Thirty-eight children (22 males and 16 females) between the ages of 18 months and 15 years (mean age 6.5 years) were studied. All of the patients had eyelid afflictions; 5 (13.2%) with eyelid edema and 33 (86.8%) with periorbital cellulitis. All of them were unilateral without side predominance. The signs and symptoms included fever (37) and orbital pain and headache (24), with 28 patients presenting other forms of sinusitis. CT scan was applied in 24 children (63%). Thirteen of these patients demonstrated complications of the orbit, 6 with orbital cellulitis, 4 subperiosteal abscess and 3 orbital abscesses. Surgery was performed in 3 cases., Conclusions: We conclude that the CT scan is a radiological procedure that must be applied when there are signs or symptoms compatible with orbital complications. Patients should also be scanned if their exam is worse or unchanged after 24-48 hours of antibiotic therapy. Early diagnosis and antibiotic treatment can prevent complications subsidiary of surgery.

Although anatomic variations in the development of the nose and paranasal sinuses such as the Haller's cell do not themselves represent a disease state, in many cases they are responsible for the patient's symptoms. Particularly in the absence of extensive associated mucosal changes, these conditions may be easily overlooked unless specifically sought. Haller's cells may cause recurrent or chronic sinusitis and persistent sinugenic headache, without significant findings on physical examination including nasal endoscopy. The presence of Haller's cells on coronal CT in a patient with corresponding symptoms deserves consideration as the potential cause of the symptoms. When medical therapy is ineffective, such cases respond well to surgical therapy through the functional endoscopic approach.

Subperiosteal abscess of the orbit (SPA) should be considered an important part of the group of orbital complications following acute sinusitis. This situation requires early surgical intervention to avoid visual loss or ophthalmoplegia. Six cases of children with SPA of the orbit treated successfully by Functional Endoscopic Sinus Surgery (FESS) are reviewed. The importance of ophthalmological examination, nasal endoscopy and CT scan is emphasized concerning the management protocol. The major advantage of FESS is the avoidance of external ethmoidectomy with the resultant scar. FESS is demonstrated as a safe and convenient procedure with excellent post operative recovery of the patients.

A 38-year-old woman was admitted for intranasal ethmoidectomy. She had a history of serious anaphylactic reactions, including respiratory distress, hypotension and unconsciousness, to nonsteroidal anti-inflammatory drugs (Loxonin, Niflan) and antibiotics (Kefral, Minomycin). Preoperative intradermal skin tests against anesthesia-related drugs showed positive reactions to succinylcholine and vecuronium. After bilateral maxillary nerve block with 0.5 % bupivacaine (negative intradermal test) 3 ml, anesthesia was induced with diazepam, nitrous oxide, oxygen and sevoflurane. Trachea was intubated smoothly without muscle relaxants. Anesthesia was maintained with nitrous oxide, oxygen and sevoflurane 0.5-1 %. The anesthesia and postoperative course of this patient were uneventful. To confirm the initiation of allergic reaction to anesthetics used in the patient, serum histamine, tryptase, and complement 1, 3 and 4 factors were measured at 3 points: preoperatively, immediately after the induction, and after extubation. They showed normal levels. These results showed that no allergic reaction occurred perioperatively. In conclusion, the valuable information was provided for the choice of anesthetics by thorough evaluation of the past history and intradermal testing.

We herein report a young patient with cerebral venous thrombosis (CVT) with clinical and neuroradiological findings of the left maxillary and anterior ethmoid sinusitis. Serial brain MRIs showed cerebral venous infarct and thrombosis in the superior sagittal sinus (SSS). MR angiography demonstrated nonvisualization of SSS and bilateral transverse sinus. According to our knowledge, CVT associated with maxillary and ethmoid sinusitis has been reported very rarely. High index of suspicion and neuroimaging studies, especially brain MRI, and conventional or MR angiography are very important for the early diagnosis of CVT.

Complications and local extension of paranasal sinus infections most often involve the orbit and periorbita. Because of the widespread use of antibiotics since World War II, intracranial extension of maxillofacial sinusitis is rarely seen today. Nevertheless, the clinician must be aware of the potential for these complications, because late recognition of this condition and delays in treatment can increase morbidity and mortality rates. A comprehensive, current review of sinogenic intracranial complications is presented, with illustrative cases of brain abscess, subdural empyema, meningitis, cavernous sinus thrombosis, epidural abscess, and osteomyelitis. The mechanisms and potential for intracranial spread of infection from the frontal, sphenoid, and ethmoid sinuses are discussed in detail. The management of each type of complication is outlined, including the use of computed tomography and magnetic resonance imaging, and the role of surgical drainage.

The contiguous spread of inflammation from infected ethmoid sinuses to the surrounding tissues of the lacrimal drainage system can produce symptoms easily confused with acute dacryocystitis. We report the cases of two patients with presumed dacryocystitis whose patency of the lacrimal apparatus was established by probing, irrigation, and dacryocystography. Computerized tomography and magnetic resonance imaging demonstrated opacification of anterior ethmoid air cells adjacent to the region of the lacrimal sac. A greater awareness of this diagnostic possibility of pseudodacryocystitis arising from anterior ethmoiditis, together with improved noninvasive imaging techniques, will likely increase the observed incidence of this disease. This distinction is important since anterior ethmoidectomy, rather than dacryocystorhinostomy, is the treatment of choice when such pseudodacryocystitis proves unresponsive to antibiotic therapy. In misdiagnosed patients who undergo dacryocystorhinostomy, it is the coincidental limited anterior ethmoidectomy and not the lacrimal-nasal fistula that provides the cure.

Orbital cellulitis secondary to acute sinusitis is uncommon, dangerous, and can lead to blindness and death. The ethmoid is the predominantly involved sinus. Management policy consists of early drainage of the affected sinus combined with systemic antibiotic therapy. If no improvement is achieved within the first 48 h, exploration of the fronto-ethmoidal region is mandatory. Endonasal endoscopic surgery facilitates early drainage of the affected sinus, eradication of the disease from the fronto-ethmoidal region, and drainage of the subperiosteal abscess. Sixteen cases of orbital cellulitis were treated successfully by endonasal endoscopic surgery with no complications.

A case of orbital subperiosteal abscess (SPA) complicating a minimally displaced zygomatic complex (ZMC) fracture is reported and the aetiology and management of this potentially life-threatening condition is discussed. The value of CT scanning in staging orbital infection and determining the site of the abscess and involved paranasal sinuses is emphasised. The correct interpretation of a lateral skull radiograph with the patient brow up may have lead to earlier diagnosis and treatment.

The development of stereotactic radiosurgery has been a major advance in the treatment of intracranial lesions. By using a stereotactic head frame attached to the skull, large doses of radiation can be delivered precisely to the lesion while sparing surrounding tissues. Although adults can usually undergo this procedure with local anesthesia or conscious sedation alone, children frequently require general anesthesia. This report describes our experience with the anesthetic management of all children who have received this therapy at our institution since the inception of our stereotactic radiosurgery program in 1986 through June 1993. Sixty-eight radiosurgery procedures were performed in 65 patients. Anesthesia time averaged 9.2 h (range, 7-15). Twenty-two patients (ages 11-17; mean 14.3) received local anesthesia alone, two patients (ages 11 and 15) received local anesthesia plus i.v. sedation, and 44 patients (ages 2-14; mean, 7.3) received general anesthesia. Four potentially serious anesthesia-related events occurred; in one child (age 7) receiving general anesthesia, an endotracheal tube obstruction developed during radiosurgery requiring rapid reintubation while the child was still in the head frame; another (age 7) who was undergoing chemotherapy and had neutropenia and rhinitis had a lobar collapse while intubated, requiring mechanical ventilation and endotracheal tube suctioning for lung expansion. Another (age 5) with a recent upper respiratory tract infection had copious endotracheal secretions and sinusitis (ethmoid and maxillary) noted on initial computed tomography scanning and was given antibiotics and decongestants (following nasotracheal extubation), and another (age 15) receiving sedation without endotracheal intubation vomited an undigested meal midway through the procedure while her head was partially immobilized in the head frame.(ABSTRACT TRUNCATED AT 250 WORDS)

The place of conservative treatment in sinogenic orbital complications has not been fully explained in the literature. The question that remains unresolved is--at which stage of the disease is surgery indicated? A study was undertaken in 240 patients with sinogenic orbital complications, to determine this. The patients were divided into three groups according to the stage of the disease as determined clinically: Group 1 (52 patients) with early stage disease, as detected by cellulitis only; Group 2 (76 patients) with intermediate stage, as detected by periorbital cellulitis and proptosis, but with full range of eye movement and unaltered vision; Group 3 (122 patients) with late stage disease, as detected by periorbital cellulitis and gross proptosis, with limitation of eye movement and altered vision. Group 1 and Group 2 patients were treated conservatively, with intravenous antibiotics and antral lavage. Group 3 patients were treated with intravenous antibiotics and surgery. External frontoethmoidectomy was performed in 31 (bilateral in two), ethmoidectomy in 91 (bilateral in five), sphenoidectomy in 15 and bilateral antral washout in all (122 patients). There was 100 per cent success with conservative treatment in Group 1 patients, whilst in Group 2 there was 98.6 per cent failure. The 75 patients in whom conservative treatment failed were successfully treated with surgery: frontoethmoidectomy was performed in 66 and ethmoidectomy in nine. In Group 3 patients, 100 per cent success was achieved with intravenous antibiotics and surgery. Sinogenic orbital complications can be treated conservatively and surgically, depending on the stage of the disease on presentation. Conservative treatment is only suitable for early complications, i.e. patients with periorbital cellulitis only.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors describe an uncommonly stubborn course of a phlegmon of the lacrimal sac in two newborns, developing after latent ethmoiditis. They emphasize the necessity of a timely consultation of a qualified ENT specialist to plan the rational treatment strategy in such patients.

Spread of infection from paranasal sinuses is uncommon but, when it occurs may lead to serious ocular or intracranial complications. In this article we present four patients, three of them with orbital complications and one with an intracranial abscess, who were successfully treated with endoscopic surgery of the sinuses and antibiotic therapy. We describe some potential advantages of this approach.

Sphenoid sinusitis is often ignored by doctors, for the sphenoid sinuses are the most neglected paranasal sinuses and sphenoid sinusitis lacks specific symptoms. 58 cases of sphenoid sinusitis were reported in this article. The specific clinical symptoms remain to be deficient. At present, computerized tomography, MRI and telescope help to make accurate evaluation of sphenoid sinus diseases. The endoscopic intranasal surgery for sphenoid sinusitis enables the complicated surgical procedures simple. In our series, most cases (53) are sphenoethmoid sinusitis. The isolated sphenoid sinusitis is rare in clinical practice.

Objective: To determine the efficacy of endoscopic sinus surgery in pediatric patients with chronic sinusitis and asthma., Setting: Patients were selected from the tertiary care practice of a pediatric pulmonologist (R.S.) and immunologist (R.L.W.); all underwent sinus surgery at Children's Medical Center at Dallas (Tex)., Patients: Fourteen pediatric patients aged 3.5 to 13 years with severe asthma requiring at least intermittent systemic steroid therapy. All patients had a history of sinusitis aggravating asthma and all had computed tomographic evidence of chronic sinus disease., Intervention: All patients underwent endoscopic sinus surgery consisting of bilateral total ethmoidectomies and middle meatus antrostomies at a minimum., Main Outcome Measures: The period 12 months prior to surgery was compared with 12 months postoperatively with regard to total hospitalization days for asthma treatment, number of school days missed, pulmonary function test results, and systemic glucocorticoid medication requirements. Symptom scores for asthma and sinusitis were assessed via parental questionnaire both preoperatively and postoperatively., Results: No significant difference was found for pulmonary function test results. Eleven of 14 patients demonstrated a significant reduction in hospitalization and school days missed. Twelve of 14 patients experienced a reduction in glucocorticoid requirements. Eleven of 14 and 13 of 14 patients experienced a significant improvement in asthma and sinusitis symptom scores., Conclusion: Endoscopic sinus surgery was effective in reducing sinusitis and improving the overall management of asthma in a majority of study patients.

We report a case of sinusitis associated with disorders of visual acuity. The patient's vision was dramatically improved by sinus surgery despite the fact that the changes in the ethmoidal cells were slight and had no direct observable relation to the optic nerve canal. Possible mechanisms involved in nasal optic neuritis are discussed.

The entity of spontaneous cerebrospinal fluid rhinorrhea is a rare condition that presents a special challenge to the practicing allergist. Delayed diagnosis can be associated with significant morbidity and mortality. We describe two cases of this condition occurring in association with allergic rhinitis and sinusitis. The presentation and management of these cases is described. A high index of suspicion for this condition should be maintained in all patients who present with profuse and often unilateral rhinorrhea.

We report an unusual case of orbital cellulitis in a patient with only one seeing eye and severe facial asymmetry secondary to a road traffic accident twenty two years previously. Facial trauma sustained in the road traffic accident created continuity between the right orbit and the adjacent ethmoidal cells. The abnormal communication between the ethmoidal labyrinth and the right orbit rendered this patient highly susceptible to an orbital cellulitis from an adjacent paranasal sinus infection. However, this case is unusual with regard to the length of time that elapsed before such an infection became manifest and the presence of gross distortion of anatomy masked the usual presentation and thereby caused a delay in diagnosis.

A 10-year-old boy with a unilateral septic cavernous sinus thrombosis complicating infection of the ethmoidal and maxillary sinuses is described. The causative agents identified were Eikenella corrodens and Staphylococcus aureus. The disease was cured without any sequelae.

A case of pneumococcal meningitis in association with sphenoidal sinusitis is described. A focal gas collection was demonstrated adjacent to the posterior clinoid process. No discernible breach of the sphenoidal sinus walls could be shown.

We report a case of rhinogenous optic neuritis in a 50-year-old man demonstrating drastic diurnal variation in visual function. His left vision was 20/15 in the morning, which gradually decreased to counting fingers at night. Pupillary reaction and visual field showed the same fluctuation as vision. Complete remission of visual symptoms was achieved after endonasal ethmoid sinusotomy.

The association of headache and sinusitis was studied in 207 patients who underwent surgery for chronic sinusitis that failed to respond to medical management. Sixty-nine percent of the patients had headaches and 31% did not. In 9% headache was the only symptom and the diagnosis of sinusitis was made on clinical and/or CT grounds. The pain was usually pressure in character, moderate in intensity and lasted for hours. Its location usually, but not always, pointed to the sinuses involved. Discreet sphenoid or ethmoid disease discovered on imaging may be responsible for midline pains. Sinusitis may also trigger or aggravate vascular headaches.

Congenital malformations of the branchial arches are not infrequent. Among them first branchial cleft anomalies are common and they are to remain asymptomatic. The case reported is one of symptomatic fistula auris, which at the beginning led us to the initial diagnosis of an orbital cellulitis, secondary to ethmoidal sinusitis. We have made a review of the literature dealing with these anomalies and we expose in the paper an update perusal of the clinical features and the management of this rare complication.

Orbital complications of ethmoiditis are not uncommon in children. They are, however, much rarer in the very young. A case is presented in which a neonate of gestational age 39 weeks developed a periorbital abscess. The relevant literature is reviewed with respect to embryology, aetiology and treatment.

We report on 498 patients suffering from chronic maxillary sinusitis verified by sinusoscopy through the inferior meatus and by computed tomography of the sinuses, which permitted also the diagnosis of coexisting chronic ethmoidal sinusitis. The patients were treated by temporary drainage through a polyethylene drain tube left in place at the end of the antroscopy for daily lavage with saline solution and daily instillation in the sinus of thiamphenicol glycinate hydrochloride (similar to chloramphenicol) and N-acetyl-L-cysteine. We followed up 847 maxillary sinuses during the lavages according to 2 parameters: 1) recovery of a clean washout product at the macroscopic examination and 2) recovery of normal ostial patency as measured by sinusomanometry. We concluded that 1) the association with ethmoidal sinusitis does not significantly modify the treatment duration, and 2) fewer than 4% of the maxillary sinuses are likely to recover normal parameters after the 23rd day of lavage, and it is therefore useless to continue this treatment much longer. Of the maxillary sinuses, 36.25% were not submitted to any surgery. The results gained by the lavage technique have to be protected from recurrence by the treatment of general, focal, or local causes.

Esphenoetmoidal diseases when complicated may present serious diagnostic and therapeutic difficulties. A case of esphenoetmoidal mucocele compressing the optic nerve, treated with marsupialization by endoscopic intranasal way, is reported. The literature concerning the subject is commented.

To assess the clinical presentation and outcome of infectious sinusitis in HIV-infected patients, we analyzed in a retrospective study, the records of HIV-infected patients hospitalized from June 1986 to November 1989. Twenty-eight episodes of infectious sinusitis, defined by radiological signs, were recorded in 20 HIV-infected patients. Clinical presentation suggestive of acute sinusitis was inconstant and in 6 episodes a persistent fever was the only symptom. Concomitant pneumonia was detected in 8 episodes. Bacteria were isolated in 8 episodes, and in 4 of them, Haemophilus influenzae was identified. Clinical relapses occurred in 8/20 patients, requiring a surgical drainage in 3 cases. The frequency of relapses and the possibility of chronicity justify a more prolonged and aggressive therapy in infectious sinusitis occurring in HIV-infected patients.

Two cases of severe unexplained fatigue with mid-facial pain and rhinitis are presented. Sinus computerized tomography (CT) findings were minor, but both responded to functional endoscopic nasal surgery with resolution (Case 1) or near resolution (Case 2) of chronic fatigue. Possible mechanisms linking nasal disease and chronic fatigue include reflex etiology and sleep disturbance associated with abnormal nasal airflow. Often not considered by the primary care physician in differential diagnosis of fatigue, chronic sinusitis should be explored as a cause in unexplained cases.

The authors report on an 8-year-old girl who experienced bilateral subdural frontoparietal and interhemispheric empyema following sinusitis. The child improved after initial treatment with a 3 weeks course of parenteral antibiotics. Surgical drainage was further required because of clinical aggravation; however, this evolution was related to bilateral frontoparietal brain edema and abscesses fluid was sterile.

Oto-rhino-laryngologists usually deny the existence of infant chronic ethmoido-maxillary sinusitis, generally agreeing that the earliest signs of pneumatization of the maxillary sinuses cannot be observed earlier than 18 months of age. Based upon ten cases we present evidence that this notion of "late sinusal pneumatization" should be re-examined, pneumatized maxillary sinuses being possible as early as 11 months of age. Thus, at that age, radiodiagnosed apneumatosis which is considered as physiological, may express various conditions, such as true anatomical apneumatosis, chronic glue sinusitis, or simple inflammatory sinusitis of the mucous membrane. Because it is impossible to clinically differentiate these different conditions we believe that in some particular cases, a short course of combined corticoid-antibiotics treatment with sinus X ray before and after treatment, may be useful. In case of confirmed sinusitis (sinus visualization after treatment), a secondary preventive treatment may reduce the risk of chronic maxillary sinusitis. We suggest that further studies should be performed in order to better define the reality of chronic ethmoido-maxillary sinusitis in infants younger than 18 months of age, and to study the possible role of a phenomenon of immuno-inflammatory trapping in its pathologenesis.

Although the literature is replete with papers discussing the results of surgery for chronic inflammatory sinus disease, critical comparison of results is difficult due to limited knowledge of the prognostic factors and the variable criteria reported for success. Detailed prospective and retrospective data collection was therefore undertaken to evaluate the results of surgical intervention in 120 patients who underwent endoscopic sinus surgery. Results were evaluated both by symptom questionnaire and by endoscopic follow-up examination. Over 240 data fields were collected on each patient, including information regarding presenting symptoms, endoscopic and computed tomography (CT) findings and surgical procedures performed. In order to reduce potential bias, the results of the follow-up questionnaires were compared to questionnaires from other patients unable to return for follow-up endoscopy. Mean follow-up time was 18 months. Potential prognostic variables were evaluated statistically. A strong correlation was identified between the extent of disease and the surgical outcome. Other identified potential factors appeared to have little or no significance. Therefore, a staging system for inflammatory sinus disease based on the extent of disease is suggested.

A case of fistulae in the inner canthus arising from the ethmoidal air cell sinuses is presented. This type of complication is very rare, and to the best of our knowledge no similar case has been reported in the literature. Clinical findings, imaging, pathology and treatment are presented and discussed.

Three hundred sixty-seven successive patients suffering from chronic maxillary sinusitis (CMS) were thoroughly examined by means of maxillary sinusoscopy, a CT scan of the facial sinuses, and sinusomanometry (SMM). Ninety-eight cases of unilateral CMS, 269 cases of bilateral CMS, and 444 chronic ethmoidal sinusitis (CES) cases were evaluated. According to SMM, the maxillary ostia were divided into two groups: 1. maxillary ostium patency (MOP) group and 2. the maxillary ostium nonpatency (MONP) group. The unilateral and bilateral pathologies were separately analyzed so as to minimize the effects of general or systemic causes on the results. MONP is, in both bilateral and unilateral groups, significantly linked with the presence of ethmoidal sinusitis (P < 10(-6); P = .026), while the correlation between MOP and the ethmoid status does not appear to be significant in either group. Thus, there seems to be a close relationship between CES and maxillary ostial dyspermeability in cases of CMS.

Acute infection the paranasal sinus is a rather frequent pathology in children. On the contrary, local orbital complications are rare. The employment of antibiotics reduces the incidence of complications but can sometimes conceal their appearance so that diagnosis is delayed. Orbital as well as intracranial complications of ethmoidal and maxillary sinusitis are most often encountered in childhood. Within a brief time span, 8 patients with complicated frontal and ethmoid-maxillary sinusitis were diagnosed and treated: 4 cases of periorbital cellulitis, 2 of subperiorbital abscess and 2 of orbital abscess (one of which with cavernous sinus thrombosis). Particularly relevant from the diagnostic point of view was the employment of C.T. scan which furnished an accurate definition of the orbit and its surrounding structures which influenced treatment choice. Under antibiotic cover all patients but one (who had been treated very early and had responded immediately to intensive antibiotic therapy) were treated surgically and the clinical course of the disease showed significant improvement very shortly after surgical drainage.