W. Sibbald Robertson
1921 The Lancet  
EAR, NOSE, AND THROAT, MAIDSTONE. THE following case is interesting, although the recent Hunterian Lecture by Mr. W. J. Howarth has shown me that the condition is not so uncommon as I had formerly supposed. On May 18th I was asked by Mr. G. Potts, ophthalmic surgeon to the hospital, to examine a patient, aged 57, for frontal sinusitis. She had a slight swelling at the inner canthus of the left eye, and complained of some " pricking in the left eye," but not of headache or other subjective
more » ... m. The swelling was firm and could not be pressed away. Intranasal examination showed no discharge on either side, mucous membrane quite normal in appearance, and no enlargement of turbinate bones. Post-nasal space clear of discharge. Transillumination showed both frontal sinuses clear and of about normal size ; maxillary antrum also clear ; no history of a blow. My report was : frontal, ethmoid, and maxillary sinuses unaffected. Three months after this the patient was admitted into hospital with a compressible swelling on her left frontal sinus. The house surgeon, Dr. K. Reed Hill, needled it and got pus. There were no subjective symptoms such as headache, and the temperature was negligible. The eyeball was pushed downwards and outwards with swelling of the soft tissues of the upper eyelid and inner angle of orbit. Operation.-I operated as soon as the patient could be got ready, making an incision along the eyebrow ; there was an immediate gush of odourless, reddish muco-pus. A gloved finger was inserted into the cavity, which was felt to be unusually large. I therefore made a further incision at right angles to the original at its inner angle, going well up the forehead ; the flap was turned upwards and the cavity swabbed dry and all bleeding arrested. The following was then made clear : The anterior wall of the sinus, with the exception of a thin pliable piece of bone adherent to the flap, was absorbed. The floor, except for a small plate of bone over the orbit, the posterior wall, and the septum between the two sinuses were also absorbed, so that the right frontal sinus could easily be explored ; portions of dura mater were missing, red and inflamed brain substance being exposed. A probe could be passed on either side into the nose ; the posterior ethmoid cells were absorbed. The fronto-nasal duct could not be made out; the probe could be passed down to the loop of the post-nasal space, the mucoperiosteum everywhere being intact, except where the orbital plate had been absorbed ; here the probe passed into the cheek. The sagittal sinus was intact, but the whole left frontal lobe was completely exposed and could, if it had been desirable, have been raised and its under surface explored. The wound was sutured with the exception of its outer and inner angle, which were drained. Recovery was gradual and the temperature and pulse negligible throughout, until at the end of three weeks a pocket of pus, quite different from the original infection, formed under the scalp at the inner angle of the original incision and extended down to the cheek. This was opened, gently scraped, and swabbed out with hypochlorite solution. The patient is now quite well. I deemed it inadvisable to open up any communication with the nasal cavities, as I felt that the cavity would become filled with fibrous tissue, the condition, in my opinion, being one of mucocele of the frontal sinus which had become infected. Abstract of Ophthalmological Report. Patient attended hospital on May 1.1th complaining of slight discomfort behind the left eye. On examination Mr. Potts found vision R.E. 6/6, L.E. 6/12 ; small swelling felt below left supra-orbital notch ; slight proptosis and displacement of eye downwards and outwards ; no diplopia. Fundus normal. On re-examination four months later the eye had returned practically to its normal position. The proptosis had disappeared, but there was very slight displacement of the eye downwards, the level of the left pupil being about 2 mm. below that of the right. Fundus, optic disc, and media normal. On testing for heterophoria the left image was found to be situated above and to the right of the right image, but they were approximately fused by a 12° prism base upwards and inwards. The extrinsic muscles appeared not to have been affected, as there was no limitation of movement of the eye. The fields showed no contraction, nor were any scotomata to be made out with either white or colours.
doi:10.1016/s0140-6736(01)33612-7 fatcat:nksddbymnrdd5iyhm4fid6sb4m