What are the symptoms and treatment options for a patient with frontal sinusitis, potentially complicated by allergic rhinitis or asthma?

Frontal Sinusitis: Symptoms and Clinical Presentation

Frontal sinusitis presents with supraorbital headache as the cardinal symptom, often accompanied by purulent nasal discharge, and requires immediate recognition of warning signs that indicate potentially life-threatening intracranial complications. 1

Primary Symptoms

The hallmark presentation of frontal sinusitis includes:

• Supraorbital headache that is the defining feature, typically increasing when the head is bent forward 1
• Purulent nasal discharge (anterior and/or posterior, often unilateral) 1
• Pain and pressure over the frontal sinus region that may be pulsatile, peaking in early evening and at night 1
• Facial pain upon pressure in the area over the infected frontal sinus 1

These symptoms typically follow an upper respiratory infection and may be accompanied by nasal congestion and olfactory disturbance. 1, 2

Red Flag Symptoms Requiring Urgent Hospitalization

Any patient with frontal sinusitis showing the following signs requires immediate hospitalization, bacteriological testing, and parenteral antibiotic therapy due to high risk of intracranial complications: 1

• Periorbital or palpebral edema 1, 3
• Exophthalmos or displaced globe/proptosis 1, 3
• Ocular mobility disorders or visual changes (double vision, reduced visual acuity) 1, 3
• Meningeal syndrome (signs suggesting meningitis) 1, 3
• Severe frontal headache with frontal swelling 3
• Altered consciousness or neurological signs 3
• Severe pain preventing sleep 1

The proximity of the frontal sinus to the dura, frontal bone marrow, and rich communicating venous system facilitates intracranial extension, leading to complications including osteomyelitis, cavernous sinus thrombosis, meningitis, and cerebral abscess. 2

Complications in Context of Allergic Rhinitis and Asthma

Patients with allergic rhinitis are at increased risk for developing sinusitis because:

• Allergic inflammation causes mucosal swelling that obstructs the sinus ostium 4
• This obstruction creates favorable conditions for bacterial growth 4
• Up to 50% of patients with sinusitis have concurrent marked rhinitis (allergic or nonallergic) 4

For patients with asthma, frontal sinusitis can trigger bronchospasm through parasympathetic stimulation of the bronchial tree from infected sinus nerves. 4 More than 75% of patients with allergic rhinitis may develop asthma, and up to 40% of asthma patients have allergic rhinitis. 5

Diagnostic Approach

Physical examination reveals:

• Purulent rhinorrhea on nasal examination 1
• Pain upon palpation over the frontal sinus 1
• Roentgenographic studies showing opacification or air-fluid level within the frontal sinus 2
• CT scanning is invaluable for confirming frontal sinusitis and detecting intracranial involvement 2

Notably, classic signs and symptoms may be subtle or undetected during routine examination, particularly in male adolescents who show a notable preponderance for this disease. 2

Treatment Imperatives

Antibiotic therapy is definitely indicated in all cases of frontal sinusitis due to the high risk of complications. 1

First-line treatment options include:

• Amoxicillin-clavulanate 1
• Second-generation cephalosporins (cefuroxime-axetil) 1
• Third-generation cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil) 1
• Pristinamycin (particularly for beta-lactam allergy) 1

For frontal sinusitis specifically, fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) should be considered as first-line therapy due to the high risk of major complications. 1

Treatment duration is 7-10 days, though some agents have demonstrated efficacy in 5 days. 1

Adjunctive Management for Concurrent Allergic Rhinitis

When allergic rhinitis complicates frontal sinusitis:

• Intranasal corticosteroids (such as flunisolide) promote drainage and aeration by decreasing inflammation and white blood cell influx 4
• Oral and topical decongestants to promote drainage 4
• Fluids and expectorants 4
• Treatment of the underlying allergic rhinitis improves asthma symptoms when both conditions coexist 5

Common Pitfalls

The most critical error is failing to recognize warning signs of intracranial complications, which can develop even when classic symptoms are subtle or absent. 2 CT scanning should be incorporated into the diagnostic workup whenever frontal sinusitis is suspected, particularly in adolescent males. 2

Aggressive medical and surgical management is advocated for all adolescents presenting with frontal sinusitis to avoid intracranial complications. 2