Frontal sinusitis with pyocoele
60 year-old with three day history of painful swollen left eye and headache. On examination, left sided proptosis and chemosis.
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Complete opacification of the left frontal sinus and the anterior aspect of the left ethmoidal sinuses, with a 2 cm bony defect due to destruction.
Rim enhancing lentiform collection measuring 2.5cm x 1.5 cm in the left superior orbit and medial aspect of the extraconal space displacing the medial rectus muscle medially.
Small amount of fluid in the left maxillary sinus. No intracranial extension. Left pre-septal oedema.
Sinusitis can cause bony destruction (aggressive appearing but not malignant) typically presenting to ophthalmology due to eye symptoms.
The ethmoidal sinuses are the most frequent culprit, with destruction of the laminae papyracea resulting in a medial subperiosteal collection.
In this case the frontal sinus is the chief site of disease and the degree of bony destruction is more extreme than normal.
The patient proceeded to surgery with a subperiosteal abscess and pyocoele drained via a left frontal sinus incision.