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Pain is also a variable symptom in chronic sinus infections. Many people do
not complain of any pain. It is more often met with in chronic frontal
sinusitis on account of impeded drainage in the nasofrontal duct, but it may
occur from swelling of the middle concha pressing on the lateral wall of the
middle meatus.

Headache is a more common symptom, although chronic sinusitis accounts
for only a small proportion of headaches. The headache is frequently referred
to the frontal region, and this is always so in chronic frontal sinusitis. Chronic
maxillary sinusitis may cause frontal headaches or an ache below the infra-
orbital margin. Chronic inflammation of the sphenoidal and ethmoidal
sinuses may cause frontal headaches or the pain may be seated behind the
eyes or be felt in the occipital region. A type of headache, known as 'vacuum
headache', results from the closure of the nasofrontal duct resulting in a
diminished air pressure in the frontal sinus from absorption of the air and a
passive congestion of its lining membrane. It may occur at any time and is
often present during descent in an air flight. This headache is increased by
movement of the eyes and there is tenderness in the floor of the frontal sinus.
Pharyngitis is a common accompaniment of chronic sinusitis while
catarrhal deafness or otitis media, either a recurring acute infection or a
chronic infection, may be precipitated or maintained by infection in the

PATHOLOGY. In chronic catarrh of the sinuses the mucous membrane
becomes greatly thickened or even polypoidal, and a similar state occurs in
chronic allergic conditions especially in the maxillary and ethmoidal sinuses.
Provided that chronic pyogenic infection does not supervene this mucosal
change may be reversible after appropriate treatment. When chronic pyogenic
infection takes place the pathological changes may become irreversible until
surgery has been performed. The changes are those described in acute
sinusitis, but the mucosa becomes thickened and often polypoidal, and the
surface epithelium is destroyed.

CLINICAL FEATURES. Anterior rhinoscopy will show redness and swelling of
the nasal mucous membrane. The inferior concha may be turgid thus obscur-
ing a view of the middle meatus. If the middle meatus is seen, mucopus or pus
will be found in it and running down to pool on the floor of the nasal cavity
(see Plate III, 2, 3). If the ostium of the infected sinus is blocked there may
be no abnormal secretions visible. Nasal polypi may be seen and their
location should be identified.

Posterior rhinoscopy may reveal mucopus or pus in the posterior naris
(see Plate 1II9 4) or in the nasopharynx, sometimes towards its roof.
Polypi may also be found in the choana, and on occasion there may be a
mulberried hypertrophy of the posterior end of the inferior concha.

Radiography of the nasal sinuses must be performed. The routine occipito-
mental and lateral views should be taken, but when infection is suspected in the
ethmoidal and sphenoidal sinuses in particular oblique or verticomental views
may also be obtained (Fig. 30). A well-exposed film will show details of
mucosal thickening or early polypus formation. A homogeneous opacity may
be found if the infected sinus is filled with secretion, while if it is partially
filled a fluid level will be seen (see Fig. 29, p. 67). The translucency of the
sinuses is compared with that of the orbits, and a haziness in a sinus may
suggest a lack of air entry into the sinus. A polypus will appear as a rounded