80 THE NOSE AND PARANASAL SINUSES mucosa and mucopus may be seen in the middle meatus or the olfactory cleft. The affected sinus will be tender to the touch. Radiography of the sinuses will confirm, the source of the orbital infection. TREATMENT. This is initially antibiotic and unless a sample of the pus is available a broad-spectrum antibiotic, such as a mixture of ampicillin and flucloxacillin (Magnapen) or ampicillin and cloxacillin (Ampiclox), should be given. If no improvement is apparent, and imperatively if visual symptoms deteriorate, the orbit should be opened through an incision in the superomedial quadrant of the orbit and the abscess sought for and drained. PROGNOSIS. Many of these cases recover completely with a return of full vision. Blindness may ensue if optic atrophy is not promptly relieved. Death may occur from a spreading thrombophlebitis of the ophthalmic veins to involve the cavernous blood sinus. OSTEOMYELITIS Osteomyelitis of the skull may occur wherever there is diploetic bone in the neighbourhood of an infected sinus, and thus it is most frequently found in frontal sinusitis and less commonly in maxillary sinusitis. Acute osteomyelitis may occur in untreated acute sinusitis or it may follow operations upon inflamed sinuses. The disease is more common in young people. Pus under pressure may produce a septic thrombophlebitis in the diploetic bone between the two tables of the frontal bone. Surgical opening of diploetic bone in the presence of an acute infection and, especially, curettage of cancellous bone, may precipitate osteomyelitis. Surgery of non-diploetic bone, such as the bony wall of the floor of the frontal sinus or the wall between the nasal cavity and the maxillary sinus, may be undertaken in the acute phase without the danger of osteomyelitis, but such surgery must be strictly limited to these areas. The common organisms are staphylococcus and streptococcus, especially its anaerobic variety, while H. influenzae and pneumoccocus are less frequent causes. SYMPTOMS. Symptoms may not be marked unless the condition is fulminat- ing. The disease occurs a few days after the sinusitis or the surgical procedure, and is ushered in by pyrexia often accompanied by rigors. There is a dull boring pain in the affected bone, and a headache which may be generalized or occipital. A swelling appears over the affected bone which is tender. Further swellings may appear later in the frontal region if'this sinus is the source. Radiography (Fig. 37) will show the sinus infection and may reveal a mottled appearance in the osteomyelitic areas. TREATMENT. A broad-spectrum antibiotic such as ampicillin either alone or combined with cloxacillin (Ampiclox) or with flucloxacillin (Magnapen) should be given unless sensitivity tests of the responsible organism are available. The affected sinus should be drained through non-diploeic bone, the maxillary sinus being opened intranasally and the frontal sinus through a small burr hole in its floor. The pus is cultured and sensitivity tests done and the appropriate antibiotic is given in maximum dosage. Many cases settle completely with this regime, but a fulminating osteomyelitis of the frontal bone may produce sequestra which can be seen radiographically. If these appear the osteoplastic flap operation (p. 76) will afford the best opportunity of removing them.