Primary Malignant Disease of the Frontal Sinus

IN the Journal of Laryngology and Otology, Vol. LXIV, No. 5, Professor Handousa Bey of Cairo reported a case of primary malignant disease of the frontal sinus in a male of 48. He also briefly reviewed the literature. The following case record is a further example of this rare condition. Mrs. E.R., aged 57, was referred to me by her general practitioner on October 4th, ig$i. She complained that pus was running into both her eyes and that she had some difficulty in seeing. Two months previously her left eye had swelled and closed up ; a few days later there was a spontaneous discharge from above the eye which had continued since then. A few weeks later the right eye had repeated this performance and was also discharging continuously. There had been an almost complete absence of pain on both sides. She told me that she had had some soreness of the frontal part of her head for many years, but that this had never been associated with any nasal discharge and that her general health had been good. Her appearance at this time is shown in the accompanying photographs. On examination she had considerable boggy swelling of her forehead extending from below the supra-orbital ridge on each side to within 4 cms. of the hair line on the left side and 5^ cms. on the right side. The examining finger on firm pressure sank into the swelling and the frontal bone could not be felt over the area described. She had fistulae below the supra-orbital ridge on each side and these were discharging large amounts of pus which dripped constantly into both her eyes. She could scarcely see out of either eye. A probe entered each frontal sinus easily through these supra-orbital fistulae. The middle turbinate region on both sides of her nose was slightly cedematous but there was no pus in the nose. The left antrum was less translucent than the right. She was admitted to the County Hospital, Omagh under my care the following day where X-ray examination revealed an enormous bony defect of her frontal bone with some surrounding sclerosis. Her W.R. was negative. She was somewhat dull mentally, but this did not appear to be a recent change and her central nervous system appeared normal. I made a provisional diagnosis of chronic osteomyelitis of the frontal bone secondary to frontal sinus infection and explored the area two days later under a general anaesthetic. She was receiving systemic penicillin and sulphadiazine. I turned down a large forehead flap using a curved incision behind the hair line from one temporal region to the other. The whole soft tissue flap was dissected downwards until it hung well over her eyes. This revealed the bony defect to be filled with pus and malignant granulation tissue ; the pus being