A 52-year-old man was referred to the ENT department with a 10-week history of facial pain. He described the worst pain he had ever experienced and had been unable to work during the preceding fortnight.He had noted increasing swelling around his left eye and forehead and green discharge from his left nostril, with occasional blood-staining. He had received three courses of antibiotics with little effect.The patient described a long history of sinus problems, previously requiring hospital admission for intravenous antibiotics. He had undergone functional endoscopic sinus surgery (FESS) on three occasions electively for nasal polyposis and had undergone emergency surgery to the maxillary sinuses for an episode of orbital cellulitis. He is an asthmatic and had previously had an attack triggered by aspirin.On examination, marked tenderness was noted bilaterally over the orbital and maxillary regions and there was a fluctuant swelling in the region of the left forehead. Eye movements and vision were normal. Polyps and pus were visible on anterior rhinoscopy. Full blood count, renal function and electrolytes were normal.Swabs from both nostrils were sent for culture and sensitivity and an urgent CT scan was requested (Figures 1 and 2) showing soft tissue swelling with abscess formation overlying the left frontal sinus, bony erosion of the anterior wall of the sinus and inflammation of most paranasal sinuses. Figure 1. Axial CT showing bony defect of the anterior wall of the frontal sinus with overlying soft tissue swelling Figure 2. Coronal CT showing extensive shadowing of the paranasal sinuses suggestive of mucosal thickening and retained secretions What do these findings indicate and why would this patient be prone to develop this condition? Answer and Discussion

A 52-year-old man was referred to the ENT department with a 10-week history of facial pain. He described the worst pain he had ever experienced and had been unable to work during the preceding fortnight.He had noted increasing swelling around his left eye and forehead and green discharge from his left nostril, with occasional blood-staining. He had received three courses of antibiotics with little effect.The patient described a long history of sinus problems, previously requiring hospital admission for intravenous antibiotics. He had undergone functional endoscopic sinus surgery (FESS) on three occasions electively for nasal polyposis and had undergone emergency surgery to the maxillary sinuses for an episode of orbital cellulitis. He is an asthmatic and had previously had an attack triggered by aspirin.On examination, marked tenderness was noted bilaterally over the orbital and maxillary regions and there was a fluctuant swelling in the region of the left forehead. Eye movements and vision were normal. Polyps and pus were visible on anterior rhinoscopy. Full blood count, renal function and electrolytes were normal.Swabs from both nostrils were sent for culture and sensitivity and an urgent CT scan was requested (Figures 1 and 2) showing soft tissue swelling with abscess formation overlying the left frontal sinus, bony erosion of the anterior wall of the sinus and inflammation of most paranasal sinuses. Figure 1. Axial CT showing bony defect of the anterior wall of the frontal sinus with overlying soft tissue swelling Figure 2. Coronal CT showing extensive shadowing of the paranasal sinuses suggestive of mucosal thickening and retained secretions What do these findings indicate and why would this patient be prone to develop this condition? Answer and Discussion