Sinus disease can present in a variety of ways and may occur in individuals who are not otherwise aware that they have problems (occult sinusitis). An unusual presentation of occult frontal sinus disease in a 64-year-old patient was reported. A fistulous communication with the upper lid, causing a persistent abscess. There was a 6-month delay in making the correct diagnosis and the patient was treated with repeated courses of antibiotics and even an incision and drainage procedure. Finally, the correct diagnosis was made following CT imaging and the patient underwent functional endoscopic sinus surgery which closed the communication, but left the patient with a tight upper lid, which required further oculoplastic surgery. The patient was pleased with the final visual outcome and the fistula remained closed.
A Rare Presentation of Occult Sinusitis: Upper Eyelid Fistula
From the Wolverhampton and Midland Counties Eye Infirmary, New Cross Hospital, Wolverhampton, United Kingdom.
The authors have no proprietary interest in the work presented herein.
Address correspondence to Mrs Nirodhini Narendran, Wolverhampton and Midland Counties Eye Infirmary, New Cross Hospital, Wednesfield Road, Wolverhampton, WV10 0QP, United Kingdom.
Accepted: August 19, 2009
Posted Online: March 09, 2010
Sinus disease can present in a variety of ways and may occur in individuals who are not otherwise aware that they have problems (occult sinusitis). We report an unusual presentation of frontal sinus disease that has been rarely reported in the literature: a fistulous communication with the upper lid causing a persistent abscess. There was a delay in making the correct diagnosis and the patient was treated inappropriately before finally undergoing sinus surgery with good functional result.
A 64-year-old woman presented to the eye casualty and ophthalmology clinic with recurrent episodes of a discharging right upper lid abscess (Fig. 1). The patient was fit and healthy and was not known to have any ENT history, previous insect bites or trauma around the affected area. Visual acuity was 6/6 in both eyes and the result of ocular examination was otherwise normal. The abscess was treated with oral antibiotics at each episode, but never settled completely. After 5 months of symptoms the abscess was incised and drained, however she went on to develop a persistent serosanguinous discharge with a tight upper lid (Fig. 2). She was referred to an oculoplastic specialist for further opinion. A suspicion of sinus disease with fistulous communication to the upper lid was raised and this was investigated with a CT scan of the orbits. The scan revealed ipsilateral sinus disease, with a right-sided fronto-ethmoidal abscess and fistula on to the right upper lid (Fig. 3). The patient was referred to the ear, nose and throat team and underwent successful functional endoscopic sinus surgery. Following this the fistula was closed but the right upper lid remained tight (Fig. 4), although there was no lagohthalmos.
Figure 1. Color Photograph Showing Persistently Discharging Right Upper Lid Abscess.
Figure 2. Color Photograph Showing Tight Upper Lid with Serosanguinous Discharge Following Drainage of the Abscess.
Figure 3. CT Scan Showing Previously Undiagnosed Right-Sided Sinus Disease (maxillary Sinus Involvement).
Figure 4. Color Photograph Showing Tight Upper Lid Remains Following Functional Endoscopic Sinus Surgery and Closure of the Fistula.
The patient was referred back to the oculoplastic team for an opinion on the unsatisfactory appearance of the right upper lid. She was advised to allow the area to settle a little longer before considering further surgery. Sixteen months following the original incision and drainage of the lid abscess, the patient underwent left upper lid blepharoplasty with removal of the medial and middle fat pad (to maintain symmetry) and right upper lid excision of scar with fat graft to fill the depression. She was pleased with the final cosmetic outcome.
Sinus related fistulae presenting as upper lid lesions are uncommon, with only 3 previous references in the literature.1–3 Seyhan and Ozerdem describe a case of a 21-year-old man with an upper lid abscess who was treated with several courses of oral antibiotics.1 Following each course, the abscess would settle and then recur after 4 to 5 months. He developed a continuous discharge and, finally, after 3 years the correct diagnosis of a frontal sinus fistula was made using CT Casady et al. describe a series of 5 patients who initially presented with upper eyelid abscesses, but following investigation were later found to have sinus related fistulae.2 Comparison of the history revealed that there were some common presenting features including an absence of concurrent systemic illnesses, lack of pyrexia and presence of sinusitis symptoms including a nasal discharge and headache. Imaging revealed occult sinus disease and all patients improved following functional endoscopic sinus surgery. Another more recent retrospective case series from Moorfields Eye Hospital describes features of 8 patients presenting with eyelid fistula due to chronic sinus disease.3 All presented with discharge from the fistula which was situated either centrally or medially in the upper lid. In addition, three of the patients had associated ptosis, two had proptosis, and one had a medial upper lid ectropion. All had opacification of their ipsilateral frontal or ethmoidal sinus on CT imaging; five showed bony erosion and two had sinus mucocoeles. In all cases the management was functional endoscopic sinus surgery, which was successful. The authors mention that contracture and thickening of the skin can occur around the fistula, which was also a feature of the case presented here. Once again in this case series, delayed diagnosis was common with the longest delay being almost 2 years. In keeping with the literature, our patient also presented in an apyrexial state with no history of sinus pathology, and had an unfortunate delay in her diagnosis including an attempt at incision and drainage of the abscess. She responded well to functional endoscopic sinus surgery, but had to undergo additional surgical reconstruction of her deformed upper lid to obtain better cosmesis. These cases illustrate that occult sinusitis may occur in patients who are otherwise systemically well. Secondary fistulous communication to the upper lid is relatively uncommon but should be suspected if an individual presents with a chronic upper lid abscess that does not appear to settle and imaging with CT scanning should be considered at an early stage to investigate the extension of all persisting abscesses. Failure to recognize this condition and commence appropriate treatment can expose the patient to the other more serious and more well-known risks of sinus disease, such as cavenous sinus thrombosis and orbital cellulitis. For patients who develop scarring of the upper lid following surgical closure of the sinus, we found that blepharoplasty with fat graft appears to give excellent cosmesis.
- Seyhan T, Ozerdem OR. Upper eyelid fistula caused by chronic frontal sinusitis. J Craniofac Surg. 2005;16(1):171–174. doi:10.1097/00001665-200501000-00036 [CrossRef]
- Casady DR, Zobal-Ratner JL, Meyer DR. Eyelid abscess as a presenting sign of occult sinusitis. Ophthal Plast Reconstr Surg. 2005;21(5):368–370. doi:10.1097/01.iop.0000179372.05969.6a [CrossRef]
- Rossman D, Verity DH, Lund VJ, Rose GE. Eyelid fistula: a feature of occult sinus disease. Orbit. 2007;26(3):159–163. doi:10.1080/01676830701519424 [CrossRef]