Diseases Of The Accessory Sinuses Of The Nose

Diseases Of The Accessory Sinuses Of The Nose
By ROBERT CUNNINGHAM MYLES, M. D.,
OF NEW YORK CITY.

THE, accessory sinuses of the nose are cavities in the bones of the head and face that connect with the nasal fossae by one or more narrow apertures. There are three bilateral single sinuses the antra of Highmore, or maxillary sinuses, the frontal sinuses, the sphenoidal sinuses, and two bilateral groups of sinuses, the anterior and posterior ethmoidal sinuses.

ANATOMY.

The maxillary sinuses are situated on both sides of the face, between the orbits and upper teeth (see Fig. 545); their average measurements are about 27 millimeters through the center, both vertically and antero posteriorly. They have an oblong or fissure like opening into the middle meatus of the nose, about its middle third. Accessory openings posterior to the hiatus are common. Occasionally the roots of the molars project like small cones from the floor of the sinus, and frequently there are partitions and membranous bands, one fourth to one half an inch high, dividing the floor and walls into compart¬ments. These are often regarded by observers as pathological formations, but I believe that they are normal. The walls of the canine fossae and the inner or nasal wall, from one third of an inch above the floor, are very thin, excepting that part which gives an attachment to the inferior turbinated bone. Fluids of low specific gravity will sometimes flow from the frontal sinus, down through the infundibulum, into the antrum of Highmore. This is important, as it shows that the antrum may serve as a pus reservoir for the inflammatory products from the frontal sinus or anterior ethmoidal cells. The ethmoidal cells are situated between the nasal process of the superior maxillary and lachrymal bones and the frontal sinus in front; the sphenoid and palate bones behind; the sphenoid, cribriform plate, and frontal bones above; and the os planum, lachrymal, sphenoid, and superior maxillary bones on the outer side. The inner side is bounded by the space from the cribriform plate to the middle third of the middle meatus in front and to the attachment of the middle turbinated bone behind. (Fig. 543 shows the ethmoidal cells partially exposed.) They are separated by an unbroken partition into anterior and posterior cells. Sometimes the anterior cells communicate with the infundibulum or frontal sinus direct. The anterior cells drain by an opening in the median wall of the ethmoidal bulla, and frequently by another opening into the superior meatus. The sphenoidal cells are best described as being in the body of the sphenoid bone; they are separated from the posterior ethmoidal cells by a common wall, and discharge their contents through an opening in the upper anterior wall. (Fig. 548 shows right and left cells as they cross the median line.) The frontal sinuses are situated in the frontal bone, above the inner canthus of each eye. Their walls are made up by the frontal bone, excepting a part of the floor, which is formed by the ethmoidal cells and the projecting portion of the nasal process of the superior maxilla (see Fig. 547). These cavities are irregular in size: in the average sinus the perpendicular and transverse diameters are about one inch in their longest axis. The central antero posterior diameter measures about three eighths to one fourth inch; it is not uncommon to find one large and one very small cell in the same head. The large cells usually extend toward the temporal region, from one to three millimeters beyond the orbital notch, and they discharge their secretion through an irregular' tortuous canal, the infundibulum. They are divided by a bony wall, which is rarely central and occasionally perforated (see Figs. 544 and 548).

PHYSIOLOGY.

Although the physiology of these cells is not definitely settled, an analysis of their function points to the conclusion that they are intended to supply warm air and moisture for respiratory purposes, and also probably to act as resonators for modifying certain qualities of the voice. When we consider that about 400 cubic inches of air are inhaled per minute, which should be warmed to a temperature as near 98.5' F. as possible, and that this same air should be charged with vapor nearly to the point of saturation, I cannot conceive of a more satisfactory arrangement than these cells afford. During respiration the apertures, including the naso lachrymal ducts, have a tendency to dilate, while during expiration they partially close. At the beginning of inspiration, the partial vacuum produced takes a part of the latent air from within the cells, and the velocity of the inspired current further draws from them. Toward the end of the inspiratory act, new air enters the cells to fill the partial vacuum, aided by the natural law by which warm air is displaced by cold. On expiration, the vis a tergo pressure partially closes the cells. The to and fro currents of air constantly draw the tenacious mucus from the cells, overcoming the adverse conditions of small openings and the laws of gravity.

EMPYEMA OF THE MAXILLARY SINUS.

Etiology. Distinguished specialists have written a great deal within the past few years concerning the cause of pyogenic conditions within the antrum of Highmore; and they are about equally divided on the question whether disease of the nose or the teeth is the more frequent causal factor of disease. My own experience in the chronic cases is that the teeth and nose are about equally responsible for the purulent condition. Many of my worst cases were caused by fillings placed in teeth with very large cavities where the nerves were either exposed or dead. Suppuration bad evidently occurred in the root end ; the pus had discharged itself, with little resistance, through the thin bone lying between the top of the alveolus and the floor of the antrum, and from that time the tooth had not given the patient any pain nor the dentist any concern. But the patient bad been trying nearly all of the patent catarrh remedies, and had been treated by different specialists for nasal and post nasal catarrh. A few cases seemed to be caused by alveolar periostitis, caries, and necrosis, which had been originally started by a decaying tooth. The majority of the cases of nasal origin began with polypoid degeneration. In some of my patients their septa were so far deflected in the upper middle region that the middle turbinal bodies were pressed firmly against the hiatus; the secretions had been retained under putrefactive and fermentative conditions, and bad produced chronic inflammations of the membranes and bones, and probably necrotic areas. Influenza, la grippe, or acute inflammations of almost every kind appear to produce empyema when the swelling is so great as to close the normal opening, especially by pressing the upper and inner valve like lip of the hiatus outward against the semilunar partition. Atrophic rhinitis, syphilis, tuberculosis, tumors, and foreign bodies occasionally cause suppuration in the antrum.

Symptoms. In cases of acute empyema with complete occlusion the pain is extremely severe, and there is a feeling as though the antrum would rupture from the intense pressure. In four of my suppurative cases with complete stenosis the pain ceased immediately after the evacuation of the pus. In those instances where the acute and subacute catarrhal process either occurred simultaneously with nasal cold or extended into the antrum by continuity there was a slight fullness and a sensation of stuffiness in the region beneath the eye, together with a thick muco purulent discharge into the middle meatus beneath the bulla, which usually stopped within from three to six weeks. The chronic cases all had the symptoms of so called post nasal catarrh, and in the majority of them the mucus and pus were discharged also through the anterior nares. Certain patients complained of the fluid running downward over the tipper lip whenever the head was inclined forward; others complained of asthma, tubal stenosis, tinnitus aurium, and impairment of hearing, which were relieved after an operation or by irrigation of the antrum. In my series of cases pain was the most irregular and deceptive symptom of all. Frequently it was entirely absent; at other times it would occur in the frontal, maxillary, temporal, or occipital regions, or in two or more of them.

Pathology. I have classified the usual pathological conditions under eight subdivisions, as follows, representing the pathological states approximately as I have observed them in my cases:

1. Acute catarrhal, suppurative, and infectious sinusitis, without complete stenosis of the normal outlet.
11. Acute catarrhal, suppurative, and infectious sinusitis, with complete occlusion of the normal outlet.
III. Subacute and chronic catarrhal and suppurative sinusitis, with rnoderately obstructed opening, with or without decayed puro mucoid debris.
IV. Polypoid degeneration.
V. Alveolar periostitis and periodontitis, attended by suppuration, caries, necrosis, or other pathological changes at the root end.
VI. Atrophic rhinitis.
VII. Tumors and foreign bodies.
VIII. Syphilis.

Acute cases without stenosis are very common. The mucous membrane of the nose and cavity is usually congested at first, and then it begins to swell, and continues to do so until it is several times its normal thickness. At this stage it usually throws out a thick muco purulent secretion ; the discharge gradually ceases within from three to six weeks, and the membrane is left a trifle thicker, having undergone slight hyperplasia. In the completely stenosed cases, where neither nature nor surgery relieves them, necrosis of the soft tissues usually occurs, and occasionally the bone is involved in the same process.

In the subacute and chronic catarrhal and suppurative cases, where the opening is moderately obstructed, the mucus frequently becomes partially inspissated and forms a lump, which enlarges by accretion and acts as a foreign agent, causing a bacterial development the corroding by products of this frequently destroy the surfaces of the mucosa and start small ulcerated areas, which, if not cured, extend in time to the periosteum, and often to the bone itself.

Polypoid degeneration extends front the ethmoid, or has its origin upon the antrum membrane. In its early stages this peculiar condition may be classed as watery edema. If it occurs on the lateral or upper walls of the cavity, and remains more or less flat or mammillated, there is a possibility of its returning to its normal state under favorable conditions; but if it once becomes pedunculated it seems to lose this power of self restoration. Caries, necrosis, and burrowing periostitis in the molar or bicuspid roots frequently extend through the floor of the bone and burrow in a fistulous inanner beneath the periosteum, elevating it and frequently leaving the entire membranous floor floating in muco purulent matter. A rupture may take place through this membrane at a distance from the injured bone and discharge itself into the Dose. The membrane becomes very thick and granular, and debris from the mucus, pus, and bone degenerates in the cavity. The atrophic process, which is the consequence, in my opinion, of suppurative rhinitis in early childhood, invades the antrum, frequently destroys the epithelium and the serous glands of the membranes, and leaves a sclerosed membrane which secretes a semipurulent matter; this, in turn, degenerates in the warm cell and issues through the normal opening into the nose, where it is formed into crusts by the inspired air.

Tumors, especially sarcomata, may form in the antrum and simulate empyema. Syphilis usually attacks the antrum walls by the formation of gummata; while at rare intervals the germ's of scarlet fever, measles, tuberculosis, and diphtheria invade the antrum, as do aspergilli and other fungi.

Diagnosis. A unilateral pus discharge from the nasal cavity is by far the most suspicious symptom of empyema of the maxillary sinus. On rare occasions this unilateral pus or muco pus discharge is only made manifest posteriorly. On the other hand, polypoid degeneration, which, in my experience, is next in frequency to the irritation caused by decaying teeth in causing antrum trouble, is usually bilateral. The classical symptoms as laid down in the older books are usually wanting, save in the acute stenosed cases. The frequency and urgency of diseases of the antrum have led us to abandon the consideration of a great deal of the circumstantial evidence upon which formerly so much stress was laid, and we make small delay in trying to obtain positive evidence at once. This is usually secured first by inspection of the middle meatus. If pus is detected beneath the bulla ethmoidalis under the middle turbinal body and the hiatus semilunaris, we know that one of the three cavities is diseased the anterior ethmoidal cells, the frontal sinus, or the antrum of Highmore. After cocain has been applied to the membrane and pus is found, a cotton applicator should be used to wipe it away, and, if pus then exudes from beneath the middle turbinal body and on the lateral side of the bulla ethmoidalis, it of course comes from the anterior ethmoidal cells. If, after wiping it away and placing the patient on a lounge, with the top of his head near the floor, pus comes from the hiatus, the evidence is almost positive that its source is the antrum. In those cases in which the pus is liquid in character it will flow readily into the nose and will have a more or less offensive odor. If, however, the pus is very thick and much intermixed with mucus, it will sometimes merely protrude through the opening. In the frontal sinus cases I have usually been able to detect the pus at the very uppermost anterior part of the hiatus. Usually it is well, even after the pus discharges with the bead in a downward position, to introduce a curved irrigation tube into the hiatus, and inject warm water into the cavity; if this is successfully (]one, we are almost invariably rewarded with the evidence of pus in the returned fluid. In those obscure forms of latent empyema, the first evidences of their existence are usually shown by the electric light (Plate 14). Although this procedure is not infallible, it is of great value in the bands of one who knows bow to employ it. A pus discharge on one side, with a dark umbra beneath the corresponding eye, is almost conclusive evidence; yet, to make assurance doubly sure, I nearly always remove some of the pus from the antrum, either through the natural opening with the silver irrigation tube or by means of the trocar and cannula passed through the antrum wall in the middle meatus, just below and posterior to the hiatus.

In a few of my cases even these tests failed to demonstrate positively the pathological state within. They were cases in which the antrum was full of polyps, and in most of them there was a thick, tenacious mucus with occasional hardened lumps. The irrigation fluid simply passed over the polyps. Puncture through the bone of the canine fossa or through the alveolus of the tooth has always seemed to me too serious a procedure to be justified for merely diagnostic purposes. The small trocar and cannula (Fig. 588) passed through the middle meatus, below the posterior end of the hiatus, where there is either very little or no bone, causes but little pain and apparently no after disturbance. Tenderness on pressure and dulness of percussion may occur from periosteal irritation or may be due to the smallness of the antrum; but they have little significance, except as they may concur with a train of symptoms, to make the diagnosis by exclusion.

Prognosis. Diseases of these sinuses rarely cause death directly; but they frequently make life miserable. The dangerous cases of antrum trouble which I have seen have been those in which the orbital plate was broken through by the intense pressure of the confined gases and fluids; and a few cases are reported in which the pus, burrowing through the orbit and ethmoid, has extended to the brain. In nearly all of the acute and subacute cases resolution takes place within a few weeks. If a case has existed over a year with a history of constant muco purulent discharge, disclosing, when the cavity is opened, carious and necrotic bone, with destruction of a considerable area of the mucosa, the prognosis in regard to an early cure is unfavorable, as it usually takes several months or a year or two for the tissue to regain, even approximately, its former state. I have found cases of necrosis of the septa of the superior maxillary bone and general polypoid degeneration of the mucous membrane of the cavity the most obstinate in treatment and unfavorable in prognosis.

Treatment. The best procedure in treating these cases will be determined by the pathological state and by the history of each case. Acute and subacute cases, not of dental or polypoid origin, can usually be readily cured by restoring the nasal mucous cavities to their normal state, and by irrigation of the sinus through the natural openings. In cases of dental origin the offending tooth should be removed; and, in those of recent date, the tissues should be let alone for a few weeks in order that they may have an opportunity to resume their normal condition, the causal factor of disease having been removed. If the trouble has existed for more than six or ten months and there is a decided odor from the antrum, with evident carious and necrotic trouble at the root end, I advise immediate penetration by making an opening, about 5 or 6 mm. in diameter, through the alveolus floor. Irrigation with disinfectants should be passed through with the regulation tubes and syringes. If the internal walls appear on probing or curetting to be in an extremely degenerated state, with serious. carious and necrotic conditions of the bone, I think that the safest and most effective operation under these circumstances consists in a large opening into the antrum through the canine fossa and the anterior lower border of the malar ridge. This opening should be from 10 to 15 mm. in diameter; the cavity should be carefully curetted, and in certain cases a counter opening (Fig. 589), at least 8 to 10 mm. in diameter, should be made through the inferior meatus wall into the Dose. I have operated by cutting off the inferior turbinal and trephining through the inferior meatal wall, and have also cut into the lower border of the hiatus in the middle meatus. The cases in which I did this were so extensively and seriously diseased that I did not get as good a result as I bad anticipated, chiefly because I could not curette the walls through this intranasal perforation. The after treatment should consist of aseptic and antiseptic irrigations, and in certain cases keeping the canal open by means of rubber (Fig. 590) or silver tubes, with occasional careful curettage of the necrotic and granular surfaces and the insufflations of boric acid and of iodoforin in certain cases where there is frequent accumulation of foul smelling pus. I have found the injection of a drachm and a half of liquid albolene, containing 3 to 10 grains of iodoform, left in the cavity, to afford marked and decided relief.

CLASS I. The cases of acute nature without stenoses are very common, and usually last from three to six weeks. They come on after the manner of an ordinary cold in the head, followed within a few days by very disagreeable feelings of fulness, oppression, and dulness ; in some cases a certain amount of headache exists, or toothache, and a dull feeling is present in the ears. This stage is relieved by a copious flow of muco pus. During the course of these cases the ordinary treatment for a severe cold is the best. Most individuals who are subject to this condition have from two to four attacks during the year. The rational treatment is one of prophylaxis, which consists mainly in reducing and removing the intumescent and abnormal tissues within the nose, which should be done during the intervals of the attacks.

CLASS II. Acute Catarrhal, Suppurative, and Infectious Sinusitis with Stenosis. These cases, besides requiring the ordinary treatment, demand the evacuation of the retained secretion at once. A limited amount of a saturated solution of cocain should be applied to the parts around the natural opening, and a persistent effort should be made to enter the cell with a tube, or, failing in this, penetration with trocar and cannula should be made, and the cavity should be carefully aspirated and irrigated. As soon as its patulency is restored the patient recovers rapidly. These cases call for the same treatment during the intervals as that described for Class 1.

CLASS III. Subacute and Chronic Catarrhal and Suppurative Sinusitis, with Moderately Obstructing Stenosis, Thickened Mucosa with or without Retained Decaying Puro mucoid Debris. This class of cases is the most fruitful source of post nasal catarrh, and is rather difficult to diagnose accurately. The symptoms rarely indicate the latent pathological condition sufficiently to warrant the operative procedures necessary for a proper diagnosis or treatment. In these cases attempts should he made to irrigate through the natural openings. In certain cases removal of the, anterior end of the middle turbinal facilitates this procedure, and frequently we are rewarded with a cure or decided relief. It is taken for granted that in all classes of cases any abnormal intranasal conditions should be rectified. When these cases resist the irrigation treatment and are of sufficient importance, a counter opening should be made in the cell walls and proper curettage and drainage should be carried out.

Mrs. C., aged thirty. Acute empyema; sent for me to visit her. Complained of great pain and fulness which came on with a cold in the left jaw, which was swollen and tender. The hiatus was closed by tumefaction of all the tissues near the part. After applying cocain crystals, I washed out the antrum through the natural opening; muco pus flowed out with the boric acid solution; immediate relief from the severe pain followed, and the patient gradually recovered.

Miss L., aged twenty six, had been suffering for several days from severe pain and oppression in the right side of the face, with a sensation as though the face and orbital cavity would burst. Her septum was deflected with an ecchondrosis; the turbinals were much swollen, and transillumination produced an umbra under the right eye. I reduced the intumescent tissues with cocain, and found the tissues about the right hiatus swollen and papillomatous in appearance. On introducing one of the smallest silver tubes the confined pus escaped with the irrigating fluid, which gave her immediate relief. I removed by snare a fungating papillary growth, about three millimeters in diameter, from the internal margin of the hiatus. After several irrigations at three days' intervals the cavity gradually returned to a normal condition.

Mr. A. W., aged fourteen, consulted me in May, 1892. Complained of (in his own words) " Very bad discharge from nose for the last four or five years, which consists of pure matter Sometimes there is a buzzing noise in the head on waking in the morning. A bad smell from the nose." There had been a muco purulent discharge with unpleasant odor, mostly from the right side, for the past three or four years.

Rhinoseopic examination showed the septum deflected to the left with an ascending oblique ecchondrosis. The septum was deflected to the right superiorly, pressing the middle turbinal body outward; pus mixed with mucus was issuing from the right hiatus. He had excessive hypertrophy of all the turbinal tissues, and also of the third and faucial tonsils. The electric light produced a light spot beneath the left eve and an umbra beneath the right. I reduced the hypertrophy of the turbinals with the electric cautery and chromic acid, and irrigated the right antrum. through the natural opening two or three times a week for a few months.

The patient gradually improved, pus ceased to flow, and the electric light produced the light spot beneath both eyes.

CLASS IV. Polypoid Degeneration. This class furnishes by far the majority of the operative cases. Woakes, Bosworth, Casselberry, and others have well described them and their treatment. Large counter openings, packing, careful and repeated curetting, good drainage, and irrigation are the essentials for successful treatment.

CLASS V. Odontic Periostitis and Periodontitis, Sometimes Terminating in Caries and Necrosis. It is universally conceded that the offending tooth in this class of cases should be removed, and, if the case be of long standing, the cavity should be opened, carefully curetted, and dressed. Formerly, following the advice of many dentists and surgeons in these extensively necrosed cases, after the tooth bad been extracted, I drilled upward through the socket; but the after history of many of such cases has caused me to regret it. The principal objectionable features are: the distance through the bone to the floor of the antrum ; the dense thick tissue of the gum ; the difficulty experienced in curetting, the long walls of the opening preventing the proper play of the handle of the curette; the easy entrance of food into the antrum, and the necessity of plugging the tube, when one is worn for drainage, while eating. I take it for granted that every one would prefer the lower anterior border of the malar ridge for penetration in all cases where the first molar tooth has been absent for some time. The most serious obstacle which I have met with is the decided objection of the patient to losing a tooth.

In nearly all extensively diseased cases, where some other operation was performed in place of the one through the malar ridge, the patient and myself have both bad cause to regret it. On the other hand, a great many of the worst types of cases have done well when the operation was properly made through the point of election. The surgeon has complete, subsequent control of the antrum, and can keep it open and curette it at any time without inconvenience to himself and with very little pain or annoyance to the patient. The canine fossa, where the bone is very thin, is the next point of preference; the main disadvantages are its distance up under the cheek and the elevation of the opening above the floor of the antrum. The history of the following cases presents some of the difficult problems of this class of cases.

Mr. C. H., aged twenty five. Presented for treatment, 1891. There was a history of long continued catarrhal discharge from the nostrils, anteriorly and posteriorly, much greater on the right than on the left, and a most unpleasant ocior in the expired breath. The nostrils were very disagreeably stenosed, the right more than the left. The secretions were muco purulent, excessive in the mornings, at times decidedly creamy in color and consistence, and leaving more or less of a permanent yellowish stain on the handkerchief. The objective symptoms were a moderately deflected septum, hypertrophy and passive dilation of turbinal tissues, which I reduced with electric cautery and chromic acid. On certain mornings there was a stream of muco purulent matter issuing from the posterior end of the right hiatus semilunaris, and continuing its course, on the upper surface of the inferior turbinal body, to the naso pharynx, and not, as usual, passing over the inferior turbinal toward the floor of the nostril. After reducing the general hypertrophy, I diagnosed empyema by placing the electric light in the mouth, ng a very dark shadow over the right antrum and bright spot under the left eye; and besides the corroborating evidence of pus discharged from ostium maxillaris, I passed a curved needle through the antrum wall in the inferior meatus after Mikulicz's method and found pus in considerable quantity. Irrigation of the antrum through the hiatus gave similar results. He had splendid teeth, but on close inspection the right second molar was pale white in color and appeared as though the nerves were dead. This tooth had been filled with an amalgam four years previously and had given no disturbance since. I proposed removal of the tooth and trephining, but he refused an operation in which he would lose a tooth. Subsequently I sent him to a dentist, who removed the filling and found some purulent secretion and offensive gas in the palatine root; he treated it for some time with the hope of arresting the trouble above, but without avail, and the patient finally consented to have the operation performed. Under gas Drs. Bradley and Dixon removed the tooth and I trephined a space about 6 millimeters in diameter through the socket. The antrum was full of the most offensive pus and gas it has ever been my ill luck to detect. I curetted from the cavity a great deal of granulation tissue and some carious bone, and after irrigating the cavity with an antiseptic solution, packed it with iodoform gauze, which remained in for a few days. Subsequently I packed it once a week, and there was very little pus or odor when I removed the gauze. He improved steadily for a few months, wearing a gold tube fitted to a special plate, and irrigated the cavity regularly; then the hole gradually closed, and all of the old time unfavorable symptoms reappeared. I then removed a part of the external wall of the antrum and found extensive granulations and carious bone, which were carefully curetted. He wore the rubber tube for a long time, and when I saw him last was in a very good condition, the irrigation bringing away daily only a small lump of mucus about as large as a pea.

This is a typical case due to the filling, of a tooth before the pathological state in the root had been relieved.

The results in the cases where I have penetrated through the walls of the meatus have not been so satisfactory as those reported by Grant and other European writers. I have noticed that many cases under thorough and careful curetting ultimately did better than those which were extensively or overcuretted, or those in which the curette was used too moderately. I have found the greatest benefit from recuretting, at intervals of about one month, until all bare bone is covered and granulation tissue cicatrized.

CLASS VI. Atrophic Rhinitis. The bacilli of atrophic rhinitis frequently find a permanent home in the sinuses. Robertson of Newcastle on the Tyne and Grunwald have done some original and efficient work in this class of cases.

affection : one in which the semi solid putrid debris is confined in the cavity and remains a causal factor in keeping up the condition, and the other in which the tissues have undergone degenerative changes. Irrigations will frequently relieve the first; curetting and drainage are generally necessary to restore the latter.

CLASS VII Tumors. Tumors occasionally develop in these cavities. Early diagnosis is of the greatest importance, for it frequently enables the surgeon to save the patient's life by timely removal, and rescues him from a condition of intense pain and distress. Among the benign tumors mucoceles and osteomata are the most important.

Among the malignant tumors, sarcoma (spindle and round celled) and osteosareoma are the most common. The prompt removal of the superior maxilla in a patient of Dr. Wyeth's and mine has apparently cured him of an otherwise fatal disease.

The patient was sent to me in February, 1894, by Dr. Wyeth for my opinion concerning the right antrum of Highmore. He bad was troubled with a diseased tooth, pain in the right upper jaw, and with an extremely unpleasant discharge for two years. A diseased tooth had been extracted. In August, 1892, a local dentist opened the antrum, but the pain continued. In September, 1893, Dr. Wyeth (the patient being under ether) opened and curetted the antrum through the tooth socket, but little relief from the discharge was experienced. In January, 1894, Dr. Wyeth recuretted the antrum, but the unfavorable symptoms continued.

In passing the curette over the antrum I noticed a thick and peculiar lining on the antrum walls, which produced very much the same sensation as one experiences when scraping a raw potato. I expressed my opinion that it was a malignant neoplasm, and, upon Dr. Wyeth's suggestion, a specimen was sent to Dr. Prudden, who reported that it was a large celled sarcoma. In March, 1894, Dr. Wyeth removed the superior maxillary bone, with part of the pterygoid plate. The patient recovered from the operation, and seems to be doing very well with an artificial jaw, and continues in the practice of his profession as a lawyer. There remains one unfortunate result: the continuance of a. constant sweetish and extremely disagreeable taste. in the mouth. There is a little muco pus issuing at the point where the section of the naso lachrymal duct was made. I saw the patient in the summer of 1896, and there was no recurrence,

CLASS VIII. Syphilis. Gummata frequently develop in the nasal walls of the antrum. I had recently under observation three cases of gum of the internal wall of the antrum of Highmore. They did well under iodid of potassium and occasional scraping of the necrosed bone.

An illustrative case, Mrs. S., aged fifty, applied to me in 1894. She was suffering from such severe pains in the left side of her head that she had only slept a few minutes at a time for several nights and days. I removed a degenerated gummatous internal wall of the antrum; found the cavity extensively diseased and full of putrid secretion and tissue debris. Besides local measures I gave her iodid of potassium; controlled the pain for a few days with morphin. She improved rapidly, and in two months was apparently well.

DISEASES OF THE ETHMOIDAL CELLS.

The large number of the ethmoidal cells and the peculiar latency of their affections make it difficult to determine the extent of their pathological conditions and to adopt a successful line of treatment. These cells, in my experience, are oftener diseased than any of the other cavities. Polypoid degeneration is their most frequent affection. The bacteria of grippe and influenza invade these cavities and produce alarming and distressing symptoms. In the young suppurative rhinitis nearly always terminates in atrophic rhinitis, and is a frequent cause of chronic ethmoidal empyema.

Etiology. Woakes and Thudicum have probably done more than any others to inaugurate active methods of treatment of these cavities. The mucosa of the ethmoid bone seems to have a peculiar proneness to watery infiltration, which if not relieved will terminate in a polypoid state. This condition seems to affect all of the tissues, including the periosteum and the bone, and it ultimately renders the bones soft and brittle. Occasionally the septum, or an exostotic or ecchondrotic growth protruding therefrom, so presses into the ethmoid or middle turbinated body as to close the natural openings, and degeneration takes place as a consequence. In a few cases inflammatory and necrotic processes extend from the antrum to the ethmoid. In others the process extends from the frontal sinus. Cysts occasionally form in one of the cells and extend backward and forward, breaking down the intercellular walls, and finally make their appearance above the inner canthus of the eye, where the bone is probably thinnest.

Again, acute catarrhal inflammation of the Schneiderian membrane is frequently attended by an edema which continues so long that it obstructs the respective openings of the cells for several days. This causes putrefaction of the retained secretions; they in turn irritate or destroy the mucous lining of the cells; and pus either discharges through the normal outlet or forces its way by pressing through it (?) or through an artificial opening. If the pressure has been sufficient to produce necrosis, and if the drainage has Dot been free, we have as a result chronic thickening with pus production, or watery edema or polypoid changes. Syphilis at times will form gummatous tumors, which in breaking down present the appearances of polypoid degeneration. Osteomata and malignant tumors in this region are occasionally the cause of considerable pain and a discharge of broken down tissue products.

Symptoms. The most common symptoms of ethmoid disease are mucopurulent discharges through the rhino pharynx and through the anterior Dares, with dull and deep seated pain around the orbit, frontal region, or in the temporal and occipital regions. In chronic cases the pain is largely dependent upon the retention of the secretions and the amount of periosteal disease. The chronic cases with free drainage usually complain of Muco pus in the pharynx, larynx, and bronchi. Acute cases with stenosis complain of profound oppressive pain and fullness throughout the post orbital, frontal, and temporal regions, and usually show some mental dullness the patients complaining of disinclination to mental activity. In cases of mucocele the symptoms are often very obscure. The pain in the ethmoid region and behind the eye is rather constant and severe; and the nasal walls of the ethmoid rarely bulge or protrude sufficiently to awaken our suspicions, although ultimately the orbital plate, just above the inner canthus of the eye, gives away and protrudes.

Diagnosis. In cases of acute inflammation and stenosis of the ethmoidal cells the diagnosis is extremely difficult, save when it is inferred from the intense subjective symptoms. The subjective symptoms are usually those of acute and infectious rhinitis; rarely, indeed, do we have sufficient evidence to warrant us in penetrating into one of these cells when a condition of acute empyema exists. Frequently in cases of grippe the patient implores the physician to cut into the cells to relieve the distressing and almost unbearable symptoms of pressure. In chronic cases with discharge the diagnosis is not difficult; but in cases where abnormal conditions obstruct the view there is some difficulty in distinguishing between empyema of the anterior ethmoidal cells, of the frontal sinus, and of the antrum of Highmore. In those cases where the muco purulent discharge flows from the septal side of the bulla ethmoidalis, the evidence that there is empyema of the anterior ethmoidal cells cannot be disputed. Pas in the superior meatus can mean only one of three things posterior ethmoidal, or sphenoidal trouble, or subperiosteal bone disease. Pus issuing from the posterior ethmoidal cells must pass over the posterior end of the middle turbinal body ; and when the source is the sphenoidal cell it usually passes behind the tip and over the posterior upper border of the choana. Occasionally sneezing or forced blowing of the nostril forces muco pus into the upper chambers. In such cases wiping the mucus away and awaiting its reappearance will decide. The posterior rhinoscopic mirror is most valuable in demonstrating muco purulent secretions in the superior meatus. The degree to which the pathological state has extended can be determined by the objective appearances, especially by the character of the pus, muco pus, and the edematous, polypoid, and sclerosed states. I have been able to confirm my suspicions on many occasions when the irrigation tube had been passed into the natural opening. The probe will convey an idea of the diseased state of the membrane, but it is frequently deceptive concerning the bone. The periosteum and mucous membrane of these bones is very thin, and frequently the probe feels as if it was on bare or exposed bone when it is in a fairly normal state. This has led many of our best writers into controversy on the diagnosis of diseases of this region.

Treatment. Although we have done much in the treatment of ethmoidal disease, many questions in regard to the best methods are yet to be settled. The ethmoid is really the home of nasal polypi; the majority of the serious cases are the cause or consequence of polypi, and are etiological features in the deeper degenerative changes of tissue and bone. All pedunculated polypi should be removed by the wire snare, and 11 have found the Bosworth snare by far the best for this purpose. In a few cases it is well to pull out the polypi after the wire has been well tightened around the pedicle; on the other ban(], it is sometimes better to cut through the pedicle and afterward destroy the small polypi that grow around the base. The profound symptoms of pain, shock, and hemorrhage that follow tearing away great sections of the mucous membrane and bone by traction on the Snare should contraindicate its indiscreet use. After the practice of these methods in my cases I have never observed the recurrence of polypi in the space of the pedicle; yet I have noticed little polypi growing around the parts, and that their growth continues, being favored by the absence of the larger ones; these should be removed by some excisor forceps. I have found Jarvis's to be the best. In nearly all serious ethmoidal cases the question of removing a part or all of the middle turbinal body should be carefully considered, and as it is necessary in most cases, it is well to decide this question early. I do not believe in the method of tearing this bone away with forceps, as advocated by some earlier writers because the membranous tissues that passes through the cribriform plate with the olfactory nerve, and extend downward over the middle turbinated bone, are quite tough, and sometimes they are torn loose from the bone up to the plate instead of breaking off where the middle turbinated body joins the ethmoidal bone. In my experience I have found the most feasible procedure to be that of making a section with nasal clippers or scissors through the middle of the bone. The Bosworth wire snare with small cannula will remove the anterior and posterior sections readily and effectively, with little disturbance to the membranes of the parts above. Deflected septa, narrow nostrils, and hemorrhage are the chief difficulties to be overcome. The floors of these cells can be penetrated with shoulder protected drills and trephine with very little danger to the neighboring parts. The antero posterior nasal

excisor foreeps, a cut of which I present, has been extremely valuable for enlarging these openings and for removing the floors of the cells. The patient rarely experiences disagreeable results, save in the case's where the cancellated parts of the ethmoid bone have been cut into. The small malleable curettes are extremely valuable in removing pus, polyps, and granulationtissue. When the holes are large enough the cells usually drain so well that it is necessary to irrigate them at stated intervals only. When the process extends far up into the little cells above the orbital cavity, or in some of the recesses under the cranium, the results of treatment are not so satisfactory. I have found that it is advantageous to freely spray the nose two or three times a day with a preparation of liquid albolene 4 oz., carbolic acid, eucalyptol, and menthol, aa 10 grains; this is usually very soothing and beneficial. In the suppurative cases I use the nasal douche, 1 quart of warm water, I teaspoonful of salt, 1/2 drachm of carbolic acid, applied by a fountain syringe through the narrower nostril; with occasional insufflations of boric acid, aristol, and iodoform. Bosworth reports most remarkable results from drilling into these cavities with an ordinary burr and breaking down the intracellular walls; and I believe that he accomplishes this entirely by the sense of touch and appreciation of distances and directions from the anterior nares.

As to results, regarded from the standpoint of the subjective symptoms, about three fourths of my ethmoidal cases are apparently well; but on inspecting them, in the majority of cases, a small quantity of pus and mucopus can be seen either in the nose or issuing from the natural or artificial openings. This increases in winter, and is very much diminished in the summer time.

DISEASES OF THE FRONTAL SINUSES.

The frontal sinuses develop about the age of puberty, and apparently are the extension of the ethmoid cells into the frontal bone. They are much more frequently diseased than is generally suspected, and many supra orbital headaches are due to trouble in these cavities. Improved methods of inspecting the region of the opening of the infundibulum and the use of silver irrigation tubes have thrown a great deal of light upon their pathology, and have led to procedures that have indisputably relieved the morbid conditions.

Etiology. Polypoid or myxomatous degeneration has been the cause of the diseased conditions in the majority of the cases that have come under my observation. Of nine frontal sinuses which I have opened externally, seven had polypi within the cavity and one bad fronto ethmoid necrosis. I have seen a great many cases with polypi in the region of the infundibulum, and evidently extending up into the frontal sinus, which were operated upon per nasi and carefully treated. These cases have improved under drainage, but did not seem to get entirely well. I have bad one case of osteoma. I have seen a few cases of syphilitic invasion resulting in necrosis. Parasites sometimes invade this cavity, especially in the southern parts of the American continent, as by the screw worm or larva of the compsomyia mascellaria, cases of which have been so well reported by Sir Morell Mackenzie.

Symptoms. Pain above the eyes and through the frontal bone is the almost constant subjective symptom of frontal sinus disease ; this is frequently made worse by bending the head forward and downward. In cases of complete stenosis of the infunaibulum the pain is very great, and the symptoms of oppression and suffering are profound. In the chronic cases, where the nose is not occluded by deflection or hypertrophy, muco pus can be seen at the very uppermost end of the lower lip of the hiatus semilunaris, rather anterior to the bulla ethmoidalis.

Diagnosis. The diagnosis can frequently be inferred from the constant pain, tenderness, and discharge in the region of the middle meatus, but the only infallible test is the demonstration that pus really comes from the cavity. The silver irrigation tube is by far the most valuable and reliable means of attaining this evidence; although I think that we are justified in operating when the subjective symptoms indicate frontal sinus trouble and when the objective conditions demonstrate that there is pus in the infundibulum. and the anterior cells. Tenderness to deep pressure, dulness on percussion, and failure of transillumination (see Plate 14) furnish auxiliary evidence.

Prognosis. The prognosis, as regards the relief of the pain and the excessive discharge, is very good indeed if we secure and maintain good drainage from the cavity; but in many cases life is jeopardized on account of the opposition on the part of the patient to an external operation.

Treatment. In acute cases with complete stenosis of the infundibulum the region of the nasal opening of the infundibulum should be thoroughly cocainized and an attempt made to enter the infundibulum with a silver irrigation tube a cut of which is shown in Fig. 593. In several cases I have succeeded in dislodging the gas and pus and in equalizing the external and internal atmospheric pressure. It may not be necessary to enter the frontal sinus in all the cases, as the relief seems to be secured after the manner of that produced by the Eustachian catheter in tympanic troubles. The following case illustrates a brilliant result obtained by this method.

The patient sent for me; I found him almost in a state of collapse and in great agony. He had been suffering for several days with intense pain, together with a full feeling in the right frontal sinus. I sprayed the nostril with cocain and applied it on cotton. The hiatus and infundibulum were very much swollen; the middle turbinal body was moderately so. I passed a tube into the infundibulum and injected gently but firmly a borated solution ; a gush of pus and offensive gas followed, with immediate cessation of the severe symptoms. The muco purulent discharge continued for a few weeks, but the patient recovered completely.

When relief of the retained pus cannot be secured through the nose, and when the subjective symptoms are profound, an external 0peninng should be made without delay by making an incision extending from the center line of the forehead and on a level with and through the eyebrow, or above it, outward to within two millimeters of the supra orbital notch. A small bole, 6 or 8 millimeters in diameter, should be chiselled through the bone (Fig. 544), the cavity carefully cleansed and inspected, and afterward a probe or bougie should be passed through the obstructed infundibulum into the nose. If deemed expedient, one of the silver retention tubes can be kept in and the external wound closed. Subsequent irrigation can be easily carried out through the tube in the nose.

The two chief considerations in the treatment of the chronic cases are: First, the removal of the pathological tissues and their products. Second, the securing and maintenance of proper fronto nasal drainage.

On account of the irregularity in the size of the frontal sinus and infundibulum, the procedure that would be successful in one case would not be so in another with the same pathological conditions. The selection of a place for making the incision and chiselling through the bone is a very important one, and the more I operate the more I am convinced that a small opening should be made just above the supra orbital ridge, close to the median line; it should then be extended upward and outward for a sufficient distance to make an aperture about 8 to 10 millimeters in diameter. The direction of the chiselling will be determined by the position of the dividing wall of the sinuses. If none of the ridge is removed we have very little resulting depression; and the great advantage is secured of being able to trephine, chisel, and inspect the floor of the sinus, the infundibulum, and the anterior ethmoidal cells, through which, in my opinion, it is absolutely necessary to make a free drain way into the nose. In the other operation which I have performed quite frequently, and which seems best in cases where the wound is intended to be left open and packed for any length of time, it is very difficult to chisel, trephine, and properly enlarge the infundibulum through the hole in this below the supra orbital 'ridge space; although in a few cases I have removed the anterior wall down to the nasal process of the superior maxillary bone and succeeded in making a partially satisfactory and permanent opening into the nose (Fig. 594). Luc has evidently grasped the most practical idea that has yet been presented that is, to close the external wound at once after having made a large opening through the fronto nasal canal and inserted a large silver drainage tube. The after treatment of these cases consists of irrigating the cavity through the tube for three or four weeks, and then until the discharges cease, continuing the irrigation through the patulous canal which bad been created by the tube.

In seven cases with severe and prolonged disease of the frontal sinus I opened nine of the sinuses. One of the sinuses was obliterated by packing for nine months, but there was a resulting depression. The patient is entirely relieved of' the original symptoms. In one of the polypoid cases the frontal sinus was opened by the infra orbital ridge method, packed and curetted; the necrosed bone was scraped, and this cicatrized over. The patient made a complete recovery, and the sinus has been well since the closure of the external wound. In another case of fronto ethmoidal abscess the anterior wall of the ethmoidal cells was drilled and chiselled away: almost all of the nasal process of the superior maxillary was removed, the cavity was scraped, irrigated, and drained with a tube, and the sinus seems to have been in good condition ever since. Some of the cases were troubled with acute swelling and retention, and the scar tissue was reincised with immediate relief. Three of the cases operated upon by the same method remained in apparently good condition up to six months or one year; but in each one of them, on two or three occasions, extreme pain occurred, with swelling in the sinus ; the infundibulum seemed to be closed, this being the result of acute cold. Silver tubes were introduced through the infundibuli and the accumulation of degenerating mucus and pus dislodged. The patients improved at once, and subsequent irrigation brought away only clear fluid. At times these patients discharge a mucus from these cavities, which seems to be of a catarrhal and transitory nature.

DISEASES OF THE SPHENOIDAL CELLS.

Etiology. Acute inflammations of the sphenoidal cells accompany or are consequent upon acute rhinitis, especially in cases due to infection. Polypi are frequently the cause of chronic disease within the cell. Syphilis commonly affects the cell wall with a gummatous deposit. Ethmoidal mucocele will occasionally break through the dividing wall. Tumors occasionally develop in or extend into the cavities.

Symptoms. The subjective symptoms of acute inflaminations of the sphenoidal sinuses are headache and a full, heavy feeling over and behind the eyes. In the cases of chronic suppuration, the subjective symptoms are deep-seated pains in the orbital, temporal, and occipital regions, feelings of depression and oppression, discharge of pus or muco pus over the anterior surface of the sphenoidal cell at the posterior extremity of the middle turbinal body, and disturbances of the field of vision. The objective symptoms are hyperplastic edema of the nasal mucosa covering the cell, discharge of pus, muco pus, polypi, and pharyngitis sicca, due to destruction of the epithelium by the pus, which flows constantly over the post pharyngeal wall.

Pathology. The osseous modification and chances in the vitality of the bone occur in those sphenoidal cases in which the mucosa has undergone polypoid degeneration, the bone becoming brittle and losing much of its cohesive quality. In neglected syphilitic cases, necrosis of the bone or soft tissues always follows the gummatous process. The chronic suppurative cases with stenosis of the normal opening are usually protracted by the irritating qualities of the degenerating products.

Diagnosis. The diagnosis is comparatively easy in those cases where the nasal fossoe are not seriously obstructed by septum deflections and the throat is tolerant enough to permit posterior rhinoscopy. The obstruction in many cases is the posterior end of the middle turbinal body; its early removal will facilitate matters greatly. Under favorable conditions the pus can be seen flowing from the normal opening, which is situated above the superior turbinal body in the uppermost part of the anterior sphenoidal wall. An irrigation tube passed through the opening will confirm the provisional diagnosis.

Prognosis. Since surgeons have adopted the method of making a large opening of 8 to 10 millimeters in diameter into this sinus, the prognosis is much more favorable.

Treatment of Chronic Empyema. The treatment of chronic empyema is essentially surgical. Much annoyance and delay in the favorable progress of these cases will be avoided by removing the posterior half of the middle turbinal body as a first step in the operation, as it almost always lies in the direct line of the operative field. In my experience the most simple and satisfactory procedure for the removal of the middle turbinal body is carried out by cutting into its middle section with the nasal clippers (Fig. 592), placing the wire of the Bosworth snare in the cut and over the posterior end, and by firm traction removing the whole posterior half. In certain cases a long and rather small silver probe can be passed through the normal opening of the sinus, and this can be followed with some form of gouge or curette. Usually it is best to enter the sinus about 1/4 to 1/2 inch below the normal opening, and about 3 or 4 millimeters externally to the septum. The wall is usually thin at this spot, and the only objection is the probability of wounding the naso palatine nerve and the spheno palatine artery, which traverse the bone near this region. After the opening has been made, it is well to pass in one of the smallest size antero posterior nasal clippers (Fig. 595), and cut out the wall upward and laterally; the instrument cuts after the manner of a rongeur forceps. When the blood is wiped away the Sinus can be easily observed and the pathological state rather definitely determined. In my experience polyps have been found in the majority of the cases. It is well to curette them away very gently and carefully, for any tearing of the upper walls might bring on intracranial trouble. I have noticed diseased conditions rapidly improve tinder simple drainage and careful attention. The tendency of all these openings, even when large enough to admit the little finger, is to close, and it is very remarkable with what rapidity they become occluded. They then require a second excision of the contracting membrane. The syphilitic have given me more trouble than the polypoid cases, because of extension of the necrosis into the body of the sphenoid bone. Tumors occur sometimes in the sphenoid; but they usually originate in the fibrous tissues of the rhino pharynx or in sarcomatous degenerations of the ethmoid, and extend through the wall into the cell. Certain types of infections or septic rhinitis invade this cavity and produce a diseased 'state of the mucosa which in turn generates a putrid product, and this product acts as a perpetual nidus for new reinfecting material. Proper opening of the sinus and curettage, followed by antiseptic irrigation, usually cures the case or affords decided relief.

Sphenoidal Cases. In two of my Sphenoidal cases the symptoms were so severe that death was anticipated. The anterior walls were punctured, and after breaking through with a gouge the antero posterior clippers were used to enlarge the opening. The cavities were curetted, and the patients improved at once and steadily. These openings gradually closed, and at the end of six or eight months had to be re excised; this brought about immediate relief from the severe symptoms which had returned. I noticed in the latter cutting of the bone that it bad becomes much harder than it was originally. One syphilitic case, which is under observation at the present time, is apparently well in a subjective sense, save for a certain amount of postnasal catarrh; and I can detect dead bone, which extends from the rostrum of the vomer into the sphenoid. I have been gradually removing this necrosed bone at intervals with a drill which excavates laterally.

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