It is the writer’s opinion that the general surgeon should abstain from operative intervention in the ordinary diseases of the middle ear, save in the presence of symptoms which accompany mastoiditis, acute infections of the sinuses, or even of the brain itself. When it comes to an extensive operation, such as is often required in such instances, including not merely opening of the mastoid antrum and cells, but exposing the dura and judging of the condition of the sinus, with perhaps the simultaneous ligation of the jugular in the neck and washing out of the intervening portion, then these are measures requiring such surgical judgment and operative skill that it would seem that the general surgeon should be peculiarly equipped for this task. But the ordinary office operations should be left to those who make a specialty of these diseases.
When the cavity of the tympanum is involved in a suppurative condition, with caries of the surrounding bone and extension into the spongy tissue of the adjoining mastoid, this abscess cavity should be cleaned out. Therefore the more radical operations of the aurist, by which the membrana tympani is destroyed, the ossicles of the ear removed, etc., are but applications of broad surgical principles to a limited region of the body, but made justifiable by their results. Moreover, in a more chronic type of cases, where the tympanum is filled by redundant granulation tissue and by polypoid formations, which are producing more or less circumscribed caries or necrotic processes in the bone, by which bony partitions between the cranial cavity and the ear proper are gradually thinned or lost, and by which encroachment on the intracranial sinuses with all its dangers is incurred, they are still to be subjected to the same general radical methods of treatment, no matter whether it be carried out by a specialist or a general operator.
THE ACCESSORY CRANIOFACIAL SINUSES.
While these cranial cavities are connected with the respiratory tract there are, nevertheless, good topographical and physiological reasons for considering their lesions in this place. There is free venous communication between each of them and the cranial cavity, and free lymphatic communication as well from at least three of them. Infection, therefore, may and often does travel from the smaller to the greater cavity, and thrombophlebitis, brain abscess, or purulent meningitis may be the ultimate result of apparently trifling infection of one of the sinuses.
They are four in number—the frontal, the ethmoidal, the sphenoidal, and the maxillary, or antrum of Highmore. They are all connected with the nasal cavity, and all lined with the same Schneiderian membrane, which affords a continuous pathway of infection. At least two of them are cellular in character, much resembling the mastoid cells. Their means of communication with the nasal cavity are small, and often obstructed by catarrhal swelling and inspissated discharge. If thus plugged their retained contents may undergo decomposition and intensify the trouble. It has been shown that the effect of inward currents of air through the nostrils is to suck out from these sinuses more or less of their secretion. In this way perhaps may be accounted for the strings of tenacious mucopus which slowly make their way out of especially the anterior sinus openings. Some surgeons believe that if one sinus is affected all the others on that side of the head are more or less involved; while this may be true in many cases, and is easily explained on anatomical grounds, it is not strictly true of all instances, least of all in cases of chronic empyema of the antrum, which often long remains simple and uncomplicated.
Surgical lesions within the accessory sinuses result from infective processes, proceed often to suppuration, often, too, with caries of the surrounding spongy bone as well. These conditions may result from the ordinary acute catarrhs, or follow the more specific fevers, like influenza and the exanthems, and frequently follow diphtheria. Traumatic causes may also conspire to produce the same effect. In the maxillary sinus disease is often due to extension upward from carious teeth. In syphilitic and tuberculous patients these affections will partake to a greater or less degree of the specific nature of these diseases.
Symptoms differ according to location and are often obscure enough to make diagnosis difficult. Perhaps the most prominent symptom is pain, either deep-seated, vague, or disquieting, located in the neighborhood of the diseased sinus; or intense and neuralgic in character, radiating from the source of the trouble. Its severity is proportionate to the acuteness of the case. When the frontal and maxillary sinuses are involved there occur external swelling and tenderness. If the sinus openings be patulous there will be more or less purulent discharge into the nasal cavity, that which comes down from the upper sinuses appearing beneath the middle turbinate body. Transillumination by means of a small electric light, passed into the nostril, will demonstrate an opacity in the region of the affected sinus which does not appear on the healthy side. The condition is frequently associated with nasal polypi, small or large; while granulations in time spring up within these cavities and may even escape therefrom as these become filled. The general clinical picture is one of nasal obstruction, with more or less constant discharge, sometimes mucopurulent, sometimes offensive, which perhaps may be favored by certain positions of the head, this being especially true of the maxillary antrum. Along with these features go a degree of headache, of local pain, and even of mild or severe febrile disturbances, proportionate to the severity of the lesions which produce them.
When the anterior ethmoid cells are involved pain is usually referred to the temples rather than the forehead, though both may suffer alike.
Treatment should be based upon the fact that we have affected and infected cavities whose interiors are diseased, and whose outlets are blocked. The more free and thorough the drainage and the cleansing which can be given, the more prompt the results. In all well-marked cases, then, radical treatment is indicated. The ordinary treatment by sprays, inhalations, etc., is useless, as the source of the trouble is not reached.
Special treatment for each sinus will now be considered.