The principles and practice of modern surgery

by Roswell Park

Frontal Sinus.—Most of the symptoms of affection of the frontal sinus are objective, and there is frequently external swelling, with tenderness and edema. For its relief intranasal methods will often suffice. In almost all cases we may expect to find hypertrophic conditions within the nose. When empyema exists there is often a deviated septum. It is impossible to avoid the conclusion that there is a strong relation between hypertrophic lesions and sinus retention. The difficulty may arise from many causes, most of which lead to sneezing, coughing, and hacking, by which the mucous membrane of the nasopharynx is both thickened, loosened, and predisposed to polypoid changes. The irregularities thus produced harbor more germs than usual and their effect is, in a measure, proportionate to their numbers. For the examination of the upper part of the nasal cavity Killian’s speculum is of great help.

The frontal sinus differs very much in shape and size, not only in different individuals but on opposite sides of the same individual. It may be rudimentary upon one side and large upon the other. It is usually more capacious in those individuals who have prominent foreheads and resonant voices. Here, as elsewhere, it will usually be found that the most radical operation is the best, although one endeavors naturally to preserve cosmetic features of the nose, so far as he can, without sacrificing the patient’s interests. The nasopharyngeal duct is so often connected with the ethmoidal cells, as well as the frontal, that the former may be easily affected when the frontal sinus is diseased.

In case of sinus disease, especially when the frontal sinus is involved, it is better to encourage patients to snuff materials back into the throat rather than to forcibly blow the nose or expectorate them, as the latter would tend to force into the sinus that which it would be better to have aspirated out of it.

The frontal sinuses may be attacked from within the nose or externally. It is perhaps the least open to mild and conservative treatment, as it is the most difficult of access by non-operative methods. The anterior ethmoid cells are usually connected with it and infection rarely spares one part to involve the other alone. Therefore if it be necessary to operate on the frontal sinus the anterior and upper cells should be exposed at the same time. Thus operations which have for their object continuous drainage have usually as an objection the necessity for wearing the drainage tube for months. After opening the sinus from without the nasal duct may be enlarged to any size and desired degree, and a tube inserted which shall afford ample drainage downward. This may be covered with a flap and allowed to remain for a number of weeks. Nevertheless it is a foreign body which has to be subsequently removed from the nose. Killian’s method is doubtless the best for most cases, as the most anterior of the ethmoid cells, and those which extend over the orbits, cannot be easily reached through the nose, and if disease involve the posterior ethmoid cells its extension to the sphenoid may be expected. The operation includes an incision from the temporal end of the shaved eyebrow, along its curve to the side of the nose, and down to the middle of the nasal processes. The periosteum is divided along a line a little higher, and again in the centre of the frontal process, the intent being to so remove it that a bony bridge may be left after removal of the anterior lower wall of the sinus. The first periosteal incision should correspond to the upper border of this bridge, either above or below it. The sinus is opened at first with a chisel, afterward with bone forceps or surgical engine. It is then completely scraped out, leaving the supra-orbital ridge for a bridge. Its floor is resected along with the frontal process of the superior maxilla. Through this opening the anterior and middle ethmoid cells may be reached and cleaned out to the middle turbinate. The ethmoid cells may then be attacked, the sphenoidal cells inspected, and also attacked if necessary. The opening into the nose should be made free, and a flap should be formed from the nasal mucoperiosteum, so that there may remain a permanent opening of sufficient size. This method may be modified to suit various needs. After doing all the work necessary the external wound is closed, with a tube for drainage, while the formation of the bridge above alluded to prevents much of the sinking in of the anterior wall of the sinus, which would otherwise occur. If the little pulley over the superior oblique muscle has been interfered with in the operation or loosened from its attachment there will be at least temporary and perhaps permanent diplopia. This should be carefully avoided. There is also danger of injury to the contents of the orbit. For some time after the operation there will be some drooping of the upper lid. Nevertheless the results are usually satisfactory. After the operation the patient should be permitted to lie upon the healthy side and be forbidden to blow his nose; he should rather attempt to aspirate the fluid from the wound. If necessary both sinuses can be attacked at the same time and after the same fashion, the septum being removed.

Here as with the other sinuses the test of the efficacy of the treatment will be furnished by relief of the headache, pressure, and pain. Should carious or necrotic bone be exposed, or should there be indications of malignancy, much more radical surgery would be indicated.

The Ethmoidal and Sphenoidal Cells.—For the exposure of these, especially the latter, it is necessary to make room for work. This would be true even in normal cases, and is still more so when the parts are hypertrophied and the passage-way is obstructed. It is necessary at least to remove all deviated portions of the nasal septum, and to clear away not only all hypertrophies of the turbinates, but to remove more or less of these bones. With a free passage-way it is possible to expose the opening of the sphenoidal cells, whose anterior wall may then be broken down, after which granulations may be removed with an appropriate small spoon, or the purulent contents cleaned out with swabs.

In dealing with the ethmoidal cells by intranasal methods it is necessary to break down the slight compartments between them, one after another, because of the fact that they all constitute foci of disease. An opening at least 2 Cm. in length will usually be required, and can be comfortably made, under suitable illumination, if all obstructions have been removed; after this a probe is gently passed upward and alongside of the nasal septum until it rests against the ethmoid, then passed backward until it meets the posterior wall, which will be in the immediate neighborhood of the sphenoidal opening, through which, by gentle manipulation, it may be passed. At this point the presence of polyps or a greatly thickened mucosa may be detected by palpation with the finger within the nasopharynx, while should pus be removed by the end of the probe it would indicate empyema of this cavity.

In all these accessory nasal sinus examinations and operations the greatest aid will be afforded by cocaine solution, which has the double advantage of not merely abolishing sensation, but of contracting and rendering anemic the mucous membranes, and thus to a certain extent shrinking them. When necessary for this latter purpose, or for the control of hemorrhage, adrenalin may be added to the cocaine. For all these purposes a spray of a mild solution may be first used, for its general benumbing effect, after which it would be advisable to use a strong solution, even saturated, very sparingly, applying it by the aid of illumination just to the area where the effect is desired, and not allowing it to come in contact with other parts of the nasal cavity; this is done to avoid unpleasant symptoms from cocaine absorption. Another benefit obtained from the use of cocaine is in thus abolishing sensation to an extent which does away with reflex vasomotor symptoms, shock, etc. Therefore even when a general anesthetic is used it will be well to use at least a small amount of it for this latter purpose.

The question of instruments and of methods will depend much on the equipment of the operator and his expertness in the necessary technique.

The Maxillary Antrum of Highmore.—This is the largest of the accessory sinuses, the most easily approached, and the one whose disturbance is most quickly and easily appreciated. It may be infected by continuity, along the Schneiderian membrane which lines it, or by extension upward of disease from carious teeth, as well as after a variety of injuries involving its integrity. So long as its opening into the nose be not plugged it will, when involved in catarrhal or suppurative inflammation, discharge into the latter a characteristic fluid, which is especially likely to escape when the head is held downward and to the opposite side. Any statement of this fact, coupled with evidences of local inflammation, should enable an easy recognition of antral disease. In more chronic cases it becomes blocked by thickening of its membrane, the production of granulations or of polypi, which sometimes completely fill it. When thus plugged and filled there is a tendency to protrusion of its anterior outer wall and floor, while the overlying cheek may become somewhat edematous, the parts at the same time being tender. The pain from a diseased antrum will often induce the patient to go to the dentist for extraction of a molar tooth, which, however, affords little relief.