Fig. 322. Puncturing the Maxillary Sinus. The dotted part represents the portion of the exploring needle which passes under cover of the inferior turbinal.

While the nasal cavity is kept under inspection, air is blown through the needle, and any secretion can be observed escaping from under the centre of the middle turbinal. This douche of air is then followed by an irrigation of warm normal saline solution. In an acute case this lavage can be repeated daily until the symptoms of tension are relieved, or until the secretion begins to escape spontaneously.[68]

Puncturing the maxillary sinus from the middle meatus incurs a greater risk of striking the orbit and is not so likely to reveal a small amount of thick secretion on the floor of the cavity.

PUNCTURING THE MAXILLARY SINUS FROM THE ALVEOLAR MARGIN

This is one of the oldest methods of drainage. It is less frequently employed nowadays, partly because carious teeth and empty sockets are not so commonly met with, and partly because the results have not proved very satisfactory.

Indications. The operation is useful as a diagnostic or palliative measure. In cases of unilateral multi-sinusitis, if a suitable tooth socket be available, the alveolar operation serves both to determine the condition of the maxillary sinus and to establish drainage, while the other cavities are being investigated or treated. In patients who are too old or feeble to endure more radical measures, or who decline them, the obturator may be left in indefinitely. In that case, if the neighbouring teeth be intact, a solid gold plug should be fitted to the denture bearing the false first molar. During the night this is exchanged for the soft rubber plug. If several teeth be missing it is more comfortable to have the obturator and denture separate—the latter being made with a setting to receive the flange.

An anæsthetic should always be given. Nitrous oxide gas or chloride of ethyl are generally recommended for this short operation, but in cases that present any difficulty it is better to follow the nitrous oxide with ether, or the chloride of ethyl with chloroform.

Fig. 323. Antrum Drills.

Fig. 324. Solid Rubber Obturators. Used in alveolar drainage of themaxillary sinus.

Fig. 325. Antrum Nozzle.

Operation. The most suitable tooth socket is that of the first molar, but if this be not available, that of the second bicuspid or second molar may be employed. If a tooth in one of those situations be carious, or be suspected as the cause of the sinusitis, its extraction and the drilling of the alveolus may be carried out under the same anæsthetic. The patient can be recumbent on an operating table, or lying back in a dentist’s chair. A small antrum drill (Fig. 323) is grasped in the hand as a bradawl is held, with the forefinger lying along it to within 1 to 1½ inches from the end, where it acts as a stop to prevent the instrument from plunging too deeply into the sinus. The drill is held vertically against the alveolar border, and with a few quick, rotatory thrusts is pushed into the cavity. The inner of the tooth sockets is selected. If required, the hole can be enlarged by a similar instrument of a larger bore. A plug, which fits firmly into the opening, is introduced, and nothing further is required for that day. A solid vulcanite obturator is recommended. It should be left in situ for two or three days, when it is removed to allow of the cavity being syringed through, and is then replaced by a solid, soft rubber plug, of a somewhat smaller diameter (Fig. 324). The vulcanite obturator is better for establishing the canal; if removed too soon it may be difficult to replace it, and manipulation may set up severe neuralgia. A small size—No. 6 or 7—is quite sufficient.