Fig. 326. Washing out the Maxillary Sinus from an Alveolar Opening.
At the end of two or three days lavage of the cavity is gradually instituted. A pint of warm sterile normal saline solution is sent through the cavity by a Higginson’s syringe, fitted with a suitable nozzle (Fig. 325). As the stream issues from the nose it is received in a black vulcanite tray, which readily demonstrates the colour, quality, and quantity of antral secretion (Fig. 326). When the pint of liquid is finished, air is blown through, so as to leave the sinus as dry as possible. The patient should be advised to replace the rubber obturator, properly cleaned and purified, as soon as possible. If this be neglected—for even as short a time as 5 minutes—the soft tissues may obstruct the channel so as to render the reintroduction painful and perhaps impossible. Another useful warning is not to wear a plug so long as to allow of the flanges being worn away, and so risk the penetration of the rubber tube into the cavity.
The syringing should at first be daily, even twice a day if necessary, and then gradually diminished in frequency, until after the lapse of a week it is found that the maxillary sinus is quite free of any pus or flocculent mucus. By changing the obturator daily the patient can readily tell whether a washing out is required. When three to six months have passed without any trace of secretion, the empyema may be considered cured. This is the more likely if a formerly obscure sinus becomes translucent, and if the patient passes through a ‘cold’ without suppuration beginning in it again. A trifling amount of discharge is sometimes kept up by the mere presence of the obturator.
If the saline solution fails to arrest the discharge permanently, I have rarely found that any other lotion is more effective. Strong antiseptic solutions are too irritating; milder ones, like boric lotion, permanganate of potash, weak mercurial lotions, &c., are without effect. If the discharge remain thick and offensive, peroxide of hydrogen may be added to the salt solution in the proportion of 2 vols. %. As an astringent, sulphate or chloride of zinc may be tried, in the proportion of 1 grain to the ounce; or the cavity may occasionally be washed out with a 2% solution of argyrol or nitrate of silver.
In cases where a cure has been obtained, the obturator is first discontinued during the night and is then exchanged for one of smaller size. The opening in nearly all cases will close spontaneously. Occasionally the track may be stimulated with nitrate of silver, pure carbolic acid, or a small curette.
Results. This method of treatment is only curative in uncomplicated cases limited strictly to the maxillary sinus. If all suppuration has not disappeared before the end of three months, a complete cure is not to be expected by persevering longer.
OPERATION THROUGH THE CANINE FOSSA ONLY
Desault’s operation. Previously to the introduction of the Caldwell-Luc operation it was customary to make an opening into the maxillary sinus from the canine fossa, and to curette, drain, pack, and carry out all subsequent treatment through the buccal orifice. The reinfection of the cavity from the mouth was, of course, inevitable: the treatment was prolonged and unpleasant: and the results were so unsatisfactory that the method has now been abandoned in favour of one or other of the operations to be described.