The next step is the making of a free communication with the nose. If the inferior turbinal is hypertrophied on the affected side, or comes so low as to obstruct any access to the antro-nasal wall, its anterior extremity should first be removed (see [p. 587] and [Fig. 289]). It is better to have done this a few weeks previously under cocaine. The antro-nasal wall lying below the attachment of the inferior turbinal is next attacked with a chisel, hammer, and punch-forceps (Fig. 330). This can be done from the antral aspect, but I have always found it useful to break it through first from the nose with Krause’s curved trochar and canula. When the end of this makes its appearance in the sinus, it forms a useful landmark (Fig. 329).

This antro-nasal opening should be made as large as possible, particular care being taken to bring it well forward and to smooth down the remains of the ridge separating the nose from the sinus. The opening should allow of the surgeon’s little finger passing freely from the antrum into the floor of the nose, and vice versa (Fig. 328).

Fig. 330. Carwardine’s Punch-forceps. Used in breaking down the lower antro-nasal wall.

Whenever the ethmoid is diseased, as it often is in maxillary sinusitis, that part of it which bounds the inner antral walls should be punched away. The middle turbinal, in that case, will probably have been already removed.

Fig. 331. The Opening into the Maxillary Sinus from the Inferior Meatus of the Nose. The anterior extremity of the inferior turbinal has been amputated. The opening can be extended backwards, level with the floor of the nose, and under cover of the inferior turbinal.

Some surgeons recommend that the infected corners of the antrum be now wiped out with a solution of chloride of zinc (40 grains to [℥]j), and the cavity packed with a strip of gauze which is led out through the nostril, whence it is removed at the end of 24 to 48 hours. The use of this irritant seems inadvisable. The sinus may be syringed out with warm saline solution, and temporarily packed with a long strip of iodoform gauze, while the operation is being completed. The wound in the cheek can be closed with a couple of catgut sutures; but if there has been no destruction of the bony alveolus, this is unnecessary: the soft parts will fall into natural and complete apposition. The post-nasal sponge is removed, the iodoform ribbon gauze is withdrawn through the nostril, and the patient is put back to bed with the affected side uppermost.

After-treatment. A large pad of cotton-wool, bound firmly to the cheek over the region of the canine fossa, will relieve pain and help to keep the edges of the wound together. Nourishment should be fluid for the first three days, and taken from a feeding-cup from the opposite corner of the mouth. As a rule, there is no reaction, and the temperature seldom rises above 100° F. A little puffiness below the orbit will soon subside, and pain is relieved by a few doses of phenacetin, aspirin, pyramidon, or some similar anti-neuralgic. The patient is frequently up and out in a few days.

As a rule, the less the local after-treatment the better. The nose may require to be cleansed with the usual alkaline lotion (see [p. 579]). If secretion hangs about the antro-nasal opening, or collects in the cavity, the latter should be washed out once or twice daily until it ceases. A short length (4½ in.), but large bore, silver Eustachian catheter is passed from the nose into the maxillary sinus, and a pint of warm saline solution is sent through it with a Higginson’s syringe. The patient soon learns to do this for himself, and it may have to be continued for a few weeks. If the discharge persists, the cavity may be painted over with a solution of nitrate of silver, or a strip of ribbon gauze can be moistened with argyrol solution (25%) and passed through the antro-nasal opening into the sinus, where it is left for a few hours.