Results. In cases of chronic empyema of the maxillary sinus this operation is very successful. Failure may be due to overlooking stumps of teeth within the cavity, and from leaving detached pieces of the carious wall within it. If the pyogenic polypoid mucous membrane be not carefully removed, suppuration may persist. The corner which is difficult to reach is the acute anterior one. At the same time, an unnecessary denudation of the cavity will delay healing, and the scar tissue which more or less occupies the sinus will then tend to be irregular and dry, instead of being smooth and moist. Removal of too much of the inferior turbinal is apt to induce a scabby condition.
But persistence of nasal suppuration after this operation is generally found to be due to overlooked disease in some other sinus. The ethmoid is so frequently affected that it should always be carefully explored, and treated either before or at the time of the operation upon the maxillary sinus. Any suspicious-looking cells can be cleared away under cocaine during convalescence. Suppuration in the frontal sinus will have generally been excluded beforehand. It is perhaps more common for reinfection from the sphenoidal sinus to be overlooked.
Dangers. Operation upon this sinus is generally regarded as quite free from the risk of cerebral infection. This undeniably is so, when the antral empyema is uncomplicated by suppuration in other cavities, but the operation is not free from risk if they are also infected. An operation upon one maxillary sinus has been known, even in the most skilful hands, to cause death by meningitis or diffuse septic osteomyelitis of the cranium. Post-mortem examinations show that this disaster was due to infection spreading upwards from an infected ethmoid, frontal, or sphenoidal sinus, when local resistance had been diminished, or the virulence of the organisms has been increased by the surgical traumatism of the maxillary sinus.
Such risks are best avoided by determining the condition of all the sinuses before commencing treatment of nasal suppuration. If a tooth socket be available, the maxillary sinus should first be drained through it, so as to diminish the septic intensity of the affection. The ethmoid region, if diseased, is next treated (see [p. 615]). The sphenoidal orifice should be enlarged if that cavity be diseased, and the frontal sinus, if suppurating, should be operated on before the maxillary. If no tooth socket be available, both frontal and maxillary sinuses can be operated upon at the same sitting. Plugs are best avoided; communication should be made as free as possible; stitches need not be employed; and everything should be done to avoid retention and secure free drainage.
Fig. 332. Denker’s Operation. This is an operation for gaining access to the maxillary antrum and the lower part of the nasal cavity on the same side. The incision through the mucous membrane, and the steps of the operation, are a combination of the operations of Rouge and Caldwell-Luc.
Modification. In the above operation the region which generally requires to be denuded of mucous membrane is the rough floor—the irregular surface lying over the cusps of the teeth. The ridge of the antro-nasal opening is a situation in which secretion is apt to lodge and dry into scabs. To overcome this drawback it has been suggested by Bönninghaus that the muco-perichondrium of the outer part of the nasal floor and the interior surface of the antro-nasal wall should be carefully preserved in the form of a flap which is then laid down over this bare area, and fixed there by a stitch and packing.
Another drawback of the Caldwell-Luc operation is that, although inspection and treatment of the greater part of the maxillary sinus is secured, still there are two corners which are not well exposed. They are both on the floor of the antrum, the round posterior corner and the narrow acute corner in front. The antro-nasal wall corresponding to these two situations is not removed, and hence the corners are apt to escape inspection at the time of the operation and free drainage afterwards.
To avoid this Denker has proposed that the opening in the canine fossa should be carried forward into the nose, and the opening in the antro-nasal wall extended forwards to meet it. This allows of much more complete inspection and treatment of the sinus cavity, and abolishes the anterior angle. The flap of muco-perichondrium proposed by Bönninghaus can also be much more easily manipulated. It is said that there is no fear of disfigurement from the cheek falling in (Fig. 332).