Indications. This method is indicated—
(i) As a first step in diagnosis and treatment.
(ii) To diminish the risk of retention and decrease virulence in those patients where an external operation is not indicated or is declined.
(iii) It is rarely required for acute frontal sinusitis, although it might be used in acute exacerbation of a chronic suppuration.
Operation. It is very seldom that it is possible to sound a frontal sinus, unless the anterior ethmoidal cells have been broken down by disease. When this has occurred—or when the anterior extremity of the middle turbinal has been removed, as described on [p. 592]—the anterior region of the middle meatus is well anæsthetized. Under good illumination a thin silver canula is then introduced until it reaches the middle meatus with its beak lying below and in front of the bulla ethmoidalis. By depressing the hand the point of the instrument is then directed upwards, forwards, and slightly outwards, until it slips into the frontal cavity (Fig. 333). No force should be employed. The end of the catheter is bent to suit the conditions met with. A bead of pus exuding from the hiatus semilunaris will often serve as a useful guide. If there be any uncertainty as to the catheter having entered the frontal sinus, its exact situation can be determined by the Röntgen rays (Figs. 334, 335).
| Fig. 334. Radiograph to show the Value of the Röntgen Rays. The canula might be thought to have entered the frontal sinus, whereas the X-rays show that its point has only penetrated an ethmoidal cell. Compare with the following figure. | Fig. 335. Radiograph showing Canula in the Frontal Sinus. |
A Politzer’s inflation bag is now connected with the end of the frontal canula, and air is blown through it. This will be heard gurgling through the sinus, and if the anterior region of the middle meatus is at the same time kept under observation, thick mucus or pus will be seen to be driven out by it. The Politzer’s bag is then replaced by a syringe, and a pint of warm sterile normal saline solution (ʒj to Oj) is sent into the sinus, and as it returns is received in a black vulcanite tray. The latter readily shows up the presence of any flakes of mucus or pellets of pus. If successful, the above proceeding can be repeated twice daily.
When the cavity can be catheterized from the nose it should be washed out daily with liquids similar to those indicated for suppuration in the maxillary antrum (see [p. 630]).
Results. I am very doubtful if a permanent cure is ever effected by this treatment in a case of established chronic suppuration. In a case in which I was certain that the suppuration was not of more than four months’ duration intranasal treatment was a failure, although carried out most carefully on 44 successive days.[71]