A System of Operative Surgery, Volume 4 (of 4)

by Unknown

Fig. 342. Killian’s Operation upon the Frontal Sinus. The periosteum has been preserved on the bridge. Above this the frontal sinus is exposed: at its inner (nasal) extremity the frontal bulla is indicated, mounting up into the cavity; at the outer extremity an arrow indicates the orifice of a fronto-orbital cell which should be opened up. The periosteum lying above the bridge has been retracted up with the soft parts on to the forehead. Below the bridge is the opening to the ethmoidal region. The curved retractor is protecting the eyeball.

The next step is to make the opening below the bridge. The exposed surface of the nasal process of the superior maxilla is cut through with the triangular chisel. The opening is enlarged with bone-forceps until free access is obtained to the anterior ethmoidal cells. The pledgets of cotton-wool placed in the nose at the beginning of the operation now come in to help as guides. The periosteum is further elevated from the lachrymal bone above its groove, from the orbital plate of the ethmoid as far back as the anterior ethmoidal vessels, and from the orbital plate of the frontal bone below the bridge and extending outwards to the trochlear attachment and the supra-orbital notch. During this proceeding the contents of the orbit are protected from pressure by several folds of gauze, and are carefully retracted outwards by Killian’s protector. The area of bone which can now be clipped away comprises parts of the lachrymal, of the lamina papyracea, and of the floor of the frontal sinus. The whole of the floor of the sinus must be removed, either from above the bridge or from below. If this cannot be done without anxiety as regards the attachment of the pulley of the superior oblique, it is better to risk this than to leave pus-secreting pockets of orbito-ethmoidal cells cut off from drainage in the roof of the orbit. But the pulley of the superior oblique should never be divided from its attachment to the rim of the orbit. It is much safer to reflect the periosteum further outwards and downwards from the lower border of the Killian bridge. In doing this the pulley of the superior oblique is detached with it; any diplopia, most noticeable on looking downwards and outwards, is generally temporary; and as a rule it will disappear when the swelling subsides and the periosteum gets back to its anchorage (Fig. 342).

It is this part of the operation which is the most delicate, tedious, and important. It is very common to meet with irregularities. The orbital recess of the frontal sinus itself may run back in the roof of the orbit nearly as far as the foramen opticum. One or two galleries may be met with in the roof of the orbit—prolongations of orbito-ethmoidal cells—passing outwards as far as the temporal end of the eyebrow. Their presence can only be revealed after removal of the floor of the frontal sinus proper, and in this way two or three bony dissepiments may have to be removed before the orbital fat arises, as it should do, to occupy the lower part of the exposed frontal sinus. In this part of the operation much help is obtained by the careful use of a probe, by frequently securing a field free from bleeding by pressure with adrenalin or peroxide, and by the knowledge previously gained by skiagraphy.

If the Röntgen rays have shown that the frontal sinus does not extend above the level of the bridge, or if radiography be not available and there is any uncertainty as to the extent of the cavity, this lower opening should be made first.

In the inner part of the large orifice which has been made below the bridge the deeper ethmoid cells can be treated, and the sphenoidal ostium is much nearer than when viewed from the introitus narium, so that it is easy to enlarge it and deal with the contents.

Now, as throughout the operation, great care must be taken to shield the eyeball with gauze pads and the protector. The hanging pressure forceps are apt to be pushed against the globe.

The whole area of operation is next carefully cleaned with warm normal saline solution. Any projecting corners or loose spicules of bone are removed. If any point of pus should show up it must be carefully followed to its source. The cotton-wool pledgets are removed from the nose. The pressure forceps are twisted off, and any vessels that require it are ligatured. A strip of ribbon gauze is loosely packed in the lower part of the enlarged fronto-ethmoidal space, and the end is led down to the nasal orifice. The flaps are brought together, and care is taken that the reflected periosteum is pulled back with them. Formerly Killian in the majority of cases used to sew up the whole wound at once. He now agrees that it is safer to leave the external angle with a small drainage tube running inwards and downwards to the area of the fronto-ethmoidal cells. The inner part of the incision in the eyebrow, and all the part lying below the bridge, can be closed. Killian employs aluminium-bronze wire, and a metal suture seems preferable, as the contamination of the wound edges makes stitch-abscess not uncommon.

Secondary suture—on the second or third day—is reserved by Killian for cases when (1) the history or appearance of the mucosa indicates a recent exacerbation, (2) there is a history of erysipelas, (3) the pus is very fœtid, (4) there is any history of a tendency to wound complications, or (5) there is marked invasion of the diploë in the frontal bone.

Double cyanide gauze, rung out of boric lotion and covered with a good supporting pad of cotton-wool, is then put on. But when there is any question of intracranial complication, when the pus is fœtid or there is any necrosis, and when the surgeon is forced to operate during an acute exacerbation, it is better to apply warm boric fomentations and leave the upper and outer supra-orbital part of the incision freely open.