After-treatment. The patient is put to bed on the sound side, so as to assist drainage. He is advised not to blow the nose, but to hawk as much of the secretion as possible backwards and then expectorate it. The gauze drain is removed from the nose at the end of twenty-four hours, and is not renewed. The drainage tube at the temporal end of the incision is changed at the end of forty-eight hours, and afterwards is removed and cleansed daily. The dressing is also changed daily, after the first forty-eight hours, so as to keep a careful watch for any retention. On the fifth day the sutures can be removed, and soon afterwards the dressing can be discontinued and the eye left uncovered. Intranasal treatment should be avoided for a while. But after two or three weeks the granulating surface behind the bridge is painted occasionally with a 2 to 3% solution of nitrate of silver. Any crusts are removed after soaking with peroxide of hydrogen.
Complications and dangers. The operation is not free from danger. Latent cerebral trouble connected with the sinus may be roused into activity by the local traumatism, however skilfully effected. The shock, or the lowered local resistance, may stimulate a latent infection in neighbouring sinuses, and also weaken the lines of defence protecting the cranial cavity.
In 1905 Logan Turner collected the record of twenty-four deaths which had occurred after operation on the frontal sinus.[72] This number has been exceeded by the fatalities since published and the much greater number which have never been recorded.[73] The chief dangers are (1) a spreading septic osteomyelitis, (2) meningitis, and (3) abscess in the frontal cerebral lobe.
Infection of the bone is indicated chiefly by a puffy, tender swelling on the forehead or temple, adjoining the upper flap. There may be little or no rise of temperature, and little complaint on the part of the patient. But no time should be lost in laying the wound freely open, searching for any shut-off focus of pus, and applying hot boric fomentations diligently. Once infection is established in the bone it may be impossible to stay its progress, even by the most thorough removal of diseased tissue: but the effort should be made.[74]
Meningitis is an equally dangerous complication. It may arise without direct injury to the cerebral wall of the sinus. If, during removal, the anterior end of the middle turbinal be damaged too high up, the lymph channels around the olfactory nerve may be opened so freely that infection spreads along them to the meninges. Or the cerebral wall may sometimes be broken through without a serious result, if the dura mater be left intact behind it. But if there be any damage done to the wall in the neighbourhood of the crista galli or cribriform plate, the dura mater is almost inevitably injured at the same time, and a rapid and fatal meningitis may be expected. The infection is generally streptococcal, and surgery is powerless to stop its progress.
Abscess in the frontal cerebral lobe may arise from operation on the frontal sinus. In my experience it is more apt to occur independently of interference with the sinus, to remain latent, and then to be simply roused into activity by the local traumatism. The symptoms are, unfortunately, very vague. Rise of temperature, headache, irritability, drowsiness, and optic neuritis may be present. On the occurrence of these symptoms the sinus should be freely reopened, and the posterior (cerebral) wall carefully inspected for any necrosing area. In any case it should be removed and the frontal lobe explored in all directions.[75]
These dangerous complications, in many cases, were no doubt due to a failure to recognize that the complicated group of ethmoidal cells were involved in all cases of chronic frontal suppuration, and that previous to the introduction of the Killian operation our operative methods were very apt to dam up suppuration in dangerous corners. Finally, it was only when rhinologists first began to investigate frontal sinusitis that it was recognized what a dangerous region this is. To be convinced of this it is only necessary to compare the anxiety inspired by our regard for the cerebral wall of the frontal sinus with the calmness with which we regard an opening into the middle fossa, or through the dura mater, in mastoid operations.
We are not yet in possession of definite evidence in regard to the proportionate number of deaths which are due directly or indirectly to pus in the frontal sinus. Some observers hold that more deaths have occurred from operation than from neglected cases. Molinié has followed the history of fifteen private patients with frontal sinusitis, and not operated on, for ten years. Only one has died, and that was from another cause.[76] In any case we may still accept Lermoyez’s dictum: ‘Avoir une sinusite chronique est chose moins grave qu’on ne croit: opérer une sinusite frontale est chose plus sérieuse qu’on ne le dit.’[77]
Doubtless the dangers have been diminished since the more general adoption of the Killian operation, but accidents may occur in the most skilful hands. This must be kept in mind when drawing up the indications for interference.
Results. In uncomplicated cases, successfully operated on, the results are most satisfactory. The preservation of the Killian bridge quite prevents any really unpleasant disfigurement. The depression which may form above it is proportionate to the size and depth of the cavity. No man need decline the operation on account of the scar left. In women we are able, with the help of a radiograph, to form an idea beforehand as to the degree of depression which may be left. This, if required, can be remedied by the injection of paraffin (see Vol. I), but, fortunately, the frontal sinus in women is not, as a rule, so deep as in men.