Fig. 346. Killian’s Long Nasal Speculum.
If this plan be not successful, the ostium sphenoidale can more certainly be discovered in the following way. A more complete and prolonged application of cocaine is carried out, particularly in the neighbourhood of the olfactory cleft and the spheno-ethmoidal recess. Killian’s long nasal speculum (Fig. 346), sterilized and warmed, is inserted between the middle turbinal and the septum. By separating the blades of the speculum the passage is dilated, so that the instrument can be slipped further in, and so, by alternating movements of expansion and advance, the front wall of the sinus is brought into view. During this procedure the middle turbinal is crowded outwards, and no alarm need be caused if a slight cracking sound shows that its attachment has been fractured.
The mouth of the sphenoidal sinus is often indicated by the muco-pus oozing from it or pulsating in harmony with the pulse. If discharge be not escaping the ostium may be only a potential and not an actual orifice—like that of the meatus urinarius—and has then to be more carefully sought for and detected with a probe. If there be difficulty in finding the ostium, the front wall should not be broken through until the presence and size of the sinus has been demonstrated by means of a radiograph (Figs. 343 and 344). The sinus is washed out, as described for the frontal and maxillary cavities.
OPENING THE SPHENOIDAL SINUS
Indications. Profuse purulent post-nasal catarrh, persistent headache, orbital or ocular or intracranial symptoms, call at once for relief. Not infrequently suppuration in other cavities will not cease, even though operated on, until the sphenoidal sinus has been treated.
Fig. 347. Radiograph showing a Probe in the Sphenoidal Sinus. An india-rubber obturator is in the maxillary antrum.
Operation. Unless long-standing suppuration or ozœna have produced such atrophy of the middle turbinal that the front wall of the sphenoidal sinus is easily inspected from the front, it will be necessary to remove the greater portion of the middle turbinal. If the anterior end has had the typical amputation performed (see [p. 592]), then the rest can be removed with the punch-forceps of Grünwald, the wire snare, or, under nitrous oxide anæsthesia, the spokeshave.