This will bring the anterior wall of the sinus with its ostium into view. Killian’s long nasal speculum (Fig. 346) may still be necessary. With the help of cocaine the ostium can then be enlarged with various instruments. Hajek’s hook can be inserted into the orifice and the front wall torn away. I have not found this satisfactory. It is much simpler to insert the beak of a small Grünwald’s forceps into it, or a small ring-knife, and by a series of boring and screwing motions to render the ostium patent. It is then easy to introduce a beaked Grünwald’s or some such punch-forceps as those of Cordes (Fig. 348) and cut away as much of the front wall as may be required. This can be done freely in an inward and downward direction, and an opening as large as the tip of the little finger, and sufficient for drainage and treatment, is thus established.
Fig. 348. Sphenoidal Punch-forceps.
When describing the removal of posterior ethmoidal cells (see [p. 616]) it was pointed out that the tip of the forceps not uncommonly breaks through the thin portion of the anterior sphenoidal wall.
If the natural ostium sphenoidale be not visible it would be risky to make an artificial opening without first determining by radiography the presence and size of the sinus. When this has been ascertained, palpation with a pair of sinus-forceps or a Lichtwitz’s trochar and canula will generally detect a thin spot where firm pressure is sufficient to penetrate into the cavity. The opening is then enlarged as described.
In all these procedures care must be taken that the instrument does not burst suddenly through the front wall with such force that it impinges on and damages the posterior wall.
The opened sinus must be dealt with according to the conditions met with. Necrosed portions of bone may require to be removed, but they rarely occur, except in syphilitic cases. Polypoid masses of mucous membrane, obscuring the opening, may be carefully lifted out with forceps or curette, so as to facilitate drainage; but it is never necessary to think of curetting the interior generally, and particular regard should be paid to the posterior wall.
After-treatment. Profuse hæmorrhage has sometimes occurred after opening the sinus. In a case of Gleitsmann’s the bleeding did not take place until seven days after the operation,[84] and in one of C. R. Myles’s cases profuse hæmorrhage occurred on the ninth day and required ligature of the external carotid.[85] It is possible that the bleeding in such cases may come from a branch of the internal maxillary artery, or even from the cavernous sinus. It can be met by firm plugging with a long strip of 1-inch ribbon gauze, of which the end is soaked in adrenalin or peroxide of hydrogen. Hæmorrhage is not a complication that I have ever met with, after having opened a large number of sphenoidal cavities, and I do not think it is to be dreaded if the opening be made as directed.
The sinus is washed out with a warm normal saline solution. The addition of peroxide of hydrogen may be useful. The condition of the mucous membrane may be improved by cleansing the sinus with iodoform emulsion, or plugging it for twelve or twenty-four hours with iodoform ribbon gauze. Any pigment can be kept in contact with the walls for some time by dipping the end of a piece of ribbon gauze into a solution of argyrol (25%) or nitrate of silver (2%) and packing it into the cavity. The other end of the strip is left just within the vestibule of the nose, so that the patient can withdraw it himself.
But if a sufficient opening has been made into the cavity to allow of natural ventilation and drainage, it is well to abstain from too much local medication—particularly if there be neither polypus, necrosis, nor foreign body in the sinus, and if it be not subject to reinfection from the suppuration in the posterior ethmoidal cells. It is remarkable how, under such conditions, suppuration will cease in a sphenoidal sinus if left alone, when, if frequently treated, secretion will continue indefinitely. In my experience the sphenoidal sinus is one of the most satisfactory of the accessory sinuses to treat.[86]