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Chronic Suppuration in the Nasal Accessory Sinuses and Its Treatment

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Chronic Suppuration in the Nasal Accessory Sinuses and Its Treatment Hospital Clinics. CHRONIC SUPPURATION IN THE NASAL ACCESSORY SINUSES AND ITS TREATMENT. Two Lectures by "YVm. J. Chichele-Noukse, F.R.C.S.(Edin.), Surgeon to the Central London Throat, Nose, and Ear Hospital; late President of the British Laryngological, Rhinological, and Oto- logical Association. the These lectures were specially reported for during one of the specific fevers, such as typhoid,, columns of The Hospital to illustrate the nature scarlatina, or (especially) influenza. Chronic of the graduate teaching given at this important sinusitis, either the sequel of an unhealed acute been special centre. The notes have very kindly catarrh or, possibly, originating de novo. revised by the lecturer. Simple Empyema: Cystic disease or mucocele, and and tumours. Besides The Grouping of the Sinuses. benign malignant these, the sinuses are liable to be invaded by malig- For clinical purposes, the accessory sinuses of the nant disease or by gummata arising in neighbour- nose may be divided into two groups, according to ing parts, or their bony walls may become necrosed the position of their ostia. The maxillary antrum, or carious. the frontal sinus, and the anterior ethmoidal cells, Chronic Sinusitis. meatus having their ostia opening into the middle The key to the study of diseases of the sinuses is. of the form an anterior The nose, group. chronic sinusitis. To this part of the subject, there- sinus and the ethmoidal sphenoidal posterior cells, fore, as the time is limited, it is proposed to confine opening into the superior meatus, form a posterior the following observations: group. In chronic sinusitis the becomes In each muco-periosteum group the ostia lie very close together. thickened, vascular, and and Those of enormously polvpoid, the anterior group are situated in the secretes and small abscesses have hiatus pus, occasionally semilunaris under cover of the anterior end been found embedded in it. of the middle turbinal that of the frontal body; The local signs are often obscure, so that the above, the ostium maxillare and the smus_ below, diagnosis is not always easy; but the patient may openings of the ethmoid cells close the others. by suffer from pharyngeal or laryngeal irritation, Sometimes the antrum has an accessory ostium, or bronchial disturbance, or malaise in the gastric general opening middle meatus much further back. but without obvious reason, really caused by the The ostium of the sphenoidal sinus is situated absorption of septic pus flowing unobserved into the. high up and far back in the posterior wall of the and those of the naso-pharynx. nose, posterior ethmoidal cells in The Diagnosis. the spheno-ethmoidal recess. The best mode of proceeding in the diagnosis is The Sinuses in Health. to take the sinuses in order, beginning with those of of the anterior group, and to deal with each one In health, the lining the sinuses consists of a by exclusion before to the next. It must be very thin mucous membrane, blended passing inseparably remembered that sinusitis is but with the periosteum, the whole forming a thin layer rarely isolated; hence the that one sinus is affected must closely adherent to the bony wall beneath. The discovery not deter the from the con- is and the walls of the sinuses surgeon investigating blood-supply scanty, of are dition the others. Frontal sinusitis is often almost destitute of secretory glands. accompanied by antrum disease, and an affection of either of these with The Sinuses in Disease. sinuses is generally associated suppuration in the ethmoidal cells. ? neighbouring The sinuses are liable to several diseases: Again, sphenoidal sinusitis is usually linked with Acute the result either of the extension sinusitis, disease in the posterior ethmoidal cells, and vice of an acute or of infection catarrh from the nose, versa. Occasionally all the sinuses on one or both 344 THE HOSPITAL. August 18, 1906. sides are affected, when the condition is called pan- Practical Significance. sinusitis. Tlie vagueness of tlie local symptoms of chronic Lermoyez Classification of the Signs. sinusitis lias already been alluded to. Tlie classic in the older text-books are Lermoyez classified the signs of chronic suppura- signs given conspicuous tlieir and what be called tion in the accessory sinuses as presumptive, pro- by absence, may directing are often bable, and certain. The following table is based signs altogether wanting. The of the this division : particular value and upon " " significance presumptive signs is that the presence of any PRESUMPTIVE SIGNS. of them indicates the need for a systematic exami- 1. Subjective fcetor. nation of the sinuses. It must be understood that liberation of 2. Pain, relieved by discharge. are not unilateral dis- 3. Unilateral flow of pus from the nose. they pathognomonic?a from the nose an offensive 4. Polypi or polypoid hypertrophies in the middle meatus. charge accompanied by smell observed by the patient, besides a pos- PROBABLE SIGNS. being sible of sinusitis, may be due to a Antrum : symptom equally of a Pus in the middle meatus. rhinolith, to the presence foreign body in the Discharge intermittent, increased on bending forward or nostril, or to syphilitic necrosis. on bending the head to the opposite side. Pain, relieved by liberation of discharge is Infra-orbital pain. of but unfortu- Opacity on transillumination. strongly suggestive suppuration, it is not a constant The occurrence Swelling, redness, and tenderness in the canine fossa. nately sign. Swelling of cheek (rare). of pain in sinus disease may be entirely independent Bulging of nasal wall of antrum. of retention, or it may be altogether absent. from N.B.?Distinguish simple empyema. Polypi are almost always associated with suppu- (a) Nasal type : ration. With in or suppuration nose, in other sinuses of Probable Signs. anterior group. (0) Dental type : Commencing with the antrum, the probable signs molar or caries. Upper bicuspid given in the table need a few words of comment. If Tooth tender on percussion. pus can be seen in the nose its situation affords some Verify by indication of the sinuses affected. When Puncture nasal and probably through wall, perflation, irrigation. the secretion lies between the anterior Sign of capacity (Mahu). extremity of Blood coming through cannula (Lubet-Barbon). the middle turbinal and the outer wall of the nose Opacity persists after puncture (Guisez and Guerin). the suggestion is that its source is in the sinuses of Frontal Sinus : the anterior group. On the other hand, when pus The antrum being excluded or emptied?? appears between the middle turbinal and the sep- Pus in middle meatus. tum, or above the middle turbinal, it most likely Discharge persistent. comes from the If the antrum has Pain; frontal. posterior group. usually an the whole of its secretion Frontal tenderness. accessory ostium, may into the Opacity on transillumination. drain backwards naso-pliarynx and be when the nose Verify by quite invisible is examined from the Cannula and perflation. front. The ostium of the antrum is situated at a level Anterior Ethmoidal Cells : After exclusion of antrum and of frontal sinus? considerably above the floor, so that secretion may Pus in middle meatus, often profuse. accumulate in that cavity, and will flow out on Pain ; supra-orbital or lachrymal. altering the position of the head. Tenderness in the same regions. of ethmoid cells into nose. Bulging Transillumination and its Interpretation. Asthenopia. Mental depression. Transillumination is performed by introducing Granulations, etc., in middle meatus. an electric light into the mouth so as to illuminate Verify by the soft parts of the face. If the antra are normal, Use of probe. an illuminated crescent at the lower of Puncture of bulla. appears edge the orbit, the pupil of the eye reflects a red glow, Sphenoidal Sinus : and the is aware of a sensation of light. Pus in meatus patient superior ; These are best marked in between septum and middle turbinal phenomena young people (anteriorly), and are absent when the antrum is on superior and middle tufbinals (posteriorly). females; they Pain, sometimes occipital. wanting, when its walls are abnormally thick, when Ocular disturbance. it is occupied by a tumour, or when it contains pus. Polypi. .Verify by Chronic Sinusitis or Simple Empyema. Cannula and perflation. A distinction must be made between chronic sinu- Pus from ostium seen. sitis of the antrum and In sinu- N.B.?Avoid exploratory puncture. simple empyema. sitis the lining membrane of the antrum is in a Posterior Ethmoidal Cells : state of disease, and is pus; in Having excluded the sphenoidal sinus secreting simple by irrigation-? on the other the Pus persists. empyema, hand, the lining of Bare bone felt. antrum is healthy, but the cavity becomes a reser- middle Polypoid turbinal. voir for pus, which drains into it from elsewhere. Verify by The pus in empyema may have flowed into the Effects of treatment. antrum through the ostium maxillare from the August 18, 1906. THE HOSPITAL. 345 frontal or the anterior ethmoidal cells. A glance opacity, being due to tlie thick vascular lining, per- at the anatomical arrangement of the outer wall sists. ?of the middle meatus will explain one way in which If pus reappears in the middle meatus after it is this may occur. The hiatus semilunaris, having definitely proved that the antrum is healthy, or the opening of the frontal-nasal canal at its upper after that cavity has been thoroughly washed out, ?end, and the ostium maxillare in its lower part, perflated with air, and the middle meatus of the forms a sort of gutter between the two, so that pus nose dried, the other sinuses of the anterior group formed in the upper sinus is very likely to flow into must be examined. the lower; probably, also, pus from the anterior Symptoms of Chronic Frontal Sinusitis.
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