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. ?ethmoidal cells will drain down into the antrum. But, besides the sinuses, a recent case showed that A continuous discharge of pus may be the only the source of the pus may sometimes be the nose symptom of chronic frontal sinusitis. Neither pain itself. nor tenderness are constant symptoms, nor are either retention of Pus MAY COME FROM THE NoSE ITSELF. necessarily dependent upon secretion. A middle-aged man came to the hospital com- Transillumination is performed by placing a plaining of subjective foetor and discharge from the hooded lamp in the inner angle of the roof of the left nostril; the left antrum was opaque on trans- orbit. Owing to the occasional absence of the sinus, illumination, and on puncture and irrigation to the variations in its size and in the thickness of through the nasal wall proved to contain a quantity its anterior wall, this test is much less reliable than of foetid pus. for the antrum. Upon further examination, the patient was found The ostium of the frontal sinus is situated at its to have a breaking-down gumma in the middle posterior and lowest point, so that in sinusitis the meatus, from which the pus drained into the pus tends to slowly drain away. Permanent re- antrum. The ordinary treatment for specific tention is not common, but occasionally such cases disease, and one or two irrigations of the antrum occur with the formation of an orbital abscess. As through Lichtwitz' trocar, cured the disorder. a rule the fronto-nasal canal becomes larger than the normal, probably owing to an atrophic condi- Origin may be Dental. tion produced by continuous contact with pus. The result of this is that no amount of pus accu- The other source of pus in emypema is dental. A large mulates in the sinus at one time, but there is a con- peri-apexial abscess at the root of a carious bicuspid tinuous flow, sometimes so small as to be or molar may burst into the floor of the antrum and scanty scarcely noticeable : this is the most usual condition continue to discharge pus into the cavity until a found. Sometimes, however, a or a large quantity has accumulated. Caries of upper granulation cluster of may the exit of teeth, or tenderness of a tooth upon will polypi impede discharge, percussion, which then collects in or the a greater create suspicion of empyema from a dental source. quantity; of the fronto-nasal canal may become in- The presence of pus in the antrum may be veri- lining flamed and swelled from some fied by puncture with a fine trocar through the in- temporary cause, with the same result. ferior meatus, perflation, and irrigation with a clear .-antiseptic lotion. Verification of Diagnosis, In order to the it has been Differential Diagnosis of Sinusitis and verify diagnosis, pro- to the source Empyema. posed distinguish of the pus by using small tampons of gauze for damming the ostia of The differential diagnosis between sinusitis and the various sinuses in turn ; but, owing to the diffi- is not so empyema easy: the effects of repeated culty in seeing the parts, this' is not reliable. The and and puncture irrigation, the presence of foci only certain way of proving that the frontal sinus 'of in other suppuration sinuses or in the nose, are is suppurating (besides opening the sinus) is to pass which have to be factors considered. a suitably curved cannula into it from the infundi- Malm has out m pointed that true chronic sinu- bulum and to blow or wash out the contents. We sitis the mucosa is greatly increased in thickness can then be quite sure of the source of the pus. In" ?even the so during early stages, that the capacity health the fronto-nasal canal is often merely a ^>f the sinus is reduced. considerably The antrum narrow chink winding between ethmoid cells, and having been washed out with a fine canula through the introduction of even a fine curved probe is diffi- 'the inferior he advises that meatus, its capacity cult and often impossible; but in sinusitis the ex- should be it measured by filling with lotion, which perience of the author is that it is usually possible is then to be withdrawn with a graduated syringe. to pass a cannula. If the of sucked out in this is quantity liquid way The most conveniently instrument is one less than 1.5 case shaped cubic centimetres, the is a curve probably with bold at the end, about one- one of true sinusitis. forming third of the circumference of a circle, so that the A or two of flows drop blood sometimes from the is directed and forwards in- cannula point upwards during after puncture : this is Lubet- thought by troduction. When the point is engaged in the Barbon to prove that sinusitis is Another present. fronto-nasal canal it slips on by a sliding movement differentiating sign, suggested by Guisez and round the circumference of its the handle uerin, is that in curve, simple empyema the opacity on being until the ransillumination should gradually depressed, point impinges on the front wall of the The manoeuvre must a iter disappear immediately sinus. washing out the pus, whereas in sinusitis the be carried out without any force. 346 THE HOSPITAL. August 18, 1906.

After introduction, the position of the cannula often suggestive of commencing atrophic rhinitis;, can be estimated the by placing probe parallel to there may be fcetor, a certain amount of wasting, it along the outside of the nose; air is then blown and a tendency to the formation of crusts. ..Sub- through the cannula, while the middle meatus is jective foetor is commonly complained of, ? The

The Frontal Sinus Probes Designed by Mr. Nourse, and made for him by Messrs. Mayer and Meltzer. under observation. If the sinus contains pus, a few closeness of the sphenoidal sinus to the optic nerve* drops will be driven out by the side of the cannula. the cavernous sinus, and other important intra- If necessary, the sinus can be irrigated. cranial structures and the occasional dehiscence of its roof will account for the serious Suppuration in the Ethmoidal Labyrinth. bony symptoms occasionally observed in cases of suppuration in this of cells on Some the ethmoidal bordering the cavity, in dealing with which both caution and fronto-nasal canal are involved when the usually gentleness must be exercised. frontal sinus is diseased. Suppuration in the ethmoidal labyrinth is met Diagnosis Confirmed. with independently of disease in the frontal sinus The diagnosis of suppuration in the sphenoidal or the antrum as well as in association with them. sinus may be confirmed by examining the sinus with It is often accompanied by the formation of polypi a probe and perflating or irrigating it by means of and by polypoid degeneration of the nasal lining in a cannula. It may be well to observe that the intro- the middle meatus; the ethmoid region bulges in- duction of instruments into the nose or sinuses wards into the nose, and may cause an apparent should never be attempted except under good illu- duplication of the anterior end of the middle tur- mination by means of a forehead mirror. The binal. One or more of the cells may become greatly probe, which should be nearly straight, and prefer- dilated at the expense of others, and will then con- ably graduated in centimetres, is passed obliquely tain quite a large quantity of pus; the discharge is upwards and backwards between the nasal septum often profuse. Ziem has drawn attention to the and the middle turbinal body until it touches the ,ocular symptoms produced by this and other posterior wall of the nose. By moving the point diseased conditions in the nose and accessory slightly the ostium will probably be met with, and sinuses. The diagnosis can be confirmed by using the probe will pass on for some distance further. the probe, which will sometimes pass a considerable The average depth of the further wall of the sinus distance into dilated suppurating cells. Further touched by the probe is 8.5 centimetres from the confirmation can be obtained by the liberation of lower edge of the nostril. The cannula is passed in the same manner. pus during treatment. If by chance the posterior nasal The posterior group of sinuses is situated in an wall is within view, the manipulation is so much inaccessible region at the back of the nose, and the easier, and the diagnosis can be confirmed by obser- diagnosis of their diseases is correspondingly diffi- vation. cult. When pus persists in the posterior part of the nose after the exclusion of the The Shhenoidal Sinuses and the Symptoms of definite sphenoidal it is to be that it comes from the Suppurati6n. sinus, presumed ethmoidal cells. This would be verified a posterior The ostium of the sphenoidal sinus is very small during surgical treatment. aperture high up in the posterior wall of the nose. (To be continued.) In the healthy nose it cannot be seen from the front, being hidden by the middle turbinal body, but in diseased conditions, when the turbinal has been des- troyed or atrophied, it becomes visible, and dis- charge can sometimes be seen coming from it. The ostia of the posterior ethmoidal cells are situated close to the former in the spheno-ethmoidal recess, looking backwards; they are quite out of sight. Pus coming from the sinuses of the posterior group is usually seen from the front lying between the middle turbinal and the septum; and, on posterior rhinoscopy, flakes may be observed adhering to the roof of the naso-pharynx or on the hinder ends of the middle and superior turbinal bodies. The symptoms of suppuration in this region are